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 Columbia ^IniUcrsitP 
 inti)cCitpof i^cU) J)oiU 
 
 College of ^Ijpsicinns nub ^ui scons 
 
 ^Svef erence ?tifararp 
 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/insicknessinhealOOroos 
 
A TRAINED NURSE, 
 
IN SICKNESS 
 AND IN HEALTH 
 
 A MANUAL OF 
 
 DOMESTIC MEDICINE AND SURGERY, HYGIENE, 
 DIETETICS, AND NURSING, 
 
 DEALING IN A PEACTICAL WAY WITH THE 
 
 PROBLEMS RELATING TO THE MAINTENANCE OP HEALTH, 
 
 THE PREVENTION AND TREATMENT OF DISEASE, 
 
 AND THE MOST EFFECTIVE AID IN EMERGENCIES 
 
 BY 
 
 GEORGE WALDO CRARY, M. D. WILLIAM P. NORTHRUP, M. D. 
 
 FREDERIC S. LEE, Ph.D. FRANK W. JACKSOX, M. D. 
 
 JOSIAH ROYCE, Ph.D. SAMUEL WALDRON LAMBERT. M.D. 
 
 JOSEPH HAMBLEN SEARS, A. B. FREDERICK PETERSON, M. D., Ph. D. 
 
 SAMUEL T. ARMSTRONG, M. D., Ph. D. HENRY A. GRIFFIN, M. D. 
 
 ALEXANDER B. JOHNSON, M. D. ANNA CAROLINE MAXWELL 
 
 J. WEST ROOSEVELT, M. D. 
 
 EDITOR 
 
 N E W Y^ O R K 
 D. APPLETON AND COMPANY" 
 
 1896 
 
CorTRir.nT, ]8n6. 
 By D. APPLETON AND COMPANY. 
 
PUBLISHERS' NOTE. 
 
 In response to what appeared to be a general denmTid, the pubhsliers 
 have prepared a book for household use that, while popular and at- 
 tractive, embodies in a thoroughly practical form the latest and mo.st 
 complete information in regard to domestic science and kindred topics, 
 including medicine and surgery, hygiene, dietetics, and nursing. 
 
 Knowledge of the laws governing health and disease, how to pro- 
 mote the former and how to avoid the latter, as well as what to do and 
 what not to do in emergencies, has hitherto been hidden away for the 
 most part in text-books and special treatises to which the unprofessional 
 man and woman had no access, or, if accessible, the information was so 
 shrouded in technical language as to puzzle and disconcert the reader. 
 
 It is hoped that this work, which combines scientific Avith literary 
 excellence, will meet the requirements of the intelligent reading public. 
 The aim throughout has been to give absolutely correct information in 
 clear and simple language. 
 
 In order that the various topics might be treated by those qualified to 
 write with authority, the publishers secured the services of an able corps 
 of specialists, each eminent in his own domain, who worked under the 
 direction of experienced editors. 
 
AliTlCLKS AND ('( )NTKI lU'TOKS. 
 
 The AiiutoiiiT <»f the lliiiiian lUnly. 
 
 Wv tiK>Ui;K Wm.ko (kakv, M.I'.. 
 
 • >ii-A<i<-ii<liii>:SiirKriiiijii Uoiisi-- 
 
 .\'«'-KMiii Siirt:<-<'ii lo l{iM.sf 
 < )ii> I'aiii-iit l>f|Mtrliiii-iil. mill 
 . ,. „ 1 r«iii-.T lli>s|iiiitl, Ni'vv ViirU. 
 
 IMiynioIosry : The Vital Procossps in 
 
 llpitlth. 
 
 I*v I'lci MKRir S. Lki:. I'll. !».. 
 
 • rroft-wtoiof I'liyslolotry. C'<>liiinl>iii 
 
 Ni-vv Y»rk ; Mi-imIht of tin- NfW 
 
 \i-nil<Miiy "f S»-i<'itf<-s. "if till- Aincri 
 
 i.iii riiy>ii«li>>;ii'al Sm-ifty. ntul of the So- 
 
 cifty of'Aiiirrifuii Natiinilwis. 
 
 OiitliiH's of rsvclioldirv : or, A Study 
 
 ol (lit' Hiiiiiati .Miiitl. 
 
 Uv .lo-siAii KoYCK. !'h. !>.. 
 
 ' I'rofi'ssor of tin* Histiiry of riil|i)so|i)iy, 
 
 11.11 v.iril I'lilvi-rsily. C'iiiiitiri(l};«>. M.-issucliii- 
 
 v.M- ; iKiilior of Till- i:<li<ii"iis Aniii'cl of 
 
 ;•■./.. >.>;//ij/, Tlir S/iirit «/ Modern PliilvM- 
 
 I'hjsifal Tiainiiiir. 
 
 Ily .losKi'i! Uambi.ks Skars. a. 15.. 
 ' llnrvnrcl C'oncli nml i-x l'a|»iaiii of i)ii> Mar- 
 vnnl Kootlvill Tram; rililor of ll^njn r.s 
 /t'oiiiu/ Tablr. 
 
 Hvirit'nc. 
 
 lU- SvMi'Ei. Treat Arm.'^tuknii. M.D.. 
 Ph. I).. 
 
 VisiiiiiK Physician to tin- Willan! PaikiT 
 
 aii'l KiviTsi(|«> Mospitnls. N»mv Yoiv : ex- 
 
 l'is.s»-,| A!^<iisiant Snriri'on, I'niii-il .'^tali's 
 
 Mariiif • HoKjiiliil Strvirc : Kt-jlnw of the 
 
 Aiii.ri .III Mi-ilical A'isiMMntion. of tin- 
 
 ' 'ihlic lli-nlih Association: one 
 
 vniloi-s of yiialrr'H h'.iicyflit- 
 
 it hirtiiiiiorii. ftc. 
 
 Snin:ii;il liijiiiics aiitl Siiru'nal IMs- 
 oanoH. 
 
 !lv .\|.KXAM>I II V>. .l«)II\s(fV, .M.I>.. 
 
 \...,i-i ...1 Vi->tiii- Snrir<'on t<i |{oc.s.-vr-|| 
 II .-|. -.11 ; \-M-titit .siirjjron lo RoosfVi'll 
 Il.~|.i'.il. 'ml r.iiK-nt l><'pnrlfni'nt. New 
 ^ork: MciniMToi (h<- Sock-iy oi Ahiinnl of 
 Uelleruo HuHpiLal, utc. 
 
 Disoascs in (><Mioral. 
 
 \\\ .1. Wkst Uooskvklt, M. D.. 
 
 ami Wll.l.lA.M I'. NORTIIKL r, .M. I).. 
 
 Ailiiiiul I'rofcssor, Discast's of fliililrcn, 
 l;.llfVllc ilos|iital Mfdioal College. Ni'W 
 York; AUcinliiitc I'liysli-iun to I'ri'sliyte- 
 liati, Ni'W York I''oiin«llin);. and Willard 
 I'arkcr llospitals, and Consulting Tliybiciaa 
 to New York Infant Asyliini. 
 
 Diseases of Di^'cstive Org-ans, Heart, 
 and Liintrs. 
 
 I'.y I'ltANK \V. Jackson-. !\l. 1)., 
 ' Cliii'f of clinir anil Instructor in Practical 
 Medicine, .'Medical Dcparlnienl. t'olle>;c of 
 I'liysicians and SiUKeons ; Atleiidinfr I'liy- 
 sic'i.'in to Koosevelt Hospital, Outl'aiicnl 
 l)i'partnu;nt, and Assistant Visit ins Physi- 
 cian lo Ucllevuc Ilf)-i)ital, New Y'ork. 
 
 Diseases of the Kidneys and Urinary 
 
 Deransrenients. 
 
 I)V .1. \Vi;sT I{oosi;vi:i,t. "^l. 0., 
 
 I'liysiciiui in Cliait;e of Seton Hospital for 
 Consumptives; Visituip Physician to Bellc- 
 \ Me. ami AtlendiiiK Physician to Roosevelt 
 Hospitals. New York. 
 
 Diseases of Women and Midwifery. 
 
 I'.y Samikl Wai.dko.v IjA.mukkt, M. 1).. 
 
 Allindirijr Pliysiclan to Nursery and Cldlds 
 Hospital and .\c\« York Lyiiifj in Hospital. 
 
 Nervous and Mental Diseases. 
 
 I'ly I'^UKDKKICK I'lTKKSON, M. I)., Ph. D., 
 
 Child' of Cliidc of Nervous Hcpartment, 
 ('■ille^;e of Physicians and .Suitreons. New 
 ^ork ; Consulting Neiirolotrist to Kaiidall's 
 Island Hospitals; Patholopist to the New 
 \ii\\i City Insane Asylums, etc. 
 
 Medicines and Treatment. 
 
 l!y lliNKV A. (iiiiii'ix, M. D.. 
 
 As'-isianI Physiciati to Hoosevelt Hospital, 
 Out Patient IJeparlment, New York. 
 
 Nursing the Siek. 
 
 P)y .Anna t'Ai{t)i,i.M': Max\vi;i,i„ 
 
 (iraduate of the lioston City IIo.s[)itnl Train- 
 iiu; .School ; Sii[)erintendeiit of the Training 
 School for Nurses, Presbyterian HoHpilal, 
 New Y'ork. 
 
 fKI.KSTK WI.NANS II KliliK'K, A. B., 
 
 MA.NAtilMi KDITOK. 
 
TABLE OF CONTENTS. 
 
 AUTICLE PAGE 
 
 r. The Anatomy of the Human Body ..... 1 
 The skeletoi] — The bones — The joints — The muscles — The appa- 
 ratus for the circulation of tlie blood : the heart and blood-vessels 
 — The lymphatic system — The nervous system — The digestive or- 
 ,a:ans : alimentary canal, liver, pancreas, and spleen — The re- 
 spiratory system : lungs and air-passag'es leading to them — The 
 genito-urinary system : kidneys, ureters, bladder, urethra, etc. — 
 The organs of special sense : tongue, nose, eye, and ear— The skin 
 — The development of the embryo. 
 
 II. Physiology : The Yital Processes in Health ... 85 
 
 Man a product of evolution — The human body a machine — Or- 
 gans — Tissues — Cells — Protoplasm — Vital energy : nature and 
 source — Food stuffs — Nutrition — Digestion — Absorption — Circu- 
 lation of the blood — Resi)iration^ — Metabolism, or chemical work 
 of cells — Excretion of waste products — The muscular system — 
 The voice — The nervous system : brain, spinal cord, and nerves — 
 Special senses : sight, hearing, smell, taste, touch, and tempera- 
 ture — Equilibrium of the body — Reproduction — Life — Death — 
 DitTerences between man and woman — Heredity. 
 
 III. Outlines of Psychology; or, A Study of the Human 
 
 Mind 171 
 
 Definition of psychology — General characterization of mental 
 life — The methods, conditions, and scope of- psychology — The 
 classes of mental facts — The physical basis of mind — Nervous 
 conditions of the manifestation of mind — Structure and function 
 of the nervous system — Sense organs— Adjustment to the envi- 
 ronment — Brain processes — Habit — Brain centres and lower 
 centres — Inhibition — " Set " of the brain — Self-control — Sugges- 
 tion—Healthy activity — Variation of labour — Worry — The feel- 
 ings— Relation of feeling to consciousness — Pleasure and pain — 
 Desires and aversions— Brain-fatigue — The emotions — The intel- 
 lect, or the organization of experience — Association — Attention — 
 Discrimination — Identification — Sensations — Perceptions — Mem- 
 ory and Imagination — Thoughts — Judgment, belief, and reason- 
 ing — The intellectual life — Nervous exhaustion — Hallucinations 
 
vi CONTENTS. 
 
 ARTICLE PAOE 
 
 — Dohisioiis — Eoot'iitrioity — The Avill. or tlio diroction of conduct 
 — Inherited instincts — Traininjr of the will — Disorders and de- 
 fects of the will. 
 
 T\'. Pmysuwi, Tu.mnixc; 235 
 
 Necessity t)f sini])le hut regular exercises — Value of outdoor and 
 indoor, day and nij^ht, exercises contrasted- -Value of {>-anies and 
 s])ecijil exercises contrasted — Exercise for hrain as well as hody — 
 Exercise as iniportiint for old as young and for women as men — 
 Systematic work the secret of success — Influence on morality, 
 temperance, etc. — Foothall — Baseball — Tennis — Rowino- — Skating 
 — Kunning— Golf — Croquet — Polo — Ice sports — Riding — Cricket 
 — Bicycling — Track athletics and others — Gynniasium and hoin(> 
 exercises — The navy " setting-up " exercises — The Swedish system 
 — The Delsarte system — " Training " — A scheme for a day : rising, 
 bathing, dressing, food, arrangement of work, rest, recreation, 
 exercise, retiring, sleeping. 
 
 V. IIvciExi; 305 
 
 Hygiene of the connnunity, of the home, and of the individual — 
 Shortcomings of modern sanitary methods — The vitiation of air — 
 Methods of ventilating, warming, and lighting — The influence of 
 climate on health — The soil and its influence on health — Water : 
 sources of supply, composition, purification, and examination — 
 Bathing — The dwelling : its site, construction, exposure, etc. — The 
 disposal of excreta and other refuse — The inspection, imtritive 
 value, and cost of foods — Clothing in relation to climate and 
 health — The hygiene of infancy, adolescence, and old age — Men- 
 tal hygiene — The hygiene of offensive and noxious trades — Com- 
 municable diseases and their prevention. 
 
 VI. Surgical Injuries and Surgical Diseases .... 431 
 Emergencies — General advice — Wounds : incised, punctured, con- 
 tu.sed and lacerated, gunshot, inflamed, and poisoned — The heal- 
 ing of Avounds — Relation of bacteria to the inflammation oc- 
 curring in wounds — The antiseptic treatment of wounds — How 
 to stop bleeding — Dressings and how to apply them — Bandages 
 and bandaging — Contusioiis — Surgical diseases of the .soft jjarts: 
 boils, carbuncle, anthrax, gangrene, necrosis, erj'sipelas, septicae- 
 mia, pyaemia, tetanus, hydrophobia, and surgical tuberculosis — 
 The effects of cold, heat, and caustics upon the tissues, and their 
 treatment — Injuries and diseases of the bones — Fractures : sim- 
 ple, compound, comminuted, complicated, and incomplete — The 
 symptoms, repair, and treatment of fractures — Acute suppurative 
 inflammation of bone — Rickets — Injuries and diseases of joints : 
 contusions, s]>rains, dislocations, inflannnation, and wounds — 
 Tumours : benign and malignant — Injuries and diseases of special 
 regions — Injuries and diseases of the head and face — Injuries of 
 the .scalp : contusions and infected wounds — Fractures of the skull 
 — Concussion, compression, and laceration of the brain — Foreign 
 
CONTENTS. vii 
 
 bodies in the nose, eye, ear, larynx, and alimentary canal — 
 Nosebleed — Wounds of the eyeball — Inflammation of the eye 
 — Inllamniation of the middle ear — Rupture of the drumhead 
 — Wounds, acute inflammation, tubercular ulceration, and 
 tumours of the tongue — Congenital defects : tongue-tie, cleft 
 palate, and harelip — Catarrhal and ulcerative inllamniation of 
 the gums and mucous linings of the cheeks — Aplithai or can- 
 kers — Sprue — Noma — Quinsy sore throat — Enlargement of the 
 tonsils — Decay of the teeth — Alveolar abscess — Injuries and 
 diseases of the neck — Injuries, contusions, and fractures of the 
 ribs — Wounds of the heart and lungs and large vessels of the 
 thorax — Injuries, contusions, and wounds of the breast — In- 
 juries and diseases of the spine — Injuries and diseases of the 
 abdomen — Appendicitis — Intestinal obstruction — Diseases of 
 the anus and rectum : painful fissure, piles, fistula, cancer — 
 Hernia — Varicocele — Hydrocele — Injuries and diseases of the 
 upper extremity and armpit — Wounds of arteries and veins of 
 upper arm — Boils and abscesses in the armpit — Injuries of fore- 
 arm : wounds — Bleeding from elbow, forearm, and ^\Tist — Teno- 
 synovitis of wrist — Ganglion of the wTist — Wounds of the 
 hand — Abscesses of hand and fingers — Rosenbach's erysipelas 
 — Inflammations about the matrix of the finger nails — Dupuy- 
 tren's contraction of the jialmar fascia — Warts — Injuries and 
 diseases of the lower extremity — Bow legs — Knock knee — Vari- 
 cose veins — Housemaid's knee — Ulcers of the leg — Flat foot — 
 Bunions — Ingrowing toenail — Club foot — Death and the signs 
 of death — Transportation of the injured — Genito-urinary. vene- 
 real, and skin diseases. 
 
 YII. Diseases in General. ....... 609 
 
 The causes of disease — Unhygienic surroimdings — Improper 
 food — Alcohol, tobacco, and other di'ugs — Injurious habits 
 and occupations — Lack of exercise — Inherited diseases — Infec- 
 tious diseases : theories of infection — Theories of immiuiity 
 from infection : inherited immunity and acquii'ed immunity — 
 Bacteria : what they are and how they are recognised — Harmless 
 or useful bacteria — Bacteria of disease — How bacteria get into 
 the body — Their effects upon the tissues — The prevention and 
 cure of bacterial diseases^ — Tuberculosis : its cause ; the man- 
 ner in which the bacillus finds entrance, and how it sj)reads 
 — Vaccination — Method of vaccination (inoculation) — Revac- 
 cination — Time for vaccination in infants — Small-pox — Vario- 
 loid — Scarlet fever — Chicken-pox — Measles — German measles 
 — Typhoid fever — Whooping-cough — Mumps — Diphtheria — 
 Meningitis^Malarial diseases — Yellow fever — Diseases of the 
 blood — Gout — Rheumatism. 
 
 VIII. Diseases of Digestive Organs, Heart, and Lungs . . 66'? 
 Pleurisy : simple and subacute — Empyema — Pneumothorax — 
 Pyopneumothorax — Diseases of the bronchi — Laryngo-ti'ache- 
 
viii CONTENTS. 
 
 itis — BroiK'hitis : acute and chronic — Diseases of tlie lung — 
 Emphysema of the lung-s — Pulmonary tuberculosis : acute 
 and chronic — Pneumonia — Broncho-pneumonia — Influenza — 
 Asthma — Spitting of blood — Diseases of the heart — Endocar- 
 ditis: acute, chronic, and malignant — Dilatation of the heart: 
 acute and chronic — Fatty heart — Angina pectoris — Nein-algia 
 of the heart — Palpitation of the heart — Tachycardia (rapid 
 heai't) — Exophthalmic goitre — Pericarditis — Aneurism t)f the 
 arch of the aorta — Diseases and disorders of the digestive sys- 
 tem — Dj'spepsia — Gastritis: acute and chronic — Ulcer, cancer, 
 and dilatation of the stomach — Diseases of the intestines — Diar- 
 rho-a: acute and chronic — Dysentery: acute and chronic — Con- 
 stipation — Intestinal parasites — Diseases of the liver — Jaundices 
 — Cirrhosis, cancer, and abscess of the liver — Diseases of the 
 pancreas — Diseases of the spleen — Peritonitis. 
 
 IX. Diseases of the Kidneys and Ukixakv Derangements . 707 
 
 Sjnnptoms of kidney disease — Stoniach disord(>rs ; headache, 
 nausea and vomiting- — Dropsy — Acule Bright's disease — Chronic 
 Bright's disease. — Changes in the urine in diseases (jf various 
 kinds and in disease of the kidneys. 
 
 X. Diseases of Women and Midwifery ..... 725 
 
 Menstruation — Significance of menstruation — Puberty — Normal 
 phenomena of menstruation — Disorders of monsti'uation — 
 Menopause — Pregnancy — Signs of pregnancy — Period and dura- 
 tion of pregnancy — Hygiene during pregnancy — Preparation 
 for labour — Care of a woman in labour — Antisepsis — Care of the 
 newborn child — Lying-in period — Lactation — Artificial foods — 
 Weaning — Diseases of pregnancy — Diseases of lying-in women 
 — Diseases of non-pregnant women. 
 
 XI, Xervous and Mental Diseases 779 
 
 Heredity — Sti*ess or strain — Nervous diseases — Abscess of the 
 brain — Alcoholic inebriety and paralysis — Anaemia of the brain 
 and spinal cord — Ansesthesia-r- Aphasia — Apoplexy — Atrophy- 
 Bell's and birth palsy — Catalepsy — Convulsions — Cramp — Epi- 
 lepsy — Exoplitlialmic goitre — Headache — Water on the brain — 
 Hypnotism — Hysteria — Infantile si)iiial ])ai"alysis — Insomnia — 
 Lead poisoning — Locomotor ataxia — Meningitis — Myelitis — Neu- 
 ralgia — Neurasthenia (nervous prostration) — Neuritis — Paraly- 
 sis — Sclerosis — Softening of the brain — St. Vitus's dance — Tic 
 convulsif — Tic douloureux — Tremour — Vertigo — Wryneck — In- 
 sanity — Delusi(ms — Dementia — Hallucinations — Illusions — Im- 
 perative conceptions — Mania — Melancholia — General paresis — 
 Paranoia. 
 
 XII. ]\[edigines and Treatment ....... 823 
 
 The prevention of di.seases — General considerations — Com- 
 mon .sen.se— Food — Drink — Exercise — Cleanliness — Temperance 
 
CONTENTS. 
 
 ARTICLE 
 
 — Sleep — Regular habits — Avoidance of special dang-ers, conta- 
 gion, etc—Treatment of disease by the laity— The use of drugs — 
 The family medicine chest— Diet and drink in disease — Position, 
 rest in bed, etc. — Ventilation — Temperature — Light — Hygiene^^ 
 Poultices— Plasters — Stupes — Baths — Leeching — Douches — 
 Enemata— Artificial respiration— Disinffiction— Simple cojidi- 
 tions not requiring a professional attendant— Biliousness— Chok- 
 ing— Cholera morbus— Colic — Constipation — Cough — Diarrhoea 
 — Earache — Epilepsy — Inflammation of the eyes — Fainting — 
 Fever— Flatulence— Headache— Hiccough— Hysterica] mani- 
 festations and nervousness— Loss of appetite— Muscular rheuma- 
 tism and rheumatic pains — Sleeplessness— Sore feet — Sore mouth 
 —Styes— Toothache— Vomiting— Emergencies demanding a pro- 
 fessional attendant— Treatment to be employed pending his ar- 
 rival—Apoplexy—Bleeding from lungs, stomach, and bowels- 
 Coma and unconsciousness — ^Convulsions — Drowning — Exhaus- 
 tion— Prostration— Shock— Poisoning— Suffocation— Sujistroke 
 — Gymnastics— Massage— Movement cures— Mineral springs- 
 " Cures " : milk, whey, grape, etc. 
 
 XIII. Nursing the Sick ••••..,. 
 Selection of the sick-room— Care of the patient and room— Heat- 
 ing— Ventilating— Lifting and moving the patient in bed— Posi- 
 tion— Light— Draughts— Methods of giving baths— The preven- 
 tion and treatment of bedsores — Methods of taking and recording 
 temperature, pulse, and respiration— Bedside notes— The prepa- 
 ration of invalids' food— Receipts— The administration of food 
 and medicine— Enemata— Suppositories— Douches— Counter-ir- 
 ritation — Applications of heat and cold— Stupes — Poultices— 
 . Packs— The ice coil— Care of the patient at night— Medical, 
 surgical, and obstetrical nursing— Care of sick children— Con- 
 tagious cases — Management of convalescence— Preparation of 
 the dead. 
 
 903 
 
LIST OF ILLUSTEATIONS. 
 
 PACK 
 
 The Human Skeleton 3 
 
 The Right Femur, or Thigh Bone, sawn in two lengthwise 3 
 
 Fibula tied in a Knot, after Maceration in a Dilute Acid (Dalton) .... 4 
 
 Sixth Dorsal Vertebra, from above (Quain) 5 
 
 The Spine, Lateral Aspect 5 
 
 The Human Skull 7 
 
 Skull of a Child at Birth, from above (Leishman) 8 
 
 Thorax, Anterior View (Sappey) 9 
 
 Thorax, Posterior View (Sappey) 9 
 
 Upper Surface of Left Clavicle, or Collar Bone 10 
 
 Left Scapula, or Shoulder Blade 11 
 
 Ijeft Humerus, or Bone of the Upper Arm 13 
 
 Bones of the Forearm : Left Radius and Ulna 12 
 
 Bones of the Left Hand ; Palmar Surface 13 
 
 Right Femur, or Thigh Bone 14 
 
 The Patella, or Knee Cap ' 15 
 
 Right Tibia, or Shin Bone, and Fibula or Splint Bone 16 
 
 Bones of Right Foot : Dorsal Surface 16 
 
 Right Knee Joint (Quain) 18 
 
 A Section of the Hip Joint 19 
 
 The Muscular Sj^stem 21 
 
 Muscular Fibres 23 
 
 The Bones of the Upper Extremity with the Biceps Muscle 23 
 
 The Diaphragm 24 
 
 The Heart and Large Blood-vessels 25 
 
 Heart and Ribs 26 
 
 A Schematic Diagram of the Heart 28 
 
 The Abdominal Aorta 29 
 
 The External Carotid Artery and its Branches (after Henle) 30 
 
 The Subclavian Artery (after Henle) 31 
 
 The Brachial Artery and its Branches (after Henle) 32 
 
 The Femoral Artery (after Henle) 33 
 
 The Jugular Vein, etc 34 
 
 The Veins of the Lower Extremities 35 
 
 The Portal Vein, etc 36 
 
 Lacteals and Lymphatics during Digestion (Dalton) 38 
 
 Multipolar Ganglion Cells from the Human Brain 40 
 
 xi 
 
xii LIST OF ILLUSTRATIONS. 
 
 i'AOE 
 
 Tlie Cerebro-ppinnl System of Nerves 41 
 
 A Vertical Mfilian .Seelioii of the Brain inclosed in its Meniluancs ami the Skull . 42 
 I'ppor Surface of the Cerebrum, showing: the Convolutions of tiie l^iain ;mil its 
 
 Double Structure 43 
 
 Dia<;ram of the Outer Hemisphere of tile Human Brain 44 
 
 The Base of liie Brain (from Kannev, after llirschfeiti) 45 
 
 A Vertical Section of the Brain (from Flint, after llirschfelil) 48 
 
 JJrain and Spinal Cord, with the Thirty-one Pairs of Spinal Nerves .... ol 
 Diagram showing the Relative Position of tlio Cranial and Upper S|)inal Nerves as 
 
 they enjcrge from their Foramina 52 
 
 The Sympathetic or Ganglionic Nervous System .IS 
 
 Tempnrary and Permanent Teeth (.Sapjjey) .5!) 
 
 Salivary Ci lands (Tracy) (Il 
 
 Position of Abdominal Contents 62 
 
 The Stomach . . 63 
 
 Under Surface of the Liver, showing the Gall Bladder and a Section of Blood-vessels 66 
 The Pancreas, partly cut away so as to show the Duct which collects the Pancreatic 
 
 Juice and empties it into the Duodenum 67 
 
 Longitudinal Section of the Human Larynx, showing the Vocal Cords (Sappey) . 6!) 
 
 Posterior View of the Muscles of the Larynx (Sappey) 70 
 
 Lateral View of the Muscles of the Larynx (Sai>pey) 70 
 
 Showing the Relative Position of Heart and Lungs in the Cavity of the Chest . . 71 
 
 Thyroid and Thymus Glands (Sappey) 72 
 
 ^luscles of the Eyeball (Sappey) 7(i 
 
 Choroid Coat of the Eye (Sappey) 77 
 
 General A'iew of the Organ of Hearing (Sappey) 79 
 
 Segmentation of the Vitellus (Haeckel) 82 
 
 Primitive Trace of the Embryo (Liegeois) 83 
 
 Typical Cells from the Human Body 87 
 
 Human Alimentary Canal 89 
 
 Gland from the Human Intestine 92 
 
 Red and White Corpuscles of the Blood (magnified) 95 
 
 Diagram of the Heart and Vessels, with the Course of the Circulation, viewed from 
 
 behind 97 
 
 Capillary Circulation in (he Web of a Frog's Foot 98 
 
 Diagrammatic Section of Veins, with Valves 99 
 
 Termination of Two Bronchial Tubes in Enlargement beset with Air Sacs (Huxley) . 105 
 
 Trachea and Lungs, dissected to show Broncliial Tubes lOd 
 
 Diagrammatic View of an Air Sac 107 
 
 Diagrammatic View of Course of Uriniferous Tubules in Kidney Ill 
 
 Vertical .Section of Kidney Ill 
 
 Vertical Section of Skin (magnified twenty diameters) 112 
 
 Surface of Palm of Hand (magnified four diameters) 112 
 
 Composition of some Common Foods 117 
 
 Unstriped Muscle Fibres of Man (magnified 200 diameters) 121 
 
 Striped Muscle Fibres (magnified 250 diameters) 122 
 
 Series of Figures from Instantaneous Photographs to illustrate Movements in Slow 
 
 Walking 124 
 
 Expression of Extreme Terror 124 
 
 Expression of Various Emotions, showing Characteristic Muscular Contractions . 125 
 
 The Average Range of Human Voices 127 
 
 Interior of Larynx, as .seen by Laryngoscope, during Production of A, Chest Voice 
 
 (MaiAll and Grutzner), B, Head Voice (Mills) 128 
 
LIST OF ILLUSTRATIONS. xiii 
 
 PAOE 
 
 Diagram of a Typical Neuron l-HJ 
 
 rsyciiic Brain Cells in Different Stages of Evolution I'-H 
 
 Diagram to illustrate Nervous Mechanism in (1) Automatic Action, (2) Reflex Action, 
 
 (;3) Passage of Sensory Impulse Upward and of Motor Impulse Downward 
 
 within Central Nervous System (Mills) 1-52 
 
 Diagram intended to show the Relations of tlie Brain, the Spinal Cord, and the 
 
 Peripheral Organs lo3 
 
 Diagram to illustrate Reflex Actions l-'iO 
 
 Section of the Cerebral Cortex of Young Mouse, showing Psychic Cells and their 
 
 Branches 1-37 
 
 Side View of the Human Brain, intended to show the Positions of Various Nervous 
 
 Centres (after C. K. Mills) 138 
 
 Median View of the Human Brain, intended to show the Positions of Various Ner- 
 vous Centres (after C. K. Mills) 139 
 
 Diagram intended to show the Nervous Mechanism employed in the Understanding 
 
 and Use of Language (James, after Ross) 140 
 
 Diagram intended to show the Paths of Nervous Impulses (James) .... 141 
 
 Section of the Eyeball (Flint) 143 
 
 Diagrammatic Section of the Retina (Schultze) 144 
 
 Diagrammatic Section of the Retina, intended to illustrate the Recent Discoveries 
 
 as to the Structure and Relations of the Various Layers 145 
 
 Diagram for demonstrating Existence of Blind Spot 146 
 
 Diagram illustrating Refraction of Rays of Light and Formation of an Inverted 
 
 Image by a Lens 146 
 
 Diagram illustrating the Mechanism of Accommodation of the Eye .... 147 
 
 Diagram of the Ear 150 
 
 Diagram of Membranous Labyrinth and Distribution of Auditory Nerve . . . 151 
 Diagram of Cross-section of Canal of Cochlea, showing Organ of Corti resting upon 
 
 Basilar Membrane 151 
 
 Diagram of Longitudinal Section of Ampulla of Semicireidar Canal, showing Crista 
 
 Acustica 153 
 
 Vertical Longitudinal Sections of the Cavity of the Nose 154 
 
 Nerve and End Organs of Sense of Smell 155 
 
 Two Taste Buds from the Rabbit's Tongue, magnified 450 diameters (Engelmann) . 155 
 
 A Human Egg much enlarged 158 
 
 Female Reproductive Organs (two thirds the natural size), as seen from behind . . 159 
 
 Human Spermatozoa 160 
 
 Segmentation of the Egg of the Rabbit 161 
 
 Embryo within the Uterus (diagrammatic) • 163 
 
 Polo : " On the Ball " (from Harper's Magazine) 241 
 
 Diagram of Football Ground • 242 
 
 Football : A Successful " Tackle " 243 
 
 Lacrosse . 244 
 
 View of a Cricket Crease with the Game going on (from Harper's Weekly) . . . 246 
 
 Golf: Act of Driving . . . ." ' . . .247 
 
 One-hundred-yard Dash 249 
 
 Rowing : Eight Oars 250 
 
 Swimming : Proper Position 254 
 
 Bicycling : Incorrect Position 255 
 
 Bicycling : Correct Position 255 
 
 Throwing the Hammer 258 
 
 Putting the Shot 258 
 
 A Woman Playing Golf 262 
 
xiv LIST OF ILLUSTRATIONS. 
 
 PAGB 
 
 Bicycling: Correct Position fur a Woiium 2G4 
 
 The Fnrncse Ilorcules 268 
 
 Apollo Belvoiloro 269 
 
 Sparring . . . ' 271 
 
 Fencing 274 
 
 Single St iiks 274 
 
 Piuu'hing Bag 276 
 
 Ordinary Pulley Weights for Home or (iyiiuiasiurn I'se 278 
 
 The Home (Jynmasiuin : Horizoi\tal Bar 279 
 
 The Home Gymnasium : Parallel Bars in the Wimlow 280 
 
 Developing the Tricejis and SliouUler Muscles 282 
 
 Exercising the Al)dominal and Front Tiiigh Muscles 286 
 
 Kxercising the Alulominal Muscles 287 
 
 Diagram showing Death-rates of Children under Five Years of Age . . . .313 
 
 Diagram showing Uie Composition of Food Materials 384 
 
 Diagram sliowing the Pecuniary Economy of Food 394 
 
 Mortality Percentage of the London Smallpox Epidemic, 1871-1881 .... 418 
 
 (iranulating Wound undergoing Cicatrization 433 
 
 A]iplication of an Improvised Tourni(|uet to the Femoral Artery 447 
 
 Schapp's Tonrniiiuet (Tiemann) 448 
 
 Esmarch's Triangular Bandage 455 
 
 Triangular Bandage applied Jis a Sling and as a Retentive Bandage to Various Regions 455 
 
 Rolling a Bandage l)y Hand 456 
 
 Antiseptic Dressing applied 457 
 
 Application of a Roller Bandage to the Arm by the Spiral Jlelhod .... 457 
 Application of a Roller Bandage to the Arm by the Figure-of-eight Method . . 457 
 
 Spica Bandage applied to the Shoulder 458 
 
 Comminuted Fracture of the Lower End of the Humerus, caused by a Fall ui)on the 
 
 Elbow 500 
 
 Transverse Fracture of the Femur 500 
 
 Oblique Fracture of the Clavicle (Stimson) 501 
 
 Longitudinal Fracture of the Tibia (Stimson) 501 
 
 Toothed Fracture of the Femur (Stimson) . . . 501 
 
 Y-shaped Fracture of the Condyles of the Humerus, caused by a Fall upon the Elbow 
 
 (Bruns) . . . ." .... 501 
 
 T-shaped Fracture of the Lower End of the Femur, caused by a Fall upon the Knee 
 
 (Bruns) 501 
 
 Incomplete Fracture ("Grecnstiek " Fracture) of the Clavicle 501 
 
 Impacted Fracture of the Neck of the Femui' (Stimson) 502 
 
 Varieties of Displacement of the Fragments in Cases of Fracture 503 
 
 Fibrous Union after Fracture of the Patella (Stimson) 504 
 
 Deformity following Fracture of the Jjeg near the Ankle (Stimson) .... 505 
 
 The First Strip (Sayre's Dressing for Fractured Clavicle) 508 
 
 Sayre's Dressing for Fractured ("lavicle (Front View) 509 
 
 Sayre's Second Strip for Fractured Clavicle (Back View) 509 
 
 Colles's Fracture, Silver-fork Deformity in Fracture of the Lower End of the Radius 
 
 (Stimson) 511 
 
 Apparatus for making Continuous Extension in Fracture of the Femur . . .514 
 Wire or Wooden Screen to keep the Bcdclothing from resting upon Fractured Limbs 515 
 
 Agnew's Splint for Fracture of the Patella (Agnew) 516 
 
 Plaster-of-Paris Dressing in Fracture of the Leg 518 
 
 Deformity in Pott's Fracture (Stimson) 519 
 
 Four-tailed Bandage for Fracture of ihc Lower Jaw (Stimson) 520 
 
LIST OF ILLUSTRATIONS. xv 
 
 Inward Dislocation of the Shoulder (Stimson) 
 
 Digital Compression of Common Carotid Artci'y 
 
 Line showing the Course of the Brachial Artery 
 
 Digital Compression of the Brachial Artery . 
 
 Digital Compression of the Femoral Artery . 
 
 Flexion of the Thigh upon the Pelvis in Jlip-joint Disease 
 
 Lordosis, or Bending Forward of the Spinal Column, in Hip 
 
 Flexion of the Thigh and drooping of the Furrow below the Buttock on the AlTecled 
 
 Side, in Ilip-joint Disease 
 The Travois, or Indian Litter . 
 Patient across Shoulder . 
 Patient across Back . 
 The Rifle Seat .... 
 Two-handed Seat 
 
 i'Af;H; 
 
 . riVi 
 
 . 577 
 
 . o77 
 
 . 58:^ 
 
 . 584 
 
 joint Disease . . . 584 
 
 5M5 
 
 rm 
 
 504 
 5!i4 
 594 
 504 
 
 The Bacillus Anthracis (after De Bary) 624 
 
 The Bacillus Megaterium (after De Bary) 624 
 
 Young Malarial Parasite inside Red Blood-cell with Nucleus, no Pigment, magnified 
 
 1,000 634 
 
 Young Parasite inside Swollen Red Blood-cell, the Tips of the Crescent holding the 
 
 Hyaline Nucleus, magnified 1,000 6o4 
 
 Fully developed Parasite, Rods of Pigment arranged in Round Areas, Nucleus indi- 
 cated by Opening, also Vacuoles 635 
 
 A Urinometer (Tiemann) '. . . . 722 
 
 Cutting the Umbilical Cord 750 
 
 Making a Square Knot 750 
 
 A Nipple Shield (Davidson Rubber Co.) 701 
 
 Freeman Pasteurizer ari-anged for Heating Milk (James T. Dougherty) . . . 765 
 Freeman Pastuerizer arranged for Cooling Milk (James T. Dougherty) . . . 765 
 
 Hieks's Clinical Thermometer (Tiemann) 843 
 
 An Oxygen Flask 853 
 
 An Atomizer (Tiemann) 854 
 
 A Croup Kettle (Tiemann) 854 
 
 Screw-capped Ice Bag 855 
 
 A Rubber Ring . .- 855 
 
 A Glass Rod (Tiemann) 856 
 
 A Glass Dropper (Tiemann) 856 
 
 A Stomach Tube (Tiemann) 856 
 
 Hirudo Medicinalis, or Leech 867 
 
 A Hand-bulb Syringe (Tiemann) 868 
 
 Sylvester's Method of Artificial Respiration — First Movement (Inspiration) . . 870 
 Sylvester's Method of Artificial Respiration — Second Movement (Expiration) . . 870 
 
 An Iron Bedstead 904 
 
 Method of changing the Bed of a Helpless Patient 905 
 
 The Clean Sheet 906 
 
 Method of lifting Patient from one Bed to Another 910 
 
 A Back Rest Oil 
 
 A Crane 912 
 
 A Portable Bath Tub .914 
 
 A Bath Thermometer (Tiemann) 015 
 
 A Cotton Ring 917 
 
 Temperature Chart 919 
 
 Bedside Notes 919 
 
 The Peerless Graduated Measure . . , • , 921 
 
XVI 
 
 LIST OF ILLUSTRATIONS. 
 
 A Porcelain Feeding Cup 
 
 A Glass Feeding Tube (Tieinann) 
 
 A Bed Tray .... 
 
 The Arnold Slerilizer (Wilmot Castle) 
 
 The Curve of the Rectum 
 
 A Test Tube (Tieniann) . 
 
 A Stupe Wringer . 
 
 Wet Pack: Fii-st Stage (after Baruch) 
 
 Wet Pack : Second Stage " 
 
 Wot Pack: Third Stage " 
 
 An Ice Coil (Tieniann) 
 
 An Ice Coil in Opemlion . 
 
 SanitJiry Sputa Cup . 
 
 Diagram of Sanitary Spula Cup 
 
 Flannel Stocking for Use during Operations 
 
 A Crescont-sha|icd Basin (Tieniann) 
 
 Sanitary Najikin 
 
 Aluloniinal Binder . 
 
 Binder witli Shoulder Straps . 
 
 Sloane Breast Binder 
 
 The Sloane and Abdominal Binders applied 
 
 The Y Breast Bandage in Position 
 
 A Nursing Bottle 
 
 A Nightingale: for the Use of an Invalid 
 
 A Convalescent resting in a Steamer Chair 
 
 PAQB 
 
 . 934 
 . 924 
 . 925 
 . 925 
 . 938 
 . 937 
 . 940 
 . 941 
 . 941 
 . 942 
 . 942 
 . 943 
 . 94G 
 . 947 
 . 950 
 . 951 
 . 954 
 . 957 
 , 958 
 . 958 
 . 958 
 . 959 
 . 9(53 
 . 908 
 . 9G9 
 
 COLOURED PLATES. 
 
 I.— A Trained Nurse Frontispiece 
 
 II.— A Dissection of the Human Body showing the Principal Organs and Vessels 
 
 in the Abdominal and Thoracic Cavities 02 
 
 111.— Examples of Micro-organisms 024 
 
 IV.— Typical Cases of Measles (o) and Scarlet Fever (j3) 040 
 
I. 
 
 THE ANATOMY OF THE HUMAN BODY. 
 
 By GEORGE WALDO CRARY, M. D. 
 
 INTRODUCTION. 
 
 Human anatomy is the science which treats of the structure of the 
 human body. In the study of it we learn the identity and characteristic 
 features of the various organs composing the body, and their location in 
 relation to one another. Anatomy has but little to do with the functions 
 of these organs, and hence can be studied upon the dead body with the 
 aid of dissection. By dissection is meant the exposing of a structure by 
 cutting away from it all other organs which by their presence obscure it 
 from our view. 
 
 SECTION I. 
 THE BONES. 
 
 The scaffolding or skeleton upon which the body is constructed 
 is composed of bones and bears much the same relation to the whole as 
 do the steel columns and beams to the modern building. These bones 
 are joined together in a variety of ways ; in some cases very iirmly, for 
 strength, in others loosely, for motion. 
 
 Bone is the hardest structure entering into the formation of the body, 
 
 and is composed of two kinds of tissue. One of these is soft and light, 
 
 and is composed of slender fibres which are interlaced 
 Structure of Bone. , , , ,, , .-,.-,. 
 
 and have between them spaces oi considerable size. 
 
 This, called the cancellous tissue, always occupies the inner portion of the 
 
 bone and contributes much to its strength, while adding but little to its 
 
 weight. The outer portion is hard and dense, like ivory, and is heavy, 
 
 the fibres being very closely interlaced and the spaces exceedingly small. 
 
 This outer compact layer is very thin in the flat bones, such as make up 
 
 the vault of the head ; is thick along the middle of the long bones, as in 
 
 3 1 
 
2 THE ANATOMY OF THE HUMAN BODY. 
 
 the extremities; but ay;aiii thin near their ends. This latter condition is 
 well shown in the accompanying illustration (Fig. 2) of along bone sawed 
 through lengthwise, where it can be seen that the tibres are arranged ac- 
 
 7 cervical vertebraj. 
 
 ^,„j„ Clavicle, or collar bone. 
 
 Scapula, or shoulder-blade. 
 
 .Bones of the carpus. 
 
 >Si, . . Bones of the 
 ' I* metacarpus. 
 
 ■i\ 
 
 . . Phalanges of the 
 fingers. 
 
 . . Bones of the tarsus. 
 . . .Bones of the metatarsus. 
 
 .Phalanges of the toes. 
 
 Fio. 1.— The skei.kton. 
 
 cording to the best mechanical laws for enabling the bone to perform its 
 function of supporting weight. 
 
 During life the bones are closely covered by a somewhat thick and tough 
 membranous envelope called the periosteum, which protects the bone, and 
 
STRUCTURE AND COMPOSITION OF BONE. 
 
 from which blood-vessels pass to the outer compact tissue of the bone, and 
 
 thus to it is carried the nourishing; blood-supply. The inner, softer tissue 
 
 receives nourishment from vessels which reach it after perforating the 
 
 outer layer. The long bones are hollow cylinders the cavities of which 
 
 contain marrow — a yellow substance composed almost entirely of fat. In 
 
 the interior of the fiat bones is another kind of marrow which is red and 
 
 contains only a trace of fat and which consists mostly of water, with a 
 
 little albumen and some other substances. 
 
 Chemically, bone consists, in the healthy adult, of one third animal 
 
 matter and two thirds mineral matter, so intimately combined that either 
 
 one may be removed without the shape or size of the 
 
 ^ ., . bone beinff altered. The mineral matter gives to the 
 
 Composition. _ ^ o 
 
 bone its hardness and rigidity, while the toughness and 
 elasticity are contributed by the animal matter. For example, if we soak 
 a long bone in dilute mineral acid so as to dissolve 
 out the mineral matter, though its appearance will 
 be little changed, it will become soft and pliable and 
 can even be tied into a knot, as the illustration shows 
 (Fig. 3). If we put a long bone in the fire and de- 
 stroy the animal matter contained in it, we shall find 
 that we have left a bone somewhat less heavy, but 
 which will break and crumble unless very carefully 
 handled. The bones of young children contain 
 more animal than mineral matter, and frequently a 
 fall which would result in broken bones in the adult 
 causes no harm at all, or only a bending of a bone, 
 in a child. Such a bending or partial break of a 
 bone is known as a " green-stick " fracture. In some 
 diseases, such as rickets, this preponderance of ani- 
 mal matter is so great that the bones are weakened 
 and become curved and bent by the weight of the 
 body or by the action of muscles. At a verj^ earl}^ 
 period of life, and some months before birth, the 
 bones are composed entirely of animal matter. Then, 
 at one or more points in each bone the mineral sub- 
 stance begins to be deposited, and from these points 
 the deposits gradually extend until at length the 
 whole bone becomes what is called " ossified." This 
 process is very incomplete at birth and is not finished 
 until about the twenty-fifth year. In the aged, and 
 in certain diseases, the proportion of mineral matter increases beyond the 
 normal two thirds, and the bones become brittle and are easily broken by 
 sudden movements or by slight violence. 
 
 Fig. 2. — The kight fe- 
 mur, OR THIGH-BOXE, 
 SAWN IX TWO LENGTH- 
 WISE, SHOWING AR- 
 RANGEiCENT OF COM- 
 PACT AND CANCELLOUS 
 TISSUE. 
 
THE ANATOMY OF THE HUMAN BODY. 
 
 Tliere are two liundred bones in the human body, and wlicn joined 
 together they form tlie skeleton. Tliese bones are distributed thus: 
 
 Spinal column 26 
 
 Skull........ 22 
 
 llyoid bone, breast bone, and i-ihs 26 
 
 Upper extremities 64 
 
 Lower extremities 62 
 
 200 
 
 The bones vary widely in size, shape, and position, according to their 
 
 use, but are largely arranged in pairs, so that of these two hundred bones 
 
 there are one hundred and sixty-six in pairs ; and of the 
 
 . , thirtv-four sino:le bones, all are in the median plane of 
 
 Arrangement. • . . . 
 
 the body and have a right and a left half of similar 
 shape. According to their shape, bones are said to be long, short, flat, or 
 irregular. Long bones, as the bone of the arm or of the thigh, are com- 
 posed of a middle long portion called the "' shaft " and two ends called 
 " extremities." The short bones are such as are found 
 in the wrist. The flat bones are found where broad 
 surfaces are required for protection or for muscular /i 
 
 attachment. Flat bones are bones the length and 
 breadth of which greatly exceed their thickness — the 
 shoulder-blade, for example. The bones of the vault 
 of the skull are of this variety. Bones which are not I '| ' 
 
 long, short, or flat are classified as irregular, and some ' ' 
 
 of the bones of the skull — such as the cheek bones, the 
 lower jaw, etc. — come under this heading. 
 
 The spinal column or backbone is composed, in the Tj V- 
 
 adult, of twenty-six irregular bones, called vertebrte, 
 
 placed one above another. It is di- J^^ 
 The Spine. • i i • ^ n i j • ,i 
 
 vided into well-marked regions — the 
 
 neck or cervical region, containing seven vertebrae ; the 
 
 dorsal or chest region, containing twelve ; and the 
 
 lumbar or loin region, containing five ; below this comes Fm. 3.— Fibula tied 
 
 the sacrum, formed by the fusion of five vertebne which mackration m a 
 
 are distinct in early life ; and still lower down the ""'spkc^men ^prT 
 
 coccyx, composed of the fusion of four partly devel- fi)"iJ'on )^ ^^"*'''- 
 
 oped vertebrae. While a vertebra from one end of the 
 
 spine differs much from one taken from the other end, two contiguous 
 
 vertebrte differ only slightly. Each vertebra is composed of a solid front 
 
 portion or body and a branched back portion, which latter encloses a ring 
 
 (Fig. 4). If we remove from about the middle of the spine a vertebra 
 
 and study it, we shall see that the solid portion or body has an upper and 
 
THE SPINAL COLUMN. 
 
 SPINOUS PROCESS 
 
 lower surface, wliich is flat and roui^h, for the attaclirnent of the inter- 
 vertebral substances which connect it to the vertebrte above and below it. 
 
 In front it is rounded, and 
 behind slif^htly hollowed 
 out where it assists in form- 
 ing the spinal canal. Pro- 
 jecting backward from 
 each side of the body, and 
 nearer its upper than its 
 lower surface, we see a pro- 
 cess of bone which forms 
 the beginning of the arched 
 portion. These are called 
 the pedicles. The arch is 
 completed by two plates 
 called the laminae, which 
 spring, one from each pedi- 
 cle, and join in the median 
 line be- 
 
 FiG. 4. — Sixth dorsal vertebra, from above. (Quain.) hind. At 
 
 this point 
 of junction of the two laminse behind there is another 
 process of bone known as the spine of the vertebra, and 
 it is the ends of these processes which we can feel as we 
 pass our finger down the middle of some one's back. 
 There are six other processes of bone springing from 
 this branched portion — four for articulation with other 
 vertebras and two for muscular attachment. 
 
 The solid portions, taken together with the inter- 
 vertebral substance, or cushions of dense fibrous material 
 between them, form a strong column 
 which supports the great bony cavities 
 of the body. The back and branched portions form a 
 series of arches called the spinal canal, for the passage of 
 the spinal cord, which is thus strongly protected. Be- 
 sides supporting weight and protecting the cord, the 
 spinal column gives numerous places of attachment to 
 muscles which move the body itself and the extremities. 
 When we look at the spinal column from the side we see 
 that it is curved in four places. These curves are for 
 the purpose of giving greater elasticity to the column, 
 thereby enabling it to bear greater shocks, and without 
 80 much disturbance to the structures supported by it. lateral aspect. ' 
 
 Curves of the Spine. 
 
 < 
 
6 THE ANATOMY OF THE HUMAN BODY. 
 
 They are formed by the shape, partly, of the bodies of the vertebn\% and 
 partly of the intervertebral substances, and are so arranged as to increase 
 the capacity of the two great bony cavities partially formed by the spine 
 — namely, the chest and pelvis. In the cervical, or neck, and in the 
 lumbar or loin regions, the convexity is forward, while in the dorsal, or 
 chest, and in the pelvic regions formed by the sacrum and coccyx, the 
 concavity is forward. 
 
 The disks of intervertebral substance existing between the bodies of 
 
 the vertebrte are tough and elastic and, while forming strong bonds of 
 
 union between the vertebras, act as cushions and allow 
 
 Interveriebml ^^^^^^ movement to take place. This movement is small 
 
 Substance. , , • i • i i 
 
 between any two vertebrae, but in the spme, as a whole, 
 
 is rather extensive. During the day the body is said to lose in height and 
 to retrain it auain during repose in a horizontal position. This loss is due 
 parti V to some flattening of each intervertebral disk and partly to the in- 
 crease in the normal curves of the spine. The aged lose in height from 
 the same and other causes. In that condition of the spine known as Tott's 
 disease (or spinal disease) the bodies of one or more vertebrae are so soft- 
 ened that the weight of that portion of the body above them causes them 
 to collapse, and then the normal curve is enormously increased and the 
 body much shortened in consequence. Such a course of events results in 
 the condition known as hii7nj) hack. (See Surgical Injuries and Surgical 
 Diseases.) 
 
 THE SKULL. 
 
 Of the twenty-two bones of the skull, eight go to make up the head or 
 
 cranium, which is the bony box in which the brain is lodged and protected 
 
 from ini'ury. In the adult this is closed, with the excep- 
 
 ^ "' . tion of one large openino; for the passage of the spinal 
 
 07- Cranium. or o r o r ^ 
 
 cord, and numerous small openings for the transmission 
 of nerves and blood-vessels ; but in the infant, owing to the fact that ossifi- 
 cation is not complete, there is left on top, toward the forehead, a large, 
 diamond-shaped opening, " the soft spot " (through which the pulsations 
 of the arteries of the brain may be felt), and five other small openings, 
 two upon each side and one near the back of the head. (See Fig. Y.) 
 This slow ossification of the bones of the head allows for the growth of 
 the brain ; a child born without any of these openings is apt to be idiotic, 
 have convulsions, and may even die. 
 
 A full and detailed description of the individual bones of the head 
 cannot be given in a work of this kind, and nothing beyond an enumera- 
 tion of them and their most striking peculiarities and position will be 
 attempted. The eight bones are : One occipital, two parietal, one frontal, 
 two temporal, one sphenoid, and one ethmoid. The occipital, shaped 
 
THE BONES OF THE HEAD. 7 
 
 something like a butter scoop, such as is used in a dairy, with a hole in 
 
 the bowl and a l)roken handle, occupies the back of the head. This large 
 
 hole, the foramen magnum, is nearer the front than the 
 
 Occipital, Parietal, back and corresponds to the spinal canal in the vertebral 
 
 Frontal, Tempo- gQi^j^n, and transmits the spinal cord and a few nerves 
 ral, Sphenoid, and , , . tt i • i r it,- j: i a 
 
 Ethmoid Bones. ^"^^ arteries. Upon each side of this foramen, but near 
 
 its front border, is a kidney-shaped, smooth surface, 
 
 which articulates with similar surfaces upon the sides of the first cervical 
 
 vertebrae. There are two parietal bones — a right and left. They are of 
 
 a curved quadrilateral shape and form most of the roof and a great por- 
 
 OCCIPITAL 
 
 Fig. 6. — The skull. 
 
 tion of the sides of the cranium. The frontal bone much resembles a 
 cockle shell in form and consists of two portions which join at nearly a 
 right angle. The vertical or frontal portion forms the forehead and the 
 front wall of the cranial box. The horizontal portion extends backward, 
 forming the roofs of the cavities for the eyes, known as the orbits, and also 
 a part of the roof of the nasal cavity. In the young the bone is divided 
 into two lateral halves, and even in late adult life the remains of this divis- 
 ion may be seen. The temporal bone is divided for description into three 
 portions : One, a thin plate of bone, assists in forming the side of the cra- 
 nium ; another, the mastoid, forms the prominence which can be felt back 
 
8 THE ANATOMY OF THE HUMAN BODY. 
 
 of the ear, and is hollowed out in its intorior by a number of cavities which 
 have a connection with the middle ear, and in active cases of neglected ear 
 disease become seriously involved in the intlammation ; the third portion 
 of the temporal bone is of an irregular conical shape and assists in forming 
 the base of the skull, and contains within it the 
 organ of hearing and the canal leading from the 
 middle ear to the outer world. The sphenoid bone, 
 the most irregular bone in the head, is shaped 
 something like a bat with its wings spread. The 
 central portion or body enters into the formation 
 of the base of the skull. The outer surfaces of the 
 great wings, upon each side of the skull, appear 
 upon the outer surface of the cranium at about 
 FiQ. 7.-SKILL OF A CHILD ^]^q poj^t ordluarlly called the " temple." The 
 
 AT BIKTIl, FROM ABOVE. "^ -^ _ ' 
 
 (Leisiiman.) One tiiikd. inner surface of these wings forms the back part 
 
 ''■ «."poJ?eKor SnSeiie ! of the outcr walls of the orbits. This bone is 
 
 i A, parietal eminences, ^ygdgcd into the base of the skull and has manv 
 
 (Quain.) *= _ ^ ■' 
 
 processes which serve to connect it with many of 
 the other bones both of the head and face. The ethmoid bone is a light, 
 spongy bone situated at the front part of the base of the skull, between 
 the orbits, and forms the greater part of the inner walls of these cavities. 
 It also forms part of the septum, or dividing partition between the two 
 nasal cavities, as well as a portion of their roof. 
 
 The bones of the face are : Two nasal, two superior maxillary, two 
 lachrvmal, two malar, two palate bones, two inferior turbinated, one 
 vomer, and one inferior maxillary bone. The nasal 
 onef, of e ace. ^^^^^ form together the " bridge " of the nose. The 
 superior maxillary is the upper jaw. It forms almost all of the floor of 
 the orbit, the greater part of the outer walls of the nasal fossa, and the 
 major part of the roof of the mouth. Into it are inserted the upper 
 teeth. The palate bones join on to the back of the superior maxillfe and 
 complete the floor of the orbits, the outer walls of the nasal cavities or 
 fossae, and the roof of the mouth, but are too far back to have any of the 
 teeth inserted into them. The lachrymal bones are small and fragile, 
 about the size of a finger-nail, and are placed upon the inner walls of the 
 orbits very near the front. The malar bones form the prominence of 
 the cheek, and in the thin and emaciated are especially noticeable. The 
 turbinated bones are situated one upon the outer wall of each nasal fossa, 
 and are frequently nowadays the subjects of operation by specialists be- 
 cause of undue enlargement. The vomer is a thin plate of bone which 
 assists the ethmoid in separating the two nasal cavities one from the 
 other. The inferior maxillary, or lower jaw, is of irregular horseshoe 
 shape, with the ends bent upward at almost a right angle. These ends 
 
ARRANGEMENT AND ATTACHMENT OF THE RIBS. 9 
 
 are surmonnted by two prominences. The one in front is pointed, and 
 gives attachment to tlie strong temporal muscle which closes the jaw. 
 The one behind is of somewhat rounded shape at tlie top, and is called 
 the condyle. It is constricted below where it joins the bone, and this 
 constricted portion is called the nech of the condyle. This is the one 
 bone of the skull which is movable, and it articulates, by means of this 
 condyle, with a shallow cavity upon the under surface of the temporal 
 bone just in front of the ear. Into the lower jaw are set the lower teeth. 
 The jawbone in the young is composed of a right and left piece which 
 meet at the chin. It will thus be seen that of the fourteen bones of tlie 
 face there are twelve occurring in six pairs, and only two which are single 
 bones — viz., the vomer and the inferior maxillary. 
 
 THE RIBS. 
 
 There are twenty-four ribs, twelve upon each side of the chest. All 
 are connected behind with the dorsal vertebras of the spine in such a way 
 
 3 2 
 
 Fig. 8. — Thorax, anterior view. (Sappey.) 
 1, 2, 3, sternum ; 4, circumference of the up- 
 per portion of the thorax ; 5, circumfer- 
 ence of the base of the thorax ; 6, first 
 rib ; 7, second rib ; 8, third rib ; 9, 10, 
 floating ribs ; 11, costal cartilages. 
 
 Fig. 9. — Thorax, posterior view. (Sappey.) 
 
 1, 1, spinous processes of the dorsal verte- 
 
 brffi ; 2, 2, laminte of the vertebrse ; 3, 3, 
 
 transverse processes : 4. 4, dorsal portions 
 
 of the ribs ; 5, 5, angles of the ribs. 
 
 as to allow considerable motion. The upper seven are connected in front 
 with the breast bone or sternum, and are called true ribs. Of the remain- 
 ing five or false ribs the upper three ard too short to reach the sternum, and 
 each one is connected in front with the rib just above it ; the two lower 
 ribs are not attached to anything in front, being very short, and are called 
 floating ribs. The ribs are arranged one below another in such a manner 
 
10 THE ANATOMY OF THE HUMAN BODY. 
 
 that spaces are left between tlieni called " intercostal spaces." The ribs 
 are not composed entirely of bone, for their front extremities are formed 
 of cartilafje, which arrangement adds elasticity to the chest wall. This 
 cartilage is a snbstance softer than bone, bnt of linn consistence and con- 
 siderable elasticity; and is of a pearly white colour. Besides forming the 
 front ends of the ribs, cartilage covers the articular ends of the bones, and 
 forms the framework of the outer ear and most of the nose. 
 
 THE UPPER EXTREMITY. 
 
 The upper extremity consists of the arm, forearm, and hand, and is 
 connected with the body at the shoulder. The bones of the shoulder are 
 two in number — the collar bone or clavicle and the 
 aiu e^rnu shoulder-blade or scapula. The collar bone is shaped 
 
 something like the Italic letter /. It is nearly hori- 
 zontal, and by its inner end joins the breast bone near the top, form- 
 ing here a movable joint. This joint is the only hony connection the 
 iq^jM'/' extremity has with the body. The outer end of the clavicle is 
 attached to that portion of the shoulder-blade which arches up to meet 
 
 Fig. 10. — Upper sukface of left clavicle, or collar bone. 
 
 it. The shoulder-blade or scapula, a large flat bone of somewhat trian- 
 gular shape, forms the back of the shoulder, and is held in position 
 most largely by muscles. From the back of this bone a large process or 
 plate of bone arches upward and forward, forming what is known as 
 the spine of the scapula. The end of this process of bone or " spine " 
 forms the summit or "point" of the shoulder, and joins with the outer 
 end of the clavicle, as mentioned above. The upper and outer angle 
 of the scapula is thick, and is called the head of the bone. It is occu- 
 pied by a shallow cup for the reception of the head of the bone of the 
 arm which joins it at this place. This cup itself is very shallow, but 
 the spine already mentioned, and another smaller process of bone called 
 the coracoid process, which springs from the scapula just above its head, 
 make it practically deejier than it appears. These processes of the scapula 
 arch over the cup for the head of the bone of the arm, and render the 
 joint more secure. 
 
 In the arm proper or upper arm there is only one bone, the humerus. 
 It is the longest and largest l)one of the upper extremity, and its shape is 
 
THE SURGICAL NECK OF THE HUMERUS. 
 
 11 
 
 somewhat suggestive of a dumb-bell with small ends and a long liandle. 
 Only the upper end, however, is distinctly globular, and this globular 
 end, called the head of the humerus, represents one 
 umerus. third of a sphere, and fits into the shallow cup or socket 
 
 in the head of the shoulder-blade. At this upper end we have also two 
 rough prominences or tuberosities for the attachment of muscles, and 
 
 Fig. 11. — Left scapula, or shoulder-blade. 
 
 between them a groove for the passage of one of the tendons of the 
 biceps muscle. Just below these tuberosities the shaft of the bone is 
 somewhat constricted, and it is here that fracture or break of the bone 
 most frequently occurs. This is called, therefore, the surgical neck of 
 the humerus. The lower extremity of this bone is somewhat flattened 
 from before backward, and thus appears wider when looked at from in 
 front or behind than from the side. The lower extremity has a rough 
 knob of bone upon either side for muscular attachment. Along the mid- 
 
12 
 
 THE ANATOMY OF THE HUMAN BODY. 
 
 die of this lower end of the humerus are two smooth surfaces, one of 
 which, the radial head, is round and situated toward the outer side. This 
 surface has artifulating with it the upper end of the (uiter hone of the 
 
 
 
 €-^ 
 ■/V" 
 /f 
 
 ^ 
 
 TROCHLEA RADIAL HEAD 
 Fig. 12. — Left humeru.«. 
 
 Fig. 
 
 ARTIC WITH 
 SEMILUNAR AND 
 SCAPHOID OF CARPUS 
 
 18. — Lkkt radius and ulna, or 
 bones ok the forearm. 
 
 forearm. The other of the two smooth surfaces, the trochlea, is on the 
 inner side, and is curved for articulation with the inner bone of the 
 forearm. 
 
THE BONES OF THE FOREARM. 
 
 13 
 
 The inner bone of the forearm is called the ulna. Its upper extrem- 
 ity is large while its lower extremity is small. In most long bones the 
 
 smooth surfaces by which they -join or articulate with 
 Ulna and Ramus. , , , , , , , i , . , 
 
 otlier bones are at the extreme ends, but in the upper 
 
 extremity of the ulna the smooth surface for articulation with the hu- 
 merus is hollowed out of the front portion at a little distance from the 
 end. The lower extremity of the ulna is small and somewhat pointed. 
 
 ARTICULATE WITH RADIUS FORMING WRIST JOINT 
 
 CARPUS 
 
 METACARPUS 
 
 Fig. 14. — Bones of the left hand ; palmak surface. 
 
14 
 
 THE ANATOMY OF THE HUMAN BODY. 
 
 The outer bone of the forearm is the radius. In this bone the upper end 
 is small while the lower end is very large and broad, and to it the wrist 
 and hand are joined. This bone is the one that supports nearly all 
 the pressure brought to bear upon the 
 hand, and hence is frequently broken 
 by falling upon the hands. (See Fig. 
 26, Surgical Injurit's and Surgical Dis- 
 eases.) 
 
 The wrist is composed of eight cube- 
 shaped bones arranged in two rows. The 
 lirst row joins above with the lower ex- 
 
 „, „ tremity of the radius, 
 
 The Hand. . , ^ ... ' 
 
 and below with the sec- 
 ond row ; the second row joins above 
 with tlie first row, and below with the 
 metacarpal bones. These latter are five 
 rather long bones arranged nearly parallel 
 to each other. They are very similar in 
 shape to the bones forming the fingers, 
 but are connected together in such a way 
 as to form a more or less solid portion of 
 the hand. The first one of these bones 
 makes an angle with the rest, and to it the 
 thumb is attached. This bone is so joined 
 to the wrist bones that in closing the hand 
 it can be carried over in front of the other 
 fingers, and when the hand is only par- 
 tially closed it can be approximated to 
 any of the other fingers. The power and 
 perfection of the human hand, and its 
 superiority over the prehensile members 
 of all other animals, result from this 
 unique ability of the thumb to approxi- 
 mate itself to the other fingers of the 
 hand. To the second bone of the hand 
 proper the index finger is attached, to 
 the third the middle finger, to the fourth 
 the ring finger, and to the fifth the little 
 finger. In the fingers there are four- 
 teen bones, three for each finger and two for the thumb. The end 
 bone of each set is differently shaped from the other two, and supports 
 the pulp of the finger tips. 
 
 Fio. 15. — Kuiiri' f?;mi:i{, oit tiiioii bonk. 
 
HIP BONES, FEMUE, AND BONES OF THE LEfi. 
 
 THE LOWER EXTREMITY. 
 
 The lower extremity consists of tlie thigh, the log, and the foot, and 
 is connected to the body on each side by means of tlie hip bone. These 
 two irregular hip bones, one on each side of the body, 
 were called by the old anatomists the innominate, or 
 nameless bones, because they bore no resemblance to any known object. 
 In the young, each innominate bone consists of three portions joined 
 together near the centre, and here forming a cup-shaped cavity or socket 
 for the reception of the head of the thigh bone. Of these three por- 
 tions, the upper forms the prominence of the hip. Of the two remaining, 
 one is behind and forms the prominence upon which the body rests in 
 sitting, while the other joins in front of the body with the similar por- 
 tion of the opposite bone, and thus forms what is known as the pubes, 
 so called because in the adult it is covered with hair. Each innominate 
 bone is joined behind to the sacrum, and thus a somewhat incomplete 
 bony basin or cavity called the pelvis is formed, which contains the lower 
 portions of the bowels, the bladder, and, in the female, the vagina, the 
 uterus, and the ovaries. 
 
 The thigh bone, or femur, extends from the hip to the knee, and is 
 the longest, the largest, and the strongest bone in the body. At its upper 
 end we find a smooth rounded head which forms three 
 quarters of a sphere. This head is connected to the 
 shaft of the femur by means of the neck at an obtuse angle of about a 
 hundred and thirty degrees. At the junction of the neck and the shaft 
 we have two large processes of bone, called the 
 tuberosities, for muscular attachment. The shaft 
 of the bone in the greater portion of its extent 
 is nearly cylindrical in shape. At the lower end 
 of the shaft we find that the bone is much en- 
 larged for articulation with the large bone of the 
 leg, here forming the knee joint. The knee cap, 
 or patella, is a small, smooth, rounded bone which 
 protects the front of the knee joint from injury 
 ^'^' ^*^'~2^^ .™''''^' °" and assists the large muscles of the thigh that 
 
 KNEE CAP. O & 
 
 pass in front of the joint to act upon the leg, 
 as in kicking or walking. 
 
 In the leg there are two bones, though one, the fibula, is slender and 
 
 adds but little to the strength of the leg, serving mostly as a place of 
 
 attachment for some of the muscles that move the foot. 
 
 It is placed on the outer side of the leg and extends 
 
 downward to form the outer ankle. The larger of the two bones of the 
 
 leg — viz., the tibia — is situated on the inner side of the leg and somewhat 
 
16 
 
 THE ANATOMY OF THE HUMAN BODY. 
 
 iu front of the fibula. It has a broad upper end for articulation with the 
 femur and a smaller lower end for articulation with the foot. This lower 
 end is continued downward somewhat beloAv the joint, and forms the 
 
 Fig. 17. — Right tibia, or shin bone, 
 and kibula ok .splint bone; ante- 
 kior surface. 
 
 Fig. 18. — Bones of right foot ; dorsal 
 
 SURFACE. 
 
 inner ankle. The shaft of the bone is triangular upon cross section, with 
 
 its sharp edge in front, commonly known as the shin. 
 
 The foot is formed of twenty-six bones. Seven of these 
 are nearly cuboid in shape, and are clustered together 
 
 Foot. 
 
FUNCTIONS OF THE JOINTS. 17 
 
 somewhat after the fashion of the bones of the wrist. The rest of the 
 foot is similar to the hand, with the important exception that the great 
 toe cannot be " approximated " to the others, as is the case witli the 
 thumb in the hand. The bones of the toes, also, ai-e shortc]- than the 
 bones of the fingers. 
 
 SECTION 11. 
 THE JOINTS. 
 
 The various bones of the skeleton are united by what are called joints, 
 or articulations. When no motion between the bones is required, as in 
 ^, . ,. ^ -r . , the head, they are brought into close contact and 
 
 V CtT'hPt'i ^ S of fJ0'i71 /S 
 
 dovetailed into one another in what are called sutures. 
 Such a joint is known as an immovable joint. Where great motion is 
 required, as in the shoulder joint, for example, the ends of the bones are 
 covered by a smooth layer of cartilage. This elastic substance renders 
 the motion between the bones smooth and easy, and protects the ends of 
 the bones from injury. In snch a joint the bones are held together in 
 their proper relation to one another, and their motion is limited by 
 numerous bundles of white shining fibres called ligaments. These liga- 
 ments usually surround the joint completely, thus forming what is called 
 the capsular ligament, or capsule, and they are especially strong where the 
 greater strain is to be resisted. The ligaments are tough and inextensile, 
 but they are very pliable, thus allowing movement to take place freely, 
 but within limits sharply controlled by their length or position. The in- 
 ternal surface of the capsule or of any ligament in close relation to a joint 
 is lined by a smooth and delicate membrane called the synovial membrane, 
 which secretes a viscid fluid of the consistence of the white of egg. This 
 fluid is the lubricant of the joints, and is called synovia, or sjmovial fluid. 
 Such a joint as this just described is designated as a movable joint. A 
 joint which is not freely movable, but which allows slight motion to take 
 place, as between the bones of the spine, is spoken of as a mixed articu- 
 lation. Of the movable there are two principal varieties. One of these 
 is the " ball-and-socket " joint, formed by the reception of a globular 
 head into a cup shaped cavity, and capable of motion in all directions. 
 The hip and shoulder joints are examples of this variety. (See Fig. 20.) 
 The other variety of movable joints is the " hinge " joint, and in this 
 motion takes place only in two directions — viz., forward and backward. 
 As examples of the hinge joint we have the elbow, the knee, and the 
 ankle. (See Fig. 19.) Joints are further strengthened by the muscles 
 and tendons which surround and pass over them. In order to bring out 
 4 
 
IS 
 
 THE ANATOMY OF THE HUMAN BODY, 
 
 more vividly the structure of joints, we will look more minutely into 
 certain of them and study somethino- of their detail. Let us take first 
 the articulation of the inferior nuixilla with the temixtral hone. 
 
 
 v._ 
 
 
 Flo. 19, A. — KlGIlT KNEE JOINT, FROM THE INNER SIDE AND ANTERIORLY. (Quuiu.) 
 
 1, tendon of the rectus muscle near its insertion into tlie patella: 2, insertion of the vastus internus 
 into the rectus tendon and side of the patelhi ; 3, lisraiuentuni patelUo tlesreiidlnfr to tlie tubercle 
 of the tibia ; 4, capsular fibres forming a lateral ligament of the patella prolonged in part from 
 the insertion of the vastus internus downward toward the inner tuiaerosity of the tibia; 
 5, internal lateral ligament; 6, tendon of the semimembranosus muscle. 
 
 Fig. 19, B. — Right knee joint, fro.m behind. (Quain.) 
 1, insertion of tlie tendon of the adductor magnus; 2, origin of the inner head of the gastrocnemius 
 muscle; 3, outer head of the same; 4, e.xternal lateral ligament; 5, tendon of the po]iliteus 
 muscle; 6, part of internal lateral ligament; 7, tendon of the semimembranosus muscle; H, i)Os- 
 terior ligament, spreading outward from the tendon ; 9, expansion of the popliteal fascia down- 
 ward from the same, represented as cut short; 10, on the head of the fibula, marks the posterior 
 superior tibio-fibular ligament; 11, upper part of the interosseous membrane with the foramen 
 at the upper end for the anterior tibial vessels. 
 
 On account of its peculiar shape, the jaw has two articulations, a 
 right and a left, but as they are alike on both sides, it will be necessary 
 to describe only one. There is a smooth rounded process 
 of bone upon the upper and back part of the inferior 
 maxillary, or jawbone, which is called the condyle. This condyle fits 
 into a shallow cavity upon the under surface of the temporal bone, and 
 the surfaces both of the condyle of the jaw and of the shallow cavity of 
 the temporal are covered by a laj^er of smooth cartilage. The articulation 
 of the jaw is different from most of the joints of the body, in that the 
 bones entering into it do not come into mutual contact. There is a disk 
 lying horizontally between them made up of firm elastic tissue, so that 
 the condyle of the jaw articulates with its under surface, while the 
 
 Jmv. 
 
THE JAW AND HIP JOINT. 
 
 10 
 
 upper surface articulates with tlic cavity of tli(; teinporal. The cavity 
 of the joint is thus completely divided into two compartments. The 
 whole joint is surrounded by a thin layer of ligamentous fibres which 
 are attached above to the margins of the cavity of the temporal, and 
 below to the constricted portion, or neck, of the condyle. This is the 
 capsular ligament, and to its internal surface the disk of elastic tissue 
 referred to above is attached at its circumference. Upon the outer side 
 of this articulation is the external lateral ligament, a short but strong 
 band of fibres, passing from the temporal bone downward to the jaw, 
 and closely connected to the capsule. The interior surfaces of the 
 capsule and of the external lateral ligament, and the upper and lower 
 surfaces of the fibrous disk, are lined by synovial membrane. Upon the 
 inner side of the joint is the internal lateral ligament, longer than the 
 external lateral. This internal lateral ligament is not in close relation to 
 the joint, being separated from the capsular ligament by a considerable 
 interval. This articulation allows of considerable motion, whicli takes 
 place in three directions, as shown in the (1) opening of the jaw, (2) 
 throwing the chin forward and drawing it back, and (3) moving the jaw 
 from side to side. In wide yawning sometimes the condyle of the jaw is 
 carried forward out of the cavity 
 of the temporal bone and becomes 
 caught so that its return is pre- 
 vented. This renders it impossible 
 to close the mouth, and results in 
 the condition of dislocation of the 
 jaw, an accident distressing to the 
 sufferer, who, however, presents 
 a somewhat ludicrous appearance. 
 This condition usually requires the 
 presence of a surgeon for its relief. 
 The rounded head of the thigh 
 bone or femur fits into a deep cup- 
 shaped cavity or socket in the hip 
 bone, thus form- 
 ing a ball-and- 
 socket joint. The joint surfaces of 
 the bones are covered by smooth 
 cartilage, and the bones are con- 
 nected by a strong capsular ligament 
 which entirely surrounds the joint. 
 
 In positions where an excessive strain is apt to be developed this capsule 
 is further strengthened by large bundles of ligamentous fibres. The cap- 
 sule is connected above with the rim of the socket in the innominate, or 
 
 Hip Joint. 
 
 Fig. 20. — A section of the hip joivr taexn 
 
 THROUGH THE ACETABULUM OK ARTICCLAK 
 CUP OF THE PELVIS AXD THE MIDDLE OF 
 THE HEAD AND NECK OF THE THIGH BONE. 
 
20 THE ANATOMY OF THE HUMAN BODY. 
 
 hip bone, and below with the neck of the femur, or thigh bone. Its 
 inner surface is Hned with synovial membrane. In the interior of tlie 
 joint is another ligament, called the round ligament, passing from about 
 the middle of the head of the femur to a rough depression at the bottom 
 of the socket of the innominate. It is lined with synovial membrane, 
 and plavs but little part in luilding the bones in place or in checking 
 motion of the femur. ^lovement in this joint is in all directions, but is 
 not as free as in the shoulder joint. The joint is rendered more secure 
 and protected from injury by the large mass of muscle that surrounds it. 
 On account of the gi-eat strength of the ligaments of this joint, disloca- 
 tion of the head from its socket is rare, the femur itself more frequently 
 breaking, while the ligaments hold firm. Dislocation of this joint, how- 
 ever, does sometimes take place, most commonly in adult life. In rare 
 instances dislocation of this joint on one or both sides is found at birth, 
 the accident having taken place during intra-uterine life. 
 
 SECTION III. 
 
 THE MUSCLES. 
 
 The great mass of the body is made up of the muscles, which form 
 what is called flesh or meat. In athletic persons, in whom the mnscles 
 are well developed and are not covered with fat, they contribute most 
 largely to the shape and weight of the body. The muscles are the organs 
 of movement, and are made of reddish fibres having the power of con- 
 tractility. There are two kinds of muscles: voluntary, or those under 
 control of the will, and involuntary, or those over which the will has little 
 or no control. The muscles of the arm or leg are examples of voluntary 
 muscles, while the muscular fibres found in the l)Owels are of the involun- 
 tary variety. 
 
 When we look at a voluntary muscle we find it to be made of bun- 
 dles called the fasciculi, which in turn are composed of fibres. Examined 
 under a microscope, each fibre is found to be marked 
 by bands, or striae, which run transversely or crosswise. 
 From the appearance of these strife, the term striped is applied to the 
 voluntary muscles. If this muscular fibre be hardened in alcohol it will 
 be further broken up into wdiat are called fibrillae. If we expose the 
 fibre to the action of dilute acid, it will be broken up ti-ansversely into a 
 series of disks or plates (Fig. 22). 
 
 The muscles, according to their intended use, are attached (1) by both 
 
 ends to different bones ; or (2) by one end to bone and by the other to 
 
 some other organ of the body, as the skin ; or (3) they 
 
 may not be attached to bone at all, as is the case with 
 
MUSCLES AND TENDONS. 
 
 21 
 
 some of the muscles of expression in the face. Muscles are rarely 
 attached directly, but usually through the medium of what are known 
 as sinews or tendons. The tendons hy which they are attaclied to the 
 organ they are designed to move are white, glistening, fibrous cords, 
 
 Fig. 21. — The muscular system. 
 
 inelastic and strong. They vary much in size and length, according to 
 the size of the muscle of which they form a part and the distance of 
 this muscle from the bone or other organ upon which it is designed to act. 
 
22 
 
 THE ANATOMY OF THE HUMAN BODY. 
 
 Arlt07i. 
 
 T^ouglily 8i)eakin<2;, ti muscular fibre can contract until it is two tliirds 
 of its original U-ngtli. The contraction of a muscle causes the distance 
 between the two tendon ends to be shortened, and 
 hence, one end being fixed and lieki immovable, the 
 other ou(], with everything directly or indirectly attached to it, will be 
 made to move. Muscles held in a state of active contraction very soon 
 
 become tired, but in healthy 
 •A ^kt^Z.^ individuals, when the fa- 
 
 tigue is not excessive, they 
 regain their full power after 
 a short rest. This is true 
 of both voluntary and in- 
 voluntary muscles, and even 
 the nmscle of tlie heart, 
 which seems to be in such 
 constant action, really has 
 a short period of rest after 
 each beat. Besides this 
 active contraction, which 
 gives rise to motion, healthy 
 muscles maintain almost 
 constantly during con- 
 sciousness a condition of 
 passive contraction. This 
 passive action of the mus- 
 cles assists much in giving 
 proper firmness to the body 
 and extremities, and keeps 
 the head and neck properly 
 poised. 
 With the exception of the knee and of the foot below the ankle, 
 all movements forward are known as " flexion " and all movements 
 backward as " extension." In some muscles passing 
 over only one joint the action is very simple, being 
 limited either to ])lain flexion or extension. But many of the muscles by 
 aid of their tendons pass over more tlian one joint, and then their action 
 becomes much more complicated. 
 
 One of the muscles most commonly spoken of is the biceps, Mdiich oc- 
 cupies the front portion of the arm (Fig. 23). This muscle is attached 
 above by two tendons, from which fact it derives its 
 name of biceps. The shorter of these two tendons, 
 which is on the iimer side, is attached to that portion of bone, the cora- 
 coid process, which arches up from the shoulder-blade or scapula, and of 
 
 Fui. -l-i. 
 !i muscular fibre, devoid of narcolenima, and breaking 
 up at one end into its fibrill* ; B, separate fibrillae ; 
 C, a muscular fibre breaking up into disks; D, a mus- 
 cular fibre, the contractile substance of wliich (a) is 
 torn, while the sarcolcmnia (A) has not given way. 
 (Magnified about three hundred and fifty diameters.) 
 
 Movements. 
 
 Birpps. 
 
ACTION OF THE BICEPS MUSCLE. 
 
 which mention has been made in tlie description of that bone. The otlier 
 of the two tendons lies to the outer side of the short tendon. 'J'his, the 
 long tendon of the biceps, passes over the shoulder joint, within the cap- 
 sular ligament, and is attached to the upper rim of the shallow cup in the 
 head of the scapula. To tliese two tendons the muscular portion or belly 
 of the muscle is attached. The biceps muscle terminates below, a little 
 above the bend of the elbow, in a single tendon, which passes downward 
 in front of the elbow joint into the forearm, and is attached, to the radius 
 near its upper end and upon its inner side. This muscle can do many 
 things according to what portions of the body or of the upper extremity 
 are rendered fixed or immovable by the action of other muscles. 
 
 We shall now study some of these movements upon the right side. If 
 we keep our left hand upon the right biceps we may feel the muscle con- 
 tract when its action is being brought into play. If the body, shoulder, 
 and arm are held still and the hand kept from turning, when the muscle 
 acts it will simply flex the forearm upon the arm at the elbow joint. If 
 the forearm is now held at right angles with the arm, and the palm of the 
 hand turned downward, contraction of the biceps will turn the forearm 
 over so that the palm of the hand will look upward. This action is called 
 outward rotation, or supination 
 of the forearm. While other 
 muscles assist in these move- 
 ments, the biceps is the strong- 
 est factor in producing them. 
 
 Because the upper tendons 
 of the biceps pass over the 
 shoulder joint, from their 
 points of attachment on the 
 scapula, to join the muscle, 
 the action of the biceps assists 
 in raising the whole upper ex- 
 tremity, and the whole action 
 
 of the muscle is well shown during the using of a screw-driver, when the 
 arm is raised at right angles with the body at the shoulder joint, the fore- 
 arm flexed on the arm at the elbow, and the hand forcibly rotated out- 
 ward in the act of driving a screw home. If, by grasping with firm 
 hold upon some object, such as the limb of a tree, we fix the hand and 
 forearm immovably, and then contract the biceps, these movements will 
 be somewhat reversed ; the arm will be fiexed upon the forearm and the 
 whole body Avill be carried along, so that if the limb of the tree of which 
 we have hold is above the head, the body will be lifted from the ground. 
 
 A peculiar muscle in its shape and action is the diaphragm. This 
 muscle is broad and thin, being shaped something like a palm-leaf fan 
 
 Fig. 23.- 
 
 -The bones of the upper extremity with 
 
 THE biceps muscle. 
 
2i 
 
 THE ANATOMY OF THE HUMAN BODY. 
 
 don. 
 
 with the handle bent at rii;;ht angles. It forms the partitiDii wall between 
 
 the chest cavity or thorax and the belly cavity or abdomen. The central 
 
 portion of this lari^e leaf consists of tendinous fibres, 
 Diaphragm. i ., i i "\lm t i- ^ • ^ 
 
 while the muscular iibres radiate irom this central ten- 
 
 These muscular fibres are attached by their outer ends to the inside 
 
 of the chest wall, and are 
 connected in an oblique 
 line with the breast bone 
 in front, the lower six ribs 
 at the sides, and the spine 
 in the lumbar region be- 
 liind. 
 
 The diaphragm is per- 
 forated by three large 
 openings : one for the 
 great artery, the aorta ; 
 one for the large vein 
 coming from the lower 
 part of the body and the 
 lower extremities, the in- 
 ferior vena cava ; and the 
 third for the gullet or 
 oesophagus, as it passes 
 down to reach the stom- 
 ach. It is also perforated 
 by smaller openings for 
 the passage of other struc- 
 tures, such as nerves and 
 small blood-vessels. The 
 diaphragm is one of the 
 muscles by which we 
 breathe. When it is re- 
 laxed it arches up in the middle from its many points of attachment, so 
 as to present a dome-like appearance ; but when its muscular fibres con- 
 tract, this curve becomes lessened and the dome is lowered, thus elonga- 
 ting the cavity of the chest or thorax and enlarging its capacity. At the 
 same time the contents of the abdomen are pushed downward and the 
 belly walls made to l)ulge forward. When this action occurs the lungs 
 are expanded by the air which is forced into them from above through the 
 mouth, and we have thus drawn in a breath. When we breathe out, an act 
 performed by other muscles, the diaphragm plays a negative part and is 
 relaxed and pushed up into its dome-shape by the organs of the abdomen, 
 which have been forced upward by the action of the abdominal muscles. 
 
 Fig. 24. — The diapiikagm. 
 a, the ensiform cartilage; 6, the central tendon; c, the open- 
 inir for the oesophagus; d., the left leaflet; «, the opening 
 for the aorta ; ./, the left crus ; g, psoas magnus ; /t, trans- 
 versalis: t, quadratus lutnboruni ; k, ligamentum arcua- 
 tuni externum : Z, ligamentum arcuatum internum; m, the 
 right leaflet; w, the opening for the vena cava; o, the 
 middle leatiet; /), the right crus. 
 
THE CIRCULATION OF THE JiLOOD. 
 
 25 
 
 Heart. 
 
 The strongest tendon in the body is tliat \)y which tlie rnusclcB form- 
 ing the calf of tlie leg are fastened to the hone of the lieol, and which is 
 
 named the "tendo Achillis." Jt is six inches long and 
 Stronger Tendon ,i • i i ^ i • i i , ^,^ , , ' . 
 
 of the Body ^^^^ thick and strong, being able to withstand the strain 
 
 of over one thousand pounds. Jt receives its name from 
 Achilles, the hero of the ancient Greeks, who, according to the old legend, 
 was dipped into the river Styx by his mother and thus rendered invul- 
 nerable, except in the heel by which he had been grasped during the 
 ducking. 
 
 SECTION ly. 
 
 ARTERIES, VEINS, AND CAPILLARIES. 
 
 The circulation of the blood through all portions of the body is car- 
 ried on by means of (1) the heart, (2) the arteries, (3) the veins, and (4j 
 the capillaries. The last serve to connect the arteries 
 and veins together. The heart is the force-pump by 
 which the constant current of the blood is maintained. It really consists 
 of two pumps, a right and a left, which are intimately connected and 
 work together. The right forces 
 the blood through the pulmonary 
 arteries into the lungs, whence, by 
 means of the four pulmonary veins, 
 it is brought back to the left side of 
 the heart, and from here pumped 
 out through the arteries to all por- 
 tions of the body. 
 
 The heart is a hollow muscle, 
 conical in form, and so placed in 
 the front and middle of the chest 
 that the apex of the cone is directed 
 downward, forward, and to the 
 left. The throbbing of this apex is 
 usually to be felt between the fifth 
 and sixth ribs toward the left side. 
 The upper border or base of the 
 heart lies behind the sternum or 
 breast bone, on a level with the sec- 
 ond rib, and is covered by the lungs. 
 The heart in the adult is about five fig. 25.— The heakt and large blood- 
 
 inches long, and at its largest part . . , . ,^^^-!f ^% . , ^^ • u* 
 
 , or A, right ventricle ; B, left ventricle ; C, nght 
 
 three and a half inches broad and auricle; D, left auricle; E, aorta; F.pul- 
 
 , 1 1 T c • 1 • 1-1 monarv arterv ; G, superior vena cava ; 
 
 two and a halt mches m thickness. h, left pulmonary veins. 
 
26 
 
 THE ANATOMY OF THE HUMAN BODY. 
 
 Valves. 
 
 Tlie average weight in the male adult is from ten to twelve ounces, and 
 in the female about two ounces lighter. The heart is divided by a parti- 
 tion running lengthwise into two halves, a right and a left. It is again 
 divided bv another partition running crosswise, so that each side has two 
 compartments — the" auricle, situated near the base, and the ventricle, 
 which is situated toward the apex. 
 
 Between the auricle and the ventricle of the same side there is a large 
 opening called the auriculo-ventricular, which is furnished with valves 
 that allow the blood to pass from the auricle to the 
 ventricle, but prevent this blood from returning again 
 into the auricle when the ventricle contracts. These valves are made 
 of strong but thin membrane, and look like inverted wall pockets 
 arranged around a circular opening, so that when the blood is flowing 
 
 from the auricle to the 
 ventricle they are emp- 
 ty and flattened against 
 the walls of the heart. 
 As soon as the ventricle 
 contracts and the blood 
 contained in it tends to 
 flow back through the 
 opening, these pockets 
 become filled with blood 
 and distended, and, 
 meeting in the middle 
 of the opening, entirely 
 block it up, thus pre- 
 venting all regurgita- 
 tion from the ventricle 
 into the auricle. In or- 
 der to prevent the valve 
 from being forced bod- 
 ily through tlie open- 
 ing, the pockets have 
 fastened to their free, unattached edges bands of strong fibres which, like 
 guy ropes, hold them from going too far. These bands of fibres are the 
 chordae tendinese, tendinous cords or " heart strings " of the heart. 
 
 Besides the auriculo-ventricular openings which lead from one cham- 
 ber of the heart to another, the heart has other openings. Into the right 
 auricle there are the openings of the two greatest veins of the body : 
 from above, the superior vena cava, through which flows the venous 
 blood from the head, upper extremities, and upper portion of the body ; 
 and from below, the inferior vena cava, which conveys the venous blood 
 
 Fig. 26. — IIeaut and bibs. 
 a,b,c,d,e, ribs; 1,2,3,4,5, intercostal spaces; 
 nipple (fourth rib). 
 
 position of 
 
Work performed by the heart. 27 
 
 from the lower part of the body and lower extremities to the right auricle. 
 
 Opening out of the right ventricle there is the pulmonary artery, which 
 
 conveys the blood from the heart to the lungs. Into the left auricle there 
 
 open the pulmonary veins, of which there are four — two for the right and 
 
 two for the left lung. Out of the left ventricle opens the aorta, by which 
 
 blood is conveyed into the general circulation. The openings from the 
 
 ventricles into the pulmonary artery and into the aorta are guarded by 
 
 valves which are in each case three-leaved, but are not supplied with 
 
 chordae tendineae. These valves are named, respectively, the pulmonary 
 
 valve and the aortic valve. The openings of the veins into the auricles 
 
 are not provided with valves, and yet no regurgitation of blood occurs, 
 
 for the contractions of the auricles are weak, the force with which the 
 
 blood enters the auricles being the chief factor which carries it through 
 
 the auricles into the ventricles, the auricles themselves playing little more 
 
 than a passive part. 
 
 To review, then, the course of the blood before going further, we shall 
 
 start with the contraction of the right auricle. The contraction of the 
 
 right auricle, with the force with which the blood comes 
 Circulation through j. ,, . • i t -, ^ ^ -, ■, 
 
 the Heart from the great vems, carries the blood through the au- 
 
 riculo-ventricular opening into the right ventricle ; the 
 right ventricle immediately contracts, the blood is prevented from pass- 
 ing back into the right auricle by the tricuspid valve, and is forced out 
 of the ventricle into the pulmonary artery. Regurgitation here is pre- 
 vented by the pulmonary valves, and the blood travels on into the lungs, 
 flowing through the capillaries here into the pulmonary veins ; it is then 
 carried into the left auricle, which then in its turn contracts, and the blood 
 is conveyed into the left ventricle through the left auriculo-ventricular 
 opening. Regurgitation into the auricle is prevented by the mitral valve, 
 and when the left ventricle contracts, the blood is forced out into the aorta. 
 The aortic valves situated here keep the blood. from flowing back into the 
 ventricle, and so the blood is carried on into the general circulation, where, 
 after passing through the arteries and capillaries, it is returned to the 
 right auricle by the veins, the last and largest of which are the superior 
 and inferior venae cavae. Thus is the entire circuit completed. 
 
 It will be readily seen that the amount of work the different portions 
 of the heart are called upon to perform is by no means equal for all of 
 the parts. Thus the auricles have simply to pass the blood on into the 
 ventricle, which is thus caused to dilate, and hence we find that there is 
 very little muscular tissue in the walls of the auricles, as little muscular 
 strength is required. The right ventricle must force the blood through 
 the pulmonary arteries into and through the small capillaries of the lung, 
 then back to the heart through the pulmonary veins. To accomplish this 
 circulation, commonly referred to as the " lesser circulation " of the blood, 
 
28 
 
 THE ANATOMY OF THE HUMAN BODY. 
 
 requires considerable force, and we find the walls of the right ventricle 
 correspondingly well supplied with a thick layer of unstriped muscular 
 
 fibres. But it is upon the 
 left ventricle that the great- 
 est amount of work is 
 thrown, for this portion of 
 the heart must force the 
 blood to the most remote 
 parts of the body, into and 
 through the various organs, 
 such as the liver, the kid- 
 neys, etc., and back again 
 to tlie heart by means of 
 the veins. Consequently, 
 when we examine the 
 heart, we find the walls 
 of the left ventricle very 
 much the most muscular of 
 any, in order that it may 
 properly perform its func- 
 tion of maintaining the 
 current of blood in what is 
 
 M\ 
 
 4, ZK 
 
 JVC---^- 
 
 Fig. 27. — A schematic diagram of the heart, showing in 
 
 ONE VIEW THE MECHANICAL ARRANGEMENT OF THE CAVI- 
 TIES AND VALVES. (Designed and driiwn by Dr. 11. 
 Macdonald.) 
 SVC, tlie superior vena cava; /F<7, the inferior vena cava; 
 RA, the ritrlit auricle ; 7'F, the tricuspid valve ; Ji \\ the 
 right ventricle; /M, the pulmonary artery; P, the pul- 
 monary valve; Po^Xha pulmonary veins; LA^ the left 
 auricle; J/ F, tlie mitral valve; ZF, the left ventricle ; 
 a, the aortic valve; Aa, the aortic arch. 
 
 called the "greater circu- 
 lation." 
 
 To facilitate the move- 
 ments of the heart, it is 
 surrounded by a sac com- 
 posed of membrane similar 
 to the synovial membrane 
 which lines the joints, and which secretes a lubricating fluid. This sac 
 is called the pericardium. The interior of the heart is also lined through- 
 out with a delicate and very smooth membrane which is called the endo- 
 cardium. 
 
 The arteries are tubes which convey the blood from the ventricles 
 to every part of the body. They are composed of three layers or " coats " 
 — an inner, an outer, and a middle. The inner coat is 
 similar in appearance and structure to the smooth mem- 
 brane lining the interior of the heart. The middle coat is composed 
 partly of involuntary muscular fibres and partly of a kind of elastic tissue, 
 so as to enable the artery to assist to a considerable extent in propelling 
 the blood onward. The outer coat is formed of strong, firm tissue, which 
 is also elastic. This coat gives to the arteries their great strength and the 
 ability they possess to remain open when empty of blood. It is through 
 
 Arteries. 
 
ARTERIES IN LIFE AND IN DEATH. 
 
 2y 
 
 the action of tlie iniddle coat that most of the Ijlood i,s forced out of tlie 
 arteries into the capillaries and veins at tlie moment of deatli. In the 
 dead subject the arteries are found open, but contain little blood, a fact 
 which gave rise to the belief among the ancients that the arteries always 
 contained air, and Cicero taught that they conveyed the " breath " from 
 the lungs to the va- 
 rious portions of the 
 body. Galen, in the 
 second century, first 
 pointed out the error, 
 and showed that dur- 
 ing life the arteries 
 contain blood. 
 
 The largest artery 
 in the body is the aorta. 
 This great tube, which 
 arises from the left 
 ventricle, is the main 
 trunk which carries 
 the blood to all parts 
 of the body. At first 
 it passes upward and 
 forward toward the 
 right side of the body, 
 then arches backward 
 and to the left, and 
 comes to lie upon the 
 left side of the spi- 
 nal column. It passes 
 down along the left 
 side of the bodies of 
 the dorsal vertebrge, 
 and, perforating the 
 diaphragm, enters the 
 abdominal cavity and 
 reaches the fourth lum- 
 bar vertebra, where it 
 divides into the right 
 and left common iliac 
 arteries. While arch- 
 ing over to reach the 
 left side of the spine it 
 soon divides into two. 
 
 Fig. 28. — The abdominal aorta. (After Henle.) 
 AI. the common iliac artery ; /, the external iliac ; H. the internal 
 iliac ; 8M, the middle sacral ; PHR, the inferior phrenic arte- 
 ries ; Z/), one of the lumbar arteries ; C, the eoeliac; J/Z"^?, the 
 superior mesenteric ; MEI, the inferior mesenteric ; 8E, tlie 
 capsular ; i?, the renal ; SPI-, the spermatic ; HI, the internal 
 hasmorrhoidal. 
 
 sends out three very large branches, one of which 
 making in all four large arteries, the two nearer 
 
30 
 
 THE ANATOMY OF THE HUMAN BODY. 
 
 the niiddlc are the two coiinnon carotid arteries, a riolit ami a left ; these 
 pass upward to supply the liead and neck with many branches. The 
 
 remaining two given 
 off by the aorta as it 
 arches backward and 
 to the left are tlie sub- 
 clavian arteries, a right 
 and a left. The right 
 subclavian lies to the 
 right of the right com- 
 mon carotid, and the 
 left subclavian lies to 
 the left of the left 
 common carotid artery. 
 The subclavian arteries 
 pass upward at first, 
 then outward, down 
 into the upper extremi- 
 ties to supply them with 
 branches. The com- 
 mon carotid arteries 
 pass upward obliquely 
 through the neck, and 
 a line drawn from the 
 articulation of the clav- 
 icle or collar bone with 
 the sternum or breast 
 bone to a point just in 
 front of the ear will 
 nearly represent their 
 course upon each side. 
 At a point about on a 
 
 Fig. 29. — Tiiii kxteknal carotid artery and its branches. 
 (After Henle.) 
 C<7, the common carotid ; CE, tlie external carotid ; C7, the inter- 
 nal carotid; TSU, the superior thyroid; Zi', the superior 
 laryngeal and tiie crico-tliyroid ; //}', the hyoid branch of the 
 lingual; -.S', the sublingual; ME^ the facial; SMJ\ the sub- 
 mental j Zi>/, the inferior labial; ZZ) 6', the coronary of the 
 upper lip; SJSf^ the a. of the septum narium ; yl, the angular; 
 CC', the occipital; AP^ the posterior auricular; TPS^ the 
 superticial temporal ; 1, the tongue ; 2, the genio-glossus mus- 
 cle ; 3, the hyo-glossus ; 4, the angle of the lower jaw : 5, the 
 hyoid bone ; 6, the thyro-hyoid ligament; 7, the tliyroid car- 
 tilage ; 8, the crico-thyroid membrane. 
 
 level with the " Adam's 
 apple " each common carotid divides into two arteries, an internal and an 
 external carotid. The branches of one, the external carotid, supply mostly 
 the outer portions of the head and face, while the branches of the other, 
 the internal carotid, are distributed throughout the brain. The subclavian 
 artery of each side at first arches upward behind the clavicle and then 
 passes down and out between the clavicle and first rib. At this point the 
 artery receives the name of axillary, and passes down below the shoulder 
 joint through the axilla or armpit into the arm. When it reaches the 
 arm this same arterial trunk is known as the brachial artery. The brachial 
 artery passes down the arm, lying to the inner side of the biceps muscle, 
 
BRANCHES OF THE AORTA. 
 
 81 
 
 and, running across the front of the elbow joint nearly in the middle line, 
 divides into the radial and ulnar arteries. It is the radial artery as it 
 passes along the outer side of the wrist that is usually felt in counting the 
 " pulse." The ulnar, though smaller and lying somewhat more deeply, 
 can frequently be felt throbbing upon the inner side of the wrist. The 
 long arterial trunk — known, according to its location, as the subclavian, the 
 axillary, and the brachial artery — gives off numerous branches in its course, 
 which are distributed to the neck, shoulder, and arm, while branches from 
 the radial and ulnar arteries supply the forearm and hand with blood. 
 
 The aorta, as it passes on downward through the abdomen, gives off 
 many branches to various organs of the body, such as the liver, the stom- 
 ach and the intestines, the kidneys, the spleen, etc. When it reaches the 
 fourth lumbar vertebra, as mentioned above, it divides into two very large 
 branches — viz., the right and the left common iliac arteries. These com- 
 mon iliacs are short branches, being only about 
 
 two inches long. Then they in turn divide, ..,^'^ 
 
 each into two large branches — an internal iliac, 
 which supplies with blood the organs contained 
 in the pelvis, together with the external geni- 
 tals, and an external iliac, which passes down- 
 ward, outward, and forward, leaving the ab- 
 dominal cavity to supply the lower extremity. 
 It passes into the thigh from the cav- 
 ity of the abdomen at about the mid- ^^y/ 
 point of the " groin," where it re- 
 ceives the name of femoral artery. 
 This femoral artery 
 
 passes down along the 
 inner side of the thigh, 
 and a line drawn from 
 the middle of the groin 
 to the inner side of the 
 knee roughly indicates 
 the position of the ves- 
 sel. A little above the 
 knee this same trunk 
 passes behind the joint 
 and becomes known as 
 the popliteal artery. The 
 popliteal artery divides 
 just below the knee into 
 
 two branches — an anterior and a posterior tibial artery. The anterior 
 tibial supplies branches to the front of the leg and the upper surface of 
 
 Fig. 30. — The subclavian- aeteet. (After Henle.) 
 AB, the innominate ; CC, the common carotid ; SA, the sub- 
 clavian ; P^, the vertebral; £A^ the basilar; M2fl. the in- 
 ternal mammary ; FS. the superior epigastric ; J/"/*, the 
 musculophrenic; IS, the superior intercostal; CT~P. the 
 deep cervical; TY, the inferior thyroid; (7 Hdl. the ascend- 
 ing cervical ; CTiS', the superficial cervical; JS, the supra- 
 scapular ; TC, the posterior scapular. 
 
32 
 
 THE ANATOMY OP THE HUMAN BODY. 
 
 tlie foot, while the posterior tibial furnishes 
 branches to the back of the leg and to the 
 sole of the foot. 
 
 The veins, as already stated, return the 
 blood to the heart from all portions of the 
 bLidv. Tliey, like the arteries, are composed 
 
 of three coats, but the mid- 
 reins. ,, , /• • • 
 
 die coat of a vein is com- 
 paratively weak, and, owing to this fact, a 
 vein, when empty, will collapse. The veins 
 differ in another important particular from 
 the arteries in that they are provided with 
 valves. These valves are most nnmerous in 
 the veins of the extremities, and they are 
 iisuallv composed of two leaves, sometimes 
 of only one, and sometimes of three leaves. 
 The valves are scattered along the course of 
 the veins and prevent the blood from flow- 
 ing in any way but one — namely, toward the 
 heart. They are so arranged that they be- 
 come tilled and block up the calibre of the 
 vein when the l)lood attempts to flow iu the 
 opposite direction — viz., away from the heart. 
 Their position can be seen in the forearm if 
 a moderately tight bandage is so placed 
 around the arm as to retard the venous re- 
 turn but not compress the arteries, and the 
 hand opened and closed a few times to in- 
 crease the supply of blood to the forearm. 
 Such a procedure will result in a distention 
 of the veins with blood ; they will stand out 
 prominently, and at the same time the loca- 
 tion of the valves will be seen readily. The 
 four pulmonary veins which convey the 
 
 Fio. 
 
 \^ . 
 
 MDU 
 EDN 
 
 COR- 
 
 / 
 
 DC 
 
 31. — The braciiiai, akteuy and its branches. 
 (After Ilcnle.) 
 H, tlie brachial; H, the radial ; /7, the ulnar; CLS, tlie ar- 
 teria deltoidea ; 6'Z/, the profunda radial ; PB, the su- 
 perior profunda; C.\f, the arteria collateralia media: 
 C'UI, the anastomotic a. of the arm ; liJi, the anterior 
 radial recun-ent; /i?C, the anterior ulnar recurrent; i^n/a wi/s 
 
 ICO, the common interosseous; /A, the anterior inter- 
 osseous: /P, the posterior interosseous; Hi, the posterior interosseous recurrent; /A V, the 
 arteria interossea anterior volaris ; lA D, the arteria interossea anterior dorsalis ; J/, the median ,• 
 O^B, the anterior radio-carpal; C'l'U', the anterior ulno-carpal ; C'DJi, the posterior radio- 
 carpal; ifZ*^-^, the posterior ulno-carpal ; ifF.S, the superticial volar ; J/r/-", the ulnar [jortion 
 of tne deep palmar arch ; DC, the tiiot palmar dij^ital. 
 
DEEP AND SUPERFICIAL VEINS. 
 
 blood from tlie lungs to the 
 left auricle, thus forming 
 the return-channels of the 
 " lesser circulation," are pe- 
 culiar in two respects : they 
 have no valves, and they 
 contain " arterial " blood. 
 
 The veins of the " great- 
 er circulation " may be de- 
 scribed as of two varieties, 
 according to their situation, 
 the deep and the superficial 
 veins. The deep veins are 
 placed deeply in the tissues 
 and follow the course of the 
 arteries ; and the superficial 
 veins, which are situated 
 nearer the surface of the 
 body, lie mostly just be- 
 neath the skin, where they 
 can be seen readily, espe- 
 cially when made to stand 
 out by the method spoken 
 of above. In the neck, be- 
 sides many smaller veins, 
 we have upon each side one 
 very large one called the 
 internal jugular vein. This 
 vein at first accompanies 
 the internal carotid artery ; 
 lower down it follows the 
 course of the common carot- 
 id to the root of the neck, 
 where the internal jugular 
 of each side is joined by the 
 large subclavian vein which 
 comes from the upper ex- 
 tremity. This junction of 
 these two large veins forms 
 the innominate vein upon 
 each side, there being a right 
 and a left. These two in- 
 nominate veins join each 
 5 
 
 Fig. S2.— The femoral aktery. (After Henle.) 
 CFI, the common femoral : ESF, the superficial epigai?- 
 tric ; CIS, the superficial circumflex iliac : FC'E, the 
 external pudic; PEF, the deep femoral : CFL, the ex- 
 ternal circumflex of the thigh ; CFJF, the internal cir- 
 cumflex of the thigh ; PF^, the first perforating a. of 
 the thigh ; P/"^, the second perforating a. : PF^, the 
 third perforating a.; AGS, the arteria anastomotic^ 
 magna ; SF, the superficial femoral. 
 
34 
 
 THE ANATOMY OF THE HUMAN BODY. 
 
 other at an angle upon the left side of the median line of the body, and 
 thus is formed the superior vena cava which empties into the right auri- 
 cle, as already mentioned. The subclavian vein, which helps to form the 
 
 innominate vein, is itself 
 formed by the veins which 
 come from the upper ex- 
 tremity, which are of the 
 deep and the superficial 
 variety. 
 
 The deep veins of the 
 upper extremity accom- 
 pany the arteries as in 
 other parts of the body. 
 The superficial veins are 
 just beneath the skin in 
 the greater part of their 
 course, and are as follows : 
 Ulnar and radial veins, 
 upon the inner and outer 
 sides of the forearm re- 
 spectively, and, in the me- 
 dian line of the forearm, 
 the median vein. At the 
 bend of the elbow these 
 veins join together so as 
 to form two large veins — 
 the basilic upon the inner side, and the cephalic, upon the outer side of 
 the arm. The basilic vein joins with the deep veins of the arm and 
 forms the axillary vein, which then receives the cephalic. Higher up 
 the axillary becomes the subclavian vein, which soon joins the internal 
 jugular to form the innominate vein, as already mentioned. 
 
 The veins of the lower extremity are divided into superficial and deep, 
 as in the upper extremity, the deep veins accompanying the arteries and 
 taking the same names. In the leg we have the anterior 
 „ . .. and posterior tibial veins, which join and form the pop- 
 
 liteal vein, which lies behind the knee joint. Higher 
 up in the thigh this vein is called the femoral until after it has passed 
 through the groin into the belly cavity, where it receives the name of ex- 
 ternal iliac vein. As the vein passes through the groin it lies upon the 
 inner side of the femoral artery. The superficial veins of the lower ex- 
 tremity are two in number : one, beginning by small branches upon the 
 outer side of the foot, runs up the back of the leg, and behind the knee 
 joint joins the deep vein, which is here the popliteal ; the other superficial 
 
 Fio. 33. 
 
 1, 1, the external juirular veins ; 2, the rifiht anterior jusjular 
 vein; 3, 3, the internal ju<ru]ar veins ; 4, 4, the subcla- 
 vian veins ; 5, the risxht innominate vein ; 6, the left 
 innominate vein ; 7, the superior vena cava ; 8, the left 
 axillary vein ; 9, the right cephalic vein : 10, the inferior 
 vena cava. 
 
EXTERNAL AND INTERNAL ILIAC VELNS. 
 
 Inferior Vena Cava. 
 
 vein of the lower extremity is longer, and, heginning upon tlie inner sido 
 of the foot, it courses upward upon the inner sirlc of the leg and thigh 
 until finally it empties into the femoral vein just befon; the latter becomes 
 the external iliac. This superficial vein, called the long saphenous vein, 
 and its branches, are subject to frequent infiainination, giving rise to what 
 is known as "milk leg," and they also frequently become distended and 
 dilated, resulting in the condition of " varicose veins." 
 
 Inside the abdominal cavity the external iliac vein is met by the in- 
 ternal iliac, which has come from the pelvic organs, and by the junction 
 of these two veins upon each side of the body the com- 
 mon iliac veins, a right and a left, are formed. These 
 two common iliacs in turn join together upon the right side of the 
 aorta to form the inferior 
 vena cava. This enormous 
 vein passes up along the 
 right side of the bodies of 
 the vertebras until, after 
 passing through the dia- 
 phragm, it enters the right 
 auricle of the heart. In 
 its course the inferior vena 
 cava receives some very 
 large branches — notably 
 the right and left renals, 
 from the kidneys, and the 
 hepatic, from the liver. 
 The blood from the stom- 
 ach and intestines, and 
 from the pancreas and 
 spleen, is collected by a 
 system of veins knowm as 
 the jportal system. The 
 smaller veins making up 
 this system join together 
 to form one large vein — 
 the portal vein. This por- 
 tal vein, instead of join- 
 ing the inferior vena cava 
 and returning the blood 
 to the heart in this direct 
 manner, enters the liver 
 and breaks up into a net- 
 work of branches, which 
 
 Fig. 34. 
 1, the left external jugular %'ein ; 2, the left internal jugular 
 vein ; 3, -the left anterior jugular vein : 4, the left in- 
 nominate vein; 5, the left subclavian vein : 6, the supe- 
 rior vena cava; 7, the large azygous vein ; 8, the small 
 azygous vein ; 9, the left inferior thyroid vein ; 10, the 
 left superior intercostal vein ; 11, the inferior vena cava ; 
 12, the right common iliac vein : 13, the right internal 
 iliac vein ; 14, the right external iliac vein ; 15, the right 
 femoral vein; 16, tlie right deep femoral vein; IT, thu 
 renal veins ; 18, the internal spennatic vein. 
 
36 
 
 THE ANATOMY OF THE HUMAN BODY. 
 
 again become joined into one large vein — tlie hepatic vein, already men- 
 tioned as opening into the inferior vena cava. From tliis arrangement it 
 resnlts tliat the hepatic vein returns from tlie liver not only the blood 
 sent to it by the artery of the same name, but also that poured into it 
 from the digestive organs through the portal system of veins. 
 
 The capillaries are the exceedingly small vessels which connect the 
 
 small terminal branches of the arteries with the small 
 
 apt a I r.s. beginning branches of the veins. They average about 
 
 one three-thousandth of an iiieli in diameter and are arranged in a iine and 
 
 close meshwork, exist- 
 ing in nearly every por- 
 tion of the body. They 
 are composed of only 
 one coat, which is con- 
 tinuous with the inter- 
 nal smooth coat of the 
 larger vessels, though in 
 the capillaries it is even 
 more delicate than in 
 the large vessels. This 
 very thin wall allows 
 the oxygen and the nu- 
 tritious properties con- 
 tained in the blood to 
 pass out into the tissues, 
 and the carbonic-acid 
 gas and other results 
 of tissue waste to pass 
 from the tissues into 
 the blood. 
 
 Almost all of the 
 blood-vessels communi- 
 cate freely with one an- 
 other — the arteries with 
 other arteries, the veins 
 with other veins, and 
 the capillaries with oth- 
 er capillaries. These 
 frequent communica- 
 tions or " anastomoses " 
 enable the circulation to 
 be maintained, even if a very large vessel should become closed or should 
 V)e tied by the surgeon. For example, if the brachial artery should be 
 
 Fio. 35. 
 1, the splenic vein ; 2, the portal vein ; 3, the superior mesen- 
 teric vein ; 4, the inferior mesenteric vein. 
 
COLLATERAL CIRCULATION. 37 
 
 tied ; for a short period of time the limb below the ligature would be 
 
 come cold and apparently bloodless, but soon an increasing amount of 
 
 blood would reach it through the communications be- 
 Communication of . , i i i £ ,^ \ i • i i_ ^ p .^ 
 
 Ri r] V' '•!• ' tween tlie brandies or the brachial artery and of the 
 
 axillary artery above the ligature, and the branches of 
 
 the brachial and of the radial and nlnar arteries below the li(>;ature. Tiii.s 
 
 increased flow of blood through the small branches soon resnlts in their 
 
 becoming larger, and one or more of them will become so large that as 
 
 much blood will reach the limb below the obstruction as before, and thus 
 
 the nutrition of the part is maintained. Such a course of events is known 
 
 as the establishment of the " collateral circulation." The most important 
 
 exception to the frequent communication of the small arteries is found 
 
 in the brain, where the small or " terminal " arteries do not anastomose, 
 
 and hence, M'hen one or more of them become blocked or plugged, that 
 
 portion of the brain supplied by the artery will be deprived of blood and 
 
 will become softened and degenerated. 
 
 SECTION Y. 
 
 THE LYMPHATICS. 
 
 Besides the vessels which act as channels for the circulating blood, and 
 which have been described in the previous chapter, there are present in 
 nearly every portion of the body other vessels, called the lymphatics, on 
 account of the resemblance of the fluid contained in them to water (Latin, 
 lympha). These vessels are also called the " absorbents," from their func- 
 tion of absorbing materials from all parts of the body containing them, 
 which material they convey finally into the circulating blood, as will pres- 
 ently be seen. The lymphatic vessels of the small intestine are known as 
 the lacteal or chyliferous vessels, because during the di- 
 gestion of the food they become filled with a milk-white 
 fluid called the chyle, which has been absorbed from the intestine and 
 represents the products of the digestive process. The lymphatics are very 
 delicate vessels with transparent walls, so that their contents may be easily 
 seen through them. The larger vessels have, like the arteries and reins, 
 three coats — all very thin ; but the smaller lymphatics have only one coat, 
 the internal, as in the capillaries. There is, however, not so much varia- 
 tion in size among the lymphatic vessels as is seen in the arteries and 
 veins. These lymphatic vessels form nets or meshwork all over the 
 body, and, like the veins, they are supplied with valves, but much more 
 abundantly, so that they have the appearance of knotted threads. They 
 are not arranged as a tree with branches, but have a resemblance more to 
 
38 
 
 THE ANATOMY OF THE HUMAN BODY. 
 
 a coinjilic'iiteil tano-le i)f throiuls (Fig. 30). Tliey are arranged in two sets, 
 supertieial and deep ; but these two sets have very frequent communica- 
 tion with each oiher. 
 
 Besides the lymphatics and the lacteal vessels there exist numerous 
 
 lymphatic glands; situated in various parts of the body, and with which 
 
 are connected the lymphatics and lacteals in their im- 
 
 * mediate neighbourhood. Some of the lymphatics open 
 
 iiito the glands and convey the lymph from the surrounding tissues to 
 
 the interior of the gland structure, while other vessels open out of tlie 
 
 gland, and carry the lymph from the 
 gland. These vessels communicate 
 with others which in turn empty into 
 some other neighbouring gland. The 
 glands vary in size from a pin's head 
 to an ahiiond. Some belonging to the 
 superficial set are situated in the head 
 around the ear, under the jaw, and in 
 the neck, while other superficial glands 
 are found in the upper extremity, in 
 the armpit or axilla, and a single one 
 upon the inner side of the arm just 
 above the elbow, while in the lower 
 extremity they occur mostly in the 
 groin ; but there is usually one or 
 more behind the knee joint in the 
 popliteal space. 
 
 The lymph and chyle of the body 
 are finally collected by two main ves^ 
 sels, one of which is small, being the 
 common lymph channel for the right 
 side of the head and neck, the right 
 upper extremity, the right side of the 
 thorax and what it contains — viz., the 
 right lung and right side of the heart 
 — and also for the upper surface of 
 the liver. This common channel is 
 called the right lymphatic duct. The 
 left lymphatic duct is much longer 
 and larger than the right, and, from 
 its course, is known as the thoracic 
 duct. This thoracic duct conveys the lymph and chyle from all ])ortions 
 of the body which are not enumerated above as supplying the right duct. 
 The thoracic duct is about sixteen inches long, and, beginning in the loin 
 
 Fio. 36. — Lacteals and lymphatics ouk 
 
 IXO DIGESTION. (DaltOll.) 
 
LYMPHATICS AND NERVOUS SYSTEM. 39 
 
 or lumbar reo;iori of the abdomen, it extends upward along the bodies 
 
 of the vertebnB, passes through the same opening in the diaj)hragm 
 
 through which the aorta goes, and enters the cavity 
 
 Lymphatic Duds. n .^ ,^ -r, .^ .^^ •, 1 
 
 01 the thorax. It then passes on up until it reaches 
 the seventh cervical vertebra, when it arches forward to its termina- 
 tion. At its commencement upon the second lumbar vertebra, where it 
 receives many large branches, the thoracic duct is dilated into a sac of 
 considerable size, but farther up the duct is about the size of a goose quill. 
 The right lymphatic duct and the thoracic duct empty respectively into 
 the right and into the left subclavian veins, near their junction with the 
 internal jugular veins, upon each side of the root of the neck. During 
 and following the digestion of food the thoracic or left lymphatic duct is 
 gorged with the chyle which has been collected from the intestine, and 
 which it receives and conveys into the general circulation by pouring it 
 into the left subclavian vein. The openings of the right duct into the 
 right subclavian vein and of the thoracic duet into the left subclavian are 
 protected by valves which prevent the blood from flowing into the ducts, 
 but allow the lymph and chyle to pass from the ducts into the veins. 
 Both of the ducts are well supplied with valves throughout their course. 
 The lymphatic vessels lying beneath the skin can sometimes be seen as 
 red lines running from the neighbourhood of poisoned wounds toward 
 the nearest lymphatic gland or bunch of glands. 
 
 SECTION yi. 
 
 THE NERVOUS SYSTEM. 
 
 The nervous system of the body is composed of two distinct kinds of 
 elements which are closely associated together in their functions and in 
 their anatomy. One, the nerve-cell, is for the production of impulses 
 and for the receipt of impressions ; and the other, the nerve-fibre, is for 
 the transmission of these impulses and impressions to and from various 
 localities. The first of these elementary varieties, then, is the nerve-cell 
 or nerve-corpuscle. 
 
 ISTerve-cells are composed of finely granular matter, and are of a red- 
 dish or yellowish-brown colour. They vary much in size and shape, 
 some being small and others large ; some are rounded, 
 some angular, and still others stellate in shape (Fig. 37). 
 The last, stellate-cells, are especially characterized by having one of their 
 processes much prolonged. This process is the beginning of a nerve- 
 fibre. All of the nerve-cells have one or more prolongations or processes 
 which are very delicate ; some of these processes apparently serve to 
 
40 
 
 THE ANATOMY OF THE HUMAN BODY. 
 
 connect the cell with neighbouring or distant cells, while others become 
 continuous with, and seem to give origin to, a nerve-libre. AVhere the 
 
 nerve cells or corpus- 
 {^ / cles are collected to- 
 
 gether in masses, we 
 have what is known as 
 the " gray matter " of 
 the nervous system, as 
 distinguished from the 
 " white matter," which 
 is composed chietly of 
 the nerve-fibres. This 
 gray matter, represent- 
 ing an aggregation of 
 nerve-cells, is found 
 upon the outer surface 
 or cortex of the brain 
 and cerebellum, in 
 smaller masses in the 
 interior of these or- 
 gans, and in the inte- 
 rior of the spinal cord. 
 It not only exists in 
 these comparatively 
 large masses, l^ut is 
 also found in smaller accumulations in vai-ious parts of the body, as will 
 be seen later. These aggregations of cells, forming larger and smaller 
 masses of gray matter, are the nerve-centres of the body. 
 
 The nerve-fibres constitute what is known as the white matter of the 
 nervous system and make up the nerve-cords of the body, and form the 
 greater bulk of the brain where they are in the interior, 
 and also of the spinal cord where they occupy the ex- 
 terior. There are two kinds of nerve-fibre. One is called the medullated, 
 and this is the variety which is found almost everywhere throughout 
 what is known as the cerebro-spinal nervous system — viz., tliat system 
 which consists of the brain and spinal cord and their branches, and 
 which controls the animal functions of the body, such as sensation and 
 motion, and the special senses. The other variety of nerve-fibre is called 
 the non-medullated, and goes to form almost entirely the nerve-cords 
 of the sympathetic nervous system, which system has control over 
 the vegetative functions of the body, such as circulation and digestion, 
 in contradistinction to those functions which are the special attributes of 
 animals. 
 
 Fig. 37. — Multipolar ganglion cells kkom the hitman ekain. 
 
 1, a cell, one of whose processes (a) becomes the axis cylinder of 
 a iierve-fibre (b) ; 2, a cell (o) connected with another (h) by 
 means of a commissure (c) ; 3, diatrram of three cells («) con- 
 nected by means of commissures (h), and runnint; into fibres 
 (c) ; 4, a'multipolar cell containinjr black pigment. 
 
 Nerve-fibres. 
 
MEDULLATED AND NON-MEDULLATED NERVE-FIBRES. 41 
 
 The nerve-fibres of tlic cercbro-spinal system are, as has been said, of 
 the mednllated variety. Such a iiorvc-fil^ro consists of (1) a central por- 
 tion, transparent, of the coTi.sLstcncu of the boiled white of an (i^<r, and 
 which forms the true conducting portion of the ncrve-fibrc. This central 
 portion, which is the fundamental portion of a nerve-fibre, is the axis cyl- 
 inder. Around this axis 
 cylinder is jjlaccd a layer 
 of liquid fat, the medul- 
 lary sheath (2), which in- 
 closes the axis cylinder, 
 protecting it and insulat- 
 ing it, and is in turn sur- 
 rounded and held in place 
 by (3) a thin, delicate, 
 membranous covering, the 
 neurilemma or real sheath 
 of the nerve-fibre. From 
 this description the simi- 
 larity in structure between 
 an insulated telegraph 
 wire and a nerve-fibre will 
 be readily seen, and as 
 both have similar func- 
 tions, the analogy is most 
 striking. These nerve- 
 fibres vary from y^Vo" ^*^ 
 ■JuVo *^^ ^^ inch in size. 
 
 The non - mednllated 
 nerve-fibres make np the 
 great portion of the nerves 
 of the sympathetic system, 
 and are also found in some 
 of the cerebro - spinal 
 nerves, notably in the 
 nerve of the special sense 
 of smell — the olfactory 
 nerve. These non-medul- 
 lated nerve - fibres seem 
 to consist of an axis cylin- 
 der somewhat larger than in the mednllated fibre, but having no insulat- 
 ing fatty envelope around it, being protected only by a thin membranous 
 sheath. Such a nerve-fibre is about half the size of the mednllated 
 variety. 
 
 Fig. 38. — The oerebbo-spinal system of nerves. 
 
42 
 
 THE ANATOMY OF THE HUMAN BODY. 
 
 Hie Brain. 
 
 When tlie nerve-tibres are collected into bundlesf; or cords of larger or 
 smaller size they form the nerves. 
 
 The cerel)r(i-s|)iiial system consists of the brain and the spinal cord as 
 the nerve-centres, and the nerves emanating from them (Fig. 38). 
 
 The brain or encephalon is contained within the bony cavity of the 
 cranium. It is divided into four principal parts — viz, the cerebrum, the 
 cerebellum, the pons Varolii, and the medulla oblongata 
 (Fig. 30). The encephalon increases rapidly in size up 
 to the seventh year, then more slowly and with increasing slowness, until 
 at forty it reaches its maximum, which is about forty-nine ounces for the 
 
 male and forty-four for the 
 female. The size of the 
 brain can not be said to bear 
 a direct relation to the intel- 
 lectual capacity of the indi- 
 vidual, for, while some learn- 
 ed men have had brains 
 which weighed as much as 
 sixty - three and sixty - four 
 ounces, persons of less than 
 ordinary intellectual-develop- 
 ment have had brains weio:h- 
 ing as high as sixty -eight 
 ounces. Man has the heav- 
 iest brain of all animals, with 
 the exception of the elephant 
 and the whale. 
 
 The brain, as it lies in 
 the cavity of the skull, is protected by three membranous coverings, 
 named, from without inward, the dura mater, the arachnoid membrane, 
 and the pia mater. The dura mater, the most exter- 
 nal of these coverings, is the thickest, being dense and 
 inelastic, and lines the internal surface of the cranial 
 cavity, where it adheres to the bone, forming for them 
 an internal periosteum. Along the middle line above, a sickle-shaped 
 process of the dura passes vertically downward into the great longi- 
 tudinal fissure between tlie two hemispheres, and forms the falx cerebri. 
 In the back of the cranial cavity another process of dura, which is hori- 
 zontal, passes inward from the circumference of the skull to support 
 the posterior lobes of the cerebrum, separating the cerebrum from the 
 cerebellum, which lies below it. This process is called the tentorium 
 cerebelli. The two lateral halves of the cerebellum are likewise par- 
 tially separated by a vertical process of the dura, the falx cerebelli. The 
 
 Fig. 39. — A vertic.vl median section of the buain 
 
 INCLOSED IN ITS ME.MBKANES AND THE SKULL. 
 
 a, b, c, convolutions of the cerebrum ; d, the cerebellum ; 
 «, medulla oblongata ; /, the upper end of the spinal 
 cord ; f/, pons Varolii ; A, corpus callosum ; *, forni.K ; 
 k, the gray commissure. 
 
 Membrmious 
 
 Coverings of the 
 
 Brain. 
 
THE HUMAN BRAIN. 
 
 43 
 
 The Cerebrum. 
 
 arachnoid is a delicate membrane which separates the dura from tlie 
 pia mater. Between the dura mater and the aracimoid membrane is 
 the sui)dural space, small but tilled with fluid ; and between the arach- 
 noid and the pia is the subarachnoid space, wider than the former, and 
 also filled with a fluid known as the cerebro-spinal fluid. This sub- 
 arachnoid space communicates with cavities in the interior of the brain. 
 The pia mater is essentially a vascular membrane, being composed of 
 blood-vessels held together by fine threads of connective tissue. It in- 
 vests the surface of the brain closely, dipping down into the fissures 
 and sulci, and it penetrates into the interior of the brain and lines its 
 cavities. 
 
 The cerebrum is the largest part of the encephalon, and occupies the 
 whole upper portion of the cavity of the skull (Fig. 40). It is nearly 
 divided into two distinct lateral halves or hemispheres 
 by a deep fissure — the great longitudinal fissure — which 
 runs from before backward in the median line. The portion of the cere- 
 brum which is not so divided, and which is left to bind the right and left 
 hemispheres together, is near the under surface of the brain, and is called 
 the corpus callosum. This structure can be seen at the bottom of the 
 great longitudinal fissure when the hemispheres are held slightly apart. 
 When the hemispheres are examined one is immediately struck with the 
 many folds or convolutions which appear upon their outer surface. The 
 external surface of these convolutions is composed of the gray matter 
 forming the cortex of the brain, while 
 their interior is composed of white mat- 
 ter. By such a plan the amount of gray 
 matter possible for a given space within 
 the cranium is much increased, and the 
 human brain has more and deeper con- 
 volutions than the brain of any other 
 animal. 
 
 While the arrangement of the convo- 
 lutions differs considerably in different 
 brains, and even upon the two sides of 
 the same brain, there is still apparent a 
 certain plan or design upon which they 
 occur. The clefts between the convolu- 
 tions when they are small are called sulci, 
 but when large they are known as fis- 
 sures. There are five great fissures (Fig. 
 
 41) : (1) The great longitudinal fissure, already mentioned, which sepa- 
 rates the cerebrum into two hemispheres, and (2) the great transverse 
 fissure, which separates the cerebrum from the cerebellum. Each hemi- 
 
 FiG. 40. — Uppek surface of the cep.e- 
 
 BRUM, SHOWING THE CONVOLrTIONS 
 OF THE BRAIN AND ITS DOUBLB 
 STRUCTURE. 
 
44 
 
 THE ANATOMY OF THE HUMAN BODY. 
 
 sphere is divided into lobes by the three reiniiining fissures : (3) the fis- 
 sure of Sylvius, which separates the parietal from the temporo-si)he- 
 noidal lobe ; (4) the fissure of Rolando, which separates the frontal lube 
 from the parietal ; and (5) the parieto-occipital fissure, which separates 
 
 F.L 
 
 F.K. 
 
 .F.S. 
 
 P.O.F. 
 
 T.F. 
 
 YiQ. 41. Diagram of the oitek hemisphere. 
 
 /■' R fi'^sure of Rolando: F. -S'., fissure of Sylvius; T. F., transverse fissure; P. O. F., parieto-occi- 
 pitaT fissure; F. Z., frontar lobe ; P. Z.. parietal lobe; (?. Z., occipital lobe; r. *'. Z., teniporo- 
 sphenoiilal lobe ; C. Z., cerebellum. 
 
 the parietal from the occipital lobe, and is seen well only when the two 
 hemispheres are severed, for it is upon their inner and opposing surfaces. 
 Besides these four lobes— the frontal, the parietal, the temporo-sphe- 
 noidal, and the occipital— there is a collection of gray matter at the bot- 
 tom of the fissure of Sylvius, near the base of the brain, which is known 
 as the central lobe, or the island of Eeil. 
 
 Each of these lobes, with tlie exception of the last, is marked off by 
 numerous sulci into convolutions, and all these sulci and convolutions 
 have been mapped out and named, and studied, and it has been found 
 that certain portions of the cerebral cortex are always occupied by cer- 
 tain centres, and from these centres the same impulses always originate. 
 Thus, for example, the centre in the brain which controls the move- 
 ments of the right leg and foot in walking is situated just behind the 
 upper end of the fissure of Rolando near the great longitudinal fissure 
 on the left side. 
 
 If we turn the brain over and examine its under surface or base 
 (Fig. 42), we find the cerebrum divided into two lateral halves by the 
 great longitudinal fissure, and each half further divided into three lobes 
 
 an anterior in front of the Sylvian fissure, a middle lobe back of this 
 
 fissure, and a posterior lobe which is covered by the cerebellum. 
 Emerging from various points upon the base of the brain we see many 
 
NERVES OF THE CRANIUM. 
 
 45 
 
 of the nerves of the cranium. In front, upon the uuder surface of 
 each frontal lobe, is seen the olfactory nerve ending in the olfactory 
 bulb ; just behind this we see the two optic tracts, which meet in the 
 centre, forming the optic commissure, and diverging again as the optic 
 nerves. In the median line in front, showing between the sliglitly 
 separated hemispheres, is seen the anterior or front portion of the cor- 
 pus callosum. Just in front of the optic commisBurc is seen a small 
 mass which seems to be in some way connected both with the nervous and 
 with the glandular systems of the body ; this is the pituitary body or 
 
 Fig. 42. — The base of the beain. (From Eanney, after Hirschfeld.) 
 
 1, 1, anterior lobe of the cerebrum ; 2, sphenoidal portion of the posterior lobe ; 3, 8, occipital por- 
 tion of the same lobe ; 4, anterior extremity of the median fissure ; 5, posterior extremity of the 
 same ; 6, 6, fissure of Sylvius ; 7, anterior perforated space ; 8. tuber cinereum and pituitary 
 body; 9, corpora albicantia; 10, interpeduncular space (posterior perforated space); 11, crura 
 cerebri; 12, pons Varolii; 13, medulla oblonffata; 14, anterior pyramids; 15, olivary body; 16, 
 restiform body (only partially visible) ; 17, 17, hemispheres of the cerebellum ; 18, fissure sep- 
 aratins^ these hemispheres; 19, 19, first and second convolutions of the inferior aspect of the 
 frontal lobe with the intervening sulcus- 20. external convolutions of the frontal lobe; 21, optic 
 tract; 22, olfactory nerve; 22', section of the olfactory nerve, showing its triangular prism.itic 
 shape ; the trunk has been raised to show the sulcus in which it is lodged ; 23, ganglion of the 
 olfactory nerve ; 24, optic chiasm ; 25, motor oculi ; 26, patheticus ; 27, trigeminus ; 28, abdu- 
 cens; 29, facial ; SO, auditory nerve and nerve of Wrisberg ; 31, glosso-pharyngeal ; 32, pneu- 
 mogastric ; 33, spinal accessory ; 34, hypoglossal. 
 
 gland. Lying partly hidden by the optic tracts are two diverging bundles 
 of white matter, the crura cerebri, which are made up of nerve-fibres 
 coming through the pons Yarolii from the medulla oblongata and from 
 
46 THE ANATOMY OF THE HUMAN BODY. 
 
 the spinal cord. Tliej^e fibres, wliifli make up the crura cerebri, pass on 
 into the substance of the brain. From the inner side of each crus is seen 
 einerp:ing the third cranial nerve, and from the outer side the fourth 
 cranial nerve. Further back is seen the pons Varolii, another mass com- 
 posed mostly of nerve-libres, some of which pass laterally between the two 
 lobes of the cerebellum, and others, mentioned above, pass from the 
 medulla upward into the brain to form the crura cerebri. Emerging 
 from the pons is the lif th pair of cranial nerves, and just behind the pons, 
 from the groove between it and the medulla, the sixth pair of nerves 
 make their exit. Behind the pons Varolii is seen the medulla oblongata, 
 the upper expansion of the spinal cord. From the medulla pass the 
 remaining six of the twelve pairs of cranial nerves. 
 
 If from a brain held in the natural position, with its base downward, 
 we slice off the hemispheres down to the level of the corpus callosum, we 
 
 find a large expanse of white matter surrounded by the 
 The Interior of the ,, j. ,^ , ] ^i • i a- +^ 
 
 „ . gray matter ot the cortex, and the indenting tissin-es 
 
 Brain. ... . , 
 
 and sulci with their gray matter. In such a section the 
 
 corpus callosum will be exposed, and it can be seen to be composed of 
 transverse white fibres which connect together two hemispheres of the 
 cerebrum. Such a band of connecting fibres is known as a commissure, 
 and the corpus callosum forms the great transverse commissure of the 
 hemispheres. Just beneath the corpus callosum is a band of fibres pass- 
 ing between the front and the back portions of the brain. These fibres 
 form a longitudinal commissure which is called the fornix. 
 
 If the brain be again sliced so as to take off still more of the hemi- 
 spheres and also to remove the corpus callosum and the fornix, the two 
 lateral ventricles of the brain will be opened into. These interior cavities 
 of the brain are of irregular shape, and are composed of a main cavity, 
 or body, and an anterior, a posterior, and a middle horn. The ventricles 
 are situated one upon each side and communicate below with the sub- 
 arachnoid space before referred to, and are lined by a delicate membrane, 
 A process of the pia mater, the velum intcrpositum, is continued from 
 the exterior of the brain into each ventricle, and covers a portion of its 
 floor, and the edge of this velum interpositum is occupied by a highly 
 vascular fringe called the choroid plexus. At the bottom of each lateral 
 ventricle, and projecting into its cavity, are two of the large collections 
 of gray matter or nerve-cells which exist in the interior of each hemi- 
 sphere. In front is seen a portion of one of these masses called the 
 corpus striatum, while behind, the optic thalamus, the other of the two 
 collections of gray matter, bulges into the cavity of the ventricle. The 
 two lateral ventricles, forming the first and second ventricles of the 
 brain, arc separated by a vertical saeptum composed of two layers of mem- 
 brane having between them a space which is called the fifth ventricle. 
 
GRAY MATTER AND WHITE MATTER. 47 
 
 Behind this and between the two optic thalatni is another space called 
 tlie third ventricle, situated in the median line. The two lateral ven- 
 tricles and the third ventricle communicate with each other and also with 
 another cavity situated in the medulla — viz., the fourth ventricle — by 
 means of a Y-shaped canal, the foramen of Monro. Before birth in man, 
 and in the adult in some animals, the lifth ventricle communicates by an 
 opening with the third, but in the human adult it is isolated from the 
 general ventricular space constituted by the four other ventricles and the 
 central canal of the spinal cord. 
 
 Of the two large masses of gray matter which project into the lateral 
 ventricle, the corpus striatum is composed only in part of nerve-cells, for 
 it contains many diverging white fibres which give to it a striped appear- 
 ance, whence its name. The greater portion of the body of the corpus 
 striatum is embedded in the white substance of the hemisphere, but a 
 small portion of it, whicli arches backward, can be seen, as stated, at the 
 bottom of the lateral ventricle in front and to the outer side. This pro- 
 cess of the corpus striatum that arches back is separated from the main 
 portion by a bundle of white fibres which ascend from the cord through 
 the pons, medulla, and crura, on their way to the surface of the brain, 
 and form the internal capsule, the name external capsule being applied 
 to the white matter upon the outer side of the main portion of the corpus 
 striatum. 
 
 The optic thalami are two large masses of nerve-cells which lie one 
 upon each side of the median line, and which project up into the 
 floor of the lateral ventricles between the corpora striata. They are 
 covered by a layer of white matter, but their interior is composed of 
 gray matter. 
 
 The cerebrum has been likened to a tree, the trunk of which is formed 
 by the medulla, which divides into two main branches, the crura cerebri, 
 and these branches in turn dividing, until finally the smallest twigs are 
 formed. These twigs have upon their extremities leaves, represented by 
 nerve-cells, forming the mass of foliage or the cortex of the brain. But 
 the analogy is incomplete, for in the cerebrum there are masses of gray 
 matter in its interior. The two largest of these in each hemisphere are 
 the corpus striatum and the optic thalamus, of which we have spoken 
 above ; but besides these two there are other smaller masses of gray matter 
 existing in the interior of the cerebral substance. The white matter of 
 the cerebrum consists of medullated fibres, and these fibres are arranged 
 into three classes, according to the office they perform and the direction 
 they take : 
 
 (1) The main body of the white matter originates in the spinal cord 
 and passes upward, and in the brain they appear as the diverging crura 
 cerebri and the internal capsule. 
 
48 
 
 THE ANATOMY OF THE HUMAN BODY. 
 
 (2) The transverse commissural fibres connecting the two hemispheres 
 and found mostly in the corpus callosum. 
 
 (3) The commissural tibres connecting ditlerent parts of the same 
 hemisphere, of which the fornix is an example. 
 
 The cerebelluni, or little brain (Fig. 42), is that portion of the brain 
 which is situated below the process or offshoot of the dura mater, men- 
 tioned above as the tentorium cerebelli, and it lies below 
 the posterior lobes of the cerebrum. The average weight 
 of the cerebellum in the male adult is five ounces and a half, and its 
 proportion to the cerebrum is about as one to eight and a half in the 
 
 The Cerebellum. 
 
 Fig. 43.— a vertical section of the brain. (From Flint, after Ilirsclifcld.) 
 
 1, medulla oblongata; 2, tuber annulare; 3, cerebral peduncle ; 4, cerebelluiu ; 5, aqueduct of Syl- 
 vius: (i, valve of Vieussens; 7, tubcrcula quadrigemina; 8, pineal gland ; 9, inferior peduncle; 
 10, superior peduncle ; 11, middle portion of the great cerebral fissure; 12, optic thalamus; 13, 
 13, gray commissure; 14, cliorioid plevus; 15, infundibulum; 16, pituitary body; 17, tuber 
 cinereum ; 18, bulb of the forni.x; 19, anterior perforated space; 20, root of the motor oculi 
 communis; 21, optic nerve; 22, anterior commissure of the cerebrum; 23, foramen of Monro; 
 24, section of the fornix ; 25, septum lucidum ; 2(), 27, 28, corpus callosum ; 29, -30, 31, 32, 33, 34, 
 convolutions and sulci of the cerebrum. The olfactory ganglia and corpora striata are not 
 shown in this section. 
 
 adult and only one to twenty in the infant. It is oblong in shape, its 
 longest diameter, three and three quarters inches, being transverse. It 
 is constricted in the centre, where it measures only half an inch in 
 circumference, and is like the cerebrum in that it is composed of gray 
 and white matter, the white matter being on the interior and the gray 
 matter mostly upon the outside. The surface of the cerebellum is not 
 thrown into convoluted folds just as is the cerebnnn, but is traversed by 
 numerous furrows, or sulci, which vary much in depth ; some are rather 
 shallow while others are deep (Fig. 43). 
 
 In man the cerebellum is composed of two large lateral hemispheres 
 which are connected together by means of a central portion or lobe. This 
 
CEREBELLUM AND MEDULLA OBLONGATA. 49 
 
 median lobe is tlic essentially fundamental part of the cerebellum, and in 
 some of the lower animals, as the fishes and reptiles, it is the only portion 
 which exists. The lateral hemisplieres are a feature of higher animal 
 life. They reach their greatest development in man. The hemispheres 
 are separated in front and behind by a median notch or fissnre. In the 
 fissure behind is received a process of dura mater which projects forward 
 from the wall of the skull in a manner similar to the falx cerebri in the 
 cerebrum. This process is known as the falx cerebelli. 
 
 Each hemisphere of the cerebellum is divided into lobes, but the divi- 
 sion is not 60 distinct as in the greater brain. If we make a longitudinal 
 vertical section of a hemisphere just to one side of the median fissure we 
 have an appearance such as is shown in Fig. 43. The peculiar arrange- 
 ment of the gray and white matter upon the cortex has led to the name 
 " arbor vitse " being applied to this portion of the cerebellum. The gray 
 matter is found mostly in this situation, but it is also found in the interior 
 of the cerebellum in one large mass called the corpus dentatum and in 
 two much smaller collections. The wdiite matter of the cerebellum is 
 situated in the interior and the fibres are arranged mostly in three groups. 
 One, composed of fibres which come from the cerebrum and are distrib- 
 uted to the gray matter of the cerebellum ; a second consists of fibres 
 which connect together the two hemispheres of the cerebellum ; and a 
 third group, which is composed of fibres passing downward and connect- 
 ing the cerebellum with the medulla oblongata. These groups of fibres 
 are known respectively as the superior, the middle, and the inferior 
 peduncles of the cerebellum. Besides these three main groups of white 
 fibres there are other more scattered fibres, some of which connect 
 together the two hemispheres while others serve to connect different 
 parts in the same hemisphere. 
 
 The medulla oblongata, though merely the upper expanded portion of 
 the spinal cord, is always described as a portion of the brain or encephalon, 
 
 and consists of white matter situated mostly upon the 
 
 The Medulla , . , , . , .^^,^^.^^.• 
 
 ^„ ' outside and gray matter mostly located m the interior. 
 
 The medulla lies within the skull, and is received into 
 
 the fissure between the two hemispheres of the cerebellum upon its under 
 
 surface. It is of pyramidal shape with base upward, and measures an inch 
 
 and a quarter in length, three quarters of an inch in breadth at its widest 
 
 part, and half an inch in thickness. The surface of the medulla is marked 
 
 in front by a shallow longitudinal median fissure and behind by a deep 
 
 longitudinal fissure, also in the median line, which divides it thus into 
 
 halves, a right and a left, each half being again divided into four columns 
 
 by means of other smaller longitudinal grooves. These fissures and 
 
 grooves and columns are continuous witli those existing in the spinal 
 
 cord. 
 
50 THE ANATOMY OF THE HUMAN BODY. 
 
 Beoinning in front, the colunin upon either side and next to the anterior 
 median fissure is the anterior pyramid. The innermost tibres (those near- 
 est to the median lissure) of this anterior pyramid split up into four or 
 live bundles which decussate — tluit is, pass across from one side to tlie 
 other of the mediaii fissure. These decussating til)res come from the kit- 
 eral cohnnns of the sj)inal curd. The greater ])ortion of the tibres nuiking 
 up the anterior pyramids do not decussate, but pass directly u])\vard. 
 These non-decussating fibres in the anterior pyramid are derived fi-om 
 the anterior column of the spinal cord. Just to the outside of the anterior 
 pyramid is another cohimn of white fibres, called the lateral tract, which 
 tract is continuous with the lateral column of the cord. The lateral tract 
 is displaced above by the bulging forward of a collection of gray matter 
 in the medulla oblongata, called the olivary body. This olivary body, 
 composed of gray matter in the interior, is covered upon the outside by 
 a layer of white substance. 
 
 Following the medulla around to its posterior or hind side, we come 
 next to the column called the restiform body. This is continuous with 
 the posterior column of the spinal cord, and as it ascends it diverges from 
 its fellow of the opposite side to make room for the space known as the 
 fourth ventricle. 
 
 Farther back, and lying between the restiform body and the posterior 
 median fissure of the medulla oblongata, upon each side, is another col- 
 umn, the posterior pyramid. This column is continuous 
 e OS euor ^^y[^\l {I^q posterior median column of the cord. At first 
 Pyramid. ^ . i i- i i i • 
 
 the two pyramids lie close together, being separated 
 
 oidy by the posterior median fissure. As they ascend they diverge to 
 allow for the fourth ventricle, and farther up they merge into the resti- 
 form bodies just mentioned. The fourth ventricle is one of the ventricles 
 of the brain, and is connected with the two lateral ventricles and w'ith 
 the third ventricle by means of the \^-sliaped passage already referred to 
 as the foramen of Monro. The fourth ventricle is continuous also with 
 the central canal of the spinal cord, of which it represents an expansion. 
 ]iy the diverging of the restiform bodies and of the posterior pyramid, 
 the fourth ventricle is open above, and when the cerebellum has been re- 
 moved the interior of the ventricle is exposed to view, and its " floor " is 
 seen to be composed of gray matter. This gray matter upon the floor of 
 the fourth ventricle contains nerve-cells which give origin to many of 
 the cranial nerves. Besides the gray matter forming the olivary body 
 and the floor of the fourth ventricle, the medulla oblongata contains a 
 few other small masses of gray nuclei. 
 
 The pons Varolii (Fig. 42) is composed almost entirely of white nerve- 
 fibres, some transverse and others longitudinal, and these fibres connect 
 together the various parts of the brain already mentioned — viz., the 
 
PONS VAROLII AND SPINAL CORD. 
 
 51 
 
 The Pons Varolii. 
 
 The Spinal Cord. 
 
 cerebrum above, the medulla oblongata below, and behind the cerebel- 
 lum. It is situated between the crura of the cerebrum above and the 
 medulla oblongata below, and lies between the hemi- 
 spheres of the cerebellum. Upon its under surface, 
 which is seen when we look at the base of the brain, appear transverse 
 fibres, and situated more deeply within the pons is another l^and of trans- 
 verse fibres. These transverse bands, superficial and deep, connect to- 
 gether the two hemispheres of the cerebellum. The longitudinal fibres 
 •come mostly from the cord through the medulla, but a few originate in 
 the olivary body of the medulla, and a few others come from the small 
 scattered masses of gray matter situated in the pons itself. 
 
 The spinal cord is that portion of the cerebro-spinal axis which is 
 contained within the canal formed by the posterior branched portions of 
 the vertebrae. The cord is about seventeen and a half 
 inches long, and in w^eight bears the relation to the 
 encephalon of 1 to 33. It does not fill the calibre of the canal by 
 a considerable margin, the space left 
 around the cord and its membranes 
 being filled with a loose fibrous tissue 
 which prevents injury to the cord dur- 
 ing motions of the spine ; nor does it 
 fill the entire length of the spinal canal, 
 but extends from the first cervical 
 vertebra to the lower border of the 
 first lumbar, a distance of two thirds of 
 the length of the spinal canal, and ter- 
 minates below in a slender filament 
 composed mostly of gray matter. It 
 consists of white matter situated upon 
 the outside and of gray matter placed 
 in the interior. In the cervical region 
 and in the upper lumbar region the 
 cord presents enlargements which cor- 
 respond to those regions of the cord 
 from which are given off the large 
 nerve branches to the upper and lower 
 extremities (Fig. 44). Upon the ante- 
 rior and the posterior surfaces of the 
 cord are seen in the median line lon- 
 gitudinal fissures. These are the ante- 
 rior median fissure, which is wide but 
 shallow, and the posterior, which is narrow but deep. Upon either side of 
 the anterior median fissure is the antero-lateral fissure, wliich corresponds 
 
 Nerves to 
 left arm. 
 
 Nerves to 
 front of 
 left leg. 
 
 Nerves to 
 back of 
 left leg. 
 
 Nerves to 
 front of 
 right leg. 
 
 Nerves to 
 back of 
 right leg. 
 
 Fig. 44. — Brain and spinal coed, with 
 the thirty - one pairs of spinal 
 
 NERVES. 
 
52 
 
 THE ANATOMY OF THE HUMAN BODY. 
 
 to the rows of niimite foramina or holes from which the anterior roots of 
 the spinal nerves emerge from the cord. Upon either side of the posterior 
 median tissure is a slight groove, the postero-lateral fissure, from which 
 emeri2:e the posterior roots of the spinal nerves. The cord is divided 
 into lateral halvcsby the anterior and posterior median fissures ; and by 
 the antero-lateral and posterct lateral fissures each half is again divided 
 into three columns, named from in front the anterior, the lateral, and the 
 posterior columns of the cord. These columns are further divided by 
 anatomists according to the source and destination of the nerve-fibres' 
 which thev contain in their various parts. The gray matter of the cord 
 is situated in its interior in the shape of two crescents which are joined 
 together across the median line by a connnissure of gray matter. In this 
 commissure is situated the central canal of the cord. 
 
 From the spinal cord arise the thirty-one pairs of spinal nerves, and 
 each nerve arises by two roots. One, the posterioi- or larger, is the sen- 
 sory root, and comes from the gray matter of the cord emerging from 
 the cord through the postero-lateral fissure ; the other, the anterior oi' 
 
 smaller root, is the motor 
 root of the nerve, and is 
 attached to the white mat- 
 ter of the anterior columns 
 of the cord. Within the 
 cord the fibres composing 
 both roots pass through 
 the white matter into the 
 gray matter of the spinal 
 cord, where they spread 
 out, passing, some upward, 
 some downward, aiul some 
 across to the opposite side 
 of the cord. 
 
 The spinal cord, like 
 the brain, is inclosed by 
 three membranes : the du- 
 ra mater, situated external- 
 ly, the pia mater, lying in 
 close contact with the cord, 
 and between them the 
 arachnoid membrane. The 
 dura mater of the cord differs from that inclosing the encephalon in that 
 it does not come in contact with the bony arches of the vertebrae, but is 
 separated from them by a considerable interval filled with loose fatty tissue, 
 and also in that it does not send partitions into the fissures of the cord. 
 
 Fig. 45.— Diagram showing the kklative position of 
 the ckanial and l'ppeh spinal nekves as tiiev 
 emerge through their koramina. 
 
 1, the olfactory nerve ; 2, the optic; 3, oculo-motor ; 4, the 
 troclilear; 5, the trifacial; G, the abducent ocular; 7, 
 and 8, the facial and auditory ; 9. the gloaso-pbaryn- 
 geal ; 10, the pneumogastric ;' 11, the spinal accessory ; 
 12, the hypoglossal. 
 
CLASSIFICATION OF CRANIAL NERVES. 53 
 
 The cranial nerves are those nerves wliich, arising from tlic cerehro- 
 
 spinal centre, pass out through openings in the base of the skull (Fig. 45 j. 
 
 They are knoM^n by special names, and are also num- 
 The Cranial Nerves. , ' , ■ . . • /• ^ ^• , , 1 -. • 
 
 berecl, beginning in iront, according to tlie order in 
 
 which they emerge from the base of the encephalon. They are as 
 
 followo : 
 
 Number. Name. Function. 
 
 First pair Right and left olfactory norves Special sense. 
 
 Second pair " " optic nerves Special .sen.se. 
 
 Third pair *' " motor oculi nerves Motion. 
 
 Fourth pair " " pathetic nerves Motion. 
 
 i Common sensation. 
 Motion. 
 Special sense. 
 
 Sixth pair " " abdueens nerves Motion. 
 
 Seventh pair . . . . " " facial nerves Motion. 
 
 Eighth pair " " auditory nerves Special sense. 
 
 ■KT- iu • u i- 1 u 1 ( Common sensation. 
 
 Ninth pair " '• glosso-pharvngeal nerves. . j 
 
 ( Special sense. 
 
 Tenth pair " " pneumoijastric nerves i 
 
 ( Sensation. 
 
 Eleventh pair .. . " " spinal accessory nerves.. .. 3 '^ 
 
 { Sensation. 
 
 Twelfth pair. ..." " hypoglossal nerves Motion. 
 
 The first cranial or olfactory nerve is the special nerve of the sense 
 of smell, and it is really a prolonged process of brain substance ending in 
 a bulb. This process arises from the brain by three roots, and lies upon 
 the under surface of the frontal lobe. From the bulbous end are given 
 off about twenty nerve filaments which pass through holes in that part of 
 the roof of the nose cavity formed by the ethmoid bone. These nerve 
 filaments are distributed to the mucous membrane lining the upper 
 portion of the nasal cavities. 
 
 The second, or optic nerve, is the special nerve of the sense of sight, 
 arising on each side from two roots which form at first the optic tracts. 
 These tracts, after winding around the crura cerebri, join in the median 
 line, and from this junction, known as the optic commissure, the optic 
 nerves proper arise. The optic nerves pass out from the cavity of the 
 skull into the orbits through holes known as the optic foramina. Each 
 nerve then pierces the coats of the eyeball at a point upon the back side 
 of the eye a little to the inner side of the middle, and is distributed to 
 the retina. 
 
 The third cranial nerve, or the motor oculi, the fourth or pathetic, 
 and the sixth nerve, or abdueens, are the motor nerves of the eyeball, 
 and are distributed to the muscles which move it. They pass from the 
 
54 THE ANATOMY OF THE HUMAN BODY. 
 
 cavity of the craniiun into the orbit thruiii:;h a hirge opening known as 
 tlie sphenoidal tissure. 
 
 The fifth, or trifacial nerve, is most largely the nerve of common sen- 
 sation of tlie head and face, but also supplies some of the muscles of the 
 lower jaw with uintur tibros, and through a branch distributed to the 
 tongue it is probably a nerve of the sjiecial sense of taste. The fifth 
 nerve is similar to a spinal nerve in that it arises by two roots, one 
 sensory and one motor, and in that the sensory root has developed upon 
 it a small mass of gray matter known as a ganglion. The two roots 
 emerge from the side of the ]>ons Varolii and ])ass forward, the sensory 
 root ending in the ganglion above mentioned. This ganglion then gives 
 off three large branches : the ophthalmic or first division of the fifth 
 nerve, the superior maxillary or second division of the fifth nerve, and 
 the third branch, whicli joins the motor root that has passed beneath the 
 iranglion to form the inferior maxillary or third division of the fifth 
 nerve. 
 
 The first division, or ophthalmic nerve, soon divides into three 
 branches, which pass from the cavity of the cranium through the sphe- 
 noidal fissure into the orbit, where they subdivide into branches which 
 supply the eyeball, the lachrymal gland, the exposed mucous covering of 
 the eye, the mucous membrane of a part of the nasal cavity, and the 
 muscles and skin of the eyebrow, forehead, and nose, all with common 
 sensation. The second division of the fifth nerve, the superior maxillary 
 nerve, passes through a small round hole in the base of the skull, and 
 after running forward through the substance of the upper jawbone ap- 
 pears upon the face below the eye. The branches of this nerve supply 
 the ujijier teeth, a portion of the throat, and the side and front of the 
 face with common sensation. The third division of the fifth nerve is 
 called the inferior maxillary division, and it is a mixed nerve composed 
 of both sensory and motor fibres. Its branches supply the lower teeth, 
 the outer ear, the lower part of the face, and the muscles of mastication 
 all with sensation. Some of its branches supply a few of the muscles of 
 mastication with motor impulses, and the lingual or gustatory branch of 
 this inferior maxillary nerve is distributed to the mucous meml)rane 
 lining the tongue and may have to do with the sense of taste. 
 
 The seventh cranial nerve is known as the facial. It arises in the 
 groove between the olivary and the restiforin bodies at the lower border 
 of the pons Varolii. It emerges from the cavity of the skull after passing 
 through that portion of the temporal bone which forms part of the base 
 of the skull and contains the organs of hearing. The canal in the tem- 
 poral bone through which the facial nerve runs is a crooked one, and 
 being of bone, is unyielding; hence inflammation of the nerve or of the 
 bone will the more readily cause pressure upon the nerve and will result 
 
NERVES OF HEARING AND TASTE. 55 
 
 in its paralysis. The nerve makes its exit from tlie skull at a point 
 behind the outer ear and divides into many branches wliich spread 
 out over the head and face and up])er ]>ortion of the neck and supply 
 all the muscles of expression with motor impulses. Through motor 
 impulses supplied by some of its branches it assists in swallowing and in 
 hearing. 
 
 The eighth cranial nerve is the special nerve of the sense of hearing, 
 and is called the auditory nerve. It arises from the groove between the 
 olivary and restiform bodies at the lower border of the pons, and enters 
 the substance of the conical portion of the temporal bone througli tlie 
 same opening as the facial nerve, but does not again emerge, for it is 
 distributed to the organ of hearing contained within the temporal. 
 
 The ninth pair of cranial nerves, the glosso-pharyngeal, arises by two 
 or three filaments from the upper portion of the medulla oblongata in 
 the groove between the olivary and restiform bodies. Each nerve 
 emerges from a rather large opening in the base of the skull, known as 
 the jugular foramen, at which point the nerve presents two swellings 
 caused by small masses of gray matter and called ganglia. The nerve 
 passes downward behind the jaw and supplies the mucous membrane 
 covering the throat and tonsil with ordinary sensation, and is distributed 
 to the mucous membrane of the tongue as the special nerve of the sense 
 of taste. 
 
 The tenth pair of cranial nerves is composed of the right and left 
 pneumogastric or vagus nerves. Each vagus arises by eight or ten fila- 
 ments from the medulla between the olivary and restiform bodies. It 
 emerges from the skull through the jugular foramen and passes down 
 through the neck, lying close to the carotid vessels, into the cavity of the 
 chest. The nerve upon the right side runs down upon the back or pos- 
 terior surface of the lung, the oesophagus, and the stomach, while upon 
 the left side it descends behind the left lung and then comes to the front, 
 its branches covering the anterior surface of the oesophagus and stomach. 
 The branches of the pneumogastric are many, and they supply the oi'gans 
 of voice and hearing with both motor and sensory filaments ; and to the 
 pharynx, oesophagus, stomach, and heart they supply motor fibres. It 
 will thus be seen how much wider distribution have the branches of the 
 vagus than those of any other cranial nerve. 
 
 The eleventh, or spinal accessory, is composed of two portions : one. 
 which joins the pneumogastric and is known as the accessory portion, 
 arises by five filaments from the lateral tract of the cord just below the 
 roots of the vagus, while the other portion, known as the spinal portion, 
 arises by filaments from the lateral tract of the cord as low down as the 
 sixth cervical vertebra. The accessory portion soon joins the vagus and 
 is distributed with it. The spinal portion passes through the jugular 
 
56 THE ANATOMY OF THE HUMAN BODY. 
 
 foramen down into the nock, and supplies two of the muscles of the neck 
 with lilameuts. 
 
 The twelfth, or hyp(>*!:lossal nerve, arises by a dozen filaments from 
 the groove between the ])vraniidal and olivary bodies in a line with the 
 anterior roots of the sj)inal nerves. Each nerve passes from the skull 
 tlironijh an openinij just in front of the kidney-shaped surface upon the 
 occipital bone. The nerve courses d(^»wnward, dividing into branches, 
 and supplies the tongue with its motor impulses. 
 
 The orii^nns of the cranial nerves i2;iven above are those known as 
 superticial. The nerve-roots have nearly all been traced deeply within 
 the gray matter of the brain and their real beginnings located, but to 
 describe them pro])erly would call for a closer and more thorough descrip- 
 tion of the brain than can be given here. 
 
 The spinal nerves are arraiiged in thirty-one j^airs, and after being 
 formed bv the junction of the anterior or motor roots with the posterior 
 or sensory I'oots, they emerge from the spinal canal 
 -^"'^ ■ through openings between the pedicles of the vertebrae. 
 
 A spinal nerve is thus seen to contain both motor and sensory fibres. 
 Upon the sensory roots of the spinal nerves small masses of gray matter, 
 called ganglia, are formed. Each spinal nerve, after passing from the 
 spinal canal, divides into two divisions — an anterior and a posterior. The 
 posterior division is usually small, and divides np into smaller branches 
 which supply the back portion of the neck and body. The anterior divi- 
 sions of the nerves are larger than the posterior, for they supply the main 
 portion of the body and give rise to the large nerve-trunks which supply 
 the extremities. 
 
 The spinal nerves have received names from the regions of the spine 
 in which they emerge, and are further known by numbers in each region, 
 counting from above. Tims there are eight pairs of cervical nerves, 
 each pair consisting of a right and a left nerve. The first cervical nerve 
 emerges from the sj^inal canal between the occipital bone and the first 
 cervical vertebra, while the eighth cervical nerve passes out between the 
 last or seventh cervical vertebra and the first dorsal vertebra. There are 
 twelve dorsal nerves, five lumbar, five sacral, and but one coccygeal nerve 
 upon each side of the body. The anterior divisions of the upper four 
 cervical nerves communicate freely with one another, and thus form what 
 is known as the cervical plexus, and the branches from this plexus are 
 distributed to the muscles and skin on the back of the head and neck and 
 over the back of the shoulder, and one long branch, the phrenic, passes 
 down and is distributed to the diapliragm, and constitutes the motor nerve 
 of that muscle. The anterior divisions of the four lower cervical nerves 
 are remarkable for their large size, and they communicate in a network 
 of branches witli one another and with the first dorsal nerve, forming in 
 
SPINAL NERVES AND SYMPATHETIC GANGLIA. 57 
 
 this manner the bracliiul plexus. Frotn this brachial plcxns are given off 
 the large nerve trunks which pass into and snj)|)ly the upper extremity. 
 The largest of these are the ulnar, upon the inner side ; the median, oc- 
 cupying the middle of the extremity ; and the niusculo-spiral nerve, 
 which winds around the back of the arm and gives off the radial nerve 
 on the outer side of the forearm. The ulnar nerve, as it passes from the 
 arm into the forearm, lies behind the elbow joint and to its inner side, 
 and is frequently hit by blows or falls upon the elbow. Such a contusion 
 of the ulnar rerve gives rise to the peculiar tingling sensation in the 
 lower arm and lingers, and is the cause of that sensation which is ex- 
 perienced when the " funny bone " or "crazy bone " is injured. 
 
 The anterior divisions of the dorsal nerves form the twelve inter- 
 costal nerves, which pass forvt^ard in the spaces between the ribs and 
 supply the walls of the chest and upper abdomen. There being but 
 eleven intercostal spaces, the last intercostal nerve runs along the lower 
 border of the twelfth ril>. 
 
 Tlie anterior divisions of the four upper lumbar nerves form the 
 lumbar plexus, and from this plexus many nerve-trunks arise, most of 
 which pass downward to the lower extremity, being distributed largely 
 upon its anterior side. The largest of these trunks is the anterior crural 
 nerve, which, as it passes from the abdomen into the lower extremity, lies 
 to the outer side of the femoral artery. 
 
 The sacral plexus is formed by the anterior divisions of the fifth 
 luml)ar nerve and of the four upper sacral nerves. The largest branch of 
 this plexus is the great sciatic nerve, the largest nerve of the body. This 
 nerve passes backward across the buttock and downward into the thigh, 
 running behind the knee into the leg. 
 
 The motor nerves of the cerebro-spinal system may be said to control 
 
 the movements of the voluntary muscles. The involuntary muscles, 
 
 which are found in the heart and in the coats of the 
 The Sympatlietic ^ ^ ^ ^ j i; ^i v n • i, j.i, 
 
 ^r o . blood-vessels and of the hollow viscera, such as the 
 
 JVervotis oi/stem. ' 
 
 stomach and intestines, are controlled by another system 
 of nerve-centres and nerve-fibres, and this system is the sympathetic 
 nervous system (Fig. 46). The nerve-centres or ganglia of this system 
 are not collected together into one mass, as in the cerebro-spinal system, 
 but are widely distributed throughout the head and trunk, and are 
 arranged largely in a series of pairs extending along the side of the 
 vertebral column, as follows : 
 
 In the neck or cervical region 3 pairs of ganglia, 
 
 " chest or dorsal "" 12 "' " 
 
 " loin or lumbar " 4 " " 
 
 " sacral " 5 " " 
 
 " coccygeal " 1 ganglion. 
 
58 
 
 THE ANATOMY OF THE HUMAN BODY. 
 
 Besides this series of ganglia there are thi-ee hirge aggregations of 
 ganglia and nerve-iibres, known as ganglionic plexuses. These are situ- 
 ated respectively in the chest, in the belly, and in the pelvis, and are 
 known as the thoracic plexus, the abdominal or solar ])lexns, and the 
 pelvic or hypogastric plexus. There are, further, sympathetic ganglia 
 connected with the fifth cranial nerves in the head, and additional scat- 
 tered ganglia in the great cavities of the body. 
 
 The nerves arising from these centres or ganglia are of two varieties — 
 viz., nerves of communication ;uul nerves of distribution. The branches 
 
 of communication connect with one 
 another the various ganglia, and also 
 connect the ganglia with the nerves 
 of the ccrebro-spinal system, which 
 in turn send branches to the sympa- 
 thetic ganglia. The branches of dis- 
 tribution, by their fre(|uent commu- 
 nications, form plexuses which sur- 
 round and follow the blood-vessels, 
 and they are distributed to the in- 
 voluntary muscular iibres situated 
 in the coats of the blood-vessels and 
 hollow viscera and in the secreting 
 cells. 
 
 The branches of the three cervi- 
 cal ganglia of the sympathetic sup- 
 ply the vessels and glands in the 
 neck, the pharynx, the larynx, and 
 through a collection of ganglia aiid 
 nerves, known as the cardiac plexus, 
 they supply also the heart. In the abdomen the branches of the solar 
 plexus divide and communicate to form many secondary plexuses which 
 supply the various abdominal organs, including the hollow viscera, and 
 thus we have a renal plexus, a gastric plexus, a hepatic plexus, etc. Lower 
 down the hypogastric plexus divides into two pelvic plexuses, branches 
 from which are distributed upon the various pelvic organs, and there is a 
 vesical plexus for the bladder, a prostatic plexus for the prostate gland, 
 a uterine ]ilexus for the uterus, etc. In addition to the branches and 
 plexuses just mentioned, plexuses with their branches accompany all the 
 blood-vessels throughout the head, the trunk, and the upper and lower 
 extremities, so that the whole body is supplied with nerves of the syni- 
 pathetic system. 
 
 Fig. 40. — The fcYMiATiiKTic or ganglionic 
 
 NEKVOU8 6*V.STEM. 
 
THE MOUTH AND TEETH. 
 
 SECTION VII. 
 THE ALIMENTARY CANAL. 
 
 The aliineiitary canal is an irregularly shaped tube, which begins at 
 the lips and ends at the anus. It is about tliirty feet long, and is lined 
 throughout with mucous membrane. It includes the mouth, the pharynx, 
 the oesophagus, the .stomach, the small intestine, and the large intestine. 
 (See Pliysioloijy : The Vital Processes in Healthy Fig. 2.) 
 
 The mouth is guarded in front by the lips, and at the sides is limited 
 by the cheeks, and behind it opens into the pharynx. The roof of the 
 mouth is formed in front by the hard palate and behind by the soft 
 
 Fig. 47. — Temporahv and peemanent teeth. ( Sappey.) 
 1, 1, temporary central incisors; 2, 2, temporary lateral incisors; 3, 3, temporary canines; 4,4. 
 temporary anterior molars; 5, 5, temporary posterior molars ; 6, 6. permanent central incisors ; 
 7, 7, permanent lateral incisors; 8, 8, permanent canines; 9, 9, permanent first bicuspids; lo! 
 10, permanent second bicuspids; 11, 11, first molars. 
 
 palate, which is drawn up during the act of swallowing, so as to shut off 
 the pharynx from the nasal cavities. From the middle of the soft palate 
 hangs the uvula. 
 
 In the mouth are the teeth, and man is furnished during his life with 
 two sets — one set for childhood and a second for adult life (Fig. 47j. 
 
60 THE ANATOMY OF THE HUMAN BODY. 
 
 The teeth of tOiildhood, called the temporary or milk teeth, are twenty 
 in number, ten for each jaw — viz., four incisors or cuttino; teeth, situated 
 in front ; back of these upon each side one canine or 
 tearing tooth ; and still farther back, two molars or 
 grinding teetli, upon each side. The temporary teeth appear as fol- 
 lows : 
 
 Seventh month, the central incisors. 
 
 Seventh to tenth month, the lateral incisors. 
 
 Twelfth to fourteenth month, the anterior molars. 
 
 Fourteenth to twentieth month, canine. 
 
 Eighteenth to thirty-sixth month, posterior molars. 
 
 The teeth of the lower jaw make their appearance somewhat before 
 those of the upper jaw. 
 
 The permanent teeth are thirty-two in number, sixteen for cacli jaw : 
 in front four incisors; behind these, u])on each side, one canine; farther 
 back, upon each side, two bicuspids ; and still farther back, upon each side, 
 three molars. Of these teeth, the incisors, the canine, and the bicuspids 
 correspond in position to the teeth of the temporary set, while the per- 
 manent molars occupy a new portion of the jaw, which has developed as 
 the result of growth. The teeth of the permanent set appear at the fol- 
 lowing periods : 
 
 Six and a half years, first molars (''six-year molars"). 
 
 Seventh year, central incisors. 
 
 Eighth year, lateral incisors. 
 
 Ninth year, first bicuspids. 
 
 Tenth year, second bicuspids. 
 
 Eleventh to twelfth year, canine. 
 
 Twelfth to thirteenth year, second molars. 
 
 Seventeenth to twenty-first year, third molars ('' wisdom teeth "). 
 
 The teeth of the lower jaw appear before those of the upper. Upon 
 each side of the opening from the mouth to the pharynx is found the 
 tonsil, a gland of rounded form. 
 
 The mouth is supplied with moisture by mucous glands situated 
 
 everywhere in its mucous-membrane lining, and the first of the digestive 
 
 fluids with which the food comes in contact is also 
 
 e I- rn 7 pourcd iuto the mouth. This is the saliva, and it is 
 balivary (jrlanas. ^ _ ' _ 
 
 secreted by six salivary glands, three upon each side 
 (Fig. 48) : the parotid gland, situated around and below the ear; the sub- 
 maxillary gland, situated under the jaw, near its angle ; and the sub- 
 lingual gland, which lies under the tongue near the front. It is the 
 inflammation and swelling of the parotid gland that is known as 
 " mumps." 
 
 The pharynx is the dilated portion of the swallowing tube which lies 
 
THE PHARYNX, GULLET, AND ABDOMEN. 
 
 01 
 
 Fig. 48. — Salivary glands. (Tracy.; 
 
 behind the nasal cavities, the mouth, and the upper portion of the wind- 
 pipe or larynx. It is made up of muscle, and is lined with mucous 
 membrane. Upon each side above opens the Eusta- 
 Vt^ ; chian tube, which connects the cavity of the middle ear 
 
 (jbsopliafjUK. _ ' ^ J 
 
 with the mouth and hence with the outer world. Be- 
 low, the pharynx opens and 
 merges into the oesophagus. 
 
 The oesophagus or gullet is 
 the canal which leads from the 
 pharynx above downward into 
 the stomach below. It thus has 
 to pass through the chest cavity, 
 and, perforating the diaphragm, 
 enters the belly cavity and con- 
 nects with the stomach. It is 
 nine inches long and is made up 
 largely of muscular tissue of the 
 involuntary variety, and it is 
 lined with mucous membrane. 
 The point of its smallest calibre 
 is where it pierces the diaphragm, 
 as may be seen by referring to 
 Fig. 24, e. Its course is somewhat curved, but its general direction is 
 downward, backward, and to the left. 
 
 The abdomen (Fig. 49) is the largest cavity of the body, and extends 
 from the diaphragm above to the bottom of the pelvic cavity below. But 
 the term " abdomen," as usually employed, is limited to 
 the large portion of the general cavity situated above 
 the pelvis. The abdomen is limited behind by the vertebi'se and lower 
 ribs, and is surrounded and inclosed by its muscular walls. The abdomen 
 proper contains the following organs or viscera : Of digestion, the lower 
 end of the oesophagus, the stomach, the small intestine, the large intestine 
 (except its lower end, known as the rectum), the liver and gall bladder, and 
 the pancreas ; of secretion, the kidneys with their ureters, and, when dis- 
 tended, the urinary bladder ; of circulation and absorption, the aorta and 
 inferior vena cava and their branches, the lymphatic vessels and glands, 
 with the beginning of the thoracic duct ; and the spleen, besides many 
 nerves. The pelvis contains in the male the rectum and bladder ; and in 
 the female also the vagina, uterus, and ovaries. 
 
 The inner membranous lining of the abdomen is the peritonaeum, and 
 it may be roughly described as forming a closed sac divided into two 
 compartments, the greater and the lesser peritoneal cavities. Into this 
 sac bulge the various abdominal organs, some to such an extent as to be 
 
 The Abdomen. 
 
62 
 
 THE ANATOMY OF THE HUMAN BODY. 
 
 almost coaipletely enveloped b^' the peritoiueuni, other;? only being 
 covered in front by the membrane. The peritonaeum lines the walls of 
 
 the abdomen and also 
 many of the viscera, and 
 in many cases it forms 
 folds which hold the 
 viscus or organ in place. 
 A large fold of peri- 
 tonaeum passes down in 
 front of the intestines 
 I'rom the lower border 
 of the stomach, forming 
 the great omentum or 
 apron, and contains 
 much fat within its lay- 
 ers. The periton.eum 
 is a serous membrane, 
 and as all serous cavi- 
 ties have a direct and in- 
 timate connection with 
 the lymphatic system, 
 they readily absorb bac- 
 terial poisons and are 
 prone to serious inflam- 
 mation when exposed to 
 infection. 
 
 Fig. 4'J. — Position of abdominal contents. 
 1, inferior surface of tlie liver; 2, round litraiuent of the liver; 
 3, gall bladder ; 4, superior surfuee of the ri;rht lobe of the 
 liver; 5, diaphragiii ; 6, lower portion of the oisophagus; 
 7, stomach; 8, gastro - hepatic omentum: 9, spleen; 10, 
 gastro-splenic omentum; 11, duodenum; 12, 12, small in- 
 testine; 13, c»cum ; 14, appendix vermiformis; 15, 15, 
 transverse colon; lO, sigmoid flexure of the colon; 17, 
 urinary bladder. 
 
 The stomach (Fig. 
 50) is a dilated portion 
 of the alimentary canal, 
 measuring, when mod- 
 erately distended, twelve 
 inches by four. It lies 
 in the upper left and 
 middle region of the abdomen. The oesophagus opens freely into 
 the stomach on its upper border and near to its left extremity. This 
 is called the cardiac opening because of its nearness 
 to the heart, being separated from that organ only 
 by the diaphragm. At the right or pyloric end of the stomach is the 
 opening into the beginning of the small intestine. This opening into 
 the small intestine is guarded by a circular valve known as the pyloric 
 valve. 
 
 The stomach is made up of four coats : (1) Serous, external, and de- 
 rived from the peritonaeum ; (2) muscular, consisting of unstriped or in- 
 
 The Stomach. 
 
A DISSECTION OF THE HUMAN BODY 
 
 Showing the Principal Organs and Vessels in the Abdominal 
 
 and Thoracic Cavities. 
 
THE STOMACH AND INTESTINE. 
 
 63 
 
 voluntary muscular fibres arranged in layers and running in all directions; 
 
 (3) areolar, composed of loose tissue in which pass the vessels; and (4) 
 
 mucous, internal. This mucous membrane lines the cavity oi the 
 
 stomach, and when the stoniach is empty it is thrown into numerous 
 
 longitudinal folds. Imbedded in the mucons membrane are the gastric 
 
 follicles, of which there are two varieties, differing in structure and in 
 
 the substance they secrete. These are (1) the pyloric glands, named from 
 
 being most numerous in the neighbourhood of the pylorus, which secrete 
 
 a substance something like nmcus ; and (2) the peptic glands, found all 
 
 over the stomach, which secrete the gastric juice. 
 
 The small intestine is a tube something over twenty feet in length, 
 
 which extends, with many curves, from the stomach to the beginning of 
 
 ^, „ , the large intestine. The first ten inches of the small ijut 
 
 The Small . , , , , . . , . . , " 
 
 Intestine. ^^ somewhat larger than the rest of it, and it is known as 
 
 the duodenum. It is curved like a horseshoe, and into 
 the concavity of the curve is placed the large end or head of the pancreas. 
 Into the lumen of the duodenum, at about its middle, empties the com- 
 mon bile and pancreatic duct. 
 The upper two fifths of the rest 
 of the small intestine is known as 
 the jejunum, and the lower three 
 fifths is the ileum. The ileum 
 joins with the big gut in the lower 
 right region of the abdomen. 
 
 The small intestine is composed 
 of four coats : (1) Serous, from the 
 peritonaeum ; (2) muscular, con- 
 sisting of invohmtary fibres run- 
 ning in two directions, lengthwise 
 and crosswise around the gut ; (3) 
 
 areolar, containing the vessels ; and (4) the mucous coat, which contains 
 muscular fibres, vessels, and glands. The mucous membrane is thrown 
 into numerous folds, which run crosswise, and from its surface project a 
 great number of very small club-shaped processes each containing the 
 beginning of a lacteal vessel, and whose function is absorption. Scattered 
 through the whole small intestine are the glands_, and in the ileum these 
 occur in groups or aggregations known as Peyers patches. In typhoid 
 fever these patches are inflamed and ulcerated. 
 
 The large intestine extends from the ileum to the anus, and is about 
 five feet long. It is much larger than the small intestine, and is largest 
 at its commencement, where it is called the csBCum. The large intestine 
 is divided into regions of which there are three — viz., the caecum, the 
 colon, and the rectum. The caecum is the large pouch which constitutes 
 
 Fig. 50. — The stohach. 
 
64 THE ANATOMY OF THE HUMAN BODY. 
 
 tlie coiniiieneeinont of the big gut, iuul it iiiL-asuivs two and a (juarter bv 
 three inches iu diaiueter. Connected with the lower and back part of 
 the ca?cuin is a narrow, wornilike tube, the venniforni 
 Inteiiii append ii'. This in some of the lower animals is very 
 
 large and adds to the size of the cajcum, but in many 
 animals, including man, it has become rudimentary and shows a ten- 
 dency to disappear gradually in the process of evolution. Opening into 
 the inner side of the large intestine, at the point where the c{\»cum 
 becomes colon, is seen the ileum. This 0])ening is ])roteeted by a valve 
 which allows matter to pass from the small intestine into the large, but 
 prevents more or less completely its retui-n from the large intestine into 
 the ileum. This is the ileo-ca^cal valve. 
 
 The colon is divided according to the direction in which it passes 
 into four regions — viz. : (1) Ascending colon, which passes up along the 
 right side of the abdomen, lying nearer to the back than the front, until 
 it reaches the under surface of the liver, when it makes a turn nearly at 
 right angles and becomes the (2) transverse colon. The transverse colon 
 passes across the body below the stomach, and upon the left side near the 
 spleen it curves downward and becomes the (3) descending colon. The 
 descending colon passes down until the left innominate bone is reached, 
 at which point the large gut becomes sinuously curved and is called the 
 (4) sigmoid flexure. 
 
 The last section of the large intestine and of the alimentary canal is 
 the rectum. The rectum is from six to eight inches long, and extends 
 from the sigmoid flexure above to the anal opening below. The rectum, 
 as in the other portions of the gastro-intestinal tract, has the four coats. 
 The serous coat, ho-svever, does not cover the lower portion of the viscus, 
 and the muscular coat is especially well developed. Just above the anus 
 the rectum is considerably dilated. The direction of the rectum from 
 the anal opening is upward and backward at first and then it passes to 
 the left side. The mucous membrane of the rectum is in transverse folds, 
 and these are sometimes very large and will interfere with the passage of 
 an instrument into the rectum. The anal opening is guarded and con- 
 trolled by two sets of circular muscular fibres, known respectively as the 
 external and internal sphincters. The blood-vessels of the rectum are 
 the haemorrhoidal arteries and veins, and the veins frequently become 
 dilated and varicose and give rise to the condition known as luemorrhoids 
 or piles. 
 
STRUCTURE AND FUNCTIONS OF THE LIVER. 
 
 SECTION VIII. 
 THE LIVER, PANCREAS, AND SPLEEN. 
 
 THE LIVER. 
 
 The liver is the largest gland in the body, and is situated in the upper 
 
 right and mid regions of the abdomen, lying mostly under the ribs of the 
 
 right side, and weighs about four pounds in the healthy 
 Size, Location, and i i, t, i . t j ^• ,i i i n ' 
 
 functions adult. Its longest diameter lies across the body, and is 
 
 about twelve inches ; from behind forward its diameter 
 is something over six inches. It is thickest through upon its right side, 
 where it measures about three inches, and it thins out as it extends toward 
 the left so as to present a thin edge. It has two functions — the secretion 
 of the bile and the production of peculiar chemical changes in certain of 
 the constituents of the blood brought to it through the portal circulation. 
 The latter action is the glycogenic function. 
 
 The upper surface, smooth and rounded, is covered by peritonseum 
 and divided by a fissure into two lobes, the right being much larger than 
 
 the left. This surface is in contact with the diaphragm. 
 , ^ . ' , ' The under surface (Fig. 51) is somewhat hollowed out, 
 
 and is divided by a broad fissure into two large lobes, 
 a right and a left. Between the right and left lobes are four other fis- 
 sures, such as the fissure for the gall bladder, fissure for the inferior vena 
 cava, etc., which subdivide this portion of the liver into three other lobes. 
 The under surface of the liver is covered with peritonaeum, and is in con- 
 tact with the stomach, the duodenum, the colon, where it makes a turn 
 from ascending to transverse, and with the right kidney. The liver is 
 held in place by five ligaments, four of which, however, are not liga- 
 mentous, being merely folds of the peritonseum. 
 
 The vessels of the liver are, like the fissures, lobes, and ligaments, five 
 in number — viz. : (1) The hepatic artery and (2) the portal vein, which 
 
 convey the blood to the liver, the former from the heart 
 Vessels. ' . . 
 
 and the latter from the gastro-intestinal tract ; (3) the 
 
 hepatic veins, which convey the blood from the liver and which empty 
 into the inferior vena cava. There are three large hepatic veins and 
 many smaller ones. (-1) The hepatic duct, which is formed by the many 
 ducts within the liver and which conveys the bile from the liver : and (5) 
 the lymphatic vessels, which are numerous and distributed freely through- 
 out the liver. The liver substance is made up of liver cells, which give 
 the appearance of honeycomb when the liver is seen through a microscope. 
 7 
 
GG 
 
 THE ANATOMY OF THE HUMAN BODY. 
 
 These liver eell> are of rouiKled variety Imt are rendered nianv-sided b}' 
 being so crowded together. They vary in size from y^Vir ^^^ ^rhi^ ^^ '^'^ 
 inch in diameter. These liver cells are the bile-secreting element of the 
 liver, and they are surrounded by a close network of small blood-vessels 
 and by the beginnings of the hepatic duct. 
 
 The gall bladder is a pear-shaped membranous bag in which the bile 
 is stored when not needed immediately in the intestine. It holds some- 
 thing more than a fiuidounce. It lies upon the under 
 The Gall Bladder. ,." j, . ,. -lA -i. ^ i -c i r 4.1 
 
 surface of the liver with its jiead or fuiuhis directed 
 
 forward, while its opening is directed backward. It is lined with mucous 
 membrane. 
 
 Fio. ."il. — Under surface of the liver, showing the gall bladder and a section of blood- 
 vessels. 
 
 Ducts. 
 
 The ducts by which the bile passes from the liver are three in num- 
 ber : (1) The hepatic duct, which is formed by the junction of two trunks 
 into which have been collected all the many smaller 
 ducts of the liver. This hepatic duct is about an inch 
 and a half long, and unites with (2) the cystic duct, which is small and 
 about one inch in length. By this junction the hepatic and cystic ducts 
 form (-3j the common bile duct. This common bile duct is about three 
 inches long and empties into the duodenum near its middle, joining just 
 at the point of entry with the pancreatic duct. 
 
 THE PANCREAS. 
 
 The pancreas (Fig. 52) is a gland similar in structure to the salivary 
 glands, and is shaped like a dog's tongue, having at its right extremity a 
 broad end called the " head " of the pancreas, and tapering toward the 
 
THE PANCREAS AND SPLEEN. 
 
 07 
 
 left to a point tliat forms tlio " tail " of the paiicroaH. Tlic tci'iri " hody " 
 is applied to that. portion of gland lying between these two ci)d,s. 1'he 
 
 pancreas is soft and loose in texture, and is not in- 
 
 Structure, Location. i i i t i t i i . . i 
 
 ' ,. closed by a surrounding capsule. Jn sheep and cattle 
 
 and Inincnon. /' o i i 
 
 it constitutes the " sweetbreads " of the market. 
 The pancreas lies in the upper middle and left portion of the abdo- 
 men, and measures about seven inches in length by an inch and a half 
 
 Fig. 52. — The pancreas, partLy out away, so as to 
 
 snow THE DUCT WHICH COLLECTS THE PANCREATIC 
 JUICE AND EMPTIES IT INTO THE DUODENUM. 
 
 in breadth and three quarters of an inch in thickness. The pancreas 
 weighs about three ounces. Running from left to right through the 
 gland is the pancreatic duct, which, receiving branches in its course, grad- 
 ually increases in size. After leaving the head of the pancreas the duct 
 opens into the middle of the duodenum, usually joining with the common 
 bile duct at the point of entry. 
 
 The function of the pancreas is to secrete the pancreatic juice, one of 
 the five dio-estive fluids. 
 
 Structure, Size, 
 and Weight. 
 
 THE SPLEEN. 
 
 The spleen is usually described as a " ductless " gland, because it 
 possesses no canal through which its secretion can be conveyed. It is of 
 flattened oval shape and somewhat curved, so as to pre- 
 sent a hollowed-out surface toward the stomach, to the 
 left of which it lies. The spleen is dark-red in colour, 
 contains many and large blood-vessels, and is of a brittle consistence. It 
 is situated in the upi^er left region of the abdominal cavity, and when 
 small lies under the lower ribs of the left side. The spleen is five inches 
 long, four inches wide, and in thickness it measures about an inch, and 
 weighs about seven ounces. It is relatively much larger in an infant than 
 in the adult, and as a result of malarious poison sometimes becomes 
 enormously enlarged. It is always larger after a full meal than during 
 fasting. 
 
 The spleen is supposed to have to do with the formation of blood- 
 corpuscles, and also to have some office connected with the digestion or 
 assimilation of food. Persons from whom it has been removed do not, 
 however, seem to suffer any great inconvenience. 
 
68 THE ANATOMY OF THE HUMAN BODY. 
 
 [SECTION IX. 
 THE THORAX. 
 
 The thorax (Figt^. S and 0) is the name a]")plied to the framework, 
 composed partly ot" bone and partly of soft tissues, which incloses the 
 cavity of the chest known as the thoracic cavity. Tlic walls of the thorax 
 are made np in part by the sternum aiul npper six costal cartilages in 
 front, at the side by the ribs, and behind by the ribs and dorsal vertebrae ; 
 and in part by the muscles and fascia which are attached to these struc- 
 tures. 
 
 The cavity of the thorax is nan-ow above, and the opening into the 
 
 neck is small. Jn its lower part the thoracic cavity is wider, because of 
 
 the increased length of the ribs and the bulging for- 
 
 nn y o le ^y.^y^ Qf \\^q sternum or breast bone, and also because of 
 
 the curve backward of the spinal column m the dorsal 
 
 region. Below, the cavity of the thorax is limited by the diaphragm, and 
 
 on account of the oblique position occupied by this muscle, which is 
 
 attached in front to the sternum at the level of the sixth and seventh 
 
 costal cartilages, and behind to the last or twelfth rib, the chest cavity is 
 
 much deeper behind than it is in front. It is also much wider from side 
 
 to side than from before backward. 
 
 Besides vessels and nerves and glands, the thorax contains the heart, 
 inclosed in its sac, the pericardium, and the lungs, inclosed by the pleural 
 membranes. The heart, with its pericardium and the position it occupies 
 within the chest, has already been described on a preceding page of this 
 article. 
 
 SECTION X. 
 THE ORGANS OF VOICE AND RESPIRATION. 
 
 As in descril)ing the gastro-intestinal tj'act we began at the lips and 
 followed the canal downward through its course, in describing the lungs 
 we shall begin with the larynx and windpipe and follow them into the 
 chest, where are located the lungs. 
 
 The larynx is the upper dilated portion of the windpipe, and is espe- 
 cially adapted to include the vocal cords and the muscular mechanism 
 which moves them (Fig. 53). The air-passages from 
 mi/ii. . ^^^^ trachea to the lips, inclusive, represent the pipe of 
 an organ, and as there is only one pipe, the production of the different 
 sounds is made possible by an elaboration of detail ; thus the vocal cords 
 
THE OEGANS OF VOICE AND RESPIRATION. 
 
 69 
 
 by which the air is caused to vihrate to produce the sound can be rendered 
 lax or very tense, and the size of the space throng]; wliicli the air passes 
 can also be rendered large or small. (See I'/ujKlologij : 77ie Vital Pro- 
 cesses in Healthy Fig. 22, A^ B.) 
 
 The larynx is, then, the organ of voice, and is made up of a iiiinibf-r of 
 pieces of cartilage joined together by ligaments in such a way that con- 
 siderable motion between them can take 
 place (Figs. 54, 55). There are nine of 
 these cartilages : three single — the thyroid, 
 the cricoid, and the epiglottis ; and six iu 
 three pairs — two arytenoid, two cornicula 
 laryngis, and two cuneiform. The cornic- 
 ula laryngis and cuneiform cartilages are 
 very small. The epiglottis is shaped like a 
 leaf, and is attached by the stem to the thy- 
 roid cartilage in the median line in front. 
 During breathing the epiglottis maintains 
 an upright position, but during the act of 
 swallowing it closes down over the opening 
 of the larynx, and thus prevents the en- 
 trance of food into the air-passages. The 
 thyroid cartilage is composed of a right and 
 a left side which unite in front, forming 
 the " Adam's apple," which can be seen 
 and felt beneath the skin in front of the 
 throat. The thyroid cartilage forms the 
 side and front of the greater portion of the 
 larynx, and to the middle of its interior sur- 
 face are attached the front extremities of 
 the vocal cords. The arytsenoid are two 
 triangular-shaped cartilages placed at the 
 back of the larynx and separated by an in- 
 terval. To these cartilages are attached the 
 posterior or rear end of the vocal cords. 
 The cricoid cartilage is the foundation 
 structure of the larynx, to which the tliy- 
 roid and arytsenoid cartilages are attached 
 and upon which they move. It is shaped 
 like a signet ring Math its expanded side 
 placed posteriorly. It is attached below to the first ring of the trachea. 
 The interior of the larynx is lined with mucous membrane. The true 
 vocal cords pass from behind forward from the arytfenoid to the thyroid 
 cartilage, and have between them a narrow fissure known as the glottis ; 
 
 Fig. 53. — Longitudinal section of 
 the human lakynx, showing the 
 VOCAL CORDS. (Sappev.) 
 
 1, ventricle of the larynx ; 2, superior 
 •vocal cord ; 3, inferior vocal cord ; 
 4, arytenoid cartilage: 5, section 
 of the arytsenoid muscle ; 6, 6, in- 
 ferior portion of the cavity of the 
 larynx; 7, section of the posterior 
 portion of tlie cricoid cartilage ; 
 8, section of the anterior portion 
 of the cricoid cartilage; 9, supe- 
 rior border of the cricoid carti- 
 lage ; 10, section of the thyroid 
 cartilage ; 11, 11, superior portion 
 of the cavity of the larynx ; 12, 
 13, arytaenoid gland: 14,16, epi- 
 glottis: 15. 17, adipose tissue; IS, 
 section of the hyoid bone ; 19, 19, 
 20, trachea. 
 
ro 
 
 THE ANATOMY OF THE HUMAN BODY. 
 
 The Trnchen. 
 
 aiid above the true vocal cords are two fokls of mucous nuMiihi-aiie known 
 
 as the false vocal cords. 
 
 The trachea or windpipe is a tube four and a half inches loni^;, which 
 extends from the larvnx downward to divide into the two ])ronchi. (See 
 J^Iiysiohxji/ : Tike Vital Processes in Healthy Fig. 5>.) 
 It is not ([uire cylindrical in shape, for it is Hattened in 
 the rear. It is nearly an inch in diameter froni side to side, and is com- 
 posed of about twenty incomplete rings of cartilage held together l)y a 
 fibrous membrane containing a few muscular til)res. All of these rings 
 are incomplete behind where the tube is completed by librous membrane. 
 The trachea behind lies in contact with the cesophagus and divides below 
 into a right and a left bronchus for the right and left lung respectively. 
 
 yiG. 54.— Posterior view hv the muscles of Fio. o5. — ^Lateral view of the muscles of 
 THE LARYNX. (Sappuy.) the larynx. (Sappey.) 
 
 Fig. 54. — 1, posterior crico-aryttenoid muscle; 2, 3, 4, different fasciculi of the arytjenoid muscle 
 5. uryticno-epicrlottidcan luuscle. 
 
 Fig. 55.— 1, body of the liyoid bone; 2, vertical section of the thyroid cartilage; 3, liorizontal sec- 
 tion of the thyroid cartilage, turned downward to show the deep attachment of the crieo-thy- 
 roid muscle; 4, facet of articulation of the small cornu of the tliyroid cartilage with the cricoid 
 cartilage ; 5, facet ou the cricoid cartilage ; 6, superior attachment of the cri co-thyroid muscle ; 
 V, posterior crico-aryta?noid muscle ; 8, lateral crico-arytoanoid muscle ; 0, thyro-urytsenoid 
 muscle; 10, aryticnoid inuselo; 11. arytieno-epiglottidean muscle ; 12, middle thyro-hyoid liga- 
 ment; 13, lateral thyro-hyoid ligarnunt. 
 
 These two bronchi subdivide many times, until finally they become very 
 small and enter into the formation of the lungs themselves. 
 
 The lungs are the organs of respiration, and form the bellows which 
 forces the air through the larynx and makes possible the production of 
 sound. There is a right and a left lung, and between them nestle the 
 heart and the large blood-vessels (Fig, 50), Each lung is cone-shaped, 
 
THE LUNGS AND PLEURA. 
 
 71. 
 
 with the apex upward at tlie root of the neck, and the base downward in 
 
 contact with the diaphj-ai^in. Each lung is divided into lobes, the left 
 having two and the right having three lobes. Tins lungs 
 are light pink in colour and are of a spongy texture. 
 
 Because of the air contained within them, the lungs will float in water. 
 
 The weight of both lungs taken together is aljout fortj-two ounces. Wlien 
 
 The Lungs. 
 
 Fig. 5G. — Showing the relative position of heart and lungs in the cavity of the chest. 
 A, left lung ; £, heart ; D, pulmonary artery ; £, trachea, or windpipe. 
 
 lung tissue is examined under the microscope it is found to be composed 
 of many-sided cells varying from Jg to 3-^ of an inch in diameter, and 
 having very thin walls. These are the air-cells, and they are found 
 grouped around and opening into the smallest division of the bronchial 
 tube. Lying closely around these air-cells are plexuses of the pulmonary 
 capillaries, the walls of which are also very thin, and it is here that the 
 interchange of substances takes place between the pure air that has been 
 breathed into the lungs and the impure blood brought to the lungs 
 through the pulmonary artery. The inner surface of the chest wall and 
 the lungs and pericardium, and also the large vessels in part, are covered 
 by a serous membrane called the pleura. The pleura, as is the case with 
 the peritonaeum in the abdomen, forms a closed sac — the pleural sac or 
 cavity. Inflammation of the pleura is known a.^ jjleiirisy. 
 
 Bearing an anatomical relation with the air-passages, hut having no 
 direct functional relation with respiration, are two ductless glands (Fig. 
 
72 
 
 THE ANATOMY OF THE HUMAN BODY. 
 
 57). One of them lies upon the front and side of the lower portion of 
 the larvnx and upper portion of the trachea, and is known as the thy- 
 roid gland. AVhen this gland is enlarged it may be 
 The Thyroid mul j.^,,^^|ji^, g^g^ j^^j f,.lt^ an cf gives rise to the condition 
 
 known as o;oitre. When this gland becomes functionally 
 inactive peculiar changes take place in the body, resulting in the disease 
 known as niyxcedeina. The other of these two ductless glands is the 
 
 Fio. 57. — Thyroid and thymus glands. (Sappey.) 
 A. 1, rijrht lobe of the thymus; 2, left lobo ; 3, grroove between the two lobes; 4, liin!::^, the ante- 
 rior borders raised to show the thymus; 5, terminal branch of tlie internal mammary vein; 6, 
 thyroid gland; 7, median inferior thyroid veins; 8, lateral inferior thyroid veins; 9, common 
 carotid artery; 10, internal juijular vein; 11, pneumoj,'astric nerve. B. Rii^'lit lobe of the thy- 
 mus with the investing membrane removed. 1, upper extremity of the lobe ; 2, lower extrem- 
 ity ; 3, external border; 4, internal border. C. Arranjjement of the lobules of the same lobe, 
 around the central cord. 1, upper extremity of tlie lobe; 2, lower extremity; 3, 3, 3, lobules: 
 4, 4, central cord. 
 
 thymus, which lies upon the front and sides of the lower trachea, 
 gland is much larger in the infant than in the adult. 
 
 This 
 
THE KIDNEYS, URETERS, AND BLADDER. 73 
 
 SECTION XL 
 THE URINARY ORGANS. 
 
 The two kidneys, a right and a left, are placed in the hack part 
 of the abdomen in the region of the loins, and are separated from one 
 _, ^,., another by the bodies of the twelfth dorsal and the first 
 
 and second lumbar vertebrae. The right kidney is 
 somewhat lower than the left. The kidneys are outside of the peritoneal 
 cavity, their front surfaces only being partly covered . by peritonaeum. 
 Each kidney is about four inches long by two inches wide and one inch 
 in thickness. The kidney weighs about five ounces. Its front and back 
 surfaces are flattened, its outer edge is rounded, and its inner somewhat 
 hollowed out. (See Physiology : The Vital Processes in Health.^ Fig. 12.) 
 This hollowed-out space is occupied by the dilated commencement of the 
 duct leading from the kidney to the bladder. This duct is the ureter, 
 and the upper dilated portion is known as the pelvis of the kidney. The 
 kidney is made up essentially of small bodies called Malpighian bodies, 
 and of small and large tubes leading from them into the pelvis of the 
 kidney. Malpighian bodies are composed of a tuft of capillary blood- 
 vessels inclosed in a sac, which is the beginning of a small tube or tubule. 
 The tubules curve and twist upon themselves in a complicated manner, 
 and are surrounded by a network of veins. It is at these two places — 
 the Malpighian bodies and the venus plexus surrounding the tubules — that 
 the fluid and solid ingredients leave the blood. After a circuitous course 
 the tubes open into the pelvis of the kidney. 
 
 The ureters are the ducts of the kidney, and they begin above at the 
 pelvis of the kidney and pass downward and slightly inward into the pel- 
 vis to reach the bladder upon its rear surface. They 
 Ureters and Supra- , ,1 1 t i i -i. 1 j.- rpi . 
 
 , ^ , enter the bladder near its lower portion. Ine ureters 
 re7ial Capsules. * 
 
 are about seventeen inches long and are about the size 
 of a goose-quill. Lying above each kidney is another of the " ductless " 
 glands of the body. They are the suprarenal capsules. 
 
 The bladder, the reservoir of the urine, is contained within the cavity 
 of the pelvis, but when it is much distended it rises up into the abdomen 
 proper, and occasionally reaches as high as the umbili- 
 cus. In the male the bladder lies directly in front of 
 the rectum, but in the female the vagina lies between the rectum and 
 the bladder. The capacity of the female bladder is something more 
 than the male, though when empty the male is the larger. The bladder 
 is covered above and behind by peritoneum, but there is a small space in 
 
74 THE ANATOMY OF THE HUMAN BODY. 
 
 front, close to tlio bone of the pelvis, which is outside of the ]>eritoneal 
 cavirv, Avhere the bhiikler may he tajijied without dan>;er of injury to the 
 peritonivum. The hhukler is hekl in ])laee by tive true h^anients and by 
 live folds of peritona'um, called false ligaments. One of the true liga- 
 ments is a cord wliieh extends from the top of the bladder to the umbil- 
 icus. This is the urachus, and it is the obliterated remains of a large duct 
 which in the embryo connects the cavity of the bladder with a sac outside 
 the body, called the allantois. 
 
 The bladder is composed of three coats : (1) The serous coat from 
 the peritonanim, which only partially covers the bladder ; (2) the mus- 
 cular coat, composed of three layers of unstriped muscular iibres; and 
 (3) the mucous coat, which forms the mucous mend:)rane lining the 
 bladder. 
 
 The canal leading from the bladder to the body surface is called the 
 urethra. In the male the urethra is about nine inches long and is divided 
 into three main portions : (1) The prostatic portion, 
 next to the bladder, the widest portion of the canal, is 
 about an inch and a quarter in length, and lies within the prostate gland ; 
 (2) the membranous portion, the narrow part of the canal, is about three 
 quarters of an inch in length ; (3) the spongy or penile portion of the 
 urethra is about six inches long. Just behind the outer opening or meatus 
 the urethra is dilated into a pouch which is called the fossa navicularis. 
 
 The average size of the male urethra is three eighths of an inch. In 
 the female the urethra is only an inch and a half in length, and opens 
 outwardly just in front and above the opening into the vagina. 
 
 SECTIOX XII. 
 THE ORGANS OF SPECIAL SENSE. 
 
 There are five organs of special sense — namely: the tongue, the seat 
 of the sense of taste ; the nose, of the sense of smell ; the eye, wherein 
 resides the sense of sight ; the ear, the organ of hearing ; and the skin, in 
 which resides the organs of the sense of touch. 
 
 The tongue, the organ of the special sense of taste, occupies the floor 
 of the mouth, and is composed almost entirely of muscle. The base or 
 root of the tongue is at the back and is attached to the 
 small IT-shaped bone — the hyoid bone. To this bone 
 is attached some of the muscles of the pharynx, and from it the larynx is 
 suspended by a fibrous membrane. The tip of the tongue looks forward 
 and lies just behind the lower incisor teeth and is freel}' movable. The 
 
OEGANS OF TASTE AND SMELL. 75 
 
 back or dorsum of the tongue is usually convex, but may be inadc to as- 
 sume a deeply concave appearance. The mucous membrane of the 
 tongue is richly supplied with papillae, which are elevations containing 
 minute branches of capillary vessels and maiiy small nerve-fibres. They 
 are covered by a layer of protecting cells called e])ithcnum or epithelial 
 cells. These papillae are of three sizes. The largest, from eight to ten in 
 number, occupy the back of the dorsum and are arranged in two lines, 
 which are directed backward and inward and join to form a V; the 
 medium-sized papillae occupy the sides and apex of the tongue, while upon 
 the forward two thirds of the dorsum are distributed the jtapillae of 
 smallest size. In the papillae of large and medium size are found the 
 so-called '•' taste-goblets." 
 
 The nose is the organ of the special sense of smell, and is composed of 
 two portions, one external and projecting — the nose ; and the other con- 
 tained within the skull — the nasal fossae or cavities. 
 (See Physiology : TIte Vital Processes in Health, 
 Figs. 43 and 44.) The whole organ is divided into two compartments, a 
 right and a left, by a median partition called the saeptum. 
 
 The prominent, projecting portion of the organ of smell, commonly 
 called the nose, is formed in small part by the nasal bones of the face, but 
 chiefly of five pieces of cartilage, two on each side and one forming the 
 saeptum. The nose is lined inside with mucous membrane and covered 
 upon the outside by integument, and just within the openings of the nose, 
 or the nostrils, are a number of hairs. 
 
 The main portion of the organ of smell is formed bj' the nasal cavities 
 or fossae. These open in front into the nose by openings called the an- 
 terior nares, and behind into the upper pharynx by the 
 Nasal Cavities. , . rr,, -, ... • , ".I • ' , 
 
 posterior nares. ihey have projecting into their outer 
 
 walls the turbinated bones, and are divided by a saeptum made up mostly 
 of the vomer bone. Each fossa has opening into its outer wall a chamber, 
 which exists in the interior of the superior maxillary bone, called the 
 antrum of Highmore. Opening into the upper part of each fossa is the 
 canal leading from the eye, w^iich conducts the tears into the nose when 
 the secretion of this fluid is not excessive. The nasal fossae are lined 
 with mucous membrane, and to the upper part of this are distributed the 
 branches of the olfactory nerve — the nerve of the special sense of smell. 
 The mucous membrane of the lower portion of the nose is supplied with 
 nerves of ordinary sensation only, and is designated as the respiratory 
 portion of the nose. 
 
 The eyes are the organs of sight, and they are contained witlun the 
 orbits, which are cavities formed by the bones of the head and face for 
 the reception of the eyeballs. Seven bones enter into the formation of 
 each orbit — three of the head and four of the face. The three of the 
 
70 
 
 THE ANATOMY OF THE HUMAN BODY. 
 
 head are the frontal, the gphonoid, and the ethmoid. They are single 
 hones, and each assists in forming hoth orbits. The fonr bones of the 
 
 face are the superior maxillary, the malar, the lachry- 
 The Eues and their ■, -, ,■, , , ,, . . , n^, i •. " 
 
 ^ , .^ mal, and the palate — all pairinij; bones, ihe orbits are 
 
 Orbits. , ^ ,.,. 
 
 . irregularly cone-shaped, Avith their a])ices directed back- 
 ward and somewhat inward, and their bases forward and somewhat out- 
 ward. At the apex of the orbit is an opening called the optic foramen, 
 through which the optic nerve and the artery of the eye enter from 
 the cavity of the skull. There are other openings into the orbits for 
 the transmission of nerves and vessels. 
 
 The eyeball is situated in the forward part of the orbit and is im- 
 bedded in a mass of fat, beinu' iniincdiatelv surrounded 
 Tfie Eyeball. , , , ti' ,• i ' ^ <• 
 
 by a serous membrane to allow ot tlie movements ot 
 
 the eyeball (Fig. 58). 
 
 Section through the eyeball (see Physiologij : The Vital Processes 
 h) Healthy Fig. 33) shows it to be composed of the union of the segments 
 of two spheres of different size. The posterior larger segment comprises 
 about five sixths of the globe, while the anterior smaller segment, repre- 
 
 Fio. 58. — MrscLES of the eveball. (Sappev.) 
 1. attachment of the tendon conneetcd witli the inferior reetus, internal rectus, and external rectus; 
 2, external rectus, divided and turned downward, to expose the inferior rectus; ;!, internal ree- 
 tu.s ; 4, inferior reetus; .5, sujterinr reetus; 6, superior oblique; 7, pulley and reflected portion 
 of the superior oblique ; 8. inferior oblique; 9, levator palpebri superioris ; 10, 10, middle por- 
 tion of the levator palpebri superioris; 11, optic nerve. 
 
 sented l)y the transparent cornea, forms ahont one sixth of the ball of the 
 eye. The eye is about one inch in diameter, being slightly less in its 
 antero-posterior diameter than in the others. 
 
 The globe of the eye is composed of several coverings, containing 
 
THE ORGANS OF SIGHT. 
 
 77 
 
 within their interior various refracting media called liumours (Fig. r/,)). 
 The coverings or tunics are in three layers : the external, composed of the 
 sclerotic and the cornea; 
 
 the middle, composed of v/r-'-ilJ^^^li-. 
 
 the choroid, iris, and cili- 
 ary processes ; and the in- 
 ternal, composed of the 
 retina alone. The re- 
 fracting humours con- 
 tained within the ball are 
 also three in number : 
 aqueous, crystalline lens, 
 and the vitreous body. 
 
 The sclerotic coat is a 
 dense opaque, fibrous 
 structure which forms the 
 outer tunic of the poste- 
 rior five sixths of the eye, 
 and gives to the ball its 
 shape and firmness. The 
 sclerotic is hid within the 
 eye socket, and it is pierced 
 behind by the optic nerve. 
 The outer surface of the 
 sclerotic is of a white 
 
 colour. The outer tunic is formed in front by the cornea to the extent 
 of one sixth of the globe. The cornea forms the segment of a smaller 
 sphere than is represented by the rest of the ball, and hence projects 
 slightly forward. This curve of the cornea is more marked in early life 
 and becomes less as age advances. 
 
 The second covering of the eyeball is formed in the posterior five 
 sixths by the choroid, which is a thin, chocolate-coloured membrane 
 containing many blood-vessels. The choroid is also perforated behind by 
 the optic nerve. The choroid is wanting in front, and around this circular 
 opening thus left the edges of the choroid are frilled, and these frills are 
 the ciliary processes. They lie behind and are hid by the iris. The 
 iris is a circular muscular curtain which nearly completes the choroid in 
 the anterior sixth of the eye. It has a round opening in its centre, the 
 pupil, which varies in size according to the action of the muscular fibres 
 of which the iris is composed. The muscular fibres are of the involuntary 
 variety, and they are arranged in two sets — one set of circular fibres, 
 which, by their contraction, render the pupil smaller; and the other, 
 composed of radiating fibres, which, by their contraction, dilate the pupil. 
 
 Fig. 59. — CiioRoir) coat of the eye. (Sappey.) 
 1, optic nerve ; 2, 2, 2, 2, 8, 3, 3, 4, sclerotic coat, divided and 
 turned back to show the choroid; 5, 5, 5, 5, the cornea, 
 divided into four portions and turned back ; 6, 6, canal of 
 Schlemm; 7, external surface of the choroid, traversed by 
 the ciliary nerves and one of the long ciliary arteries; 
 S, central vessel, into which open the vasa vorticosa: 9, 
 9, 10, 10, choroid zone; 11, 11, ciliary nerves; 12, long 
 ciliary artery ; 13, 13, 13, 13. anterior ciliary arteries ; 14, 
 iris ; 15, 15, yascular circle of the iris ; 16, pupil. 
 
7S THE ANATOMY OF THE PITilAN BODY. 
 
 The rotiiKi is the most internal of the tunics of the eye. It is a nieni- 
 hrane of soft consistence and is transparent. It is thicker hcliiiul than in 
 front, and directly in front it is wanting- alto<2;ether. The retina receives 
 the expansion of the optic-nerve fibres and is sensitive to liu'ht. At the 
 ])oint where the optic nerve enters the retina the latter is insensitive to 
 liu;ht, aiul this is known as the " blind spot." This blind s]K)t is situated 
 just to the inner side of another spot which is the most sensitive ]>art of 
 the retina, and which occupies the central position of the retina. This is 
 called the " yellow spot." 
 
 There are two cavities within the eye — one in front, just behind tl)e 
 cornea, and the other beliind, larger, and occupying the greater portion 
 of the globe. These two cavities are separated by the crystalline lens. 
 
 The anterior of these two cavities contains a few drops of a watery 
 fluid called the aqueous humour. The back chamber contains the vitreous 
 humour or body. This vitreous body is of the consistence of jelly, and, 
 like the aqueous humour, it is perfectly transparent. 
 
 The crystalline lens is double convex in shape, is composed of many 
 layers of transparent fibrous material, and it is inclosed by a transparent 
 capsule. 
 
 Situated outside of the eyeball, at the outer angle of the orbit, is a 
 
 small gland which secretes the tears. This is the lachrymal gland. At 
 
 the inner angle of the eye in front, and beneath the 
 
 ,„ J J /; , skin, are two small ducts, the lachrymal canals. These 
 Oiana and Canals. ' _ 5 j 
 
 soon open into a larger canal, the nasal dnct. These 
 ducts convey the tears from around the front of the cornea downward 
 into the nasal cavity, and it is only when there is an excessive secretion 
 of the tear fluid, or when, as in some cases, the ducts become occluded, 
 that the lachrj-mal fluid overflows upon the cheek. 
 
 The ear is the organ of hearing, and it is composed of three portions : 
 external, middle, and internal (Fig. 00). See also Physiology : The Vital 
 Processes in Healthy Figs. 39, 40, 41, and 42. 
 
 The external ear consists of two portions : one, much expanded, the 
 pinna, which appears upon the side of the head, and is composed of a 
 cartilage frame and is covered by skin ; and the other 
 portion a canal leading from the pinna to the middle ear. 
 This canal, the auditory, consists of a cartilaginous portion and of a bony 
 portion, the latter contained within the temporal bone. The entire canal 
 is somethinoj over an inch lonsr, and is lined throughout with skin. At 
 the bottom of the auditory canal is the drum of the ear. 
 
 The middle ear or tympanum is a cavity hollowed out in the interior 
 of the temporal bone, measuring a little less than half an inch from 
 before backward and al)Out a quarter of an inch from side to side and 
 from above downward. It is shut off from the external ear by the 
 
THE ORGANS OF HEARING. 
 
 79 
 
 Middle Ear. 
 
 mcmbrana tympaiii or ear drum. Tlio middle ear is filled with air, and 
 connects with the outer world through the Eustachian tube, whicli ex- 
 tends from the tympanum to the pharynx. (^ther 
 openings exist in the walls of the tympanum for tlie 
 transmission of nerves, arteries and veins, and muscles. Jiehind are 
 also seen the openings 
 into the mastoid cells 
 which are contained 
 in the temporal bone, 
 and are connected 
 with the middle ear. 
 
 The membrana 
 tympani is a thin, 
 translucent membrane 
 which separates the ex- 
 ternal from the mid- 
 dle ear. It pi-esents 
 externally a slightly 
 convex surface, which 
 is due to the attach- 
 ment to its inner sur- 
 face of one of the lit- 
 tle bones of the ear 
 — viz., the malleus. 
 The vibrations of the 
 ear drum are trans- 
 mitted to the internal 
 ear by a chain of three 
 bones, named, from 
 their shape, the mal- 
 leus or mallet, the in- 
 cus or anvil, and the 
 stapes or stirrup. 
 
 The internal ear 
 or labyrinth contains 
 the expansion of the 
 auditory nerve, and consists of a series of canals and cavities in the sub- 
 stance of the temporal bone. The labyrinth is divided into three parts : 
 (1) the vestibule, (2) the semicircular canals, (3) the coch- 
 lea. The vestibule forms the central cavity of the in- 
 ternal ear, and to its outer wall is attached the base of the stapes or stirrup 
 bone, the last of the chain of three, the first of which, the malleus, is at- 
 tached to the membrana tympani. The semicircular canals are three in 
 
 Fig. 60. — General view of the orgax of iiearixg. (Sappey.) 
 1, pinna ; 2, cavity of the concha, on the walls of which are seen the 
 orifices of a tcreat number of sebaceous glands ; 3, external au- 
 ditory meatus ; 4, angular projection formed by the union of the 
 anterior portion of the concha with the posterior wall of the 
 auditory canal ; 5, openings of the ceruminous glands, the most 
 interaai of which form a curved line which coiTesponds with 
 the beginning of the osseous portion of the external meatus; 
 6, membrana tympani and the elastic fibrous membrane which 
 forms its border; 7, anterior portion of the incus; 8, malleu.s; 
 9, handle of the malleus, applied to the internal surface of the 
 membrana tympani, which it draws inward toward the projec- 
 tion of the promontoiy ; 10, tensor tympani muscle, the tendon 
 of which is reflected at a right angle, to become attached to the 
 superior portion of the handle of the malleus : 11, tympanic 
 cavity ; 12, Eustachian tube, the internal, or pharyngeal extrem- 
 ity of which has been removed by a section perpendicular to its 
 curve; 13, superior semicircular canal; 14. posterior semicircu- 
 lar canal; 15, external semicircular canal; 16, cochlea; 17, 
 internal auditory canal ; 18, facial nerve ; 19, large petrosal 
 branch, given off from the ganglioform enlargement of the 
 facial and passing below the cochlea, to go to its distribution ; 
 20, vestibular branch of the auditory nerve; 21, cochlear branch 
 of the auditory nerve. 
 
 Internal Ear. 
 
80 THE ANATOMY OF THE HUMAN BODY. 
 
 number, and tlicy are located above and behind the vestibule, into which 
 they open. The three semicircular canals are so arranged that each canal 
 is at right angles to the other two, and hence they all occupy different 
 planes. The cochlea, shaped like a snail-shell, is ])laced in front of the 
 vestibule and connects with it. The sj)iral canal of the cochlea takes two 
 and a half turns around a " central axis,'' and is divided into two by a spiral 
 6a?ptum M'hich follows the windings of the canal. 
 
 The entire internal ear is lined with a serous membrane called the 
 membranous labyrinth. 
 
 SECTION XIII. 
 THE SKIN. 
 
 Tlie skin forms a protecting investment for the entire outer surface 
 of the body, and is the principal seat of the sense of touch, having dis- 
 tributed to it the endings of the sensitive nerves. The skin is also an 
 excretory organ, and to a limited extent it possesses the power of 
 absorption. {See Physlohx/y : The Vital Processes in Healthy Y\g. \^.) 
 
 The skin is composed of two layers. The external layer or epidermis, 
 also known as the cuticle or scarf skin, is composed of hardened epithelial 
 cells, and acts as a protective covering for the more sensitive true skin 
 beneath. In places the epidermis is especially thick, as in the palms of 
 the hands and upon the soles of the feet. 
 
 The nails and the hair belong to the epidermis, and are but modifica- 
 tions and elaboi'ations of it. The nails are firmly adherent to the true 
 skin. The hair exists in nearly every part of the sur- 
 ^ ., face of the body ; the roots of the hair are contained 
 
 in " hair follicles," and they pi'oject into the true skin, 
 and where they are very long, as upon the scalp, the roots extend through 
 the skin into the connective tissue beneath. 
 
 The deep layer of the skin is the cutis, the corium, or the true skin. 
 The average thickness of this layer is about one twelfth of an inch. 
 
 Imbedded in the corinm are the sebaceous glands, which are more 
 numerous in the skin of the face than elsewhere. These glands open by 
 small ducts upon the surface of the skin. AVTien the ducts become 
 clogged they give rise to the condition known as " black heads," and 
 
 if the blocking up of the ducts is complete, " wens " 
 Sebaceous and .-,, , , , , 
 
 Sweat Glands. ^'''^^ ^'^ developed. ^ 
 
 Also imbedded in the corium are the sweat glands. 
 These are most numerous upon the palm of the hand, where they num- 
 ber as many as 2,800 to the square inch. 
 
OMNE VIVUxM EX OVO. 81 
 
 SECTION XIY. 
 EMBRYOLOGY. 
 
 The whole human l^ody is developed from an e^^g or ovum, the prod- 
 uct of the female ; but this egg must first have been fertiHzed by a sper- 
 matozoon, which comes only from the male. Every 
 The Ugg or Ovum. ,. . ,• ' r 
 
 " time menstruation occurs an ovum escapes from one 
 
 of the ovaries of the woman and passes into the corresponding Fal- 
 lopian tube Mdiich leads from the ovary of that side into the cavity of the 
 womb or uterus. This passage through the length of the Fallopian tube 
 probably requires about a week of time. If the ovum does not become 
 fertilized it may come away from the uterus toward the end of the 
 menstrual jflow, though there is much reason to believe that it remains in 
 the uterus for a considerable length of time. Under these conditions, 
 however, the ovum does not develop, but passes from the uterus or is 
 destroyed. 
 
 The ovum (see Physiology : The Vital Processes in Health, Fig. 
 4Y) is an egg composed of yolk only, and has the structure of a 
 simple cell. It is yl^ of an inch in diameter, and is surrounded by a 
 transparent envelope known as the vitelline meinbrane. The yolk itself, 
 or the vitellus, is situated within this membrane, and it is composed of 
 granules of various sizes imbedded in a thick fluid. Within the yolk or 
 vitellus of the egg., but not occupying the centre of the egg, is a spherical 
 membrane filled with a thin fluid. This is the nucleus of the cell, or the 
 germinal vesicle of the ovum, and it measures about -^-^ of an inch in 
 diameter. Situated upon that side of the germinal vesicle nearest to the 
 periphery of the vitellus is a yellowish spot about -^-^-^ of an inch in 
 diameter, which is named the nucleolus of the cell, or the germinal spot 
 of the ovum. 
 
 The other of the two sexual elements essential at the very beginning 
 for the production of a new human body is the spermatozoon. This 
 cell, as has already been said, is the product of the male, and the sperma- 
 tozoa are contained in great numbers in the seminal fluid. A sperma- 
 tozoon (see Physiology : The Vital Processes in Health, Fig. 49) is an 
 elongated cell with its nucleus at one end forming a 
 ■ " head " and with the body of the cell drawn out into 
 a " tail." This tail has the power of a wavy motion, and causes the whole 
 cell to travel along quite rapidly, so that a moving spermatozoon very 
 much resembles a minute tadpole. 
 
 The union of the spermatozoon with the ovum takes place in the up- 
 per part of the Fallopian tube, and consists of the bodily entrance of a 
 
82 
 
 THE ANATOMY OF THE HUMAN BODY. 
 
 spermatozoon tlironp;!! the vitelline nienibnine into the substance of tlie 
 
 vitellus or yolk. Tlie tail disappears and the head only remains, and it 
 
 becomes a part of the fertilized or impregnated ovum. 
 
 Fecundation. ^,^^ ^^^^^ ^.^^^^ ^j^^^ ^^^^^^^^ ^^ fertilized has reached the 
 
 cavity of the uterus, which it does at tlie end of the iirst week, the iii-st 
 change to make its appearance as the result of the impregnation has been 
 completed. This is the " segmentation " of the ovum, and is a process of 
 cleavage by which the sul)stance of the ovum becomes divided, first into 
 two masses, then into four, then into eight, then sixteen, and so on until 
 
 Fio. 61. — Segmentation of the vitellus. (Ilacckel.) 
 
 A, the vitellus divided into two cells ; B. the two eells divided into four; C, the four cells divided 
 
 into eight; D, the blastoderm ie eells. 
 
 the ovum l)ocomes a mass of nucleated cells, called " vitelline spheres " 
 (Fig. 61), This segmentation takes place within the vitelline membrane, 
 and the spheres become arranged into two groups, an inner and an outer, 
 forminof too^ether a membrane called the blastodermic membrane. As the 
 arrangement comes to be more definite the outer group of cells or spheres 
 forms a complete lining to the inner surface of the vitelline membrane, 
 while the inner group of cells forms a disk which lines a small portion of 
 the internal surface of the outer layer. The outer layer of this blastodermic 
 membrane is known as the epiblast, and the inner layer as the hypohlastt. 
 That area of the blastodermic membrane wliich is composed of two lay- 
 ers, the qMi)last and the hypoblast, is tnown as the germinal area. The 
 impregnated ovum, unlike the unfertilized ovum, remains in the uterus 
 and continues to grow, and takes an attachment to the lining membrane 
 of the womb. During the second week the first trace of the embryo ap- 
 pears as a faint streak at the posterior end of the germinal area; this is 
 known as the primitive trace (Fig. G2). The embryo is the foetus or 
 unborn child, and the term is usually limited to the very early stages. 
 The next event in the development of the embryo is the formation of 
 a distinct layer of cells between the epiblast and the hypoblast, so 
 that the blastodermic membrane, instead of being composed of only two 
 layers, is now divided into three. This new layer, situated between 
 the epiblast on the outside and the hypoblast on the inner side, is the 
 mesohlast. 
 
DEVELOPMENT OF THE EMBRYO. 
 
 83 
 
 From the varions layers of this blastodermic meml>rane arc developed 
 all the organs that go to make up the completed human body, and, Ijesidcp, 
 they form a number of structures which belong to foetal life, and which 
 are of no further use when they have performed some temporary func- 
 tion. 
 
 From the epiblast are ultimately developed the epidermis of the body, 
 with the superficial glands, such as the breasts, the brain and spinal cord 
 and their nerves, and portions of the eye, nose, and ear. 
 
 From the hypoblast are formed the epithelial cell linings of the gastro- 
 intestinal tract, of the glands connected with it, and of the respiratory 
 organs. 
 
 The remaining portions of the body are formed from the mesoblast, 
 and include the true skin, the blood-vessels, the voluntary and involuntary 
 muscles, the kidneys, etc., together with the general connective-tissue 
 framework of the whole body. 
 
 At the same time that the blastodermic membrane is dividing into 
 three layers, instead of remaining composed of two, by this formation of the 
 mesoblast, changes are 
 taking place at the situa- 
 tion of the primitive trace. 
 The primitive trace itself 
 disappears; but commenc- 
 ing in front and extend- 
 ing backward in a line 
 with that occupied by the 
 primitive trace, the cells 
 of the epiblastic layer of 
 that portion of the blasto- 
 dermic membrane which 
 constitutes the germinal 
 area become heaped up 
 in two longitudinal ridges, 
 presenting between them 
 a groove. This heaping 
 up continues until the 
 ridges become lateral 
 
 plates which meet behind, thus transforming the groove into a canal. 
 This is the neural canal, and from the epiblast which lines it are developed 
 the brain and spinal cord and their nerves. The front portion of the 
 canal becomes dilated, and curved upon itself to accommodate the mass of 
 nerve-centres which go to make up the brain. 
 
 The further tracing of the growth of the embryo into the fully devel- 
 oped child becomes too complicated, and requires too much detail to be 
 
 Fig. 62. — Primitive trace of the embrton. (Liegeois.) 
 
 a, primitive trace ; b, area pellucida ; c, area opaca ; d, blasto- 
 dermic cells ; e, e, villi beginning to appear on the vitel- 
 line membrane. 
 
84 THE ANATOMY OF THE HUMAN BODY. 
 
 included in a work of tins size and scope, and nothing further than this 
 small beo-innin"- will be attempted. Some further details of the subject 
 are found in the article in this volume upon PhymoJogy : The Vital 
 Processes in Health, and for a complete history of the events which take 
 place at this early period of life the reader is referred to special works 
 upon the subject. 
 
II. 
 
 PHYSIOLOGY: THE VITAL PROCESSES IN HEALTH. 
 
 By FREDERIC S. LEE, Ph. D. 
 
 INTRODUCTIOK 
 
 The physiology of an organism treats of tlie healthy working of the 
 organism. It deals with the living, acting body, with what the body 
 docs and how it does it. Anatomy can be studied best upon the dead 
 body. Physiology, however, must be studied chiefly upon the living 
 body, since in death the action ceases. The present sketch is devoted 
 particularly to the physiology of man, but we must bear in mind that 
 physiology is a very broad science and has to do with all living things, 
 animals or plants. Only a limited range of observation and experi- 
 mentation is possible upon the living human being, hence the work of 
 the phj^siologist consists chiefly of work upon animals other than the 
 human species. Human physiology consists largely of careful, well- 
 guarded inferences from the results of such experimental work. 
 
 The reasonableness of such a method of inference is apparent when 
 
 one accepts as a fact what is no longer doubted by scientific men — that 
 
 the human species is both anatomically and physiologic- 
 3Ian the Result -,, j. , i . i ^ j • j x " ^.i " i i 
 
 . „ , ,. ally a form that has been derived from other and lower 
 
 of Mjvolution. -^ _ 
 
 species of animals. Such a belief gives a unity and 
 harmony, not otherwise possible, to the facts of biology. Man is physi- 
 ologically interesting in himself ; he is physiologically more interesting 
 when regarded as the latest and most complex product of a long ancestrj' 
 reaching back through mammals, reptiles, fishes, and a long line of 
 simpler animals, to the most primitive forms. The study of these ani- 
 mals is a study of the steps by which man has arrived at his present 
 stage. 
 
 Like other animal bodies, the human body is a complicated machine, 
 adapted for doing a great variety of work. The term " vital energy " is 
 often heard — -a term which indicates that the living body is something 
 fundamentally different from other machines that are made of iron, or 
 
 85 
 
80 PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 steel, or brass. Dnrinii; the present century, however, it lias been proved 
 that all kinds of energy in inorganic nature — such as mechanical work, 
 heat, light, and electricity — are only different forms of a universal energy. 
 Moreover, it has been shown that "vital energy" is not distinct from 
 t)ther kinds, and- that the actions of the living body — walking, swimming, 
 flying, speaking, the circulation of the blood, and probably the activities 
 of gland cells, of brain cells, etc. — are performed according to the same 
 mechanical, physical, and chemical laws that apply to inorganic nuitter. 
 The task of the pliysiologist consists, then, largely in a study of the me- 
 chanics, physics, and chemistry of the living body. The goal toward 
 which he is pressing is a full understanding of the nature of life itself. 
 It is unnecessary to say that that goal is still far distant. 
 
 A great advance that has taken place during the past sixty years is 
 the proof that life is always associated with a certain visible material sub- 
 stance. This substance is called protoplasm. It occurs 
 
 Protoplasm ^^ muscles, glands, skin, brain, bone, nerves, and all the 
 
 the Physical Basis r, • • ^ jji ?• • i j j? n v v? 
 
 of Life organs. It is injact the living substance oj all parts oj 
 
 all living bodies. It is always associated with lifeless 
 substance, such as the fluid parts of a body, the mineral parts of bones, the 
 hard substance of teeth, the nails, the hair, and the microscopic lifeless 
 material that permeates all parts of every body. In its simplest form 
 protoplasm is a colourless, jelly-like, nearly transparent substance, some- 
 what resembling raw white of Q^g. It is a mixture of several chemical 
 substances ; it has a variable composition, but always contains carbon, 
 hvdrogen, nitrogen, oxygen, and sulphur. It differs in appearance and 
 composition in different parts of the body, the protoplasm of muscle being 
 identical neither with that of gland cells nor with that of nervous sub- 
 stance. 
 
 Dissection shows that a body is composed of definite parts, or organs, 
 each of which, as we shall see, has a definite function to perform. Thus 
 
 the heart, the stomach, the eye, the liver, and the brain 
 igans, isf.ues, _^ organs. Each organ has its own peculiar structure, 
 and Cells. *=• ^ ■ i r 
 
 but each is made up of comparatively few structural 
 
 substances. These substances are called tissues, and each tissue — such as 
 connective tissue, muscle tissue, fat tissue — has its own work to do. Ex- 
 amination of the tissues with the microscope shows that each is composed 
 ])artly of lifeless substance, usually in small quantity, and chiefly of minute 
 living particles of protoplasm, the cells (Fig. 1). Cells vary greatly in 
 shape and size and in the work that they do, but in any one tissue they 
 are similar in structure and function. The work of a body is the sum of 
 the work of its individual cells, and the fundamental problems in physi- 
 ology lead back to protoplasm and the cells. 
 
 Every human body consists at first of a single cell within the body of 
 
DIVISION AND DIFFERENTIATION OF CELLS. 
 
 87 
 
 the motlier. In growth the shigle cell divides into two cells, the two into 
 four, the four into eight, and the process continues until in the adult 
 millions of cells exist. Along with the increase in number there occurs a 
 differentiation in form and a division of labour among the various cells, 
 such that some conqe to perform the various muscular movements, others 
 prepare digestive substances, others remove waste matter frorn the l>lood, 
 others control the breathing, still others do the thinking, some are affected 
 
 
 ''*^^'' '^0' 
 
 Fig. 1. — Typical cells from the human body. 
 Each cell consists of granular or striated protoplasm, and contains a denser protoplasmic mass, the 
 nucleus. The nucleus is round or oval, and appears darker or lighter than the rest of the cell. 
 A, seven pigment cells from retina (Schultze) : B, four epithelium cells from intestine — one 
 swollen with mucus represents a "goblet cell" (Frey); C, unstriped muscle cell (Arnold); 
 U, nerve cell from brain (Gage); E, ciliated epithelium cell — the cilia constitute the brushlike 
 upper end (Rosenthal); F, three " prickle-cells " from skin (Eobinsonj; G, three gland cells 
 from liver — the heavy dark lines represent bile ducts (Kolliker). 
 
 by waves of light; some by waves of sound, and thus we perceive that in 
 this complicated human machine each part has its own work to do, and 
 the division of labour is far-reaching. 
 
 Protoplasm is said to be irritable or excitable— that is, it is capable of 
 being thrown into activity by proper stimuli. Every kind of cell, or 
 tissue, or organ has its own natui'al method of stimulation and its own 
 natural response or function. Every vital action is a response to some 
 kind of stimulus. 
 
SS PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 The leading functions of tlie body, together with their chief agents, 
 may be grouped as follows : 
 
 Functions. Organs and other Agents. 
 
 ["-.,. \ Alimentary canal : consisting of mouth, ocsophapus, stomach, 
 
 Aiuncntauon. ^ sinull intestine iind large intestine ; liver; jmncreas. 
 
 ( Ulood system: consisting of lieart, arteries, ciipillaries and 
 .. , . . ! Circidation . . -| veins; Ivmphatic svstem : consisting of lymphatic vessels 
 Mitrition. • I and lyniV.halic glands: blood, lymph. 
 
 Respiration.. Ti-aehca. lungs. 
 ] Metabolism.. All living ceils. 
 [ E.Kcretion.. . . Lungs, kidneys and accessory organs, skin. 
 
 Motion All muscles. 
 
 Co-ordination Brain, spinal cord, nerves, sympathetic nervous system. 
 
 . ^. .^ , . , ( Eve, ear, organs of smell, of taste, of touch, of temperature. 
 
 Activity of special senses.. | -^^^^ ^^^ .uuscular sensations. 
 
 Support Bones, cartilage, connective tissue. 
 
 T, , . j Female: ovaries and accessor v organs. 
 
 Keproduction -j ^j^^^^. ^^^^^^ ^^^ accessory organs. 
 
 CHAPTER L 
 
 NUTRITION. 
 
 Like any other machine in action, the living human body constantly 
 gives off energy to the outside world in the form of heat and mechanical 
 work, and, moreover, its own material is being constantly used up. It 
 requires food to replace these two losses of energy and substance. The 
 story of nutrition is a long one. It tells how the body prepares for its 
 use the food that is given to it (digestion) ; how the prepared food is 
 taken into the distributing apparatus (absorption); how it is carried to 
 the living cells (circulation) ; how it is used there for the production of 
 new protoplasm, and how the protoplasm in action is destroyed, leaving 
 waste matters (metabolism) ; and, finally, how the wastes, being harmful 
 to the body, are removed from it (excretion). These subjects will now 
 be considered in detail. 
 
 Section I. 
 
 ALIAfENTATIOIf. 
 
 Alimentation consists of the two processes of digestion and absorp- 
 tion. Digestion comprises the chemical and physical changes which the 
 food undergoes by way of preparation for entrance into 
 Alirnentation in ^^^^ ^.^ ^^^ j^^ ^^^ , ^j^^ j.^,. g^^^gtance. Ab- 
 
 sorption is the process of the passage of digested food 
 into the blood and lymph, whence it is carried to the tissues. Alimen- 
 tation takes place in the alimentary canal (Fig. 2), which is a long tube 
 
THE HUMAN ALIMENTARY CANAL. 
 
 80 
 
 extending tlirongh tlie body, opening above at tlic mouth and below at 
 the anus ; its walls consist of muscle with glands, blood-vessels, and lymph- 
 vessels. The successive parts of 
 the canal are known as mouth, 
 pharynx, (esophagus or gullet, 
 stomach, small intestine and large 
 intestine. To it are joined, by 
 ducts, several large glands — 
 namely, the three pairs of sali- 
 vary glands, the pancreas, and 
 the liver ; all of these in their 
 origin are outgrowths from the 
 canal, but in the adult body they 
 lie outside of its walls. The 
 food enters at the mouth, and 
 is propelled along the canal by 
 the contraction of the muscular 
 walls ; the glands secrete — that 
 is, manufacture and pour into 
 the canal various fluids that differ 
 in nature in various parts of the 
 canal, and whose oiiice it is to 
 digest the food ; tlie blood-vessels 
 and the lymph-vessels, besides 
 bringing blood and lymph to the 
 walls of the canal, receive the 
 digested food and bear it away 
 to all parts of the body ; the 
 indigestible, the undigested, and 
 the innutritions substances in the 
 canal undergo chemical changes, 
 and finally are expelled from the 
 body as excrement. 
 
 The common foods, though 
 apparently so different in char- 
 acter from each 
 
 Food Stuffs. 
 
 Fig. 2. — Human ai-imentakt canal. 
 oesophagus ; 6, stoiiiaeh ; c, cardiac orifice ; </, 
 pylorus ; e. small intestine ; _/'. biliary duct and 
 gall bladder; </, pancreatic duct; A, i, J, k, 
 large intestine': h. ascending colon ; /, trans- 
 verse colon ; _/, desceudinsr colon : /•, rectum. 
 At junction of e and h is ileo-ca?cal valve, be- 
 low'which is vernuform appendix. (Dalton.) 
 
 other, ai'e found 
 by chemical analysis to be mix- 
 tures of a small number of sub- 
 stances known as food stuffs. 
 
 The most common food stuffs are proteids (the most important con- 
 stituent of all meats, fish and eggs) ; albuininoids (such as gelatin ; they 
 are closely related to proteids, and hereafter will be included with them) ; 
 
90 PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 earhohi/draies (such as starch and sugar, abundant in bread, pastry, and 
 
 vegetables) ; fats (abundant in meats, butter, and milk) ; water and salts 
 
 (such as table salt and numerous other salts). For a discussion of the 
 
 characters and value of these various food stuffs the reader is referred to 
 
 the article in this volume on Ilijgiene. 
 
 AVater aiul the salts that are dissolved in the food are absorbed 
 
 unchanged into the blood. Of the other food stuifs, protelds and cai'bo- 
 
 hydi'ates are chemically changed by the digestive pro- 
 
 igesionm cBss, the former into closely related bodies called pro- 
 (reueral. ' , , . . - , , 
 
 teoses, peptones, and derivatives of the ]ieptones, the 
 
 carbohydrates mainly into a form of sugar called maltose, together with 
 
 a small quantity of a starch called dextrin. By reason of the unsettled 
 
 tpiestions regarding the true nature of some of these digested substances, 
 
 it will suffice hereafter to speak of all the products of proteid digestion 
 
 simply as peptone, and of all the products of carbohydrate digestion as 
 
 sugar. Contrary to what is found in most of the food stuifs, peptone 
 
 and sugar are soluble, and hence when dissolved in the water of the food 
 
 are fit for absorption. The digestion of the fats consists in part in 
 
 changing them chemically into fatty acid, glycerin, and soap, and in part 
 
 in simply breaking them up m.echanically into minute droplets, this latter 
 
 process being called emulsification ; after these changes the fats are ready 
 
 for absorption. 
 
 The digestive fluids are manufactured in the glands of the alimentary 
 canal, and are poured out into it. They are five in number — viz., saliva, 
 gastric juice, intestinal juice, pancreatic juice, and bile. 
 Each consists chiefly of water together with a small 
 quantity of dissolved solids, among which, except in the bile, is one or 
 more of a peculiar class of bodies called enzymes or unorganized fer- 
 ments, to which the digestive property of the fluids is due. The enzymes 
 are peculiar chemical compounds, the exact constitution of which is un- 
 known, but, when mixed with the food stuifs, they produce extensive 
 chemical changes in the latter without being in themselves greatly altered. 
 
 A^aliva is produced by the minute glands in the walls of the mouth 
 and the tliree pairs of large salivary glands, the parotid, the submaxillary, 
 and the sublingual (see The Anatomy of the Human JBody). It is very 
 watery, containing less than 0*6 })er cent, of solids. Among the latter 
 are mucin, which gives to the saliva its slightly slimy quality, and assists 
 in the swallowing of the food ; and ptyalin, an enzyme that changes 
 starch into sugar. Saliva is produced in small quantity at all times, but 
 more abundantly when food is in the mouth. 
 
 Gastric juice is produced by the innumerable small glands lying in 
 the walls of the stomach. It is watery, colourless, sour, and contains 
 three per cent, of solid matter. Its sourness is due to hydrochloric 
 
THE DIGESTIVE FLUIDS AND GLANDS. 91 
 
 (muriatic) acid. It contains two enzymes — viz., pepsin^ wliicli cliangcs 
 proteid to peptone, and rentvm, whieli curdles miltc. Tlie glands of the 
 stomach do not act continuously, but ai-e stimulated to activity by the 
 food that has been swallowed. 
 
 Intestinal juice is secreted by the glands in the walls of the small 
 intestine. It is not abundant, is a yellowish alkaline fluid, and contains 
 at least two kinds of enzymes, one like the ptyalin of saliva, capable of 
 converting starch into sugar, and the other that changes maltose and 
 other complex sugars into dextrose, a sugar of simpler composition. 
 
 Pancreatic juice is manufactured by the pancreas; it resembles saliva 
 in appearance, but contains some thirteen per cent, of solids, among which 
 are sodium carbonate and three powerful enzymes. Of these, trypsin, 
 like pepsin, converts proteids into peptones, and, moreover, splits up some 
 of the peptones into other bodies, the reason for which is not quite clear ; 
 amylopsin^ like ptyalin, converts starch into sugar ; steapsin splits up 
 fat into fatty acid and glycerin. The fatty acid thus produced, with the 
 sodium carbonate present, forms soaps that are capable of emulsifying 
 fats. Hence pancreatic juice may digest all kinds of food stuffs. 
 
 Bile is produced by the liver. It is a yellowish or greenish -yellow, 
 somewhat slimy, alkaline fluid, and contains two to three per cent, of 
 solids that are of great variety, but apparently do not include any enzyme. 
 Its secretion goes on continually, six hundred to eight hundred and fifty 
 cubic centimetres (averaging a pint and three quarters) being produced in 
 twenty-four hours. It is stored up in the gall bladder for a time, and 
 passed out into the intestine during the course of digestion. The con- 
 stituents of bile are largely waste products, thrown off by the living sub- 
 stance throughout the body, removed from the l)lood by the liver cells, 
 and cast out into the intestine for expulsion. But in addition to its value 
 as an excretion, bile is an important agent in alimentation, aiding g^reatlv, 
 in a manner not yet fully explained, the digestion and absorption of the 
 fats. 
 
 The glands that manufacture the digestive fluids consist of chemically 
 
 active secreting cells that are richly supplied with blood and lymph. 
 
 ^. They have the power of removing from these fluids 
 
 Digestive Glands. tit • n • ^ •,•^ i 
 
 some components of the digestive fluids, like water and 
 
 salts, and other substances from which they manufacture the remaining 
 
 components. The resulting secretion passes on into the alimentary canal. 
 
 The intestinal glands, the simplest of all, consist each of a little pocket 
 
 opening into the intestine and with walls of secreting cells (Fig. 3). In 
 
 the more complex pancreas, liver, and salivary glands the secreting 
 
 pockets, or alveoli, are greatly branched, tortuous channels uniting into 
 
 one tube, the duct, which conveys the secretion to the alimentary canal. 
 
 The glands are among the most active of all the living parts of the body, 
 
02 PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 and are carefully controlled and regulated by the nervous system. The 
 digestive ferments may readily be extracted from glands that have been 
 removed from the bodies of dead animals, and may be used for the manu- 
 facture of artificial digestive fluids. AVith such 
 tiuids the processes of digestion of foods may be 
 carried on under observation in vessels in the 
 laboratory. This has been one of the most fruit- 
 ful methods of studying the subject. Gland ex- 
 tracts form the basis of many substances used by 
 the physician for the relief and cure of dyspepsia. 
 Let us now trace in order the events of diges- 
 tion. Food is put into the mouth, where its pres- 
 ence excites the salivary glands to manufacture 
 and pour out upon it the saliva. 
 
 Digestion in ihe 
 Mouth and 
 Stomach. 
 
 The food is, or ought to be. 
 
 3. — Gland from the 
 human intestine. 
 
 Tlie gland is dilated at its 
 closed end ; at the other 
 end it opens into the in- 
 testine. Each of the se- 
 creting cells of which the 
 wall consists contains a 
 deeply shaded nucleus. 
 The clear spaces repre- 
 sent cells laden with mu- 
 cus. (Flemniing.) 
 
 chewed thoroughly, so as finally 
 
 to divide it and thus to allow 
 the digestive lluids to permeate it readily. The 
 saliva mixes with it, and the chemical changes of 
 digestion begin by the conversion of some of the 
 carbohydrates present into sugar. By muscular 
 action the food is swallowed — -that is, is squeezed 
 along through the pharynx and the gullet into 
 the stomach, where it remains for a time varying 
 from a few minutes to a few hours. Waves of 
 contraction pass over the muscular walls ; the 
 food, being squeezed here and there, is kept in 
 constant slow motion. The gastric glands are 
 stimulated to activity, and the gastric juice oozing 
 forth mixes with the mass of food and converts 
 
 it into a half-fluid mass called chyme. The acid of the gastric juice puts 
 a stop to further action of the swallowed saliva. Carbohydrates are hence 
 here unchanged, but the proteids are in great part altered to peptones. 
 At intervals the passageway into the small intestine — the pylorus — opens 
 and allows the chyme to flow out into the duodenum. Thus gradually 
 the stomach completes its work, and transfers its contents to the succeed- 
 ing part of the alimentary canal. 
 
 In the small intestine the processes of muscular action, glandular 
 secretion, and digestion are continued. The food is moved about and 
 
 passed slowl^^ along. The gastric juice ceases to act, 
 
 igesiomn e intestinal juice and pancreatic juice are added to the 
 Small Intemne. •' ^ • /• i -i mi 
 
 mass, and the liver adds its contribution of bile, ilie 
 
 carbohydrates that were unaffected by the saliva aj-e changed into sugar. 
 
PROCESSES OF DIGESTION. 93 
 
 The proteids that wore unaltered by tlie gastric juice become peptones, 
 and are even in part decomposed into simpler substances. The fats are for 
 the first time affected, being in small part decomposed into fatty acid and 
 glycerin, in greater part divided mechanically into fine droplets. Tliis 
 emulsification is assisted by the soaps that are formed by a union of the 
 fatty acids and the alkalies present in the digestive fluids. Thus all 
 classes of food stuffs are attacked in the small intestine ; no other part of 
 the whole canal forms so active a digestive laboratory as this part, Be- 
 sides the changes already spoken of, due chiefly to the enzymes, the ob- 
 ject of vi^hich is to make ready the nutriment for entrance into and use 
 by the protoplasm, fermentative changes of the digested products take 
 place of a destructive character, and due apparently to the agency of 
 living microbes that are always present in the intestine. The significance 
 of this apparent destruction of nutritive substance is not understood. The 
 bacteria are not disease-producing germs ; on the contrary, they may pos- 
 sibly be of considerable value to the body, but the role that they play 
 needs investigation. Absorption of the digested food into the blood and 
 lymph is most active in the walls of the small intestine, and by the time 
 the semifluid mass has reached the ileo-cgecal valve it is robbed largely of 
 its nutritious components. 
 
 In the large intestine no new physiological features are added. Feeble 
 
 digestion, fairly active absorption of digestive products and of water, 
 
 and marked fermentation by bacteria, are the main 
 
 igesiomn e gygjjt:s : and the undigested and the indigestible sub- 
 Large Intestine. ' -, • ^ j> i • j> 
 
 stances are passed on into the rectum for expulsion from 
 
 the body. Tlie large intestine appears to be physiologically more impor- 
 tant in herbivorous animals, like cows and sheep, where, in accordance 
 vi^ith the enormous quantity of food, it is relatively large. It was doubt- 
 less larger and more important in the ancestors of the human race. But 
 in man it appears to be undergoing degeneration, as is shown especially in 
 the part known as the vermiform appendix. This appendage, probably 
 valuable in the digestive work of the ancestors of man, 
 
 enmjoim geems to be devoid of marked function in man at the 
 Appendix. . 
 
 present time, and is especially prone to inflammatory 
 
 processes set up by the presence within it of irritating substances brought 
 there by the food. It would seem a blessing if evolution could hasten 
 the disappearance of this apparently useless structure. 
 
 A word now as to the absorption of the digested food stuffs, and the 
 outline of the story of alimentation will be completed, Within the ali- 
 mentary canal the food is no more a part of the body 
 ' ■ than if it were upon the outer surface. As has been 
 
 insisted, digestion within the alimentary canal is merely a preparation of 
 the food for entrance into the actual livins: substance. The cells that 
 
94 PHYSIOLOOY : THE VITAL PROCESSES IN HEALTH. 
 
 line the canal are nourished bv absorbing food directly from the mass 
 that lies in contact with them, ^[ore distant cells require nutriment to 
 be brought to them, and this is one important office of the blood and 
 lymph with which the walls of the alimentary canal are so saturated. 
 Thin-walled blood caj)illaries and lyuij)h cajnliaries abound there, and 
 during and after digestioix the dissolved food stuffs make their way into 
 them. Absorption takes place very slightly, if at all, in the stomach ; 
 it is at its o-i'^^iitest heiiiht in the small intestine, and it is active even 
 throughout the large intestine. The method of absorption is not wholly 
 clear. Probal)ly physical processes ])lay a leading part ; but it is a ques- 
 tion whether the living cells that line the intestine, and through whicli 
 the food must pass on its way to the capillaries, may not in some manner 
 engage actively in the process. Sugar and fats pass through them un- 
 changed, peptone is mysteriously altered chemically in its ])assage. This 
 altered peptone, the sugar, and the greater part of the salts and the water 
 go directly into the blood. Fat goes into the lymph and, by way of the 
 lymphatic vessels and the thoracic duct, finally into the blood system. 
 Thus all nutriment that is not used by the living substance in the wall 
 of the alimentary canal tinds its way sooner or later to the blood, the 
 great carrier and distributer of matter and energy. Our next section 
 deals with this circulating mechanism. 
 
 Section II. 
 CIRCULATION. 
 
 In an organism that consists of one cell or a few cells, food, when 
 
 once digested, permeates all parts readily. In larger organisms this is 
 
 impossible, and hence special mechanisms must exist for the transfer of 
 
 imtriment from the organs of digestion to the more distant parts. In 
 
 the growth of all except the simplest animals such a mechanism, some 
 
 sort of a distributing svstcm. is developed. It is simple 
 Circulation in •, i • • . i ' • ' • i-j.ii 
 
 ^ , and crude m its beginnings, and in the lower organisms 
 
 remains always simple and crude. It becomes more 
 complex and perfected as the animal's size increases and his structure 
 becomes more complex, until in the completed circulatory system of the 
 highest animals and man we have an apparatus that is wonderfully 
 adapted to perform its needed work, and responsive in a high degree to 
 the demands of the other physiological systems. The transfer of nutri- 
 ment is not the only important function of the organs of circulation. Of 
 equal value are the transfer of oxygen without which the living substance 
 can not act, and the removal of w-aste products from the tissues to the 
 organs of excretion. Furthermore, it must be borne in mind that the 
 
CIRCULATION IN MAN AND IN ANIMALS. 
 
 05 
 
 food contains not only material for the manufacture of new protoplasm, 
 but also in a latent form all the energy of which the body makes use • 
 hence the circulation is the medium for the transference of energy from 
 one part of the body to another. Finally, as we shall discuss later, the 
 same system acts to keep the temperature of the various portions of the 
 body uniform. A review of the circulation comprises a study of the two 
 Huids which serve as carriers of the oxygen, the food, the energy, and 
 the wastes — viz., the hlood and the lyiajjh, and a study of the organic 
 mechanisms by which they are made to move. 
 
 Blood may be regarded as a tissue consisting of a lifeless, slightly yel- 
 lowish liquid, the jylasma^ and living cells, the corpuscles. The plasma 
 
 contains in solution the food and the waste matters, hence 
 Blood and its . .... i t. • i . 
 
 Constituents. ^^^ composition IS complex, ijesides water, it contains 
 
 eight to nine per cent, of solid substances, com'prising 
 among other bodies proteids, sugar, fats, and salts. Some of these con- 
 stituents originate in the di- 
 gested food stuffs. It con- 
 tains also a gas, carbonic acid. 
 The corpuscles are of 
 three kinds, the red, the 
 white or colourless, and the 
 blood-plates, which are also 
 colourless (Fig. 4). The red 
 corpuscles are most numer- 
 ous, it being estimated that 
 in one cubic millimetre of 
 
 ^^^*^^ ( igeag *^^ ^ cubic inch) 
 there exist five millions in 
 man and about a half million 
 less in woman. The number 
 in the whole body is incon- 
 ceivably great. They are bi- 
 concave round disks about 
 tsVtt ^^ ^^ inch in diameter, 
 and consist of a bit of pro- 
 toplasm coloured by a red- 
 dish pigment called hcBmo- 
 globin. Hemoglobin gives 
 to the blood its colour, and 
 is one of its most important 
 constituents by reason of having a special attraction for oxygen. "Wlien 
 the blood in its course passes through the lungs, its htemoglobin absorbs 
 oxj^gen from the air that has been breathed in, and holds it until the gas 
 
 Fig. 4. — Ked and white corpuscles of the blood, 
 magnified. 
 ,4, moderately magnilied : the red corpuscles are seen lying 
 in rouleaux ; at a and a are seen two white corpuscles; 
 7?, red corpuscles much more highly magnified, seen 
 in face : C, ditto, seen in profile ; i>, ditto, in rouleaux, 
 rather more highly magnified; E^ a red corpuscle 
 swollen into a sphere by imbibition of water; F. a 
 white corpuscle magnified same as B\ G. ditto, throw- 
 ing out some blunt processes; A' ditto, treated with 
 acetic acid, and showing nucleus, magnified same as Z> : 
 //. red corpuscles puckered orcrenate all over; /, ditto 
 at the edge only. (^Huxley. j 
 
06 PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 is required by the tissues. The task of the red corpuscles is henec that 
 of carriers of oxvgen. In cases of murder or other crimes, wliere a stain 
 is suspected to be caused by blood, an examination with the microscope, 
 bv revealiui;: the red corpuscles, will decide the question. Even if the 
 corpuscles have been destroyed, the presence of luvmoglobin can easily 
 be detected bv projXM- chemical methods. Human red blood-corpuscles 
 may be distinguished readily from those of tishes, frogs, reptiles, or 
 birds, but not conclusively from those of higher animals except the 
 camel. Human luemoglobin is not distinguishable from that of other 
 animals. 
 
 The white corpuscles are colourless cells of somewhat irregular shape, 
 roughly spherical, about ^tov of an inch in diameter. They are much 
 fewer in number than the red corpuscles. They have the peculiar power 
 of creeping about through the walls of the blood capillaries, and in among 
 the cells of the tissues throughout the body. Their specific work is not 
 fully known. It has been thought that they may be of special benetit 
 to the body, when attacked by germ diseases, by absorbing the bacterial 
 germs into their substance and destroying them. 
 
 The blood-plates were discovered only recently. They are minute, 
 colourless, spherical, or elliptical bodies, that go to pieces very easily. 
 This happens especially when blood is shed, in which case they seem 
 to aid in the clotting of the blood. Their ofKce within the body is 
 unknown. 
 
 The quantity of blood in a healthy man of one hundred and fifty 
 pounds is about five and a half quarts. 
 
 When blood is shed it has the peculiar property of clotting or thicken- 
 ino' into a jellj^-like mass. The special value of this property lies in its 
 use in stopping the loss of blood from wounds ; if it were not for this, 
 the slightest injury to the skin miglit result in bleeding to death. Clot- 
 ting consists in the formation iromjibrinogen, one of the proteids exist- 
 ing in the plasma, of an insoluble substance called Jibrin. Fibrin exists 
 in the clot in the form of fine whitish threads that extend in all directions 
 and form a spongy network. This holds in its meshes the corpuscles, 
 and the whole forms an effectual plug for the wound. By the spontane- 
 ous shrinking of the fibrin threads a yellownsh fluid, that is really plasma 
 minus the fibrin and is called seriirn, is squeezed out. 
 
 Lymph is a colourless fluid, occurring partly in the lymphatic vessels 
 and partly in the spaces between the cells of the tissues. It thus comes 
 more closely into contact with the living protoplasm 
 ^'"^ ■ than the blood, the latter never leaving its vessels. It 
 
 is much like blood in composition, but lacks the red corpuscles and the 
 blood-plates. After a meal of fat the lymph in the lymphatics of the 
 intestine is loaded with fat droplets, and is pure white in colour like milk, 
 
CIRCULATORY ORGANS OF THE BLOOD. 
 
 9: 
 
 Circulation 
 of the Blood. 
 
 Tk.d. 
 
 yjcj. 
 
 the whiteness of which is due to the contaiued droplets of butter. Such 
 lympli is called chyle, and the lymphatics in that region are known as 
 lacteals. 
 
 The blood is moved through the 
 blood-vessels by the contractions of the 
 
 heart. The motion was 
 
 thought formerly to be 
 
 a sluggish oozing from 
 the heart to the tissues. But in 1628 it 
 was shown by the Englishman, William 
 Harvey, physician to Charles L, that 
 every particle of blood makes a complete 
 circuit of the blood-vessels, and returns 
 ultimately to its place of starting ; that 
 the blood moves, so to speak, in a circle, 
 and since Harvey's time the movement 
 has been spoken of as the circulation of 
 the blood. The circulatory organs of the 
 blood system consist of the heart, the 
 arteries, the capillaries, and the veins. 
 The heart pumps the blood into the main 
 arteries ; along these the liquid courses 
 toward the tissues, passing into smaller 
 and smaller arteries, and finally into the 
 minute capillaries ; in the capillaries it 
 permeates the tissues and courses among 
 the living cells; from the capillaries it 
 passes into the small veins ; these unite 
 into larger and larger vessels, and finallj^, 
 by a few large venous trunks, the blood 
 returns to the heart again. For the 
 structure and arrangement of the circu- 
 latory organs, and for the general plan of 
 the circulation, the reader is referred to 
 the article on The Anatomy of the Hu- 
 man Body, Sections lY and Y, and to 
 the accompanying figure (Fig. 5). In 
 order to make the complete circuit of 
 the circulatory organs, any particle of 
 blood must traverse two sets of arteries, 
 capillaries, and veins, and all four cham- 
 bers of the heart. The path from the 
 left ventricle through the blood-vessels of 
 9 
 
 Fig. 5. — Diagram of the heart and 
 vessels, with the course of the cir- 
 culation, viewed from behind, so 
 that the proper left of the ob- 
 server corresponds with the left 
 side of the heart in the diagram. 
 
 L.A., left auricle ; L. P., left ventricle ; 
 Ao.^ aorta ; ^<(i, arteries to the upper 
 part of the body ; A^, arteries to the 
 lower part of the body ; H.A., hepatic 
 artery, which supplies the liver with 
 part of its blood ; Fi, veins of the up- 
 per part of the body ; T^, veins of the 
 lower part of the body; V.F.^ vena 
 portse ; H. F., hepatic vein ; V. C.I., in- 
 ferior vena cava ; F. C.S.. superior vena 
 cava ; B.A., right auricle ; B. V., right 
 ventricle; P. A., pulmonary artery; 
 Z<7.,'lung ; P. r'., pulmonary vein ; Let., 
 lacteals ; Ly., lymphatics ; Tk. P.. 
 thoracic duct ; ^l"Z.. alimentary canal: 
 Lr.. liver. The arrows indicate the 
 course of the blood, lymph, and chyle. 
 The vessels which contain arterial 
 blood have dark contours, while those 
 which carry venous blood have light 
 contours. (Huxlev.) 
 
OS 
 
 PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 the body, except the hiiigs and to the right auricle, is called the '' greater" 
 or "systemic" circulation; the path from the right ventricle through the 
 vessels of the lungs to the left auricle is called the '' lesser " or " pulmo- 
 nary" circulation. The significance of this double circulation lies in the 
 facts that in the .capillaries of the tissues of the bod}' the blood delivers 
 up food and oxygen to the cells and receives waste products from them ; 
 and that in those of the lungs the gaseous waste, carbonic acid, is thrown 
 otf into the air to be expelled in the breath, while the blood is in return 
 charged highly with oxygen. The left side of the heart hence carries 
 purified blood charged with oxygen, the right side impure blood charged 
 with carbonic acid and other waste matters. These latter wastes are 
 removed from tlic blood capillaries and from the body by the kidneys 
 and the skin. As has been already said, the food is received into the cir- 
 culation partly in the capillaries of the intestinal wall and partly directly 
 into the veins from the lymphatic ducts. 
 
 Thus all exchange between blood and living protoplasm takes place 
 
 through the capillary walls. In harmony with this function these walls 
 
 consist of a thin membrane made up of fiat cells joining 
 
 Sfnicture ^^^^ another edge to edge, and allowing a ready diffusion 
 
 and Function „ . ,. . , , t , ,' ,^^. ,,n . ^i ' -n 
 
 of Vessels ^^ "^® liquid blood plasma (i'lg. b). As the capillaries 
 
 pass on the one hand into the arteries, and on the other 
 into the veins, the walls become thickened by the addition of a layer of 
 muscle outside of the lining membrane and one of connective tissue 
 outside of the muscle. Both these layers are thicker in the arteries 
 
 than in the veins, and in the former the con- 
 nective tissue is highly elastic. Thus the 
 arteries are thick-walled, active, elastic struc- 
 tures, capable of altering their calibre greatly, 
 and thus regulating the amount of blood 
 going to the capillaries. If a particular cap- 
 illai-y area requires a large quantity of blood, 
 the muscles of the adjoining arteries relax 
 and the arteries dilate ; if less blood is de- 
 sired, the muscles contract and constrict the 
 supplying arteries. The veins are thinner 
 
 Fig. 6. — Capillary circulation hi i • t • ^ • c i • 
 
 IN THE WEB OF THE froq's FOOT. wallcd aud passivc, and are in brier drainage- 
 tubes for the capillaries and the tissues. 
 The arteries are thus physiologically more interesting than the veins. 
 If an artery be cut, the thickness and stiffness of its walls cause it to 
 stand wide open, and the blood gushes freely out ; if a vein be severed, 
 its walls collapse, and the blood hindered in its flow may clot more 
 readily and less loss may result. Hence wounding an artery is usually a 
 much more serious and dangerous affair than wounding a vein. In this 
 
THE HEART AND BLOOD-VESSELS. 99 
 
 connection it is interesting to recall the fact that as a rule the arteries 
 lie much farther from the surface of the body than the veins — a most 
 valuable adaptation of Nature. Exceptions to the rule are the radial 
 artery which comes near to the surface at 
 the vv^rist, the artery at the temple, and a " 
 
 few others. But the veins have one mechan- <^^;n- 
 
 ism peculiar to themselves — that is, the curi- 
 ous and very numerous little pouch-like 
 valves that project into the tubes and pre- 
 vent any back-flow of blood toward the cap- Fkj. 7.— Diagrammatic section of 
 
 .,, . , . f, 1 VEIN8 with valves. 
 
 illaries when any mfiuence, such as pressure ^^^ ^^^^ ^^^^.^ ^^^ ^l,^^,j .^ ^^p, 
 
 on the skin, tends to hinder the venous flow posed to be flowing in the nor- 
 
 ' , , mal direction from G (capillary) 
 
 (Fig. Y). Even if the veins are thin-walled to ri (heart) ; in the lower figure 
 
 , . . ^, . 1 , , n J_^ • pressure upon the surface of the 
 
 and inactive, their valves do not allow tneir vein has temporarily forced the 
 
 circulation to be seriously interfered with "f^t ^(HuxfeyV"'^ '^''"^ *' 
 by extraneous pressure. 
 
 The heart in its embryonic origin is a simple tubular blood-vessel, 
 
 and in some of the lower and simpler organisms, such as the worms and 
 
 the tunicates, it retains its tubular character throughout 
 
 Physiological ^-^^^ g^^^ -^^ ^j^^ growth of all higher animals, includ- 
 
 Anatomy of the , . . f „ . 1 t_g i 1 -^ i • 
 
 ^g^^^_ ing man, its simple form is early modmed by its being 
 
 curved upon itself, by partitions forming within its 
 cavity, by valves appearing at certain places, and by its walls becoming 
 greatly thickened by muscular tissue. It thus becomes a complicated 
 muscular pump, a part of the circulatory system specially modified by 
 Nature for the purpose of propelling the blood around its circuit. For 
 the details of the anatomy of the heart the reader is referred to the article 
 on The Anatomy of the Human Body, Fig. 27. It will be remembered 
 that the organ is four-chambered, comprising two thin-walled upper cham- 
 bers, the auricles, and two thick-walled lower ones, the ventricles. A 
 partition extends the whole length of the heart, separating the auricle and 
 ventricle of the right side from those of the left side. Each auricle re- 
 ceives blood from veins, and opens below into the corresponding ventricle. 
 The pulmonary veins, bringing blood from the lungs, join the left auricle ; 
 the two great veins that bring blood from the rest of the body, the supe- 
 rior and the inferior vense cavse, enter the right auricle. Each ventricle 
 opens into an artery — the right one into the pulmonary artery which con- 
 veys blood to the lungs, the left one into the aorta, which is the largest 
 artery of all, and supplies with blood all parts of the body except the 
 lungs. The course of the blood stream has been mentioned already, and 
 may be seen readily from the accompanying diagram (Fig. 5). The di- 
 rection of the flow^ is determined by the valves. Of these there are two 
 kinds : the auriculo-ventricular valves at the opening of each auricle into 
 
100 PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 its ventricle, and the semilunar valves at the origin of both the aorta and 
 the pulmonary artery. The former allow the blood to pass from the auri- 
 cles to the ventricles, but not to return ; the latter allow it to tit)w from 
 the ventricles into the arteries, but not to return. 
 
 The niovemeait of the blood is caused by contractions of the muscle 
 in tlie walls of the heart, the muscle being so arranged that each contrac- 
 tion diminishes the size of the heart chambers, and the 
 blood is thereby squeezed upon and forced out. The 
 contractions are commonly called ''beats," and ai-e ])ei'fc)i'iiied rhythmic- 
 allv. In the newborn child the heart beats at the rate of one hundred 
 and thirty to one hundred and forty times in the minute. During child- 
 hood and youth the rate gradually diminishes, and thi'oughout the greater 
 part of adult life remains at nbout seventy-two. The events of each beat 
 in brief and in order are as follows : The gradual liowing of blood from 
 the veins into the auricles and from these into the ventricles ; the sudden 
 short contraction of both auricles for the purpose of overfilling the ven- 
 tricles and causing the anriculo-ventricular valves to rise upward and shut 
 off communication between auricles and ventricles ; sudden contraction 
 of both ventricles by which the contained blood is put under tension, the 
 semilunar valves are pressed open, and the blood is shot out into the aorta 
 and the pulmonary arter}' with sufficient force to drive it through the 
 arteries, the capillaries, and the veins back again to the opposite auricle. 
 Immediately after contraction the semilunar valves close, each heart cham- 
 ber relaxes and fills with blood from the veins, its muscles rest, aiid, in a 
 fraction of a second, have recovered energy for a second beat. This fol- 
 lows, and a third, and a fourth, and so the cycle is repeated with alterna- 
 tions of activity and of rest, of systole and diastole, throughout the life of 
 the individual, the order of events never changing unless some form of 
 ''heart disease" interferes with the working of this most beautiful of all 
 animal mechanisms. 
 
 It is apparent that the course of the blood along the arteries is inter- 
 mittent, wave after wave following one another at intervals of less than a 
 second. Each wave or j^ulse is, of course, the direct 
 result of the ventricular beat, and hence the physician 
 regards the pulse as one of the best indications available to him of the 
 condition of the heart. The practised ear may infer much also from the 
 lieart sounds, which may be heard readily by laying the ear on the chest 
 M'all over the heart. These are two — a longer, faint, low-])it(;lied tone, due 
 to the contraction of the ventricles, and immediately followed by a short, 
 higher-pitched, abrupt one, caused by the closing of the semilunar valves. 
 If the parts are altered by disease the sounds are altered. 
 
 The smaller arteries and the capillaries are excessively fine tubes, the 
 diameter of some of the latter being even as small as -g-sinr ^'^ ^^^ inch, the 
 
BEAT OF THE HEART AND HEART SOUNDS. 101 
 
 diameter of a red corpuscle. Tlie result is that tlie resistance to the flow 
 in them is enormous, and the blood tends constantly to accumulate in the 
 arteries. The walls of the arteries are thereby put under great tension, 
 the pressure of the blood within them is great, and their elasticity is 
 brought into play. The result of this combined capillary resistance and 
 arterial elasticity is that by the time the Ijlood has reached the smallest 
 vessels the pulse has disappeared, and the flow is continuous in both the 
 capillaries and the veins. Many more details might be given of the events 
 of the blood movement were there space, for even from the very earliest 
 times, and especially since, in 1628, Harvey gave the right interpretation 
 of the leading facts, and since Malpighi, in 1661, first saw with his micro- 
 scope the exquisite and wonderful picture of the blood corpuscles pick- 
 ing their way through the tortuous capillary channels in the wall of the 
 frog's lung, the circulation has been a favourite study with all schools 
 of physiologists. Many of the once mysterious facts have been shown to 
 be explicable by the common laws of mechanics. Although the heart is 
 a living pump and the vessels living tubes, the circulatory system pre- 
 sents many of the same problems as are presented by any system of closed 
 elastic pipes through which liquid is pumped. Other problems, however, 
 defy the attacks of the mechanical, physical, or chemical physiologists, 
 and prove that the experimental laboratories have still much to do. 
 
 Of these latter problems, which for lack of a better word may be 
 called "vital," two may here be mentioned — viz., the causation of the 
 heart beat, and the regulation and co-ordination of the various parts of 
 the circulatory apparatus. The beat itself is an excellent example of what 
 physiologists are wont to call spontaneous actions — i. e., actions which 
 originate within the tissue itself, and do not require a stimulus from with- 
 out to set the tissue going. By this is not meant a causeless action ; every 
 action has one or more causes, but the causes of sponta- 
 Heart B t neous actions are to be sought within the acting part it- 
 
 self. The beat of the heart is a spontaneous action. It 
 has been abundantly proved in lower animals and even in the higher 
 quadrupeds that the heart when removed from the body will continue to 
 beat even for hours if it be supplied with proper nourishment and warmth, 
 and this fact no doubt would apply to the human heart, were it possible 
 to test it. The impulse to the beat is then to be sought in the heart 
 itself, but in what tissue ? The heart contains much nervous tissue, con- 
 sisting of nerve cells, which send off filaments, the nerve fibres, to the 
 cardiac muscle cells. In general it may be said that nerve tissue is more 
 inclined to spontaneity than muscle tissue. Within the heart, then, does 
 the impulse to beat originate in the muscle cells that do the contracting, 
 or does it originate in the nerve cells and pass from them along the nerve 
 fibres to the muscle cells ? The question is a fundamental one for physi- 
 
102 PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 oloffists, and its answer would be a valuable contribution to the interest- 
 ing subject of the evolution of muscular and nervous function. In the 
 lower and simpler animals spontaneity is a characteristic of almost all 
 kinds of cells and tissues; as the evolution of the higher animals has gone 
 on, gradually the tissues have become less spontaneous in their actions 
 and more dependent upon impulses coming to them from the nervous 
 system, until, in the higher animals, the work of the body is largely per- 
 formed as the result of nervous action. In accordance with this the nerv- 
 ous svstem retains its primitive spontaneity in a high degree. In the 
 hearts of invertebrates, as the snail, and perhaps some low vertebrates, as 
 the frog and the turtle, the impulse to beat appears to originate in the 
 cardiac muscle cells ; in the higher vertebrates it is yet unsettled whether 
 it is nervous or muscular in origin. Why the heart tissue acts rhythmic- 
 ally is another inviting subject, not yet understood, into which we have 
 here not time to go. 
 
 Although, as we have seen, the heart does not need any impulse from 
 outside to enable it to continue its contractions and do its work, yet its 
 
 contractions are always regulated and controlled by 
 Nervous Control . -, • £ i.i i • Tr> j.i 
 
 ^ji. TT . nervous impulses comino- trom the brain. I'rom the 
 of the Heart. ^ Y 
 
 part of the brain lying at its base and called the medulla 
 oblongata, situated just within the skull at the back of the neck, nervous 
 impulses go out to the heart along certain nerves. Along the two vagus 
 nerves (see The Anatomy of the Human Body) may go impulses which 
 cause the heart to beat more slowly or more weakly than before. These 
 come fi'om the so-called cardio-inhibitory centre in the medulla, and if 
 sufficiently intense they may cause the heart actually to stop beating. 
 Along the sympathetic nerves may go impulses that cause the heart to 
 beat more rapidly or more strongly than before ; these come also from an 
 augmentor or accelerator centre situated probably in the medulla. These 
 two centres are thus antagonistic in their action on the heart. They are 
 in nervous connection with other parts of the central nervous system and 
 thence with all parts of the body, and through them the heart is delicately 
 controlled constantly as to rate and force of beat, so that its work is 
 adapted to the needs of the body at every moment. As examples of ex- 
 treme activity of these nerve centres may be mentioned, first, the slowing 
 or actual stopping of the heart by a sudden heavy blow in the pit of the 
 stomach, or by a sudden shock caused by a piece of bad news. In both 
 cases the cardio-inhibitory centre is stimulated to activity; in the former 
 through nerves going up from the stomach to the medulla, in the latter 
 through nerve fibres within the brain itself, extending down from the 
 consciously acting brain centres above that have taken cognizance of the 
 bad news. In both cases the result, as stated, is slowing or stopping of 
 the heart ; the fainting that usually accompanies is a secondary result, due 
 
NERVOUS CONTROL OF THE HEART AND ARTERIES. 108 
 
 to the fact that tlie weakened heart fails to pump the necessary blood to 
 the consciously acting brain, and unconsciousness results. Second, the 
 very rapid fluttering of the heart accompanying mental excitement is no 
 doubt due to excessive stimulation of the accelerator centre, and thus of 
 the heart, by impulses coming likewise down from the higher brain ceils. 
 A little consideration will show that slowing of the heart may result 
 theoretically from activity of iidiibitory nerves or from the cessation of 
 activity of accelerator nerves ; and the like applies vice versa to accelera- 
 tion. Physiology has not yet unravelled all the mysteries of the inter- 
 actions of these two antagonistic nerve influences. It may be mentioned 
 here incidentally that the rapid pulse present in fever is probably due to 
 the hot blood stimulating directly the heart muscle to excessive activity. 
 
 The blood supply to the various parts of the body must needs vary 
 constantly, according as any part requires more or less blood at one time 
 
 than at another. A tissue in action needs more blood 
 Nervous Control , i , i , . i , i • . i r i 
 
 of the Arte -i ^^^ same tissue at rest, because it needs more food 
 
 and more oxygen, and because the injurious waste prod- 
 ucts of its activity must be removed. When the brain thinks, it needs 
 more blood than when it sleeps ; when the digestive glands are secreting, 
 they must have blood in abundance ; when a man works with his muscles, 
 they demand an extra allowance of blood. Obviously, mere alteration of 
 the heart beat affects the general blood supply, but affects all parts equally. 
 Nature has, however, evolved an eflicient method of varying the supph- 
 according to the needs of the individual parts. The method consists in 
 varying the calibre of the artery that brings blood to each part. Con- 
 striction or narrowing of an artery causes the quantity of blood to be 
 diminished ; dilatation or widening causes it to be increased. The calibre 
 of the arteries, like the action of the heart, is regulated through special 
 nerves by a particular part of the brain. Such nerves are called vaso- 
 motor, from the fact that they supply the muscles or motor part of the 
 arterial walls. The vaso-motor nerves are of two kinds, quite analogous 
 in their functions to the two kinds of cardiac nerves : the vaso-constrictors 
 have the power of causing the muscular coat of the arterial walls to con- 
 tract, and thus a constriction of the artery results (analogous to augmenta- 
 tion of the heart beat) ; the vaso-dilators cause relaxation of the arterial 
 muscle and hence a dilation of the vessel (analogous to cardiac inhibi- 
 tion). These nerves go to the arteries from a vaso-tnotor centre in the 
 medulla oblongata. This part of the brain, like the cardio-inhibitory 
 centre near which it lies, is affected by influences coming from all parts 
 of the body, and its actions are determined by the nature of these in- 
 fluences. It is capable of controlling the calibre of each artery, and thus 
 of constricting or dilating small or large vascular areas. Like the case of 
 cardiac augmentation or inhibition, arterial constriction and dilation may 
 
104 PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 result theoretically not only from direct constricting and dilating im- 
 pulses, but each may also follow from the cessation of impulses leading to 
 the opposite activity. Hence the mutual interactions of these two in- 
 fluences become excessively complicated and present a problem not yet 
 wholly solved. .As examples of vaso-motor actions may be mentioned the 
 two cases of blushing and becoming pale, due in the one case to arterial 
 dilation, and in the other to arterial constriction, of the small arteries in 
 the skin of the face. The exciting cause in each case is an unusual thought 
 or emotion originating in the brain and causing nervous impulses to pass 
 down to the vaso-motor centre in the medulla, in the one case decreasing 
 its activity, in the other increasing it. Just why one emotion causes 
 blushing and another paleness is not clear. As might have been expected, 
 of all the blood-vessels the arteries alone are known to be markedly con- 
 trolled by nerves. The vaso-motor nervous apparatus and the cardiac 
 nervous apparatus are connected within the medulla and work in harmony 
 with each other. Together they form a mechanism of remarkable adapta- 
 tion and refinement. 
 
 As will be seen from the article on Anatomy^ the lymphatic system is 
 comparable in a general way with the capillary and the venous systems — 
 
 i. e., it consists of capillaries uniting to form larger ves- 
 e ymp a ic ^^^ ^^^ these in turn unite into two large trunks. The 
 System. ' ^ ..... 
 
 capillaries take their origin in irregular spaces among 
 
 the tissues. (See The Anatomy of the Human Body^ Fig. 36.) The 
 lymphatics receive openings from such large cavities as those of the ab- 
 domen, of the chest, and of the pericardium. At intervals they open into 
 the irregular cavities within the lymphatic glands. And finally the two 
 trunks, the thoracic duct and the smaller right lymphatic duct, open into 
 the great veins at the root of the neck. The walls of the lymphatics are 
 not unlike those of the capillaries and veins in structure, but they are ex- 
 cessively thin. Valves, like the venous valves, are very abundant in the 
 vessels. The lymph not only fills the lymphatic organs, but exists also in 
 all cell spaces and interstices of the tissues, and thus bathes the living cells 
 much more intimately than does the blood. The lymph may be regarderl 
 as a carrier between the blood and the living cells, all food and all waste 
 matters probably having to pass through it in their passage between the 
 protoplasm and the blood-circulating system. The plasma of the lymph 
 is blood plasma that has escaped through the thin walls of the blood cap- 
 illaries into the spaces in the surrounding tissues ; the corpuscles of lymph 
 are in part escaped white blood-corpuscles and in part new cells that are 
 formed by division of cells within the lymphatic glands. The lymph thus 
 originating constantly in the tissues passes into the lymphatic capillaries, 
 flows constantly along the vessels, and empties itself into the veins. In 
 all vertebrates below the mammals a varying number of lymph hearts 
 
THE LYMPHATIC SYSTEM. 105 
 
 exist — simple muscular sacs attached to various lymphatic vessels, and 
 capable, like the blood heart, of rhythmic contractions. No such organs 
 are known to exist in man and other mammals. The movement of the 
 lymph is due to several agencies, such as pressure exerted upon the vessels 
 by the muscular movements of the body, the existence of a lower pressure 
 in the veins than in the lymph-vessels themselves, and possibly rhythmic 
 contraction of the walls of the vessels. The numerous valves prevent any 
 possibility of a flow in the wrong direction. Thus both structurally and 
 functionally the lymphatic system is a much less highly specialized appa- 
 ratus than the blood system. The latter, with its efficient means of pro- 
 pulsion and its elaborate nervous mechanism for regulating f-peed and 
 distribution, is, like the railway system, an efficient and rapid carrier. 
 But, just as between the factory and the railway, or between the latter 
 and the consumer, the drayman's cart is indispensable, so in the body, be- 
 tween the place of digestion and the blood, or between the blood and the 
 living cells, the lymph finds its tasks. The lymphatic system and the 
 blood system together form a most efficient distributing and collecting 
 mechanism. 
 
 We have thus traced the food from outside the body to the living cells. 
 Without oxygen the cells can not utilize it. We have now to consider the 
 source of the oxygen. 
 
 Section III. 
 
 BESPIRA TION. 
 
 The lungs and other respiratory organs have a twofold function — that 
 
 of bringing to the blood the oxygen that is as essential to life as is the 
 
 food, and that of removing from 
 Respiration in ,i i i i i p ,^ t ^ 
 
 >, , the blood and from the body water 
 
 General. _ -^ 
 
 and certain waste and poisonous 
 products, mainly carbonic acid. The great impor- 
 tance of the whole process is indicated by the facts 
 that the respiratory organs occupy so large a space 
 in the body ; that the right ventricle of the heart 
 has as its sole function that of supplying blood to 
 them ; and that during the lifetime of the individ- 
 ual all the blood in the body must pass through Ym. s.^TEKiirxATioN of 
 them once in every twenty or twenty-five seconds '^^° bronchial TrsEs 
 
 -J •' •' ^^ EXLAP.GE3IEXT BESET 
 
 — the time occupied by the blood in making the ^"h air sacs. (Hux- 
 complete circuit of the body. To insure rapid 
 
 and efficient exchange of the two gases, oxygen and carbonic acid, the 
 blood and the air must be brought into as close proximity to each other 
 as possible ; hence we find the lung to consist mainly of innumerable 
 
106 PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 small air sues (Fig. 8) with excessively thin walls containing a little elastic 
 connective tissue lined by a layer of llat, thin epithelium cells, and loaded 
 with a rich network of line blood capillaries. The air sacs are continu- 
 ous with the bronchial tubes, and communicate through the trachea with 
 the outside air (Fig. 9). The blood is se])arated from the air by the thin 
 epithelial membrane consisting of capillar}- wall and wall of air sac 
 
 Fig. 9. — Trachea and htngs, dissected to 8how bronchial tubes. 
 
 1, 2, larynx ; 3, 4, trachea ; .5, 6, bronchi ; 7, 8, 9, 10, 11, broncliial tubes, a few only being shown aa 
 
 far as their terminations ; 12, 13, 14, 15, surface of lungs. (Sappey.) 
 
 (Fig. 10). Thus the conditions needed for ready diffusion are present. 
 The total amount of air surface exposed in the lungs appears to be more 
 than two hundred square yards, and the amount of capillary surface 
 more than a hundred and fifty square yards. The blood is renewed 
 constantly by the circulation ; the air is exchanged constantly by the 
 respiratory movements ; and the result of the interchange between the 
 two media through the intervening membranous wall is that, while 
 impure blood and pure air have entered the lungs by their respective 
 channels, pure blood and impure air go out from them. 
 
RESPIRATORY MOVEMENTS. 107 
 
 The respiratory movements consist of those of inspiration and expira- 
 tion. In both of tliese acts the lungs are passive organs. The activity re- 
 sides in the muscles of the chest walls. It will be re- 
 espira ory membered that the lungs are inclosed within an air-tight 
 cavity, the thorax or chest, which is bordered at the top 
 and sides by the ribs and the intercostal muscles, and below by the dome- 
 like muscular partition, the diaphragm. Contraction of the external in- 
 tercostal muscles raises the ribs, pushes the sternum or breast bone out- 
 ward, and enlarges the whole chest cavity. Enlargement of the chest may 
 be brought about also by contracting and thereby lowering the diaphragm. 
 The inspiratory act consists in enlarging the chest by simultaneous con- 
 tractions of both these muscles with the assistance of other muscles of the 
 thoracic walls. The walls of the lungs follow passively the movements of 
 the walls of the air-tight and air-empty chest, and the capacity of the 
 lungs is correspondingly increased ; to balance this the air rushes in pas- 
 sively through the nostrils or mouth, pharynx, trachea, and bronchial tubes. 
 Thus we do not breathe air in, as our sensations might mislead us to be- 
 lieve, through any action exerted upon the air by our nostrils or lungs. 
 When we wish air we contract our diaphragm and the muscles of our ribs, 
 and air must come in. Both sexes use both muscles, but in women res- 
 piration by movement of the ribs, or " costal " respiration, predominates ; 
 in men the " diaphragmatic " or " abdominal " method is more promi- 
 nent. It has been greatly discussed and is still undecided whether this is 
 
 a fundamental sexual diilerence associated with the func- 
 Sexual Differences ^. n t •^ n • • i ,i ., • i , 
 
 in Respiration. '^^°° ^^ childbearing m woman, or whether it is due to 
 
 the tightness of woman's dress about the abdominal re- 
 gion and the prevention of the free action of the diaphragm. The expira- 
 tory act is the reverse of that of inspiration : the muscles cease their con- 
 traction, the ribs and the diaphragm return to 
 their former positions, the tension on the lungs 
 is removed ; by their elasticity the lungs return 
 to their former size, and the excess of air is 
 squeezed out. Only when the breathing becomes 
 laboured, as in active exercise, or when from 
 any unusual cause there is danger of suffocation, 
 does expiration become a muscular act, carried ^^'^^ lo.— Diagkaidiatic view 
 
 ^ ' OF AN AIK SAC. 
 
 on by various muscles attached to the walls of „^ 1^^^ ^.^^^:^^ g^, ^^ ^^^^^ 
 the chest and the abdomen. Eespiration is a to epithelium lining ^aii; 
 
 _ \ 0, partition between two ad- 
 
 rhythmic, ordinarily unconscious action, repeated jacent sacs, in which run 
 
 , • 1 , , • • 1-1 capillaries ; c, elastic eon- 
 
 on an average seventeen to eighteen times m the nective tissue. (Huxley.) 
 minute in the adult, but more rapidly in children. 
 
 At each respiration about thirty cubic inches of air (*' tidal air ") passes 
 into and out of the air passages and mixes with the " stationary air " 
 
108 PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 (about one hundred and eighty cubic inches) that the hmgs contain at 
 all times. The actual exchange of gases between the tidal and the sta- 
 tionary air takes place by diflEusion, The result of the 
 
 esptra ory exchano-e is that the expired air is saturated with 
 Changes tn Air. " . ,,..,. 
 
 - moisture, is wanner than the inspired air, and contains 
 
 about five per cent, less oxygen, about four per cent, more carbonic acid, 
 and a minute (piantity of obscure deleterious substances of unknown 
 nature, to which the odour of the breath is due. 
 
 The respiratory muscles are not, like the heart, automatic ; they need 
 
 to be stimulated for each contraction ; and a particular part of the brain 
 
 has been specialized to originate and send out to them 
 
 1 eiious on 10 ^j^^ necessary impulses. This is the so-called respiratory 
 
 of Ret^piratwn. . , t • ,• • "T n i 
 
 centre or " vital spot, and it lies in the medulla ob- 
 
 lono-ata at the base of the brain. Its presence there makes this portion of 
 the brain seem so important, for any serious injury to the centre stops 
 respiration and thus puts an end to life. Hence the fatality in breaking 
 the neck. The nerve cells composing the centre are put into activity, ap- 
 parently, by the impure venous blood circulating about them ; they in- 
 augurate an inspiratory impulse and discharge it along the intercostal and 
 the phrenic nerves to the respiratory muscles, causing the latter to act. 
 Exactly how the regular alternation of inspiration and expiration comes 
 about is not wholly explained, but the centre seems to be regulated in its 
 activity by nerve impulses coming from the lungs. It is, in fact, one of 
 the most sensitive parts of the nervous system, all modifications of breath- 
 ing that take place in laughing, crying, coughing, sneezing, hiccoughing, 
 sighing, " catching one's breath," muscular exercise, talking, singing, step- 
 ping into a cold bath, etc., being due to influences altering the regular 
 working of the respiratory centre. The peculiar facial expressions and 
 characteristic vocal sounds that accompany laughing and crying are to be 
 distinguished from the modified breathing. It is not easy to conceive 
 how and why these peculiarities of facial expression, sounds and breath- 
 ing, which are evidences of pleasure or of grief, and the beginnings of 
 which seem to be found in animals lower than man, have been developed. 
 The changes that the blood undergoes in its passage through the lungs 
 are in harmony with and are no less striking than those of the air. The 
 blood loses to the air contained in the air sacs of the lungs 
 
 Respiratory g-^^ ^.^ eight per cent, of carbonic acid, and gains from it 
 Changes in the . , . . . , , 
 
 Blood eight to twelve per cent, oi oxygen ; it comes to the 
 
 lungs purplish in colour ; it leaves them bright scarlet. 
 The gaseous exchange between air and blood takes place chiefly by the 
 physical process of osmosis through the thin cellular membrane separat- 
 ing them ; but the cells of this membrane may possibly act like gland 
 cells to " secrete " the two gases. 
 
EXCHANGE OF OXYGEN AND CARBONIC ACID. 109 
 
 Tlie change of colour of the blood is interesting. It will be i-eniern- 
 
 bered that the red colour is due to the colour of the hsenioglobin that 
 
 exists in the red corpuscles, and also . that the red cor- 
 Colour of the Blood. -, .-, • x npi i i \ • 
 
 puscles are the carriers oi oxygen, ilie hsenioglobin 
 
 exists in the body in two forms — in venous or impure blood, largely as 
 reduced hcemoglohin, and in arterial or pure blood, as oxyhcBmoglohin. 
 Eeduced haemoglobin contains little oxygen and is purplish in colour ; 
 oxyhaemoglobin contains much oxygen and is scarlet in colour. The 
 haemoglobin that is brought to the lungs is in the reduced form ; it greed- 
 ily seizes upon the oxygen that is absorbed through the capillary walls ; 
 it becomes oxidized ; and the colour of the haemoglobin, the red cor- 
 puscles, and the blood changes accordingly to the bright-red tint. 
 
 Besides the pulmonary respiration, slight exchange of oxygen and car- 
 bonic acid takes place directly through the skin. This method of breath- 
 ing is of great importance to some of the lower animals. 
 Respiration by ^ r j i, j. • -i. • v. 
 
 th '^k' ®^ ^^ frogs and worms, but in man it is very sub- 
 
 ordinate. 
 The specific respiratory organs work for the body as a whole. In the 
 broad sense, however, all living cells are respiratoiy, since they take in 
 oxygen and give out carbonic acid. Such a process is often spoken of as 
 internal or tissue respiration. The lungs and the skin mediate between 
 the air and the blood and lymph. The blood and the lymph are car- 
 riers between the respiratory organs and the living tissues. Charged 
 with oxygen in the lungs, the blood is sent throughout 
 
 „ .^ ^. the body, and everywhere in the capillaries it courses 
 
 Respiration. •' ' •' . mi 
 
 among living cells that require oxygen. Ihe oxyhaemo- 
 
 globin is robbed of its contained gas and becomes reduced, while the 
 blood changes to a purplish colour. The cells, on the other hand, are 
 constantly giving off carbonic acid, and this by diffusion passes readily 
 into the blood. The lymph has in tissue respiration a function analogous 
 to that which it has in tissue nourishment : it is the mediator between the 
 blood and the living cells. Hence the result of tissue respiration as re- 
 gards the blood is exactly the reverse of that of pulmonary respiration. 
 The respiratory relations of the pulmonary and the systemic circulatory 
 systems hence appear in a new and striking light. The former deals with 
 the respiratory needs of the body as a whole, the latter with the respira- 
 tory needs of the living particles of which the body is composed. 
 
 In considering respiration we have unavoidably touched upon the 
 excretion of one waste product — carbonic acid. The other wastes may 
 now be studied. 
 
110 PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 Section IV. 
 EXCRETION. 
 
 Leaving for the present the cousideration of their sources, we may 
 enumerate the chief waste products of protoplasmic activity as follows : 
 
 Wastk Products. Organs of Excretion. 
 Gaseous. . . .Carbonic acid. Lungs, skin. 
 
 Liquid Water. Kidneys, lungs, skin. 
 
 < Urea and other nitro- j Kidnevs. skin. 
 
 Solid \ genous wastes. ( 
 
 ( Inorganic salts. Kidneys, skin. 
 
 Protoplasm is unable to extract energy from these substances, and 
 their presence in the body in excessive quantities is harmful. Nature has 
 therefore evolved in the organs of excretion refined mechanisms for re- 
 moving them from the organism. They are cast out from the living cells 
 into the blood, and are transferred by the circulatory organs to the organs 
 of excretion. The latter will now be considered. 
 
 A. THE KIDNEYS. 
 
 The kidneys are the most highly specialized of the excretory organs. 
 Their dutv is to manufacture and pass out the urine. Urine is a clear 
 yellow or brownish-yellow liquid, consisting of about 
 96"5 per cent, of water and 3'5 per cent, of dissolved 
 solid substances. The solids are numerous, comprising organic bodies 
 such as urea, uric acid, and creatinin, and inorganic salts such as various 
 sulphates, phosphates, and chlorides. Their variety and relatively con- 
 siderable quantity indicate the great importance of the kidneys as purifi- 
 ers of the blood and thus of the body. The greatest interest centres 
 in the organic solids, of which urea is the most abundant, because they 
 represent the characteristic waste products of the destruction of the 
 important proteid substance. The special peculiarity of urea and these 
 other products is the presence within them of nitrogen ; hence the urine 
 is the medium through whicli the all-important nitrogen leaves the body. 
 The average quantity of urine that is passed in twenty-four hours is one 
 and a half quarts, but the quantity is subject to great variations, depend- 
 ing upon the weather, the character of the food, whether much water has 
 been drunk, and the occupation of the individual. 
 
 The kidneys are highly complicated glands whose structure is spe- 
 cially adapted to the removal from the blood of large quantities of water, 
 together with solid substances. They consist of a mass of minute canals 
 (the uriniferous tubules)., and of blood capillaries, inextricably woven 
 together. Each tubule begins in an enlarged cavity (the MaVpighian 
 
STRUCTURE AND FUNCTION OF THE KIDNEYS. 
 
 Ill 
 
 capsule) into which projects a tuft of capillaries, the glomerulus. From 
 the capsule the tubule takes a tortuous course, as shown in the accompany- 
 ing figure (Fig. 11), unites with other tubules, and finally 
 approaches the surface of the kidney, where, together 
 with all the other tubules, it opens into the dilated, 
 funnel-shaped beginning of the duct, the ureter (Fig. 12). The wall of the 
 tubule consists of a single layer of living cells varying in thickness in 
 
 Structure of the 
 Kidneys. 
 
 Fig. 11. — Diagrammatic view 
 of course of uriniferous 
 tubules in kidney. 
 
 /, Malpighian capsule, con- 
 taining glomerulus ; //- 
 F///, course of tubule ; Z.r, 
 opening of tubule into pel- 
 vis of kidney at apex of 
 pyramid of Malpighi ; ^, 
 outer surface of kidney ; r, 
 outer or cortical substance ; 
 g,p^ inner or medullary sub- 
 stance. (Huxley.) 
 
 Fig. 12. — Vertical section of kidnet. (Some- 
 what smaller than natural size.) 
 
 1, 2, S, 4, pyramids of Malpighi, striations repre- 
 senting uriniferous tubules ; 5, apices of pyra- 
 mids, where tubules open ; 6, cortical sub- 
 stance projecting inward between pyramids 
 and containing ^blood-vessels ; 7, dilated end 
 of ureter, called pelvis ; 8, ureter. (Sappey.) 
 
 diflEerent parts. In among the tubules is the very close network of blood 
 capillaries, and lymph permeates all the interstices. The tubules are thus 
 bathed by the circulating fluids. 
 
 Most of the constituents of the urine exist ready formed in the blood, 
 having been cast into it by the cells outside of the kidney. The process 
 of excretion consists in a discharge of these substances 
 through the cells that form the walls of the tubules. 
 Some of the cells apparently hare the power of manu- 
 facturing and casting out the few constituents that are not present in the 
 blood. In its mode of action the kidney thus seems to combine the more 
 
 Excretion by the 
 Kidneys. 
 
112 PHYSIOLOGY: THE VITAL PROCESSES IN HEALTH. 
 
 clearly physical features of the work of lung cells and the more ob- 
 scure secretory activities of gland cells, as represented by the digestive 
 glands. The urine is secreted constantly, and trickles along the tubules 
 to the dilated end of the ureter ; it then leaves the kidney in the latter 
 tube and passes- to the urinary bladder situated in the pelvis. Here it 
 accumulates until the distention of the bladder gives rise to a desire to 
 micturate. IS^ervous impulses from the brain cause the muscular walls 
 of the bladder to contract, and the urine is discharged from the body 
 
 throuii;h the ure'thra. 
 
 B. THE SKIN. 
 
 The skin ]ierforms a variety of duties. It protects the delicate parts 
 
 withiii the body ; it contains organs for the senses of touch and of tem- 
 
 peratui-e ; through its blood-vessels it regulates the tem- 
 
 ,, „, . • perature of the bodv ; and it contains important excre- 
 {he Skin. '^ - ' _^ ^ 
 
 tory organs. The latter are the two kinds of glands 
 known as svdoriferous, or siveat, glands and sebaceous glands ; the former 
 
 produce the sweat, the latter the 
 oily substance found on the surface 
 of the body. 
 
 Sweat glands are simple tubes 
 the secreting portion of which, 
 coiled into a knot, lies just be- 
 neath the skin (Fig. 13). The 
 duct passes through the skin and 
 terminates by a minute opening 
 upon the surface. These "pores" 
 
 Fig. 13. — N'tirric.vL .■section uf skin. 
 (Magnified 20 diameters.) 
 
 1, outer layer of skin ; 1, 2, cuticle or 
 epidermis ; 3, 4, inner layer of skin 
 or dermis ; 5, subcutaneous tissue ; 
 6, sweat glands ; 7, ma.sses of fat, 
 consisting" of fat cells ; 8, 9, ducts 
 of sweat glands. ( Sappey.) 
 
 Fig. 14. — Surface of palm of hand. 
 
 (Magnified 4 diameters.) 
 
 2, ridges in akin bearing (1) openings 
 
 of ducts of sweat glands. (Sapjx'y.) 
 
 may readily be seen by a common magnifying glass upon the fine ridges 
 in the palm of the hand (Fig. 14). Sweat is a colourless, salty liquid 
 
EXCRETORY FUNCTIONS OF THE LUNGS AND SKIN. 113 
 
 consisting of water and slight quantities of urea, inorganic salts (espe- 
 cially common salt), and a few other substances. It is constantly given 
 
 off. An average quantity is nearly a quart in twenty- 
 Sweat Olands. r ^ i i. i.i ' i. • i.i -iV xt 
 
 lour hours, but tiie amount varies greatly with the 
 
 weather, the occupation of the individual, and other influences. The 
 perspiration is thus seen to be an important medium of loss of sub- 
 stance from the body. This is especially evident when one exercises 
 vigorously ; it is easily possible in an hour's exercise to diminish one's 
 weight by a pound. The more one perspires, the less the kidneys ex- 
 crete, and vice versa. Hence the skin is more active in summer, the 
 kidneys in winter. 
 
 The sebaceous glands lie in the deeper part of the skin and open 
 
 chiefly into the depressions in which lie the roots of 
 
 Sebaceous Glands. i i . mi , •^ i ^^ j> t i j_ 
 
 the hairs, ihey secrete an oily substance oi slight 
 
 value as an excretion, but of use in preventing the skin and the hair 
 
 from becoming too dry. 
 
 C. THE LUNGS. 
 
 The expired air is an important medium of loss of water and the chief 
 one for loss of carbonic acid. The excretory function of the lungs has 
 been considered sufficiently under respiration. 
 
 We have followed the oxygen and the food — consisting of proteids, 
 fats, carbohydrates, salts, and water — from without the body by way of the 
 digestive organs and the lungs to the living cells. We have seen that 
 waste matters in the forms of carbonic acid, urea, salts, and water go from 
 the living cells by way of the excretory organs to the exterior. What 
 takes place within the living substance? 
 
 Section V. 
 
 METABOLISM. 
 
 If we could answer the question propounded at the end of the last sec- 
 tion we should know what life is ; yet we are unable to point to any one 
 of the millions of cells in the human body and say that we know all the 
 details of the vital process that takes place within it. The difficulties and 
 complexities of the problem are inconceivably great, but perhaps not in- 
 surmountable. We can measure and analyze the income and the outgo of 
 the body ; we can test the effect of different foods upon the general metab- 
 olism ; we can observe how the composition of the different organs changes 
 when food is withheld from the animal for a time, all of which methods 
 are helpful. But, further than this, chemical investigation is revealing to 
 us ever more clearly the steps in the pathway between food and wastes ; 
 
 10 
 
114 PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 we are approaching a knowledge of the structure of proto})lasiu and of 
 the structural changes that take place in the actively working cell ; and 
 recent studies of the action upon organisms of the environment and of ex- 
 ternal agents — such as light, heat, electricity, and chemical influences — are 
 giving us a deeper insight into the secrets of the physical basis of life. 
 We can conceive the nutritional changes that take place within the cells 
 and that constitute the metabolic process as consisting of a building up 
 and a breaking down. Ivaw material in the form of food that is rich in 
 energy is brought to and absorbed by the cells. It is 
 Metabolism in .^i^^j.^^! chemically, its atoms are recombined, and it is 
 
 Gr67l6T(ll* 
 
 built up, probably by a complex series of steps, into 
 protoplasm, its energy being retained in a latent form ; this is the con- 
 structive phase of metabolism, called anaholisiii. Later, the protoplasm is 
 changed chemically, its atoms are recombined, and it is broken down, 
 probably by a complex series of steps, into wastes, its energy being given 
 off in the form of mechanical work and of heat ; this is the destructive 
 phase of metabolism, called katabollsm. Stated in these words, the vital 
 process seems simple enough. But this is not the whole story ; for, in 
 the first place, not all the food is built up into protoplasm before it is 
 broken down into wastes ; some appears to be changed at once after enter- 
 ing the tissues and to be immediately cast out in the excretions ; other food 
 is stored up for a time, to be used subsequently for the manufacture of 
 protoplasm or for other needs of the body. Fat is an excellent example 
 of a substance that is thus stored ; it is not living, but is contained within 
 special living cells — the fat cells. The cells of the liver are likewise 
 loaded with a variety of starch, called glycogen. Fat and glycogen con- 
 stitute a stock of reserve material upon which the cells may draw in time 
 of need. Further, each of the different varieties of cells has its own spe- 
 cial metabolic peculiarities. For example, the digestive glands are pecul- 
 iar in manufacturing in quantity substances (the digestive fluids) that are 
 of the greatest subsequent value to the body ; certain of the brain cells 
 are unique in the fact that their activity is accompanied by phenomena of 
 thought ; the muscles seem to be the greatest producers of the body heat. 
 All these peculiarities complicate the problem of metabolism greatly, and 
 the real difficulty comes when we atteinpt to learn the details of the 
 matter. 
 
 The one fact that stands out above all others is the fact that the de- 
 structive or katabolic process is one of oxidation ; that is, the gas, 
 
 oxygen, is made to unite with the other elements — car- 
 Kataholismis ^^^^ hydrogen, nitrogen, etc.— that exist in the food or 
 
 in protoplasm. Thus, oi the various excreted sub- 
 stances, carbonic acid is a compound of oxygen and carbon (in the pro- 
 portions CO,) ; water is a compound of oxygen and hydrogen (in the pro- 
 
FOOD STUFFS AND WASTES. 115 
 
 portioris IlaO) ; and urea, while more complex in composition (CII/N,/J), 
 is undoubtedly formed by oxidative processes from the still more complex 
 proteids. In this vital process of oxidation lieat and mechanical energy 
 are set free for the body's use, hence the body is warm and can do work ; 
 and the excretory substances are therefore largely devoid of energy. 
 Oxidation is nothing more nor less than combustion ; the burning of 
 wood or coal or illuminating gas is oxidation. The burning of these life- 
 less substances, therefore, and the vital processes, are fundamentally of the 
 same chemical nature. So, too, as regards energy, coal, when burned in 
 a furnace, yields heat, mechanical work, and light ; protoplasm, when 
 consumed in a living body, yields heat, mechanical work, and in certain 
 animals, such as the firefly, glowworm, and some marine forms, even 
 brilliant light. Such a parallelism between lifeless and living substance 
 is interesting and suggestive. 
 
 Another striking fact is that the living tissues do not convert 
 unchanged into their own substance the substance of the corresponding 
 
 tissues that are eaten in animal food. For example, the 
 Sitpl AbZptL. f^* of t^^^ foo^ ^oes not go directly to form the fat of 
 
 the body ; the muscle proteid of beef or mutton that we 
 eat does not form directly our own muscles, nor does the animal starch — 
 glycogen — come directly from the starch of bread and vegetables. On the 
 contrary, all of the food stuffs are worked over by the living substance, 
 are resolved into other substances, and these other substances are recom- 
 bined into the proteids, the fats, and the carbohydrates that are found in 
 living matter. One practical application of this principle is found in the 
 fact that the most certain method of increasing one's weight by fattening 
 is not by eating large quantities of fat, but rather by living largely upon 
 a carb6hydrate diet (starch and sugar), since it has been found by experi- 
 ment that such a diet leads directly to the formation of body fat. On the 
 other band, to reduce the fat of one's body, a diet rich in proteid is most 
 effective. 
 
 As to the uses of the various food stuffs, it may be said that proteid in 
 some form is always necessary in the food, since it alone of the chief food 
 
 stuffs contains nitrogen, and nitrogen is an important 
 Various7o^7tuffs. constituent of protoplasm. Proteid is the chief source 
 
 of the elements of new protoplasm, and hence the value 
 of meats, eggs, and milk as articles of diet. Proteid also gives energy to 
 the body, but it is an expensive food. Fat is very rich in energy, and 
 protects the proteid substance within the protoplasm from destruction. 
 It may with advantage take the place of some of the proteid in the food ; 
 " a streak of fat and a streak of lean" is not without physiological justifi- 
 cation. Carbohydrates play a role similar to the fats in supplying energy. 
 They are a cheaper food and are easily digested. The part that is played 
 
IK) PHYSIOLOGY: THE VITAL PROCESSES IN HEALTH. 
 
 in metabolism by inorganic salts, of which common table salt may be 
 taken as the type, is not known. They exist in all the tissues, and they 
 are constantly leaving the body in the urine and the sweat. Depriving 
 animals of salt brings on weakness and even paralysis ; yet most salts are 
 not sources of energy. All that is known upon the subject may 
 be summed up in the statement that protoplasm will not continue to do 
 its work without salt. Hence salt is needed in the food to balance the 
 loss through the excreta and thus to maintain a constant supply in the liv- 
 ing substance. Nor is water a source of energy. Its presence every- 
 where in the body facilitates the chemical reactions, and all substances in 
 passing from one part of the organism to another must be dissolved in it. 
 It constantly leaves the body, partly for the purpose of regulating the 
 body temperature, as we shall see later, and partly for the purpose of car- 
 rying off the solid part of the excreta. Without it protoplasm dies, and 
 hence its necessity in the food. 
 
 Much attention has been given to the determination of a diet most 
 suitable for the average man, and it is now known with 
 reasonable accuracy what such a man requires for liis 
 daily needs. A fair division of the various food stuffs is given below : 
 
 Proteids 4 oz. 
 
 Fats 2 oz. 
 
 Carbohydrates 17 oz. 
 
 Salt 1 oz. 
 
 "Water nearly 3 qts. 
 
 It is not a simple matter, however, to proceed from such a diet to the 
 
 preparation of a suitable menu, for, although the proportions of food 
 
 stuffs in the common foods are known (Fig. 15), it does not follow that 
 
 all the food stuffs taken into the mouth are absorbed by the tissues. The 
 
 digestibility of the foods is an important factor too often overlooked by 
 
 rich and poor alike. A liberal allowance of beefsteak will not yield to 
 
 the body four ounces of proteid unless it be so prepared that the digestive 
 
 organs can deal with it. The digestibility of the various foods has not 
 
 yet been determined with sufficient accuracy ; the problem is a difficult 
 
 one, complicated as it is by the idiosyncrasies of individuals and by the 
 
 infinite varieties of method used in the preparation of foods. 
 
 Scientific investigation and the common experience of mankind point 
 
 to a combination of animal and vegetable foods as the most suitable diet. 
 
 Meat and eggs are especially characterized by the presence of proteid in 
 
 a concentrated form ; to obtain the needed amount of 
 Vegetarianism. ^ • ^ r ^ ^^ ^^ • ^i 
 
 proteid from vegetables would require tlie consumption 
 
 of an excessivel}^ large quantity of food. A strictly vegetarian diet 
 
 throws upon the digestive organs of man an excessive amount of labour. 
 
THE DIGESTIBILITY OF FOC^DS. 
 
 ir 
 
 This is not so in the case of herbivorous animals, since in them tiie teeth 
 are specially modified for grindini,^, the alimentary canal is relatively long 
 and large, and the digestive processes are adapted to their tasks. In man, 
 however, the teeth are evidently degenerating, and the alimentary canal 
 is becoming reduced in capacity, the evident outcome of which in time 
 
 Animal Foods. 
 Explanation of the signs. 
 
 Beef. 
 Pork. 
 Fowl. 
 Fish. 
 
 Cow's milk. 
 Human milk. 
 
 Troteids. AlhuminoiclR. N-free org. bodies. Salts. 
 
 6;J 
 
 T^ 
 
 55 
 
 iSI^ 
 
 73 
 
 
 73.5 
 
 89 
 
 Vegetable Foods. 
 
 Explanation of the si^ns. 
 
 W'heaten-'bread, 
 
 Peas. 
 
 Rice. 
 
 Potatoes. 
 
 Wliite Turnip. 
 
 Cauliflower. 
 
 Beer. 
 
 41.3 
 
 Proteids Digestible Non-digestible Salts. 
 
 N-free organ bodies. 
 
 |i: '' "":iH i.4 
 
 m 
 
 14 m; _:-'3 
 
 I 2.5 
 J- 
 
 90.5 
 
 i-lllliillllilii:i;il!:i|:6-5l i 
 
 |!l!"8^qo.5 
 
 90 
 
 0.3 
 
 m 21 1 
 
 a 
 
 1.9 
 
 0.5 
 
 Fig. 15. — Composition of some common foods. 
 Nitrogen-free organic bodies include both fats and carbohydrates. 
 
 will be the necessity of less bulky, more easily masticated, and more easily 
 digested food. The misguided vegetarians, in their endeavours to make 
 man herbivorous, forget that that stage in his career was passed ages ago, 
 that his body is ho longer fitted for it, either anatomically or physio- 
 logically, and th^ stemming or turning back the tide of evolution is not 
 without difficulties. 
 
lis PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 The two chief modes of manifestation of the energy of the body are 
 througli mechanical work and through heat. These may now be consid- 
 ered. Mechanical work is performed by the muscles, 
 
 Energy of ^^^ comprises all M'ork done by the hands and arms, by 
 
 Mechanical Work. ^ '',.,... , , , 
 
 the legs in walking, by tlie trunk in hiting, by the lar- 
 ynx in speaking, etc. It is comparatively easy to measure approximately 
 the amount of work performed by a man in a given task. It was 8U]>- 
 posed formerly that the energy for muscular work was derived solely 
 from the nitrogen-containing proteid of the food and of the tissues. If 
 this were so, and since urea is produced by the destruction of proteid, the 
 quantity of urea given off from the body would be proportional to the 
 amount of work done. Elaborate investigations made upon the pedes- 
 trian AYeston, and other individuals, in order to test the question, have re- 
 futed the old idea and have shown that the main source of the energy of 
 muscular work is not the proteids, but rather the fats and the carbohydrates. 
 The hunger that follows labour does not, therefore, require for its satis- 
 faction an increase of expensive proteid food. ■ About one iifth of the 
 total energy introduced into the body by the food appears again in the 
 form of mechanical work, the remaining four fifths taking the form of 
 heat. At first thought this would seem to indicate that the muscle is a 
 poorly constructed machine. But a steam engine is able to employ for 
 work only about one tenth of the total energy of the coal, the heat that is 
 lost carrying off the other nine tenths. The human body as a machine 
 for transforming energy is, therefore, much superior to the steam engine. 
 
 Perhaps no fact in all human physiology is more striking than that 
 the body of man is warm, and constantly warm during all seasons, even 
 though the surrounding temperature may be excessively low. In this re- 
 spect man is like all the mammals and birds and differs from all other 
 animals. The terms " warm-blooded " and " cold-blooded " tell a part of 
 the truth only ; " warm-bodied" and " cold-bodied " are equally applicable. 
 Yet a still more correct designation of the two classes of 
 
 y emp . q^-j^\^-^^\q ^^ ^^\^q;^ ^f constant tQin-^eraiwre and of change- 
 
 able temperature. An adult man's body has a temperature of about 98"G° 
 Fahr., and normally varies rarely more than a degree above or below that 
 point. A frog's body can not be said to possess a normal temperature. It 
 is always cold to the touch, but varies within very wide limits, depending 
 upon the temperature of the surrounding air or water. Heat is produced 
 in all animal and plant bodies, but is dissipated at once to the surround- 
 ings in all organisms except the warm-blooded animals. The heat comes 
 from the oxidation or burning of the food and body substance, and is de- 
 rived from all three chief classes of food stuffs. Its production is a fun- 
 damental property of protoplasm, and takes place wherevei- living substance 
 exists. Plence all organs and tissues yield lieat ; but the muscles, form- 
 
PRODUCTION AND LOSS OF HEAT. 119 
 
 iiig as they do so large a proportion of the bulk of the body and being 
 actively metabolic organs, are the greatest heat producers. The more 
 active an organ is, the hotter it becomes. The blood, \\hile producing 
 little heat, performs the indispensable role of equalizing the body tem- 
 perature. Receiving its own warmth from the tissues through whicli it 
 courses, it warms the more sluggish parts, and in turn cools those whose 
 temperature tends to become dangerously high. While heat is produced 
 constantly, it is as constantly being lost. We warm our clothing and 
 whatever we come in contact with that is of a lower temperature than 
 the body ; the air that we breathe out is warm ; the excretions are warm ; 
 much latent heat goes off in the evaporating sweat. Of all these path- 
 ways of loss, the skin is the chief one, eighty per cent, of the lost heat 
 leaving the body through it. 
 
 As has been seen, a warm-blooded animal differs from a cold-blooded 
 animal in the fact that the temperature of the body of the latter changes 
 with that of the surroundings, while that of the former 
 Body^Temperature. i"eraains practically constant. The cause of this differ- 
 ence lies in the fact that in the warm-blooded organism 
 both the production and the loss of heat are carefully controlled by the 
 nervous system. As regards production of heat, the lower the tempera- 
 ture of the air the more heat the body produces, partly through invisible, 
 obscure metabolism, partly through visible muscular movements, such as 
 shivering ; on the other hand, the higher the surrounding temjjerature, 
 the less active are the muscles. As regards loss of heat, the lower the 
 temperature of the air, the less blood goes to the skin, and hence the less 
 heat radiates from the surface ; on the contrary, the higher the tempera- 
 ture of the air, the more the cutaneous vessels dilate and allow the heat of 
 the blood to pass off ; at the same time the body perspires and gives out 
 abundant latent heat in the sweat. Thus the vaso-motor nerves, the se- 
 cretory nerves of the sudoriferous glands, and other nerves are employed 
 for heat regulation, and their various activities are brought into harmony 
 through the central nervous system. In the cold-blooded organism no 
 such regulating mechanism exists. 
 
 In discussing metabolism the liver must not be overlooked, since it 
 plays so important and such various roles in nutrition. We shall here 
 enumerate its chief functions. The liver produces bile, 
 the Liver ^^^® ^^^® ^^ which in the digestion of fats we have dis- 
 
 cussed. In addition to this digestive property bile con- 
 tains several complek substances which must be regarded as waste prod- 
 ucts of protoplasQanc activity, and are passed off from the body with the 
 undigested food matters ; hence the liver is an organ of excretion. The 
 liver cells contain abundant glycogen, or animal starch, which is regarded 
 as a reserve stock ; hence the liver is a storehouse of carbohydrates. 
 
120 PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 Lastly, tlie liver seems to be the chief organ in which take place the final 
 processes in the manufacture of urea ; the raw material for excretion 
 comes in the blood from the various organs to the hepatic cells, the cells 
 transform them, and the finished product, urea, is transferred to the 
 kidneys for elimination. With such a multiplicity of functions it is 
 not surprising that " liver complaints " form so large a proportion of 
 luiman ills. 
 
 The spleen, the thyroid body, the suprarenal bodies, and the thymus 
 have apparently important metabolic functions, but their exact roles are 
 little known. At present they are being actively studied. 
 
 Our story of nutrition is comjilctcd. It is but the preliminary to a 
 study of what may be called by some the higher functions of the body. 
 To these we now turn. 
 
 CHAPTER II. 
 
 MOTION. 
 Section I. 
 
 MUiSOLE IN GENERAL. 
 
 Next to producing heat, the chief mode in which the body employs 
 
 its stock of energy is by doing mechanical work. The physical sign of 
 
 mechanical work is motion. Its manifestation is most 
 
 „ , evident in the day labourer. But the professional man 
 
 General. -^ i • n 
 
 and those who are known technically as brain workers 
 
 are not simply heat producers. Aside from the ordinarily invisible in- 
 voluntary movements of the organs and the visible voluntary movements 
 of the body, without which no man passes through each succeeding 
 twenty-four hours, the man who thinks gives his thoughts to the world 
 in writing or speaking or acting, all of which are processes of movement. 
 The organs of mechanical work are the muscles. A muscle is made up 
 of muscle tissue and this in turn of muscle cells. Muscle cells alwaj^s 
 have one axis considerably longer than the other two, from which fact 
 they are often called fibres, and the essence of their activity consists in 
 their power of contracting or shortening in the direction of the long 
 axis ; in this process movement of attached parts is caused. This power 
 of contractility is one of the fundamental attributes of protoplasm ; it is 
 possessed by the living parts of plants and by the one-celled animals. As 
 the evolution of animal life in past ages went on and one-celled animals 
 gave rise to many-celled animals with a varietj' of functions, the ability 
 to contract became progressively stronger in some cells than in others. 
 
THE ORGANS OP MECHANICAL WORK. 
 
 121 
 
 Structure and 
 Varieties of 
 Muscle. 
 
 In these contractile structure and function went on developing together, 
 they became more and more perfected as organs of movement, and they 
 gave rise finally to the highly specialized muscle cells that organisms 
 possess to-day. 
 
 When we look over the whole animal kingdom 
 we recognise a very great variety of muscle tissue, 
 
 from the simple cells of the jelly 
 
 fishes, where only a part of the 
 
 cell can be called muscular, to 
 
 the highly differentiated muscle 
 fibres of actively moving organs like the wings 
 and legs of insects and the limbs of the higher 
 animals. Notwithstanding this variety, muscle 
 cells, especially in man and other vertebrates, may 
 be grouped into three chief classes that are distin- 
 guished from each other both structurally and 
 functionally. These are known, respectively, as 
 smooth., striped., and cardiac muscle cells or fibres. 
 Smooth or unstrijped muscle fibres are so called 
 because, in distinction from the other two varie- 
 ties, they are not cross-striped (Fig. 16). They 
 are usually spindle-shaped ; they are most common 
 in tubular organs, occurring in the walls of the 
 alimentary canal, the arteries and the veins, the 
 ducts of glands, the trachea, and in general in those parts of the body, 
 except the heart, that are capable of involuntary movement only. They 
 are bound together by connective tissue into muscular coats encircling 
 the tubes in whose walls they lie, and by their contraction they constrict 
 the tubular organs. They are not under the control of the will. Tliey 
 are the most primitive of the three kinds of muscle substance. Their 
 action is slow, as is indicated by the writhing, wavelike movements of 
 the stomach and the intestine during digestion. Striated or striped mus- 
 cle fibres are so-called because, when examined with the microscope, they 
 appear indistinctly cross-striped with alternate lighter and darker bands 
 (Fig. lY). They are very long, delicate,' threadlike cells, and their proto- 
 plasm is highly complicated in structure. They are usually under the 
 control of the will, and form the flesh or meat of the body — that is, the 
 muscles of the arrasy the legs, the head, and the trunk. Each muscle 
 consists of a mass 6i innumerable fibres bound together by connective 
 tissue into bundles, and is attached usually to bones by means of tendons. 
 Striped muscle is the most highly specialized kind of muscle tissue. It 
 is capable of very quick action, as is shown by the rapidity with which 
 one can strike a blow or play a piana Cardiac muscle is intermediate 
 
 Fig. 16. — Unstriped muscle 
 FIBRES OF MAN. (Magnified 
 200 diameters.) 
 
 1, nuclei of fibres; 2, fibres 
 in mass; 3, isolated fibres; 
 4, 4, two fibres joined to- 
 gether at 5. (Sappey.) 
 
122 PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 Fio. 17. 
 
 (Magnified 
 
 structurally between the other two. It consists of short, compact, indis- 
 tinctly striped cells. It occurs only in the heart, and, as we have learned 
 in studvinii- the heart beat, contracts spontaneously, involuntarily, and 
 rhythmically. 
 
 For the past liftv years muscle has been a fascinating- and fruitful 
 held of physiological reseanli. >hiny of the most interesting and funda- 
 
 j^ mental problems of general proto- 
 
 plasmic action have been and may 
 be studied here more successfully 
 than in other tissues ; not only the 
 laws of vital movement, but funda- 
 mental (juestions such as automa- 
 ticity, irritability, rhythm, animal 
 electricity, and the chemical phe- 
 nomena of life. A large variety of 
 delicate and valuable apparatus has 
 been devised for the exact investi- 
 gation of these various problems. 
 The study of striped muscle has 
 yielded the most information, and 
 our present discussion will be lim- 
 ited to this. As has been stated, 
 the essence of muscular action con- 
 sists in the power of the nmscle 
 fibres to contract. In cold-blooded 
 animals, such as the frog, the muscles retain their contractile power — that 
 is, remain living — long after the animal has been killed, hence it is easy 
 in such animals to study muscular action. During life the muscles are 
 made to contract through impulses coming to them along the nerves from 
 the brain or spinal cord. After death in cold-blooded animals they may 
 be stimulated to activity by electric shocks, heat, pinching, or by certain 
 chemicals applied either to the muscles directly or to their nerves. For 
 each stimulation the muscle gives a single twitch or contraction, during 
 which it shortens and becomes thicker and harder, and then immediately 
 relaxes into its former state. The whole period of 
 activity occupies only about one tenth of a second, yet 
 during this moment the muscle undergoes profound molecular changes. 
 Besides the mechanical changes spoken of, it produces heat and becomes 
 warmer, produces carbonic and lactic acids, and develojos a considerable 
 electric current. All these phenomena indicate what great metabolic 
 changes inuscle protoplasm is subjected to during activity. It would be 
 interesting to trace these further, l)ut it would take us beyond our present 
 space. In life it is probable that voluntary muscle rarely, if ever, gives 
 
 -S>TRIPED MUSCLE FIBRES. 
 
 250 diameters.) 
 
 A, piece of a fibre showinir cross-striations and 
 
 nuclei; R, piece of a fibre with cell-wall (sar- 
 
 coleiiima) ruptured, showing tendency of fibre 
 
 to split into fibrillcB. (Sappey.) 
 
 Action of Muscle. 
 
MUSCULAR MECHANISMS, ACTION AND TONE. l^'.i 
 
 sino-le isolated twitches. Each contraction, however quick, consists of 
 numerous single contractions following one another at the rate of about 
 twelve in the second, and becoming fused into a compound contraction 
 called tetanus. These rapid contractions give rise to a dull booming 
 sound which is emitted by the muscle and may readily be heard by in- 
 serting the tips of one's fingers into the ears and contracting strongly tlie 
 muscles of the arms. In health the muscles always seem to be in a state 
 
 of slight contraction, or "tone," whicli accounts in 
 
 Muscular Tone. , , i i i j? ii, i i.- -j. • • i 
 
 great part probably lor the elasticity, springiness, and 
 
 ready muscular response of the athlete. This healthy tone appears to be 
 
 due to nervous impulses coming constantly to the muscles from the spinal 
 
 cord. It is noticeably absent in ill health. Many muscles are so placed 
 
 as to antagonize the actions of others. For example, the flexors, which 
 
 bend the arms, legs, fingers, and toes, act in opposition to the extensors 
 
 which straighten the same parts ; the eye is closed by the orbicularis and 
 
 opened by its antagonist, the levator of the upper lid ; and the delicate 
 
 adjustments of the parts of the larynx in speaking and singing are due to 
 
 refined balancing of opposing muscles. 
 
 Section II. 
 
 SPECIAL MTISOULAR MECHANISMS. 
 
 As instances of special motor phenomena we have already mentioned 
 the digestive movements, the beat of the heart, arterial constriction and 
 dilation, and the movements of respiration. We may now notice briefly 
 a few others. 
 
 A. LOCOMOTION. 
 
 The erect posture in standing or sitting requires the co-ordinated 
 action of numerous muscles of the trunk and the legs. That this is so is 
 evident from the fact that the body collapses whenever, as in fainting, 
 the muscles fail to receive their customary stimulating impulses from the 
 central nervous system. 
 
 Walking is a complicated muscular act, participated in by a large 
 number of muscles of the legs, the trunk and the arms, that contract in 
 regular sequence (Fig. 18). Each leg is flexed as it is swung forward 
 like a pendulum ; it ii then straightened and serves as a support for the 
 swinging trunk. The movements of the trunk are peculiar. It alter- 
 nately rises and sinks, in falling forward, and sways from side to side 
 as the centre of gravity of the body comes now over the right, now over 
 the left foot ; at no time is the body wholly free from contact with the 
 ground, and for a brief interval, when the feet are farthest apart, both 
 feet touch it at the same time. In running, the sequence of events is so 
 
124 PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 far different from that in walking that at one time the body is entirely 
 free from support. The recent advances in the art of instantaneous 
 
 FlO. 18. — SeRIKS of FIOUKES FKOM instantaneous PIIOTOGIIMMIS TO ILLUSTRATE MOVEMENTB IN- 
 SLOW WALKING. 
 
 All phases of movement of tlie right arm and leg are sliov.n in fiiruivs 1 to VI. Arabic numerals 
 indicate the correspondinu' positions of the left arm and Icf^; thus position III of tlie Tu^ht side 
 is simultaneous with position 6 of the left side. (Marey.) 
 
 photography have added much to our knowledge of the mechanism of 
 bodily movements. 
 
 B. FACIAL EXPRESSION. 
 
 Changes in facial expression are muscular phenomena, due to contrac- 
 tion of the facial muscles in combinations varying with the various emo- 
 tions. This is shown by the fact tliat it 
 is easy by electrical stimulation of the 
 muscles through the skin to produce arti- 
 ticially in an individual at will a desired 
 emotional expression (Fig. 19). The 
 anatomical peculiarities of the face con- 
 stitute the features and give a certain 
 set to every countenance. The expres- 
 sions are physiological, and are produced 
 in much the same manner in different 
 individuals. In his book, entitled The 
 Expression of the ^notions in Man 
 and Animals^ Darwin has given the 
 results of a careful study of expression. 
 He analyzes into their various muscular 
 components the changes accompanying 
 joy, grief, despair, love, hatred, anger, 
 di.s(iain, contempt, pride, surprise, fear, 
 horror, etc. He finds the origin of many of these expressions in the 
 lower animals, and shows how they have gradually become habitual and 
 
 Fig. 19. — Expression of e.xtreme 
 
 TERROR. 
 
 Produced artificially by stimulating with 
 electricity the muscles of the forehead 
 and the 'jaws. The four curved rods 
 are the stimulatinij electrodes laid upon 
 tlie skin over the muscles. (From 
 Darwin, after Duchenne.) 
 
CHANGES IN FACIAL EXPRESSION. 
 
 12: 
 
 innate in man. Their primary purpose was not to reveal emotional states 
 of mind, but rather they were either of some direct bodily benefit to the 
 
 Fig. 20. — Expression of various emotions, showing characteristic muscular contractions. 
 
 A, pride and defiance ; B, helplessness ; C, childish joy ; D, childish grief. (A and B from 
 Darwin after Duchenne.) 
 
 individual or were indirectly the effect of a general excitement of the 
 nervous system. (See Fig. 20.) 
 
120 PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 C. VOICE. 
 
 The production of voice is the most deHcate of all muscular acts of 
 
 which the human body is capable. The larynx, the c)r«;an of voice, is the 
 
 moditied upper end of the trachea. However much the voice may seem 
 
 to arise at the lips, or in the mouth, or in the chest, it is only modified by 
 
 these parts, and the sound is produced in the larynx 
 
 Physiological only. Considered as a musical instrument, the larynx is 
 
 nu om>j oj most nearly like a reed instrument, of which the clario- 
 
 net is an example ; but the resemblance is not close. In 
 the larynx the parts that correspond to the reeds, by the vibration of 
 which voice is produced, are the two vocal cords (Fig. 22). They are elas- 
 tic membranes that extend from each side horizontally toward each other 
 into the cavity of the hollow larynx, and are stretched more or less from 
 before backward. They do not meet in the middle line, but have between 
 thcni a chink of variable wudth, the glottis, extending across the larynx 
 from front to back. Each cord is thickened with muscle at its outer part 
 attached to the walls, but its free edge at the glottis is thin, and consists 
 of white, tough, elastic connective tissue. Thus the air-passage to and 
 from the lungs is obstructed at its upper end by this horizontal mem- 
 branous partition, with a passageway for air between its two halves. 
 During ordinary silent breathing this obstruction is slight, for then the 
 vocal cords recede to the side walls of the larynx and the glottis is wide 
 open. During speaking or singing the cords are extended in toward 
 each other and the glottis is reduced to a mere slit. 
 
 Voice is the sound produced by the rapid vibration of the thin edges 
 
 of the cords as the air rushes between them in expiration. The essential 
 
 conditions of the production of voice are that the cords 
 Conditions of Voice. .i.^ji.!- i ii -xi 
 
 must be taut and their edges must be approxnnately 
 
 parallel. These conditions are fulfilled through the various delicate 
 muscles acting upon the cartilages to which the cords are attached, or 
 even upon the cords directly. 
 
 The natural pitch of a voice depends upon the natural length and ten- 
 sion of the cords. Variations in pitch are produced by varying either 
 the degree of tension or the length of the vibrating 
 
 ' '^j ^'^'V?^**' cord, or by varyino: both together. Thus, for the low 
 and Quality. ^ .; J t^ h t i i 
 
 tones, the more tightly the cords are stretched the 
 higher the note, just as is the case in tuning a violin. For the high tones, 
 the cords do not usually vibrate along their whole length ; a portion, 
 usually the posterior, is " stopped " by the cords being brought into con- 
 tact with each other, and the anterior part only is capable of acting (Fig. 
 22, B), just as in playing the violin the pitch is regulated by placing the 
 finger upon the string. Loudness of voice is determined by the strength 
 
QUALITY, RANGE, AND PITCH OF THE HUMAN VOICE. 127 
 
 of tlie outgoing current of air. Tlic quality of tlie voice — tliat by which 
 we distinguish one voice from another and recognise tlie voices of our 
 friends— depends upon the make and the age of the individual larynx, its 
 size, the quality of the cords, and the shape, the size, and the mutual re- 
 lations of the accessory vocal organs, such as the mouth and its parts, the 
 nose, the pharynx, and the chest ; in like manner the quality of tone 
 
 256 
 
 Soprano. 
 
 1024 
 
 171 
 
 Contralto. 
 
 684 
 
 E F G A 13 e a e £g a b c' d' e' f g' a' b' 
 
 ^ 
 
 5 r 
 
 80 
 
 6" d" e" f " g" a" b" c' 
 
 Bass. 
 
 342 
 
 1'28 
 
 Tenor. 
 
 512 
 
 Control of the Voice. 
 
 Fig. 21. — The a\erage range of human voices. 
 
 c' to f is common to all voices. The figures indicate the number of vibrations per second in the 
 corresponding tones. (Landpis and Stirling.) 
 
 of a violin depends upon age, the peculiarities of the grain of its wood, 
 and the shape, size, and connections of the various parts of the instru- 
 ment. 
 
 The muscular adjustments necessary in producing all the wonderful 
 variations in tone and in quality of which the human voice is capable are 
 inconceivably delicate, l^ot only the muscles of the 
 larynx, but those of the various accessory vocal organs, 
 the tongue, the lips, the palate, and the pharynx, and the respiratory 
 muscles, contribute their share in the process. All of these muscles are 
 under the most careful nervous control, and, as we shall see later, a par- 
 ticular area of the brain has as its special duty the management of the 
 vocal organs. The training of the voice is a training of these nervous 
 and muscular mechanisms. That which determines whether a voice shall 
 be called soprano, contralto, tenor, or bass, is partly the natural length of 
 the vocal cords and partly the general nature of the vocal mechanism. 
 The average range of the individual voice is two to two and a half oc- 
 taves ; the relative pitches of the four kinds of voice are shown in the 
 accompanying table (Fig. 21). 
 
 In singing a scale we are conscious of the necessity at certain notes of 
 rearranging our vocal organs if we wish to produce w^ell-rounded tones 
 and prevent the voice from breaking. Such adjust- 
 ments take place at different notes for different indi- 
 viduals. The compass that is possible for each adjustment constitutes 
 
 Vocal Registers. 
 
12S PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 the so-called " register." Vocal teachers detect several registers, but 
 physiologists recognise commonly two — the chest register or voice, and the 
 head register or voice. The former, employed for low notes, is charac- 
 "terized by richness and fulness of tone; the latter, employed for high 
 notes, is thinner. The difference in the mechanism of the two is not 
 fully understood, and is perhaps not the same for all individuals. The 
 appearance of the vocal cords during the production of voice, as shown 
 bv the laryngoscope (a small mirror placed in the back of the mouth and 
 reflecting a bright light down into the larynx), is presented in the accom- 
 
 FiG. 22. — Interior of larynx, as seen by laryngoscope, during prokuction of (A) chest- 
 voice (Mandl and Griitzner), (B) heau-voice (Mills). 
 
 The glottis is represented sus a black longitudinal slit in the middle of the ligures, long in A, short 
 in B; the vocal cords are shaded in A, white iu B; the curved body at the upper part of tho 
 figures is the epiglottis; the rounded elevations at the lower part of the figures arc cartilages. 
 
 panying figure (Fig. 22). The mechanism of the falsetto voice in man 
 is also in dispute. The breaking of the voice in boys at puberty is caused 
 by the rapid growth of the larynx and the constant congested condition 
 of the vocal cords. 
 
 Speech is voice modified by changes in the accessory vocal organs, 
 especially the resonance cavities, the pharynx, the nasal cavities, and the 
 mouth. The sounds of speech are classified into vowels and consonants. 
 All vowels have the same laryngeal sound as their basis ; but for euch 
 vowel, by changes in the shape of the resonance cavities, different over- 
 tones are added to the fundamental laryngeal tone, hence 
 * the difference in the sounds. Consonants are noises 
 
 produced mainly in the mouth by modifications of the outgoing current 
 of air. Some are and some are not accompanied by vocal sounds. In 
 gutturals (K, G) the modification is produced by the soft palate and the 
 root of the tongue ; in dentals (T, D, S, L, Z, N, E.) by the tip of the 
 tongue near the teeth ; in labials (P, B, F, V, M) by the lips. The details 
 of the mechanisms of the consonants must be omitted. 
 
FUNCTIONS OF AMCEBOID AND CILIATED CELLS. 129 
 Section III. 
 
 NON-MUSCULAR MO TO It MEi.'JIAMHMH. 
 
 Muscle is not the only motor tissue that is found in the human body. 
 There are two other varieties of contractile cells that in a very unostenta- 
 tious way perform mechanical work and are indispensable to the body's 
 welfare. These are amoeboid cells and ciliated cells. 
 
 Amoeboid cells comprise the colourless corpuscles of blood and of 
 
 lymph (Fig. 4, G), and are so called because they resemble and are capable 
 
 of moving about from place to place like the simple one- 
 
 Amoeboid Cells. ■^^ -k • ^ a l -r>_c l ^ ^ ^ 
 
 celled animal, Amceba. Keierence has already been 
 made to their function. 
 
 Ciliated cells are epithelial cells, and are fixed in position with one 
 end exposed to the cavity which they line. This uncovered end bears a 
 tuft of minute, delicate, hairlike filaments (the ciliaj 
 that project into the cavity (Fig. 1, E). During life the 
 cilia are in constant, rapid, wavelike motion, sweeping along whatever 
 substances come in contact with them. They are especially useful in car- 
 rying from the lungs toward the mouth and the nose mucus, and with it 
 inhaled particles of dust. They line not only the bronchial tubes, the 
 trachea, the larynx, and the nasal cavities, but the ducts of certain other 
 organs, and, being in incessant action throughout the lifetime, they ac- 
 complish a large amount of labour. 
 
 CHAPTER III. 
 
 THE NERVOUS SYSTEM. 
 
 It would be a sorry community of people wdierein every indi- 
 vidual worked for himself alone, regardless of the wants and the welfare 
 
 of others, and wherein there existed between individuals 
 Nervous System -i ^ , r • • i j • i • 
 
 . ^ , and between professions no social and no commercial m- 
 m (xeneral. ^ 
 
 tercourse. A continuance of such a state of things 
 would be impossible unless the community were composed of few indi- 
 viduals and such as were content to remain low in the scale of civilization. 
 The same principles apply to a community of protoplasmic cells and 
 organs ; if there be no intercellular and no interorganic comity and ex- 
 change there is no rising in the scale of organisms. TTe have seen that 
 in the human body the mutual interactions of the various parts are exces- 
 sively complex, and this complexity is carried so far that no part is able 
 to live when separated from the body. In both the community of people 
 11 
 
130 PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 and the organic community an agent is needed to control the relations of 
 individuals. Such an agent exists in the system of government of the 
 
 one and the nervous system of the other. 
 In every body of men that has taken rank 
 above the lowest a government exists, 
 while in every protoplasmic animal or- 
 ganism above the simplest there is a 
 nervous system. The subordinate posi- 
 tion in the organic world that is ac- 
 corded to plants is due more than all else 
 to their lack of nervous organs. The 
 nervous system is at once the servant and 
 the master of all the other systems ; it 
 responds to the needs of one by control- 
 ling the work of another ; thus it co- 
 ordinates and harmonizes, and makes one 
 of many. But it attends not only to 
 internal affairs : it keeps the organism 
 apprised of what goes on without, and 
 thus enables the body to adapt itself to 
 its environment. It is, finally, the medi- 
 um of all mental life. To accomplish all 
 this it must of necessity be complicated 
 both in its anatomy and in its mode of 
 working. No system in the body is more 
 complicated. None is more difficult to 
 investigate and to understand. The nerv- 
 ous system of man comprises the central 
 nervous system, consisting of the brain 
 and the spinal cord, and the peripheral 
 nervous system, consisting of the nerves 
 and the ganglia. A portion of the pe- 
 ripheral system is known as the sympa- 
 thetic system, though this can not be re- 
 garded as physiologically independent of 
 the rest. To this enumeration must be 
 added the organs of the special senses ; 
 these are so unique as to justify treat- 
 ment in a separate chapter. The differ- 
 ent parts of the nervous system have 
 very different structures and functions, 
 such that the w^hole may be regarded as a union of numerous complex 
 organs ; but notwithstanding the complexity, the elements of structure 
 
 Fig. 23. — Diagram of a typical keukon. 
 6, cell body; <^, dendrites, or protoplasmic 
 
 processes ; a, axis-cylinder process, or 
 
 nerve fibre. 
 
STRUCTURE AND FUNCTION OF 'J HE NERVOUS SYSTEM. I'M 
 
 and of function are fundamentally the same tlirouf^hout all parts. Witliin 
 the past ten years remarkable advances in our knowledge of nervous 
 structures liave been made. 
 
 The elements of nervous structure are the nerve cells, or neurons, as 
 they are now coming to be called. Neurons vary in shape, but each con- 
 sists of a cell body and processes extending from it 
 MrmZslZLe. ^^'^- 2'^)- The cell body consists of protoplasm and a 
 large nucleus. The processes may be of two kinds, called 
 dendrites, or protoplasmic processes, and axis-cylinder jjrocesses. 'J'lie 
 dendrites are much-branched, short filaments. The axis-cylinder process, 
 usually one in number for each cell, is the most highly specialized part of 
 the neuron. It has few branches, and may be very long (three to four feet). 
 Near its end it splits into numerous fine filaments that terminate in the 
 vicinity of the cells supplied by the neuron, whether they be muscle cells, 
 gland cells, sense cells, or other neurons. The brain and the spinal cord are 
 masses of neurons bound together by connective tissue and richly permeated 
 by blood-vessels. It was formerly supposed that the processes are joined 
 together into an inextricable network, and that nervous impulses, in pass- 
 ing from one part of the nervous system to another, traverse this maze. 
 But recent discoveries 
 liave made it reason- 
 ably certain that there 
 is no network what- 
 ever ; that, on the other 
 hand, every neuron is 
 independent of every 
 other, and that a nerv- 
 ous impulse passes 
 from one to another 
 through contact, and 
 not through continuity 
 of their respective pro- 
 cesses. In some parts 
 of the brain and the 
 spinal cord cell bodies 
 
 and dendrites predomi- ^^'^- 24. — Psychic brain cells in different stages of eto- 
 
 - , LUTION. 
 
 nate and constitute the a, frog:; B, newt; C, mouse; D, man. Series a to e shows the 
 gray matter ; in other stages that a single brain cell of a higher vertebrate passes 
 
 ■^ J 7 through in its growth. (Baker, after Kamon y Cajal.) 
 
 parts axis-cylinder pro- 
 cesses only exist, constituting the lohite matter. Nervous ganglia are 
 masses of cell bodies. Nerves are bundles of axis-cylinder processes ar- 
 ranged parallel to each other, each process being ensheathed usually in a 
 fatty covering called the medullary sheath. The axis-cylinder process 
 
132 PHYSIOLOGY: THE VITAL PROCESSES IN HEALTH. 
 
 and its proteetino; sheath form a fw/TeJihtr, and every nerve is composed 
 of numerous nerve fibres. In the embryo nerve cells arise as compact 
 bodies. The processes appear as outgrowths from them, and continue to 
 grow in length and complexit}" during embryonic life and adolescence. 
 It is a si<i:niticant fact that the neurons are more complex the higher they 
 are in tiie animal scale (Fig. 24). 
 
 The elements of nervous function comprise the functions of the body 
 
 of the neuron and those of the processes. The cell body is the central 
 
 oriran of nervous energy. It receives, originates, and 
 
 emen t. oj o;ives out nervous impulses. In most neurons the activ- 
 
 JSvfVOUS ± unction. ^ i i • i n • ^ • ^ 
 
 ity of the cell body is wholly unconscious, but m those 
 existing in the superiicial layers, the cortex of the cerebrum, mental phe- 
 nomena accompany the nervous actions, hence such neurons are called 
 psyrhic. The processes of the nerve cell are specialized to conduct nerve 
 
 impulses, the den- 
 drites conducting 
 probably toward tlie 
 cell body, the axis- 
 cylinder process in 
 some cells away from, 
 in others toward, the 
 cell body. Nerve 
 NsoRY CELL AND cclls ai'e usuallv said 
 
 FFERENT NERVE , "^ 
 
 to act either auto- 
 matically or reflexly. 
 An automatic action 
 is one in which the 
 impulse originates in 
 the cell body as the 
 result of chemical or 
 other changes, and 
 _, „, ^ passes thence along 
 
 JjiG. 25. — Diagram to illustrate nervous mechanism in (1) auto- , ■,. ^ 
 
 MATIC action-, (2) REFLEX ACTION, (3) PASSAGE OF SENSORY IM- tllO aXlS-Cy Hndcr pi'O- 
 PULSE UPWARD AND OF MOTOR IMPLLSE DOWNWARD WITHIN CEN- , r\ "^ l 
 
 TRAL NERVOUS SYSTEM. (Mills.) ccss to tlic cud organ 
 
 (Fig. 25\ The re- 
 spiratory centre is said to act automatically. The psychic cells are called 
 automatic. It is a question whether automatism in tliis sense is at all a 
 common phenomenon. A reflex action is one in wliich the nervous im- 
 pulse originates outside of the nerve cell, passes to the latter, is there 
 elaborated, and then passes on as before to the end organ (Fig, 25). A 
 typical exam])le of a reflex action is that of winking : a foreign body 
 touches the eyelashes or the eyeball ; this causes nervous impulses to go 
 to the nerve cells that control the muscles of the lids; return impulses 
 
 REFLEX CENTRE 
 
 AUTOMATIC CENTRE- 
 
 MOTOR CELL AND 
 EFFERENT NERVE 
 
THE NATURE OF REFLEX ACTIONS. 
 
 jya 
 
 Nerve Centres and 
 Nerve Conductors, 
 
 come back to the muscles, and the lids close. Keflex actions arc invol- 
 untary. The greater part of the body's actions are reflex ; not only the 
 unconscious movements that we are making constantly by means of our 
 skeletal muscles, but also the muscular moveirients of the viscera and 
 secretion in glands. The term "reflex arc" signifies the anatomical 
 apparatus required for a reflex action. It consists of (1) a sensory end 
 organ ; (2) an aflierent nerve flbre ; (3) its associated nerve-cell body ; (4) 
 a second nerve-cell body in functional connection with (3), and giving rise 
 to (5) an efferent nerve fibre ; (6) a motor end organ, usnall y a imiscle. 
 
 Thus we see that, physiologically, the 
 nervous system consists of innumerable nerve 
 centres and nerve conduct- 
 ors. The bodies of the 
 nerve cells are the centres ; 
 the processes, especially the axis-cylinder 
 processes, are the conductors. Considered 
 en masse and roughly, the gray matter of 
 the central nervous system and the ganglia 
 outside of it have the functions of centres ; 
 the white matter of the central nervous sys- 
 tem and the nerves are conducting in func- 
 tion. No fibre conducts in more than one 
 direction. The nerve fibres outside of the 
 brain and the spinal cord may be divided 
 into two great classes, according as they 
 
 conduct impulses toward the central nervous system or away from it ; 
 accordingly, they are known either as centripetal or afferent, or as 
 centrifxigal or efferent fibres. Most nerves are composed of both kinds. 
 In the case of the spinal nerves a separation of the two kinds takes 
 place at the junction of the nerve and the spinal cord, such that the 
 posterior or dorsal root consists of afferent, the anterior or ventral root 
 of efferent fibres. An afferent impulse, upon arriving at its centre, 
 may simply give rise at once to an unconscious efferent impulse, pro- 
 ducing a reflex action, or, with or without doing this, it may pass up- 
 ward to the brain and give rise to a sensation (Figs. 25 and 26). Corre- 
 spondingly, an efferent impulse may either arise in a lower reflex centre, 
 as the direct result of an afferent impulse, or it may arise high up, even in 
 the psychic part of the brain, and pass downward and outward, giving rise 
 to a voluntary act. Hence, in harmony with the classification of periph- 
 eral fibres into afferent and efferent, there occurs within the bi-ain and the 
 cord a distinction between such fibres as conduct upward toward the cere- 
 brum and such as conduct downward from the cerebrum. The former 
 are really paths for the continuation of the afferent impulses coming 
 
 Fig. 26. — Diageam intended to 
 show the relations of the 
 beain, the spinal cord, and 
 the peeipheeal organs. 
 
 Si sensory end organ ; C, spinal 
 cord ; Jf, motor end organ (mus- 
 cle) ; Hi hemisphere of brain. 
 (James.) 
 
134 PHYSIOLOGY: THE VITAL PROCESSES IN HEALTH. 
 
 from the outside to the psycliic cells, where the impulses may give rise to 
 
 sensations; hence afferent nerve fibres and those that conduct upward 
 
 within the brain and the spinal cord are often called sensor^y. On the 
 
 other hand, the downward impulses within the central 
 Sensory and Motor. i i.- i ■ i i. j- xi 
 
 nervous system are destined m iarg-e part lor tlie nnis- 
 
 cles, and pass to them along the efferent nerve fibres, hence such conduct- 
 ing paths are called motor. The same terms apply to the cell bodies 
 which the fibres join. The distinction between sensory cells and motor 
 cells, sensory fibres and motor fibres, sensory centres and motor centres, 
 and sensation and motion as nervous functions, is one of the most funda- 
 mental distinctions in the physiology of the nervous system. It is a 
 curious and as yet not explained fact that the sensory parts of the brain 
 and the spinal cord lie, in general, dorsal or posterior to the motor 
 parts. 
 
 We have now presented the elements of nervous action. The central 
 nervous system is a collection of central stations for the receipt, trans- 
 formation, and transmission of nervous energy. Each 
 
 ummary oj ^^ these stations has its own specific function, but they 
 JServous Action. , . , . , 
 
 are joined with each other in the most intricate mannei-, 
 
 and they are continually modifying each other^s work. In ascending 
 from the lower to the higher parts of the nervous system there is a pro- 
 gressive correlation of functions and a supervision of the lower by the 
 higher centres. At the top in the cortex of the cerebrum lie the psychic 
 cells, which are the physical media of mental life, the seat of the sensa- 
 tions and the place of origin of voluntary acts, and which are able to con- 
 trol the acts of all the lower centres (Fig. 20). To this elaborate mechan- 
 ism stream constantly through sensory nerves impulses from all parts of 
 the body and from the organs of the special senses, giving information re- 
 irarding the condition and the needs of the various oro-ans and tissues and 
 the occurrences of the outside world. The ultimate possible goal of these 
 impulses is the cortex of the cerebrum, there to give rise to sensations. 
 But very few of the impulses reach this goal. Those to which the atten- 
 tion is directed, those which are unusually or excessively strong, or which 
 for other reasons require consideration by the mind, pass to the cortex. 
 The great majority, however, are dealt with by the lower centres. 
 Wherever the impulses terminate they act upon sensory centres ; these in 
 turn stimulate motor centres ; and, largely as the result of the incoming 
 stream, there is as constant an outgoing stream of motor and other im- 
 pulses through efferent nerves to the tissues and the organs. These out- 
 going nervous impulses regulate the actions of the various parts and of 
 the body as a whole. Let us now consider the parts of the central nervous 
 system more in detail. 
 
 As we ascend through the series of vertebi'atc animals in the order, 
 
THE BRAIN AND SPINAL CORD. 
 
 13/ 
 
 fish, reptile, bird, mammal, man, we find that tliere is a progressive in- 
 crease in the weight of the brain as compared with the 
 weight of the body. Tliis is shown in round numbers 
 in the accompanying table (Wallerj : 
 
 Comparative Im- 
 portance of Brain. 
 
 
 Weight of l.rairi. 
 
 Weight of body. 
 
 Fish 
 
 
 5,000 
 
 Reptile 
 
 Bird 
 
 1,500 
 220 
 
 Mammal 
 
 180 
 
 Orang-outang' 
 
 120 
 
 Man 
 
 50 
 
 
 
 Moreover, there is a progressive increase in the size of the brain as 
 compared with the spinal cord ; within the brain there is a progressive 
 increase in the size and complexity of the higher parts as compared with 
 the lower ; and, lastly, there is a progressive increase in the size and 
 relative importance of the cerebral cortex. This last fact is to be corre- 
 lated with the gradual evolution and perfecting of mind, while the facts 
 together mean that in general there is a progressive subordination of lower 
 to higher centres. Accordingly we find, in ascending the series, a gradual 
 limiting of the work of the lower parts. 
 
 A fish or a frog will continue to live for days after the brain is wholly 
 destroyed if the spinal cord be left intact. This is impossible in the case 
 of man. The human spinal cord is pre-eminently the 
 central nervous organ for the reflex actions in which 
 the spinal nerves take part, hence for the actions of the hmbs and the 
 trunk (Fig. 2Y). The " tone " of the voluntary muscles depends upon it. 
 It contains respiratory, vaso-motor, and other centres which are accessory 
 to more powerful ones in the medulla oblongata. Obviously it is also the 
 path of conduction of impulses between the spinal nerves and the brain. 
 The majority of these impulses ascend and descend upon the side of the 
 cord from which their nerves arise. A few cross over to the opposite side. 
 
 The medulla oblongata and the rest of the brain stem contain the 
 reflex centres of the cranial nerves and various other automatic or reflex 
 centres ; they regulate the movements of the eyes, the 
 face, the tongue, the alimentary canal, the heart, res- 
 piration, the arteries, the larynx in speaking, the pharynx and oesophagus 
 in swallowing ; they also control the secretion of saliva and other digest- 
 ive fluids. The brain stem serves also, like the spinal cord, as a path of 
 upward and downward impulses. It is a curious fact that both sensory 
 and motor impulses here cross over from one side of the brain to the 
 other ; hence the left side of the cerebrum deals with the right half of the 
 body, and vice i)ersa. 
 
 Brain Stem. 
 
13G PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 The function of the cerebelhnii is eoninionly believed to be that of 
 
 harmonizing or co-ordinating the actions of the muscles. Injury to this 
 
 part of the 
 Cerebellum. , . , 
 
 l)rain results 
 
 in irregularity and uneertaiii- 
 
 tv of bodily movements, But 
 
 experimental evidence has not 
 
 made it clear exactly how the 
 
 oi'gan acts. 
 
 Exact knowledge regard- 
 ing the functions of the optic 
 thalamus and the corpus stri- 
 atum is quite wanting. 
 
 The cortex of the cere- 
 brum is spoken of as the 
 
 " seat " or 
 Cortex of Cerebrum. ,-, , . „ 
 
 the "organ 
 
 of consciousness and of intel- 
 ligence ; its cells form the 
 physical basis of mental phe- 
 nomena. AVhen a man thinks, 
 his cortical cells act ; and if 
 the latter be destroyed, men- 
 tal phenomena seem to cease 
 so far as that individual is 
 concerned. We can only 
 speculate as to the kind of 
 relation that exists between 
 the cerebral and the mental 
 processes ; so far as we know, 
 the latter are always accom- 
 ])anied by the former. As 
 experimental physiologists we 
 search for the cerebral pro- 
 cesses, and we find that apparently they do not differ from those that 
 take place in any mass of nerve cells whose activity is unaccompanied by 
 consciousness. Structurally the cortex is unique, being characterized by 
 the presence of the large, much-branched pyramidal cells that occur 
 nowhere else in the organism (Fig. 28) ; in details it differs in different 
 parts. Formerly it was believed that the cortex acts as a wliole, but 
 modern research has shown the untenability of this view, which, indeed, 
 seems now opposed to common sense. 
 
 In 1870 two German physiologists, Fritsch and Ilitzig, found that if 
 
 Fig. 27. — Diaoram to illustrate reflex actions. 
 A, skin; F, F', muscle fibres; larfro column at left 
 represents a piece of the spinal cord with gray mat- 
 ter witliiu and white matter witliout; B, dorsal 
 nerve roots; C, ventral nerve roots; Nl,N'l, N2, 
 K' 2, N 3, N' 3, neurons. A simple reiie.\ path com- 
 prises Nl and N 2, which include origin of axis- 
 eylinder process in end bulb (a) or between cells 
 (/' 1, alferent fibre (c, e) belonging to cell body (</), 
 branches (/) giving otf " collateral " branches ((/) 
 to terminate about N 2; cell body (/*), efferent fibre 
 (i) terminating upon muscle fibre (F). A coinpoimd 
 reflex path comprises a similar collecting neuron, 
 K' 1, one or more correlating neurons, N' 2, and dis- 
 tributing neurons, K' 3. (Baker.) 
 
FUNCTIONAL DIFFERENTIATION OF CORTICAL AREAS. ].'j7 
 
 the brain of a dog were exposed and the cortex stimulated in dilTcrent 
 places by electric shocks, contractions of the animal's muscles accom- 
 panied each stimulation, 
 and the movements varied 
 according to the particu- 
 lar corti- 
 Localization of 
 Functions in 
 the Cortex. 
 
 cal area 
 that was 
 touched. 
 Since then investigation 
 of the subject by various 
 methods upon various ani- 
 mals and man has been 
 active with the result that 
 now localization of differ- 
 ent functions in different 
 parts of the cortex has 
 become an accepted fact, 
 although there is still 
 considerable difference of 
 opinion regarding the ex- 
 act functions of different 
 areas. The accompanying 
 figures represent the opin- 
 ions of authorities at pres- 
 ent, but the details are sub- 
 ject to change by future 
 (Figs. 29 
 30). The most obvi- 
 ous principle regarding 
 localization is that the 
 motor area, which has the 
 function of controlling 
 through lower centres the 
 actions of the various vol- 
 untary muscles, is situated 
 in the middle part of the 
 cortex, extending across 
 the top of the brain ; 
 while the sensory area, 
 which deals with the sen- 
 sations arising from activ- 
 ity of the organs of the 
 
 mvestigation 
 and 
 
 ^^h- 
 
 Fig. 28. — Section of the cerebral cortex of toi">:g 
 
 mouse, showing psychic cells and their branches. 
 A-D^ various layers of cells ; E, white matter : a, dendrites 
 
 or protoplasmic processes; e, f. axis-cylinder processes; 
 
 5, (/,/, g, A, ditl'erent types of cells. (_ Baker, after Eamon 
 
 y Cajal.) 
 
138 PHYSIOLOGY: THE VITAL PROCESSES IN HEALTH. 
 
 s)->ecial senses and of the sensory nerves, lies fartlier back. The motor 
 area lies iu general on either side of the fissure of Holando, and, as is 
 
 •s £ 
 
 
 -C (-1 
 
 
 
 /5W 
 
 £-3 bo 
 c - 
 
 £ c . 
 
 c3 <£.= 
 
 seen in the figures, the centres for the actions of different groups of 
 muscles have been localized. The centre marked speech is the motor 
 
THE UNDERSTANDING AND THE USE OF LANGUAGE. 139. 
 
 centre for tlie muscles of the organs of speccli. In tlio living man it 
 exists in the area a little behind and above the left temple. The 
 
 fi; 
 
 6 
 
 whole process of the understanding and the use of language is exces- 
 sively complicated, involving many parts of the brain ; a portion of 
 
14(1 PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 the nervous mcL-lianisiii is roprescutcU in Fig. ;>1. Visual impulses (/) 
 from the printed woids pass to the centre of sight (V); auditory im- 
 pulses (a) from the spoken words pass 
 to the centre of hearing (A) ; these 
 centres are connected by '^ association " 
 litres with vnv\i dtluT and with the motor 
 centres for the arm, as used in writ- 
 ing (W), and for the vocal organs (E) ; 
 when these muscles are employed, motor 
 impulses {j/i', ///) pass to them, while sen- 
 sory impulses {s\s) inform the centres of 
 what is going on. Tiie various centres 
 do not appear to be sharply marked off, 
 but rather to overlap adjacent areas. 
 Most of them exist upon both sides of 
 the brain, and, as has been stated, each 
 half of the brain controls the opposite 
 side of the body. The right-handedness 
 of most persons is due to the superiority 
 and greater refinement of the left hemi- 
 sphere of the brain over the right, and 
 the reverse is true of left-handed indi- 
 viduals. Most persons are " left-brained 
 speakers," since the speech centre is de- 
 veloped usually upon that side only. 
 
 The functions of the frontal lobes of 
 the cerebrum are quite unknown. The 
 term " higher psycliical," in Fig. 29, should be accepted with caution. 
 We have not space here to go into a discussion of them, 
 nor of the physical bases of the various psychical phe- 
 nomena — the will, the feelings, attention, judgment, memory, etc. All 
 such subjects are still in a very hypothetical stage. 
 
 The modern doctrine of localization recalls the older school of phre- 
 nology and proves how utterly unscientific and unfounded were the 
 ])lirenological conceptions. "Where the phrenologist 
 located "hope" the scientific physiologist finds the 
 nervous mechanism of k)Comotion ; "inhabitiveness" and "self-esteem " 
 marked the centres now known to be concerned in vision. A bump upon 
 the skull does not necessarily imply a bump upon the brain; and the 
 laboratory work of Fritsch and Ilitzig relegated phrenology to the in- 
 evitable oblivion of em])iricism. 
 
 In discussing the nervous system we have tacitly assumed that the 
 function of any one part is simply to stimulate some other part to act. 
 
 i'lG. 31. — Diagram intended to show 
 
 THE NEKVOLS MECHANISM EMPLOYED 
 IN THE UNDERSTANDING AND ISE OF 
 
 LANGUAGE ( foF description, see text). 
 (James, after Ross.) 
 
 Psychical Processes. 
 
 Phrenology. 
 
SUPPRESSION OR INHIBITION OF ACTION. 
 
 141 
 
 Inhihilion. 
 
 Suppression or inhibition of action is, however, widcsprciid, and of almost 
 equal importance. The best-known example of inhibition is that of the 
 vagus nerve slowing or stopping the beat of the heart. 
 Every individual knows how often in his conscious 
 life he is compelled to say "No" to his impulsive self, and an objective 
 study of his own nervous processes, if such were possible, would show 
 him that one of the frequent tasks of his nerve cells is to prevent or put 
 a stop to the actions of other nerve cells. Probably any act of the indi- 
 vidual beyond the very simplest is the result of a combination of motor 
 and inhibitory nervous influences. Consider the nervous processes as 
 portrayed in the accompanying figure (Fig. 32). The baby sees the 
 candle flame for the first time and instinctively tries to grasp it ; the 
 nerve paths of this simple reflex action are shown in 1, 1, 1, 1, from the 
 eye to the visual centre, thence to the motor centre and to the muscles 
 that extend the hand. The finger is burned, and a second reflex results 
 in the withdrawal of the hand ; 2, 2, 2, 2, marks the reflex arc, from the 
 sensory nerve endings in the skin to the sensory centre, thence to the 
 motor centre and to the muscles that with- 
 draw the hand. But the cerebral centres 
 are apprised of the occurrences, and the 
 upgoing impulses arouse perceptions of (.si) 
 the image of the flame, {mV) the action of 
 extension, (6-2) the pain, and (w?2) the action 
 of withdrawal. The groups of cells mediat- 
 ing the perceptions are "associated" by 
 fibres, and retain in their physical structure 
 the " memory " of the events. A few days 
 later seeing the candle arouses again the 
 unconscious impulse to seize it. But the 
 cortical cells are now on the alert, inhibi- 
 tory impulses are shot down to the motor 
 centres, and the hand is withheld. 
 
 The nature of nervous impulses or nervous energy is not known. 
 When nerve centres act, their protoplasm appears to undergo katabolic 
 changes, to produce heat, to become fatigued, and thus 
 to resemble other protoplasm in its general metabolic 
 phenomena. Nerve fibres, however, are peculiar in 
 that no evidences of katabolic changes are present in them during even 
 long-continued passing of nerve impulses. The rate of transmission of 
 impulses is not difficult to measure, and in man averages about one hun- 
 dred feet in the second. A feeble electric current always accompanies the 
 impulse, but the slow i-ate and other considerations seem to forbid the 
 assumption that the impulse itself is electrical. 
 
 m 
 
 Fig. 32. — Diagram intended to 
 show the paths of nervous 151- 
 pi'LSEs (for description, see text). 
 (James.) 
 
 Nature of 
 Nervous Energy. 
 
Uo PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 During the past few years physiological psychologists have devoted 
 much attention to the measurement of the time of cerebral processes — 
 the time it takes to think. The basis of their investiga- 
 tions is the determination of the simi)le reaction time, 
 which is the time that elapses between the giving of a stimulus — say 
 sending an electric shock to the skin or light to the eye — and a signal 
 made by the person to indicate that the stimulus is felt. The average re- 
 action time — which, it is needless to say, varies greatly in different indi- 
 viduals — is between one tenth and two tenths of a second. It is shortest 
 for touch, longest for sight, and for hearing it is intermediate between 
 the other two (touch 014 seconds, hearing 0"1G seconds, sight O'lS sec- 
 onds). If the time required by the end organs and the nerves be sub- 
 tracted from the whole interval between stimulation and reaction, there 
 is left the time occupied by the brain itself in recognising the sensation 
 and willing the motor response ; this may be placed, in round numbers, 
 at one tenth of a second. Practice and attention shorten the reaction 
 time ; fatigue and complication of the cerebral process (such as would be 
 caused by offering the subject a choice between two kinds of stimulation) 
 lengthen it. 
 
 CHAPTER IV. 
 SENSATION. 
 
 All parts of the body are supplied with sensory nerve fibres, and ac- 
 cordingly from all parts of the body impulses may go to the central ner- 
 vous system and there give rise to sensations. Sensations 
 
 Sensations ifl ^ -r- ^ -j^i i • t r^ 1 
 
 P I are classmed as either general or special, (jreneral sen- 
 
 sations comprise those by which we recognise vaguely 
 the existence and condition of the various parts of our bodies ; bodily 
 comfort and discomfort, fatigue and pain, are general sensations ; all 
 parts of the body seem to possess general sensibility. Special sensations 
 comprise those that possess a more specific distinguishing quality than 
 general sensations ; they are mediated b}' specialized organs, which are 
 confined to certain specific parts of the body. Formerly it was custom- 
 ary to recognise five classes of special sensations — namely, those of 
 sight, hearing, taste, smell, and touch. Investigation has now shown that 
 two others must be added to the list — namely, sensations of temperature 
 and muscular sensations. The anatomical apparatus of each of the seven 
 senses consists of (1) delicate end organs, which are adapted in each case 
 to a special method of stimulation ; (2) special afferent nerve fibres ; (3) 
 
STRUCTURE AND FUNCTION OF THE EYE. 
 
 143 
 
 special portions of the central nervous system whicli are the seat of tlie 
 sensations. Of all the senses, sight has the most highly specialized or- 
 gans, and may profitably be considered first. 
 
 Skction I. 
 
 SIGHT. 
 
 The sense of sight arouses in us ideas of form, size, distance, light, 
 shade, and colour. The end organs of sight are the eyes, which are 
 adapted to stimulation by the vibrations of the ether that we call light; 
 the afferent nerves are the optic nerves ; and the seat of visual sensation 
 is the cortex of the occipital lobes of the cerebrum. 
 
 SUPERIOR RECTUS 
 
 CHOROID 
 
 OPTIC NERVE 
 
 NFERIOB RECTUS 
 
 Fig. 33. — Section of the eyeball (Flint.) 
 
 Considered as a piece of physical apparatus, the eyeball is a camei-a 
 
 obscura, of which the best-known example is the photographic camera — 
 
 that is, it consists of a chamber with blackened walls. 
 PM/siological Anat- mi i i n i ii -l- i ^ xi ^• 
 
 ffhF ^ ^^ back wall holds a sensitive plate, the retina, upon 
 
 which an image of the object is thrown ; the front wall 
 is pierced by a hole, the pupil, about which is an adjustable diaphragm, 
 the i7'is I and a system of transparent refractive bodies, or lenses, com- 
 prising the aqueous humour, the crystalline lens, and the vitreous hu- 
 7nour^ bring the rays of light to a focus upon the retina (Fig. 33). The 
 
144 PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 end to be reached is the stiinuUitiun of the nervous apparatus in the retina, 
 and accordingly the retina is regarded as the essential part of the eye, all 
 other parts being accessory. 
 
 In its origin the retina is a pail of the brain, \vhich has grown out 
 along the route of the optic nerve and has come to be located in the eye- 
 ball. It consists of nerve cells of different shapes, ar- 
 ranged in layers, as shown in the accompanying figures 
 (Figs. .')4 and 35), and bound together by supporting tissue. The sig- 
 nificance of the various jiarts is not understood, but the terminal end 
 
 Choroid coat. 
 
 A 
 
 V 
 
 Path 
 
 of 
 
 Path 
 of 
 
 raj-s 
 
 of 
 light. 
 
 nervous 
 impulses 
 
 10 Layer of pig- 
 ment cells. 
 
 9lj . jM 
 
 :<|:Uii|l:| n Layer of rods 
 
 *''rl /!^,Hl aud cones. 
 
 g E.Kternal limit- 
 ing membrane. 
 
 7 Outer nuclear 
 
 layer. 
 
 g Outer molecular 
 
 layer. 
 
 ir Inner nuclear 
 
 '^ layer. 
 
 p^yjsi^issii 
 
 f:''Pt^t\ T- 
 
 ...., ";k!?>€^ 
 
 3 Wik^MM 
 
 .Inner molecular 
 layer. 
 
 ...Layer of nerve 
 cells. 
 
 3 ...Layer of nerve 
 fibres. 
 
 J ...Internal limiting 
 membrane. 
 
 Vitreous humour. 
 Fig. 31. — Section of the retina (diaokam.matic). (Scliultze.) 
 
 organs of the nervous mechanism are the rods and the cones, which, 
 through forming the outer layer of the retina, seem to be the parts that 
 are sensitive to light, and upon which the image is focused. They con- 
 sist of highly specialized protojilasm ; their names and the figures indicate 
 their shape. It is e.stimated that there are at least three million cones 
 
RETINAL IMAGES AND AFTER-IMAGES. 
 
 u: 
 
 After-images. 
 
 and many more rods in each retina. Tlie dillerence in function of the 
 rods and the cones is not known. The light probably causes chemical 
 changes in them, and thus originates nervous impulses ; the latter traverse 
 the various retinal layers of nerve cells and their processes, reach the 
 optic nerve, and go thence to the 
 brain. The retina may be stimu- 
 lated mechanically by pressure upon 
 the eyeball. Thus, rubbing the eyes, 
 as is often done upon awaking from 
 sleep, produces sensations of light 
 in the form of points, spots, or cir- 
 cles. " Seeing stars," as the result 
 of a blow, is due to mechanical stimu- 
 lation of the retina. 
 
 The effect upon the retina lasts 
 frequently for a considerable time 
 after the eye is turned away from 
 the object. For 
 example, a single 
 look at the sun will enable us to see 
 suns for several seconds afterward. 
 Such an after-effect is termed an 
 after-image. Sometimes, and espe- 
 cially at first, it is of the same colour 
 as the object, but later it appears in 
 the opposite or complementary col- 
 our ; in the former case it is called 
 positive, in the latter negative. Thus 
 the after-image of a white object may be at first white, but later it is 
 gray or black ; of a red object, perhaps momentarily red but soon green. 
 Positive after-images are due to a continuation of the nervous excitation 
 after the cause of it is removed ; negative after-im^ages result from fatigue 
 of the nervous mechanism for the colour that is looked at, hence the 
 predominance of the complementary colour. 
 
 The place of entrance of the optic nerve into the retina, being devoid 
 of rods and cones, and, in fact, of all nervous organs except nerve fibres, 
 is insensitive to light, and is called the hlind spot. Its 
 blindness may be proved by the following simple ex- 
 periment : If the left eye be closed and the circular disk in Fig. 36 be 
 looked at with the right eye, it will be found that the cross is also visible, 
 except when the book is held at a distance of from nine to twelve inches 
 from the face ; at that distance the image of the cross falls upon the end 
 of the optic nerve and is not perceived. In ordinary life each eye cor- 
 12 
 
 Fig. 35. — Section of the retina (diagram- 
 matic), INTENDED TO ILLUSTRATE THE RE- 
 CENT DISCOVERIES AS TO THE STRUCTURE 
 AND RELATIONS OF THE VARIOUS LAYERS. 
 
 A^ layer of rods (a) and cones (b) ; B^ outer 
 nuclear layer; c, nucleus of cone; d, nu- 
 cleus of rod; 6', outer molecular layer; D, 
 inner nuclear layer; e, rod-bipolar cell;y, 
 cone-bipolar cell ; E, inner molecular layer; 
 F^ layer of nerve cells; g, 7i,i,j, k\ nerve 
 cells with processes branching at different 
 levels ; G, layer of nerve fibres ; I, non- 
 nervous supporting cell (fibre of Miiller). 
 (Kamon y Cajal). 
 
14ti PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 rects the invisible spot in the iiekl of the other, and hence we do not 
 appreciate the two gaps in our combined field of vision. 
 
 Fio. 3G. — Diagram for demonstrating existence ok rund spot. 
 
 Formation of 
 Retinal Image. 
 
 The formation of the retinal image is a purely physical matter, and 
 follows the laws of refraction of light. The rays of light from each 
 portion of the object looked at are bent out of their 
 course by the three refractive bodies, but chiefly by the 
 crystalline lens, and are brought to a focus upon the 
 layer of rods and cones. Thus a small inverted image of the object 
 appears upon the retina exactly as upon the ground glass of the photo- 
 graphic camera (Fig. 37). As in all optical instruments, focusing is 
 necessary in order that the picture may be sharp and distinct. By the 
 curvature of the lens and the length of the eyeball the eye is focused 
 normally for objects situated at a great distance from the observer. For 
 nearer objects focusing might be brought about theoretically either by 
 making the lens more convex or by increasing the length of the eyebalL 
 In the camera the latter method is employed by drawing back the plate 
 of ground glass. In the eye the retina can not be moved, and hence the 
 curvature of the lens is altered in the following 
 manner : The lens is elastic, and normally is 
 kept slightly flattened by the tension of sur- 
 rounding parts. When vision 
 Accom,modation. .1. , n , ^ • , ,1 
 
 IS directed to near objects the 
 
 ciliary muscle, which lies just outside the edge 
 of the lens, contracts and pulls forward the 
 choroid coat together with the suspensory liga- 
 ment of the lens. Tension on the lens being 
 thus diminished, the latter bulges forward and 
 becomes more convex (Fig. 38). Sharpness of the image is also assisted 
 by shutting out the rays that would come through the more external 
 parts of the lens. This is accomplished by the muscular diaphragm, the 
 iris, which, in proportion to the nearness of the object, contracts and 
 
 Fig. 37. — Diagram illustrat- 
 ing REFRACTION OF RAVS OF 
 LIGHT AND FORMATION OF AN 
 INVERTED IMAGE BY A LENS. 
 
 A J), object; Z, lens; b a, im- 
 age. (Martin.) 
 
NEAR-SIGHT, FAR SIGHT, ASTIGMATISM, AND OLD-SIGHT. 147 
 
 diminislies the size of the pupil. J^oth the iris and the ciliary muscle arc 
 under nervous control, and their actions are delicately harmonized reflexlj 
 through the brain, the optic nerve being the ail'erent nerve. 
 
 Considered as an optical instrument, the human eye, although appar- 
 ently so exactly adapted to its uses, is by no means perfect. Indeed, the 
 
 distinguished German physicist and physiologist, Helm- 
 Visual Apparatus, ^^o^^^' ^^^^^^ admiring its surpassing fitness, once wrote 
 
 of its shortcomings : " If an optician M'anted to sell me 
 an instrument which had all these defects, I should think myself quite 
 justified in blaming his carelessness in the strongest terms, and giving 
 him back his instrument." The eyeball may be too long {near-siyht) or 
 too short {far-sight) ; in both cases exact focusing for a wide range of 
 vision is difficult, and, unless the eye is assisted by spectacle lenses, a 
 blurred image falls upon the retina. The curvature of the front surface 
 of the eyeball, the cornea, may be irregular, a very common defect known 
 as astigtnatism^ which manifests itself also by a blurred image. The 
 
 Fig. 38. — Diagram illustrating the mechanism of accommodation of the eye. 
 In iVthe lens is accommodated for near objects ; in F^ for distant objects. (Fick.) 
 
 crystalline lens, like all lenses, produces some spherical and some chro- 
 matic aberration. Floating within the vitreous humour of all eyes are 
 peculiar opaque particles, cells of irregular shape and filaments, that 
 appear as mysterious moving particles in the field of vision ; they are 
 most evident when one gazes at a white w^all or at the sky ; they are 
 entirely harmless, A considerable number of individuals sufiier from 
 colour blindness^ which is apparently due to a lack of certain colour-per- 
 ceiving elements in the retina and will be discussed hereafter. Lastly 
 may be. mentioned the trouble with vision that appears in most persons 
 shortly after middle life {old-sight) ; it may be due to a weakening of the 
 ciliary muscle or to a loss of elasticity of the crystalline lens. 
 
 The question as to how we see colour has been and still is the cause 
 of much speculation, experimentation, and tljeorizing. Objectively one 
 colour differs from another only in the length of the waves and the rapid- 
 
14S PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 itj of vibration of the ether ; and \vhite Hu-ht is the resultant of a host 
 
 of tliese diUerent waves taking place siniultaneousl3\ By means of the 
 
 spectroscope white light may be analyzed into seven 
 
 Colour Vision. , ^^ V ll • ^ n • J 
 
 colour groups, called 'primary colours viz.: red, 
 orange, yellow, green, blue, indigo, and violet ; and, since given these 
 colours all colours whatsoever may be obtained by proper mixing, it fol- 
 lows that, if we can explain the perception of the primary colours, we 
 can explain all colour vision. But the matter is simpler than this, for 
 experiment shows that all colour sensations may be produced by proper 
 mixing of three colours only instead of seven — e. g.^ red, green, and violet. 
 This fact is the basis of the common theory of colour vision, the Young- 
 Helmholtz theory, which supposes the existence of three primary colour 
 sensations, such as red, green, and violet, all other colour sensations being 
 combinations of these. Perhaps these correspond to three kinds of 
 material elements in the rods and cones or in other parts of the visual 
 apparatus, each element being capable of stimulation by all colours of 
 light, but more especially by one colour. Thus white light stimulates all 
 three alike, red light the red- perceiving elements more strongly, and so 
 on. Colour-blindness is due to a lack of at least one of the three kinds 
 of elements — a red ribbon appears like a green ribbon because the 
 red-perceiving elements are wanting. This theory accounts for many 
 of the facts of colour vision, but is not entirely sufficient. Several other 
 theories have been suggested and are being actively tested and dis- 
 cussed. 
 
 AVith some of the lower animals, such as the rabbit, every object is 
 seen with one eye only ; each eye has its own field of vision. Man, how- 
 ever, is a binocular animal, since under ordinary cir- 
 Binocular Vision. ^ i t , i • -,-,,. 
 
 cumstances he directs his two eyes toward the object 
 
 looked at. As a matter of fact, only the middle part of his field of vision 
 is binocular, since the right eye alone sees to the extreme right, the left 
 eye alone to the extreme left ; the amount of overlapping of the right 
 and the left fields in front depends upon the shape and the prominence 
 of the nose. Slightly different pictures of the object looked at fall upon 
 corresponding points in his two retinas, but out of the two images he 
 receives a sensation of one object. Binocular vision is of the greatest 
 value, since by it we are able to form much more exact ideas of distance, 
 size, and form than by one eye alone. Binocular vision would be nearly 
 valueless, however, were it not supplemented by the muscles of the eye- 
 balls and their exact co-ordination by the central nervous system. These 
 muscles rival those of the larynx in delicacy of action, and enable any 
 point within the range of the two eyes to be turned to instantly. The 
 newly born babe often pos§esses the primitive power of moving the eyes 
 independently of each other, a power which adults rarely retain. 
 
SECRETION OF THE LACHRYMAL GLAND. 140 
 
 The eyelids exist for the protection of tlie eyeballs. Winkiri^^, by 
 sweeping across the ball and through the lachrymal canals into the nose 
 the secretion of tlie lachrymal gland, serves to keep the 
 surface of the cornea moist, and to wash away foreign 
 particles that might be injurious to it. When the secretion becomes ex- 
 cessive, it overflows in the form of tears. Lachrymal glands arose in the 
 course of evolution, when aquatic animals gave rise to those leading a 
 terrestrial life. Hence fishes, whose eyes are bathed constantly by the 
 surrounding water, neither require nor possess them, while they exist in 
 all animals above fishes. The power of weeping, although it has been 
 observed in elephants, some monkeys, and in a few other animals, is con- 
 fined chiefly to man. Usually, but not always, it signifies grief or bodily 
 suffering. Darwin believes that it arose incidentally as the result of a 
 chain of events somewhat as follows : The suffering child, like the young 
 of other animals, cries out, partly for aid from its parents, partly to 
 relieve itself by activity ; in this act the blood-vessels of the eyes are 
 gorged with blood, and to prevent injury therefrom the muscles about 
 the eyes are contracted strongly (see Fig. 20, B) ; the muscular contrac- 
 tion causes in some reflex way not wholly understood a flow of tears from 
 the gland ; in the adult all the events in the chain are not necessary, and 
 grief leads directly to weeping. 
 
 Seci^ion II. 
 
 HEARING. 
 
 The ear is the most complicated of all known sense organs. Its 
 
 essential part comprises the nerve-endings in the membranous labyrinth 
 
 of the internal ear ; the accessory parts consist of the 
 Fhysioloqical Anat- , <• ,i • , i ,^ • ^'^^ ^ ,\ 
 
 i*i, V rest 01 the mternal ear, the middle ear, and the exter- 
 
 omy of the Ear. ' _ ' _ 
 
 nal ear. In so far as the ear is used for hearing, it is 
 adapted to receive the vibrations of air that we call sound and to transmit 
 them to the nerve terminations. The diagram (Fig. 39) shows the rela- 
 tions of the various parts of the auditory organ. The pinna, or external 
 part that we commonly call the ear, is omitted from the figure, but the 
 passage {E. M., external auditory meatus) is shown, and the arrow indi- 
 cates the path of the waves of sound. The waves cause the tympanic 
 membrane {^Ty. M.) to vibrate, and this produces a gross movement of 
 the delicate ear bones {Mall., Inc., Stp.) that stretch across the air- 
 space of the middle ear (Ty.). The middle ear is seen to be really a 
 drum with one drumhead {Ty. M.) upon one side, two drumheads 
 {F. 0., F. r.) upon the opposite side, and a passage {Fu.) to the pharynx, 
 and thus to the outside air, for the purpose, as in all drums, of equalizing 
 
1 JO PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 the pressure of air uitliin and without. Through the ineiubrane of the 
 fenestra ovalis {J^\ o.) the Hquid perilymph within the bony labyi'inth 
 
 {/Sea. v., Sea. T.) of the 
 internal ear is set into vi- 
 bration. The vibrations 
 pass through the walls of 
 the membranous laby- 
 rinth, affect the liquid 
 endolyin])h, and stimulate 
 the nerve-endings {Sea. 
 M.). A more detailed 
 but still diagrammatic 
 figure of the membranous 
 labyrinth is shown in 
 Fig. 40. It is there seen 
 that the labyrinth con- 
 sists of three distinctive 
 parts, viz. : two central 
 irregular-shaped cavities 
 {utricle and saecule) in- 
 directly connected ; three 
 semieireular canals join- 
 ing the utricle, each with 
 an enlargement, the am- 
 jyulla • and the canal of 
 the cochlea {Coch.)., ]^^^- 
 ing the saccule. Each of 
 the three distinctive parts 
 contains in its walls char- 
 acteristic nerve terminations ; and, as the figure shows, there are in real- 
 ity six end-organs within the ear. Of these it is probable that the ner- 
 vous organ in the cochlea alone, the organ of Corti, is auditory in 
 function. 
 
 The organ of Corti (Fig. 41) is a complex mechanism, resting upon 
 one wall of the cochlear canal, the hasilar meinhrane., and extending 
 from the base to the apex of the cochlea. It consists of 
 a succession of curious rodlike structures, the rods of 
 Corti, beside which are columnar cells, tipped with hairs and surrounded 
 l)y the terminations of the nerve fibres ; the hairs pass through a perfo- 
 rated membrane [reticulate membrane), and over all is a curtain, the tec- 
 torial tnernbrane. The hair-cells are the proper end-organs ; they corre- 
 spond in function to the rods and cones of the retina ; through them the 
 nerve fibres are stimulated. But the method of stimulation has not yet 
 
 Fio. 39. — Diagram of ear. 
 
 The external ear comprises the external projecting part, or 
 pinna (omitted from figure), and the external auditor// 
 meatus {E. M.)\ tlie arrow indicates the direction of tlio 
 waves of sound. The middle ear or tympanum {T;/.) 
 comprises the tympanic membrane ( Ty. M.), the fenestra 
 ovalis (F.o.)y the fenestra rotunda (F.r.), the three bones, 
 malleus (.Wall.), 'incus {Inc.), and stapes {Stp.), and the 
 Eustachian tube [Eu.)\ the middle ear is filled with air, 
 and connects with the pharynx through Eu. The inter- 
 nal ear, or labyrinth, comprises the osseous labyrinth and 
 the membranous labyrinth. Both are highly diagram- 
 matic in figure, the former being reduced to scala tympani 
 {Sea. T.) and scala vestibuli {Sea. V.) of cochlea, and one 
 semicircular canal, the latter being reduced to scala 
 media {Sea. Jf.) of cochlea, and one .semicircular canal 
 {M. L.) ; the osseous labyrinth is filled with perilymph, 
 the membranous labyrinth with endolymph. All bony 
 parts are shaded with oblique lines. (Hu.xley.) 
 
 Organ of Corti 
 
THE EAR AND A THEORY OF HEARING. 
 
 16l 
 
 A.N. J'^: 
 
 been satisfactorily determined. It will Ije remembered that the org;an of 
 Corti is bathed with endolymph and tho bony labyrinth ontside the cOcli- 
 lear canal is filled with perilymph, lience the vibrations caused by sound 
 may be transmitted readily to 
 the organ of Corti. It was 
 formerly thought that the rods 
 of Corti first received these vi- 
 brations, and that from them 
 the nerves were stimulated. 
 But it seems more reasonable 
 to believe that the important 
 part of the organ is the basilar 
 membrane, which consists of 
 parallel fibres extending from 
 within outward, and which may 
 act somewhat after the manner 
 of the wire board of a piano. 
 
 In discussing voice we spoke 
 of pitch, quality, and loudness 
 as three characteristics, the pro- 
 duction of which was to be ex- 
 plained. A theory of hearing 
 must explain the recognition of these three characteristics. According 
 to the theory now usually adopted, the recognition of pitch depends upon 
 
 Fig. 40.- 
 
 P.S.C. 
 
 Coch. 
 Diagram of membranous labyrinth and 
 Distribution of auditory nerve. 
 V, utricle ; A. S. C, K S. C, and P. S. C, anterior, ex- 
 ternal, and posterior semicircular canals; A. F., 
 aquffiductus vestibuli; <S'., saccule; C, canalis re- 
 uniens; Cock., canal of cochlea, or scala media; 
 ^. iV., auditory nerve, dividing into six branches 
 that end respectively in the three aistce actisticcB 
 of the ampullae of the semicircular canals, the two 
 TYiaculm acusticce of the utricle and the saccule, 
 and the organ of Corti in the cochlea. (Huxley.) 
 
 Fig. 41. — Diagram of cross-section of canal of cochlea, showing organ of Cobti EEsrnfo 
 
 UPON basilar membrane. 
 
 z, inner, and y, outer rod of Corti ; ?', inner, and />, outer hair cells ; iV^, nerve, and ti, nerve fibrils 
 passing to hair cells ; o, reticulate membrane : Mb. Corti, membrane of Corti, or tectorial mem- 
 brane ; d, /r, a, H, G, epithelial cells. (Landois.) 
 
15:2 PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 the particular part of the bat-ilar membrane that is put into vibration. 
 The tibres of which the membrane is composed, about twenty-four thou- 
 sand in number, become increasingly longer from the 
 Recognition of ^^.^^^ ^^ ^j^^ ^^ ^^ ^j^^ cochlea. It is conceivable that, 
 J^itcn, Quality, arid . .-..,. . 
 
 Loudness. " J^^^ ^^ ^"^ ^"® ^^''^ ^^ ^'^^ piano, the longer hbres vibrate 
 
 to the lower notes only, the shorter fibres to the higher 
 notes only ; and with each note the hair-cells that rest upon that portion 
 of the membrane and their contiguous nerve libres are stimulated. 
 Quality of sound depends upon the number and prominence of the over- 
 tones that accompany the fundamental tone. When a piano-key is 
 struck and a single wire is put into vibration, other wires vibrate in 
 unison and produce overtones. So in the basilar membrane of the 
 ear, when one part vibrates other parts vibrate, and nervous impulses are 
 produced corresponding to the fundamental tone and the overtones of 
 the sound that comes to the ear. Recognition of loudness depends iipon 
 the extent of vibration of the basilar membrane. Therefore, accord- 
 ing to the theory of the all-importance of the basilar membrane in hear- 
 ing, a sound after coming to the ear and reaching the membranous 
 labyrinth is analyzed into its constituent vibrations. Nervous impulses 
 corresponding to the various vibrations are produced in the fibres of the 
 auditory nerve, are transmitted to the brain, and give rise to sensations. 
 These various sensations are combined and elaborated into a percep- 
 tion of the sound. It should be said that this theory is not wholly satis- 
 factory. 
 
 The semicircular canals and their nervous end-organs, the cristOB 
 acusticce, seem to have nothing whatever to do with hearing. They are 
 sense-organs of bodily equilibrium ; thev enable the 
 ^ , individual to recognise the turning of the head and of 
 
 the body out of one position into another. They are 
 especially prominent in fishes and in birds— animals that spend much of 
 their time in diving and turning in fiuid media, the water and the air 
 respectively. In each ear the planes of the three canals are nearly at 
 right angles to each other, so that they represent the three planes in 
 space. Each canal is hollow and filled with endolymph, and its crista 
 acustica^ which lies in the enlarged ampulla, seems specially adapted to 
 stimulation by movement of the contained liquid (Fig. 42). The cells 
 about which the nerve-fibres terminate are tipped with long hairs that 
 project into and float in the endolymph. Any curved movement of the 
 head in or approximately in the plane of a canal may readily cause a 
 bending of the hairs and a stimulation of the nerves. If a movement of 
 the head takes place in any other plane, two or more canals may be 
 stimulated at once, and by means of the six canals of the two ears acting 
 in various combinations curved movements in all possible planes in space 
 
SENSE-ORGANS OF BODILY EQUILIBRIUM. 
 
 15 
 
 may be appreciated. - Kouglily speaking, the canalB act as spirit levelf^, 
 and the delicacy of their action is realized when we consider with what 
 accuracy we can detect the slightest turning of the body out of equi- 
 librium. 
 
 Whether the saccule and the utricle are auditory in function is in 
 great doubt. It was once believed that their nervous terminations appre- 
 
 , ^,, . , ciate noises as distinct from musical sounds, which 
 Saccule ana vincle. ,. i i i , t • 
 
 stnnulate the coclilear organs. Jiut it now seems prob- 
 able that the cochlea, deals with both kinds of sounds. Structurally the 
 maculce aoitsticcB, the two nervous end-organs upon the walls of the sac- 
 cule and the utricle, are 
 similar to the cristge of the 
 semicircular canals ; the 
 hairs are shorter, however, 
 and lying upon and among 
 them is a mass of calca- 
 reous crystals, the otoliths. 
 Experiments upon fishes 
 make it practically certain 
 that these organs appreci- 
 ate the position of tlie 
 head, and thus of the body, 
 in space, and hence are or- 
 gans of equilibrium of the 
 body when at rest. The 
 mode of stimulation is be- 
 lieved to be by the con- 
 stant pressure of the oto- 
 liths upon the hair-cells, and the production thus of a constant nervous 
 impulse that gives the individual an idea of his position ; if the body be 
 thrown out of the normal attitude, the pressure of the otoliths is altered, 
 and thus the individual recognises his new position. Experiments upon 
 fishes indicate also that the saccule and the utricle appreciate simple pro- 
 gressive bodily movements in a straight line. It seems not unreason- 
 able to suppose that these parts may have in man the same functions 
 as in the lower animals. If this be so, the semicircular canals, the sac- 
 cule, and the utricle act together and form a most efficient organ of 
 equilibrium for the body in all possible movements and in all possible 
 positions. It is an interesting but unsolved problem as to how the organ 
 of equilibrium and the organ of hearing became associated with each 
 other in the ear. 
 
 Fig. 42. — Diagram of longitudinal section of ampulla 
 OF semicircular canal, showing crista acustica {cr.) 
 
 c, opening into canal ; n, opening into utricle; e, epithelial 
 lining of ampulla; n, branch'of auditory nerve supply- 
 ing crista; a. e., hair cells; a.h., hairs projecting into 
 endolymph ; c. i., connective tissue. (Huxley.) 
 
154 PHYSIOLOGY: THE VITAL PROCESSES IN HEALTH. 
 
 Smell. 
 
 Section IIL 
 smell. tastk. 
 
 Different animals vary greatly as to the relative importance of tlieir 
 various sensations. The world is made known to man, for example, 
 cliiefly through sight, hearing, and touch. The dog's 
 world is laj'gely a world of odours, and in him the sense 
 of smell, comparatively unimportant in man, is very acute. A substance, 
 in order to be smelled, must be either in a gaseous or in a very linely 
 divided condition. The organs of smell comprise the upper portion of the 
 two cavities of the nose ; the lower portion serves as, a passageway for air 
 in respiration ; hence in quiet respiration odours are not usually peiceived ; 
 they come into consciousness only when they are very strong or when 
 by sniffing the air containing them is forcibly drawn up to the olfactory- 
 organs. The organs are very simple, consisting solely of the membi-ane 
 lining that portion of the nasal cavities (Figs. 43, 44). The membrane is 
 composed of columnar epithelium cells, and contains glands that, together 
 with the cells, seci'ete the mucus with which the nose is always moistened. 
 Among the cells are scattered long delicate ones that resemble somewhat 
 the rods of the retina, and from which nerve-fibres go directly to the 
 
 Fio. 43. 
 
 Fio. 44. 
 
 Figs. 43 and 44. — Vertical longitudinal sections of the cavity of the nose. 
 Fig. 43 represents the outer wall of the left nasal cavity; F'ipr. 44 the inner wall of the right nasal 
 cavity. S7\ MT., LT., superior, middle, and inferior turbinate bones ; Pa, hard palate separating 
 nasal cavity from mouth ; Sp, septum or partition between the two nasal cavities ; /, lies with- 
 in the brain cavity, and points to the olfactory nerve, with its numerous branches; F, branches 
 of the trigeminus or liftli nerve. (Ilu.xley.) 
 
 brain (Fig. 45). These are the olfactory cells, and they are stimulated by 
 the odoriferous substance coming in contact with their exposed ends. 
 The amount of substance needed to cause a sensation of smell is incon- 
 
OEGANS OF SMELL AND TASTE. 
 
 15 
 
 ceivably small ; it is said that -OOOOOOOOS of a inilli<^rarrirno of oil of pcj>por- 
 
 mint suffices. No satisfactory classification (;f odours lias yet been made, 
 
 analogous to that of colours in light and pitcji in sound. 
 
 The sense of taste, like the sense of smell, is relatively unimportant in 
 
 man. In many respects it is not uidike the sense of smell. "J^lie organs 
 
 ,^ , of taste comprise certain portions of the lininir mem- 
 Organs of laste. , ^ ,^ ^ • . , ,„ 
 
 brane of tJie mouth cavity — viz., the surface of the 
 
 tongue, the soft palate, and the columns upon either side at the back of 
 
 the mouth (anterior pillars of the fauces). Situated in the covering of 
 
 these parts of the tongue, upon some of the 
 
 papilUe that roughen its surface, are small 
 
 gi^oups of sensory cells, called taste-huds 
 
 (Fig. 46). The gtistatory cells composing 
 
 them are not unlike the olfactory cells, in 
 
 appearance. They are sunk a little below 
 
 the surf ape, their exposed ends being reached 
 
 3 
 
 Fig. 45. — Nerve and end-organs 
 of sense of smell. 
 
 1, cells from nasal cavity of frocj; 
 a, epithelial cell; J, olfactory 
 cell ; 2, branch of olfactory 
 nerve of froff, terminating in 
 fibrils; 3, olfactory .cell of 
 sheep. (KoUiker.) 
 
 Fig. 46. — Two taste-buds from the rabbit's tongup, 
 (Magnified 450 diameters.) (Engelmann.) 
 
 Glasses of Tastes. 
 
 through a small pore. They are stimulated, like the olfactory cells, by a 
 minute quantity of the substance tlia.t is to be tasted coming to them in 
 solution. It is possible that there exist other oi-gans of taste whose 
 function is as yet undiscovered. 
 
 Like colours in light and pitch in sound, four classes of tastes are 
 recognised, viz., sweet, sour, bitter, and salty ; and probably all tastes 
 not precisely these are combinations of them. Each of 
 these classes probably has its own end-organs and nerve- 
 fibres. The front part of the tongue tastes sweet and sour substances, 
 the back part bitter substances. Some substances, like a certain com- 
 pound of saccharin, when placed upon the tip of the tongue taste sweet, 
 upon the back of the tongue bitter, because they are able to stimulate 
 both kinds of end-organs. Taste is assisted greatly by smell, the two 
 senses usually working intimately together. This may readily be proved 
 by the easy experiment of holding the nose, closing the eyes, and then 
 
156 PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 endeavouring to distinguish by taste alone between a bit of apple and a 
 bit of onion, or between a particle of banana and a strawberry. 
 
 Section IV. 
 
 TO veil. TEMPERATURE. MUSCULAR SENSE. GENERAL SENSIBILITY. 
 
 By the term " sense of touch " is now meant the sense of pressure. 
 Its organs are localized in the skin, and consist probably of various known 
 forms of touch co7'puscles. These are minute spherical 
 or ovoid bodies, consisting of cells among which nerve- 
 fibres end, the structure indicating that their natural method of stimula- 
 tion is by pressure upon the skin overlying them. Recently, physiologists 
 have succeeded in mapping out the surface of the skin into " pressure 
 points," which recognise the touch of bodies applied to the skin, and 
 minute areas between them, w-hich are wholly devoid of the sense of 
 touch. The " pressure points " probably overlie the organs of touch. 
 The forehead and the back of the hand seem to be among the most sensi- 
 tive parts of the skin, recognising a weight of -^^ of a grain, but the tips 
 of the lingers can distinguish more exactly two objects placed near 
 together. 
 
 The sense of temperature, also localized in the skin, has only recently 
 been recognised as a sense distinct from that of touch. It comprises, in 
 reality, two senses, that of warmth and that of cold, 
 ' which are now believed to be so far distinct as to have 
 separate end-organs and separate nerves. Just as with the sense of pres- 
 sure, so with temperature, it has been found possible to map out the sur- 
 face of the skin into points that recognise only warmth (" warm spots ") 
 and points that recognise only cold (" cold spots "). The warm spots are 
 di.-tinct from the cold spots, and both are distinct from the pressure 
 points. There exist in the skin various sensory organs, besides the touch 
 corpuscles, and it is believed that some of these mediate sensations of 
 temperature, but it is not yet decided as to which are organs of warmth 
 and which organs of cold. The face is the region of the skin most sensi- 
 tive to temperature. 
 
 By muscular sensation we recognise the amount of contraction that a 
 muscle is undergoing ; and from such data we form judgments of the 
 
 size, form, position, and weio;ht of objects. Since mus- 
 Muscular Sense. . . . 
 
 cular contractions occupy so large a field in our daily 
 
 life, the muscular sense is important. The existence of a muscular sense 
 
 can be indicated by a simple experiment : If an object be held in the 
 
 hand and be moved up and down, we have a distinct consciousness of the 
 
GENEKAL SENSIBILITY. 157 
 
 tension exerted npon the muscles of the arm ; from this muscular feeling 
 we can form a much more accurate estimate of tlie weight of the object 
 than from the feeling of pressure of the object upon the skin of the 
 hand ; the feeling of pressure distinct from that of muscular contraction 
 can be studied by laying the hand flat upon the table and placing the ob- 
 ject in the palm. What the sensory end-organs are that mediate the 
 muscular sense is not known ; nor is it known whether they are localized 
 in the muscles themselves, in their tendons, or in the joints. There is 
 evidence in favour of each of these three localities. 
 
 Although sensations of touch, temperature, and muscular contraction 
 
 are regarded as distinct and as mediated by three kinds of end-organs, 
 
 nerves, and brain-centres, as a matter of fact we rarely 
 
 Toitch Temperature, ^^^ ^^^ ^^ ^^^^^^ ^^^^^^^ , .^g^j^ _ r^^ ^^,^ inextricably 
 
 rarely separated, bound together in ordinary life. Especially are our 
 
 judgments of the characteristics of objects tliat are 
 
 touched by our hands formed from a mixture of these three kinds of 
 
 sensations. 
 
 General sensibility has been referred to as the property by which we 
 
 recognise, in a vague way, the existence and the condition of the various 
 
 parts of our bodies. The sensations of pain, fatierue, 
 Common Sensation. , ,i • , i • • ,• ^^• t i %.i 
 
 hunger, thirst, shivermg, tickling, nausea, general bodily 
 
 comfort and discomfort, have all been referred to general sensibility. 
 
 Since many of these sensations enter largely into our everyday life, it 
 
 seems strange that we have but little exact anatomical or physiological 
 
 knowledge regarding them. Future investigation may possibly succeed 
 
 in lifting some of them out of the ill-defined group of common sensations 
 
 into new special senses. Pain is now commonly believed to be due to 
 
 excessive stimulation of nerves of general sensation, and thus to have a 
 
 nervous mechanism distinct from those of the seven senses. 
 
 CHAPTER V. 
 REPRODUCTION. 
 
 The functions so far considered have reference to the daily life, well- 
 being, and preservation of the individual man or woman. But the human 
 
 being has. in common with other organisms, the in- 
 Reprodtiction in ,.'.'. -, ,. ^ .^, , . 
 
 ^ , stmcts of racial continuance, and racial continuance is 
 
 assured only by the production of new individuals. In 
 the simplest one-celled organisms all individuals are alike, and reproduc- 
 tion takes place by a simple splitting of the individual body into two 
 
158 PHYSIOLOGY: THE VITAL PROCESSES IN HEALTH. 
 
 bodies. In niuny-ccllod orgunisius sexes exist, individuals are either male 
 or female, and reproduction is more complicated. The essence of sexual 
 reproduction consists in the production by the two sexes of germ-cells 
 (the ovum, or a^g, by the female, and the itpermatozoihi by the male), the 
 union of these two germ-cells, and the growth therefrom of the new indi- 
 vidual. The reproductive organs subserve these three functions. For 
 the structure and relations of the organs the reader is referred to the 
 article on T/ie Anatomy of the Human Body. 
 
 The human egg (Fig. 47) is a soft, delicate, spherical cell, about -j^ 
 of an inch in diameter. It consists of protoplasm and a small quantity 
 of food substimce scattered throui^h it. In the effff of 
 the fowl, the agg most familiar to us, the vital part 
 corresponding to the human ovum is in the small whitish spot ujion one 
 side of the volk. To this is added, for the nourishment of the t!:rowine: 
 chick, the rich food-substance of the volk and the white, while the shell 
 
 J^99- 
 
 FlO. 47. — A HUMAN EGG MUCH ENLARGED. 
 
 The {,'reater part of the etrj,' consists of finely {rraniilar livinjr protoplasm and coarsely .rninular 
 lifeless yolk, the two bein.tr intimately mingled toyrether. Toward the upper part of' the ii-nire 
 lies the spherical (jertninal vesicle or nucleus, within which is the small denser fdarkifftr- 
 minal mot or nucleolus. The e^g is surrounded by a thick, transparent eRfr-mem branch or 
 z<ma pducida, whicli is penetrated by fine pore-canuls, rei)rcsented by radiatin.r lines 
 (Jlaeckel.) "^ '^ 
 
 is a protective covering. The human chick develops M'ithin the body of 
 the mother, hence a mass of food within the c^^^^ and a shell are unneces- 
 sary. Eggs are produced witliin the ovary of the mother (Fig, 48) 
 
OVULATION AND MENSTRUATION. 
 
 159 
 
 througliQut tlie period of Ium- s(!.\ual life — i. <?., from puberty, at the 
 age of. thirteen to seventeen, until the menopause, at forty to fifty years 
 
 Fig. 48. — Female reproductive organs (two thirds the katural size), as seen from behind. 
 
 M, upper part, and c, neck of uterus (in section) ; «;, upper part of vagina; od, Fallopian tuVjes (left 
 one cut off) opening into cavity of abdomen at^ ; o, riglit ovary ; po, h, accessory ovarian struc- 
 tures ; I, II, lo, supporting ligaments. 
 
 Menstruation. 
 
 of age. During this period, at intervals of about twenty-eight days, 
 unless interrupted by pregnancy or disorders, an ovum becomes ripe, 
 breaks through the ovarian wall, and is discharged from the body through 
 the Fallopian tubes, the uterus, and the vagina. 
 
 Accompanying this discharge characteristic phenomena take place in 
 the wall of the uterus and elsewhere, constituting menstruation. The 
 lining membrane of the uterus, which has become thick 
 and swollen with blood, rapidly degenerates, breaks 
 away from its attachment, and gradually passes away from the body 
 through the vagina, accompanied by a considerable flow of" blood from 
 the torn blood-vessels of the uterine wall, and by mucus. The menstrual 
 flow occupies upon an average about four days. It is preceded by a gen- 
 eral increase in physiological activity and excitability, by a rapid pulse 
 and a high temperature, and is accompanied by more or less profound 
 bodily and mental alterations, lassitude, and general vital depression, ^he 
 significance of this curious monthly cycle, which is an inheritance from 
 our mammalian ancestry, and which finds its counterpart in the "heat" 
 of animals and the actual menstrual flow of the female monkey, is a dis- 
 puted question. As has been said, menstruation is accompanied by the 
 discharge of an ovum, and there is no reason to doubt that there is an 
 important relation between the two phenomena, and probably between 
 menstruation and pregnancy. According to one prominent theory, the 
 tearing loose of the lining of the uterine wall is for the purpose of pro- 
 viding a fresh surface to which the ovum, if impregnated in its passage 
 outward, can readily attach itself and there develop. An antagonistic 
 
160 PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 theory supposes the thickened uterine membrane to act as such a bed for 
 the ovum, and the shedding of the membrane to be a sign that the ovum 
 has not attached itself. Menstruation does not usually occur during preg- 
 nancy or nursing. 
 
 The spermatozoon (Fig. 40) is a curiously modified cell, consisting of 
 a flattened, egg-shaped head, a short, rodlike middle piece, and a long, 
 slender, delicately tapering tail. Its length is from 
 
 Spermatozoon. 
 
 TOT 
 
 to 
 
 •g-^- of an inch. 
 
 The tail is a locomotor organ 
 
 Fertilizaiio7i. 
 
 solely, and is capable of very active lashing movements, Avhich are suffi- 
 ciently powerful to propel the whole spermatozoon, when ])laced in liquid 
 or upon a moist membrane. This is essential to insure j ^ 
 
 the meeting of the two germ-cells. The spermatozoa are 
 produced in the testis along with some liquid ; the mix- 
 ture, together with liquid secreted by other glands con- 
 nected with the generative passages, constituting a thick, 
 whitish fluid, the semen. The semen is produced from 
 puberty until old age, and is stored in the testis, in its 
 duct, and in the seminal vesicles. 
 
 During sexual union the seminal fluid is transferred 
 from the body of the male to the vagina of the female, 
 whence the spermatozoa make their way 
 by their own movements through the 
 uterus and along the Fallopian tubes. Here they may 
 live for several days awaiting the discharge of an ovum. 
 If the Q2^^ appears, one spermatozoon bores its way into 
 it, the tail being left outside to die. The head of the 
 spermatozoon and the ovum fuse togetlier, the process 
 being called fertilization, and the development of the 
 new being is then ready to begin. Thus it is seen that 
 every individual begins his life as a single minute coll 
 within the body of the mother, which cell consists of 
 material substance derived partly from the body of the 
 father, partly from that of the mother. 
 
 The phenomena of embryonic growth that follow 
 fertilization are probably the most remarkable of all 
 vital phenomena, and are of surpassing interest. The 
 impregnated ovum divides into two cells, each of the two into two, 
 making four cells, the four into eight, the eight into sixteen, and so on 
 (Fig. 50), this process being called segmentation. At 
 the same time the segmenting q^^^^ passes along the 
 Fallopian tube and enters the uterus., or womb, which for the subsequent 
 nine months is to be the home of the future human being. The egg 
 attaches itself firmly to the uterine wall and becomes embedded in and 
 
 Fio. 49. — Human 
 
 PPEKMATOZOA. 
 
 (Mnprnified COO 
 diameters.) 
 1, flat view ; % 
 side view. Ay 
 liead ; />, mid- 
 dle piece; C, 
 tiiil ; J), termi- 
 nal filament 
 (From Flint, 
 after Landois.) 
 
 Groii'th. 
 
PHENOMENA OF EMBRYONIC GROWTH. 
 
 1«1 
 
 covered over by its liniiii^ inoni])ninc, wliicli In tlic rncantiiric lias Le- 
 corae congested witli blood, and lias grown rapidly, as before menstrua- 
 
 Placenta. 
 
 Fig. 50. — Segmentation of the egg of the rabbit. 
 a, two-celled stage ; ft, four-celled stage ; c, eight-celled stage ; d, e, further stages ; ect, cell destined 
 to give rise to ectoderm, or outer layer of embryonic cells; erd, cell destined to give rise to 
 endoderm, or inner cells ; zp, zona pellucida ; pgl, polar globules, or cast-off bits of nucleus. 
 (Much magnitied.) 
 
 tion. The number of cells in the young and delicate embryo increases; 
 the cells become differentiated in size, shape, and function, and form 
 the tissues and the organs. The embryonic heart begins to beat, by 
 degrees the human form is evolved, and the child is gradually prepared 
 for its entrance into the world. 
 
 Into the details of embryonic growth we can not here go. One 
 point we may refer to — that is, the anatomical and physiological con- 
 nection that exists between the infant and the mother. 
 The embryo, surrounded by fluid and by membranes, 
 develops within a cavity in the wall of the womb, and by its contin- 
 ued growth and increase in size the original cavity of the womb be- 
 comes practically obliterated (Fig. 51). The embryo, however, is free 
 from actual attachment to the maternal tissues except at one point — the 
 navel of the child is connected by the umbilical cord (Fig. 51) to a con- 
 siderable area of the uterine w^all, the attachment being i\\e placenta. The 
 placenta is the embryonic organ of nutrition — food reception, respira- 
 tion, and excretion. The embryo, inclosed as it is, is incapable of using 
 its alimentary canal, lungs, and organs of excretion, and hence all its 
 income and outgo must be carried on between its own blood and that 
 of its mother. The blood and the blood-vessels of the two are quite 
 distinct from each other ; the child has its OAvn intrinsic blood system. 
 But in addition to this the large umbilical artery passes from its body 
 along the umbilical cord, there to end in the placenta in thin-walled 
 13 
 
102 PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 tufts that penetrate into large spaces filled with the mother's blood. 
 The embryonic and the maternal blood are separated by a thin mem- 
 brane only, that allows ready diffusion of food, oxygen, caihonic acid, 
 and wastes. The embryonic blood is purified and refreshed at the ex- 
 
 FiG. 51. — Embryo within the uterus." (Diafrraminatic.) 
 c, embryo ; i, alimentary canal of embryo; r,p,m,m, various structures coinposinir the umbilical 
 cord; 17, //, (^,rt, placenta; ?«. a', y',,s-, membranes surroundinir embryo; », n, liniuir membrano 
 of uterus: at eacli side extends oft' a Fallopian tube, and below "is the neck of the uterus. 
 (Licgcois.) 
 
 pense of the mother, and is returned by the umbilical vein to the body 
 of the child. 
 
 The usual duration of pregnancy is about forty weeks. Toward its 
 close the presence of rhythmically repeated pains in the uterus heralds 
 the birth of the child. These pains of labour are 
 accompaniments of Avavelike contractions that pass 
 over the muscular uterine walls. With each succeeding contraction 
 the walls press clo.ser and closer upon the foetus, the opening of the 
 womb and the vagina relax, and the child is slowly and painfully 
 forced upon the world. The first breath is drawn into the lungs, and 
 the infant announces its arrival by cries of distress. The umbilical 
 cord is tied and cut ; a few minutes after birth the placenta is expelled ; 
 and after this the wounded uterus gradually heals. 
 
 Birth. 
 
PHYSIOLOGICAL LIFE OF THE INDIVIDUAL. If,?, 
 
 Usually for some tiino after birth the child continues to depend upon 
 
 the mother for its sustenance. During pregnancy the mammary glands 
 
 ,,.„ of the mother, which form the breasts, increase in size 
 
 MtUc. , . „ . , 11.,. 
 
 and m tunctional power, and at the time of Ijirth they 
 
 are capable of secreting tlie milk that the child requires. Human milk i« 
 essentially not unlike the milk of other female animals. It contains, how- 
 ever, somewhat more sugar, and is more watery than cow's milk. 
 
 We can not bring this chapter to a close more fittingly than by a brief 
 review of the physiological life of the individual and a reference to some 
 
 ^ . . of its more special features. A lifetime may be di- 
 
 Individual. vided roughly into three periods : those of youth, of 
 middle life, and of old age. Youth is the period 
 of growth, middle life that of maturity, and old age that of de- 
 cline. A sharp distinction between these three is, however, impossible ; 
 the coming of age of the individual at twenty-one years is a convenient 
 legal fact, but not a principle of nature. Growth in height may con- 
 tinue until about twenty-five years of age, and after fifty years a dimi- 
 nution of stature may follow. Weight may continue to increase until 
 forty years, and after sixty years it may decrease. From about ten to 
 fifteen years of age girls grow more rapidly than boys, the year of most ac- 
 tive growth in girls being, in Europe and the United States, the thirteenth. 
 After the fifteenth year boys surpass girls in rate of growth, their most 
 active year being the sixteenth. Girls reach puberty before boys, and 
 attain their complete growth at an age three or four years younger than 
 boys. The metabolism during the period of youth is of necessity largely 
 constructive, during middle life the constructive and destructive phases 
 balance each other, and in old age destructive metabolism, with possible 
 fatty or calcareous degeneration of tissues, becomes more prominent. In 
 comparison with the young of most other animals, the human infant 
 comes into the world very immature and helpless. Hence the period of 
 youth is largely devoted to a perfecting of the various functions, and es- 
 pecially to the forming of associations and the laying out of paths of 
 greater and less resistance within the central nervous system — in a word, 
 to the formation of habits. Many functions vary in their activity peri- 
 odically. As examples of such variations may be mentioned the common 
 increase of weight in winter and decrease in summer, the monthly men- 
 strual flow, a regular daily variation in temperature, such that the highest 
 temperature occurs between 9 a. m. and 6 p. m., the lowest between 
 11 p. M. and 3 a. m., and a similar daily variation in the pulse rate 
 and in the rate and depth of respiration. 
 
 Of all the daily rhythms, the alternation of sleep and waking is the 
 most striking. Sleep is, in brief, a profound depression of the activities 
 
UU PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 of the eentnil nervous system. The ninscnlar reflexes, the activities of 
 the sense-organs, respiration, secretion by the glands, and g-eneral ineta- 
 bohsni are all depressed, perhaps as the resnlt of the cen- 
 . tral de})ression ; bnt the absence of consciousness — that 
 
 is, the depression of the activities of the psychic cells — is the most pro- 
 nounced feature of sleep. That the psychic activity is not always wliolly 
 eliminated is evidenced by the occurrence of dreams, but the fragmentary 
 and grotes(|ue character of dreams indicates that i)ut a few brain-cells 
 are engaged in their production. The reason for this poi-iodic depression 
 of brain activity has been long sought, bnt with little success. Perhaps 
 the accumulation within the body of the waste products of protoplasmic 
 activity causes a temporary paralysis of the brain-cells, lasting until the 
 wastes are removed. However this may be, the amount of blood in the 
 brain is probably considerably less during the sleeping than during the 
 waking hours, and this may of itself cause cerebral depression. 
 
 Sooner or later, even if disease and accident are safely overcome, the 
 vital machine is doomed to wear out, and death follows. Physiologists 
 recognise two kinds of death : death of the individual 
 and death of the tissues. The individual dies when the 
 heart ceases to beat and to supply the whole body with food and oxygen. 
 But the individual tissues vary very greatly in the time of their death. 
 The nervous tissues die almost immediately, but the muscles are capable 
 of contraction upon artificial stimulation for a considerable time after the 
 thinking man has forever ceased his activities. Probably not for several 
 hours do all the chemical changes take place within the protoplasm that 
 are the evidence of the passing away of that mysterious, unexplained 
 condition that we are wont to call life. 
 
 niAPTEP YI. 
 HEREDITY. 
 
 In the vast world of life nothing seems more marvellous than the fact 
 of inheritance. Like produces like ; a child reseml)les its parents. 
 
 This fact is easily comprehensible in the one-celled organisms, where 
 
 the parent cell, after a period of activity, puts an end to its individuality 
 
 by an equal division of its whole body into two similar 
 
 Inheritance a ii • i . i • • i i. t> j. • i.T i. • -u j 
 
 B' 1 ' IF t offspring, and notlnng is lost. Jhit m tlie higher and 
 
 larger animals, composed of countless millions of cells 
 that are specialized in a great variety of ways, the vital material con- 
 tributed by the parents consists solely of the two microscopic germ cells, 
 
INHERITANCE A BIOLOGICAL FACT. 105 
 
 and from tliis inlinitcsiinal beginnliii^ tlicro comes an organism that 
 
 resembles, often in minute and unimportant details, the ])arent8, the 
 
 grandparents, and even remote ancestors, and that does not resemble 
 
 other races. Here, if anywhere in our search after natural causes of 
 
 things, it seems necessary to bring into causal relation the supernatural, 
 
 and to hide our helplessness in an assumption of some mysterious guiding 
 
 force that is distinct from vital matter and that we know not of. Truly, 
 
 we know little of natural law, but the restless scientific spirit of man is 
 
 ill content wnth a supernatural explanation of heredity. Inheritance is a 
 
 biological fact, and must be explained in accordance with biological laws. 
 
 Before proceeding, however, to the explanation, let us review in some 
 
 detail the facts that must be explained. We have said that like produces 
 
 like. This statement must be accepted with certain 
 Facts of . . . ... 
 
 J h -f ' modifications. Obviously, no two individuals are like 
 
 each other in all points ; twins, indeed, may be " as like 
 as two peas," and yet one is not the mirrored image of the other. As a 
 general law, a child resembles its parents more closely than it resembles 
 any other individual. Between its parents, the resemblance is in some 
 cases more strongly in favour of the father, in other cases in favour of 
 the mother ; in still others, both paternal and maternal characteristics 
 seem to be present in approximately equal proportions ; rarely is the 
 child " the exact image " of either parent. At times, however, the off- 
 spring seems to possess almost or quite none of the parental qualities, but 
 to show likeness to grandparents or great-grandparents, either as regards 
 general or as regards particular features or qualities. The reappearance 
 of an ancestral quality thus, after having lapsed in one or more genera- 
 tions, is called atavism or reversion, and the subject forms one of the in- 
 teresting chapters in the story of heredity. Lastly, in rare cases a child 
 seems to be a veritable " black sheep," and to possess no qualities what- 
 ever that ally it to its progenitors. In speaking of inherited resemblances, 
 we do not mean to confine ourselves to mere anatomical matters ; likeness 
 of feature, of form, of size, of structure, is most obvious, and is the kind 
 of resemblance most commonly sought for. But likeness in things 
 physiological and things psychological, in the mode of working of the 
 body and of the mind, in things moral, in peculiarities of temperament, 
 is as common, if not so readily perceived. In fact it is difficult, if not 
 quite impossible, to draw the line between features and qualities of the 
 parent that are heritable and those that are not so. 
 
 The question of the inheritance of disease has been much debated. It 
 seems to be a fact that the germs of certain infectious diseases, such as 
 syphilis, may be conveyed to the child's organism within the parent's germ 
 cells, or even directly from the mother's body to the growing embryo. 
 It seems also probable that predisposition to certain diseases, in the form 
 
lOG PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 of constitutional weaknes^s and diuiinished power of resistance to the dis- 
 ease germs, is lieritable. Probably the apparent transmission of con- 
 sumption is thus to be explained. Inherited predispo- 
 
 " '''^' """^ ^^ sition and the fact that the child is usually brought ui) 
 Diseases. . . . , 
 
 in the liome of its consumptive parents, with every 
 
 opportunity of acquiring the very germ that it can not successfully resist, 
 are probably responsible for many attacks of this fatal malady. Predis- 
 position to nervous diseases, to insanit}', to suicide, and to crime, are 
 certainly transmissible. 
 
 A second much-debated question is that as to whether new character- 
 istics acquired by a parent may be transmitted to his child. To the mind 
 
 of the layman, and at first thought the question seems 
 Inheritance of Ac- r. r . i . i • i i • 
 
 . , „, • supernuous, lor apparently tliere are innumerable m- 
 
 qnired Characters, ' ' . . i <v. • 
 
 stances of such transmission about us — the amrmative 
 
 side of the question goes without saying. But when we examine the evi- 
 dence carefully we are surprised at its inconclusiveness. In one case the 
 peculiarity is found, after all, to be not one acquired by the parent, but one 
 j)0ssessed also by other ancestors — to be inherent in the race ; in anotlier 
 case, what is inherited may easily be a tendency, a strength or weakness 
 of mind or character, that with a suitable environment may show in the 
 child in the same striking manner as in the parent, and yet that is in no 
 sense an inheritance of anything acquired by the parent — such, for ex- 
 ample, as a taste for strong drink ; in another case, the parent's peculiarity 
 may prove, upon examination, to have been obtained subsequent to the 
 birth of the child ! And thus, one by one, innumerable cases of seeming 
 inheritance of acquired characters have been disproved. Experimental 
 investigation has proved equally inconclusive. For centuries the Chinese 
 have compressed and distorted the feet of their girls ; yet the feet of 
 Chinese girls born at the present time are apparently not different from 
 those of a generation a thousand years ago. Numerous researches made 
 in recent years upon the dehorning of cattle and the removal of the tails 
 of mice for a long series of generations have resulted in no reduction of 
 the horns in the one case or of the tails in the other. IJence, though 
 there are still many seeming arguments in favour of use and disuse as 
 important factors in evolution and in heredity, there are many persons 
 that exclude these utterly from their creed, and so the matter of the 
 inheritance of acquired characters must be left for the present undecided. 
 In view of the above facts it seems idle, and it is certainly misleading, 
 to talk of the equality of men, for Xature has established classes that are 
 much more firmly ordained than are tlios^ of society. 
 i J I ^ 'J • rpjjg environment of the child and the man has much to 
 do with what the individual accomplishes in the world, but the environ- 
 ment works upon material that already is nujuldt'd in great part by past 
 
THEORIES OF HEREDITY. 107 
 
 generations. Tlie inherited qualities of one person place hirn at once 
 well in advance in the struggle for existence ; those of another too often 
 prove a serious handicap. Heredity is a powerful factor in human 
 progress. It is to be hoped that a greater knowledge of its facts and 
 principles will gradually modify existing educational systems for tlie 
 young and penal systems for criminals. 
 
 How, now, may the above facts of inheritance be explained ? Leav- 
 ing aside all metaphysical and theological theories as unbiological and 
 
 inadequate, we must start with the belief, incredible as 
 Germ-plasm. ,, ,i , ,i i •. e , i .-, , 
 
 it may seem, that the bits oi protoplasm that constitute 
 
 the ovum and the spermatozoon contain within themselves in some form 
 the qualities of the mother and the father respectively, and to some ex- 
 tent of more distant progenitoi's. Probably we can go even further than 
 this, for there is much evidence that the real carrier of the hereditary 
 qualities, the germ-plasm, is confined to the nuclei alone of the two germ 
 cells. We have already seen that the tail of the spermatozoon is a loco- 
 motor organ, and dies after conveying the head to the ovum ; the head 
 consists chiefly of nucleus, and it alone enters the egg. Likewise, within 
 the ovum the mass of egg substance seems to subserve nutritive and other 
 purposes, while the nucleus alone is probably essentially hereditarj'. The 
 fusion of the spermatozoon and the ovum is a fusion of their nuclei, and 
 the segmentation of the egg is primarily a nuclear phenomenon. 
 
 But how is it possible for the minute germ-plasm to obtain and to hold 
 the parental qualities ? This problem has been the subject of much spec- 
 ulation, especially since the writings of Darwin set men 
 Darivin's Theory , ,1 • i • n ,^' • • £ • j -i, -l ■ 
 
 ^ D .to thinking; 01 the oriffin 01 species and the mechanism 
 
 of Pangenesis. » _ » ^ _ 
 
 of descent. In his book entitled The Yariation of 
 Animals and Plants under Domestication, published in 1868, Darwin 
 gave to the world his own hypothesis of inheritance in a chapter entitled 
 Provisional Hypothesis of Pangenesis. In brief, this theory supposes 
 that all parts of the body are giving off at all times excessively minute 
 particles, the germs of the various cells, or gemmules, as Darwin called 
 them ; these pass into the circulating blood, are carried to the repro- 
 ductive organs, and become a part of the germ cells. Hence ev^ery germ 
 cell is a mass of germs of the body eells of the parent, together with 
 some gemmules of more remote ancestors, and hence the fertilized ovum 
 contains the potentialities of the image of either parent and of some more 
 ancient ancestral characteristics. Darwin's gemmules are somewhat of 
 the nature of Herbert Spencer's hypothetical '" physiological units," which, 
 before Darwin wrote, were used by Spencer to explain heredity. Dar- 
 win's hypothesis allows the transmission of characteristics that are ac- 
 quired by the parent ; for an alteration of any part by use, disuse, loss, or 
 injury might cause altered gemmules to go to the germ cells, and the 
 
lOS PHYSIOLOGY : THE VITAL PROCESSES IN HEALTH. 
 
 child might then show in the corresponding part of his body the eil'ects 
 of use, disuse, loss, or injury in the parent. Darwin's theory is purely 
 6]ieculative. Xeither he nor later biologists have known, as an observed 
 fact, any such giving off of germinal units as he assumes. The theory 
 has not been generally accepted ; for, apart from the inconceivability of 
 the presence of so vast a number of germs within a single minute cell, 
 many facts render it improbable. But it has served a useful purpose, as 
 doubtless Darwin intended it should serve, in stimulating thought and 
 investigation. 
 
 Since the appearance of Darwin's provisional hypothesis a large lit- 
 erature upon heredity has appeared, and several theories have been pro- 
 posed. Some of these follow Darwin and attempt to 
 Weismann's Theory. i t i • i • ^ ^- ^i x- j 
 
 supply lacks in his explanation ; others are lar removed 
 
 from his speculations. AVe have here space to mention but one of these, 
 which has attracted wider attention than any other, and which has been 
 the subject of widespread and earnest discussion. This is the theory of 
 Prof. AVeismann, of the German University of Freiburg, who since 1881 
 has published several volumes of essays upon this and kindred subjects. 
 Weismann is a careful and conscientious thinker. His theory has been de- 
 veloped gradually, and, as the significance of his main conceptions has 
 broadened with continued thought and investigation, his later writings 
 contain modifications of his earlier views. 
 
 The nucleus of Weismann's theory is expressed by his own phrase, 
 " the continuity of the genn-jplasitiy This phrase means that, according 
 
 to his idea, the germinal or hereditary substance that is 
 The. Continiiitii of , • ii ^i , •• j> • t 
 
 ,, / present m the ovum or the spermatozoon oi any indi- 
 
 Orerm-plasni. ^ . 
 
 vidual, whether man, lower animal, or plant, has come 
 directly from the germinal substance of the parent of the individual ; that 
 the germinal substance of the parent likewise has come directly from 
 that of the parent's parent ; that the germinal substance of any individual 
 may bo traced through parent, grandparent, great-grandparent, and so 
 Imckward to the remotest ancestors ; that, in a word, germinal substance, 
 arising far back in the lowly and primitive predecessors of existing 
 organisms, has been and is continuous in each line of descent throughout 
 all generations. Hence, germinal substairce does not arise de novo i it 
 does not originate M'ithin a body by the concourse of multitudinous 
 minute "gemmules" that are given off from all parts of the body, but it 
 is derived solely from pre-existing germinal substance ; in this sense all 
 individuals are powerfully and equally " blue-blooded." Every individual, 
 therefore, begins life as a minute mass of germ-plasm, that consists partly 
 of male germ-plasm and partly of female germ-plasm, and- that in the 
 case of the human being is destined to grow and develop into the child 
 within the mother's womb. As growth and development go on, much of 
 
WEISMANN'S THEORY. 1(59 
 
 the germ-plasm differentiates, and produces tlie various cells, tissues, and 
 organs of the child's body. A small portion, however, remains undiffer- 
 entiated, and takes up its residence in the essential i-eproductive organ of 
 the child — in the ovary, if the child be a girl, in the testis if a boy ; and 
 this undifferentiated residue which, as has been seen, has come directly 
 from the parents, is the germ of the future progeny of the child. 
 
 Hence, according to Weismann's theory, the body of every individual 
 consists of two kinds of protoplasm, viz., genn-jjlasra, or hereditary sub- 
 stance, which in its undifferentiated form resides within 
 Qerm-plasm and ^/ ^ . , -, . i • , i i • , • 
 
 Som to I sm essential reproductive organ, and is the derivative 
 
 of past and the progenitor of future races ; and ?jody- 
 plasm, or sotnaioplasm, which is the protoplasm of the rest of the body, 
 the muscles, the glands, the heart, and the brain. The latter serves the 
 daily needs of the individual and dies when the individual dies. The 
 former subserves reproduction alone ; if the individual reproduces its 
 kind, some of the germ-plasm is passed on to the descendant ; if the indi- 
 vidual does not reproduce, the germ-plasm dies with him, and that par- 
 ticular line of descent is forever ended. 
 
 Thus far Weismann's theory seems readily comprehensible and reason- 
 able. But let us carry it, as its author does, a little farther. What relation 
 
 within an individual body do these two kinds of proto- 
 
 e a ton of plasm — the germ-plasm and the somatoplasm — bear to 
 Germ-plasm ana i i a -r-w i • i m ^ 
 
 Somatoplasm each other « Do changes m the one necessarily affect 
 
 the other ? Weisinann believes that the two are quite 
 independent of and distinct from each other. They are nourished by the 
 same nutrient blood and lymph, it is true, and any general alteration of 
 the nutrient fluids alters the nutrition of the two alike ; but this is of 
 comparative unimportance. The important consideration is that any 
 alteration of a particular part of the body-protoplasm does not affect the 
 germ-plasm ; in the origin of the latter from the parent's germ-plasm 
 instead of from the individual's own somatoplasm, and in the absence of 
 gemmules passing constantly from somatoplasm to germ-plasm, the latter 
 can not reflect the condition of the former. Hence, the loss of a limb by 
 accident, the gain of strength in particular muscles by athletic exercise, 
 the acquisition of an art, like piano-plajang, which consists of delicate 
 and intricate muscular and nervous adjustments, the long-continued 
 mental development of the man or the woman which carries with it 
 molecular adjustments of brain substance, the practice of a trade or pro- 
 fession which develops abnormally certain organs, or tissues, or cells, and 
 allows other organs, tissues, or cells to degenerate — all these affect the 
 germ-plasm in no wise, and can not be transmitted to the descendants of 
 the individual. Characteristics acquired by the parent are, therefore, not 
 inherited by the child. The noti-inheritance of acq^ured characters is 
 
170 PHYSIOLOGY: THE VITAL PROCESSES IN HEALTH. 
 
 the second finuhunental })OStulato of Wcisinaiin's theory, and is to be 
 placed beside that of the continuity of germ-phisni. 
 
 Wh}', then, are not all children alike mentally, morally, and physi- 
 cally ? From a common origin in the early history of organic beings, 
 with a descent through numberless generations by a 
 continuity of germ-plasm that leads a charmed life of a 
 certain degree of independence of environmental changes, how is varia- 
 tion possible, and how may the differences of individuals and of races be 
 accounted for ? In the first place, germ-plasm is not wholly independent 
 of environmental changes. It is capable of, and is constantly undergoing, 
 alteration as the result of general nutritional alterations taking ])lace in 
 the body in which it is housed. The germ-plasm of one line of descent 
 must therefore necessarily differ somewhat from that of another line of 
 descent, since the environment of the one differs from that of the other. 
 In the second place — and here we have the chief source of variation — the 
 individual is the result of a fusion of two varieties of germ-plasm, that of 
 the father and that of the mother, each with a history and capabilities 
 differing from those of the other. Therefore the resultant organism, 
 while possessing ancestral qualities, must possess them in a combination 
 that has never before existed ; it must differ from any organism that has 
 preceded it; and hence it follows that no two individuals, or two speciesj, 
 or two races can be alike. 
 
 These, then, are the elements of AVeismann's theory : continuity of 
 germ-plasm and non-inheritance of acquired characters tending to pre- 
 serve the uniformity of the i*ace ; slight germinal changes and sexual re- 
 production tending to destroy that uniformity.* During the past ten years 
 and more the theory in its manifold details has been fought over with 
 great vigour by its friends and its foes. The contest has been especially 
 warm over the question of the inheritance of acquired characters. 
 
 We have thus touched very incompletely upon some of the principles 
 and problems and attempted explanations of the mystery of inheritance. 
 To the scientist a mystery is always inviting, and to the modern biologist 
 that of heredity is especially so. What is needed most is careful, truth- 
 ful observation and recording of the facts that are all about us, and well- 
 directed, painstaking and unprejudiced physiological experimentation as 
 to hereditary possibilities. ])arwin, Galton, AVeismann, and others have 
 done nnich of the former service; the latter belongs largely to the science 
 of the future. 
 
 * Esmys upon IleredUy and Kindred Biological Problems. By August Weismann. 
 Authorized translation. Vol, I, 1889; Vol. II, 1892. Oxford, The Clarendon Press. 
 
 The Germ-plasm : A Theory of Heredity. By August Weismann. Authorized trans- 
 lation. ISO'S. New York, Charles Scribner's Sons. 
 
III. 
 
 OUTLINES OF PSYCHOLOGY, 
 OE A STUDY OF THE HUMAN MIND. 
 
 By JOSIAII ROYCE, Ph.D. 
 BIBLIOGRAPHY. 
 
 Of standard general treatises on psychology, the reader may Ije re- 
 ferred to the following, which are selected from the great number of 
 modern books : 
 
 Bain. The Senses and the Intellect^ and The Emotions and the Will, 
 
 2 vols. 
 vSpencer. The Principles of Psychology, ^ \o\?,. 
 WuNDT. Lectures on Psychology. 
 James, William. Psychology. Longer course in two volumes, shorter 
 
 course in one volume. 
 Baldwin, James Makk. Ha^idhooh of Psychology, 2 vols. 
 Sully, James. The Human Mind, 2 vols. 
 Sully, James. Outlines of Psychology, 1 vol. 
 Ladd. Physiological Psychology, 1 vol. 
 Ladd. Psychology, Descriptive and Explanatory, 1 vol. 
 
 On the methods to be pursued by the psychologist there is a German 
 treatise, written from the modern point of view, by Prof. Hugo Miinster- 
 berg, entitled Aufgahen und Methoden der Experimentellen Psychologie. 
 The principal modern German treatise on psychology is the Physiolo- 
 gische Psychologie of Wundt, in two volumes. 
 
 PSYCHOLOGY. 
 
 § 1. The purpose of the following sketch is twofold. For the first, 
 the reader is to be introduced, in a very general way, to the study of the 
 human mind. For the rest, this account will give also incidental sug- 
 gestions regarding the practical applications of such study to the problems 
 of the estimate and the guidance of minds in health and in disease. The 
 necessarily limited space will forbid any but the most summary statements. 
 
 171 
 
172 OUTLINES OF PSYCHOLOGY. 
 
 I. INTRODUCTORY DEFINITIONS AND EXPLANATIONS. 
 
 § 2. Psyeliology, in a general way, lias the same sort of relation to the 
 functions of the human mind that physiology has to the functions of the 
 human body. Psychology is, namely, the doctrine which 
 ■ ■ attempts to describe and, as far as possible, to explain 
 our mental life. And by our mental life, as opposed to our physical life, 
 we mean a certain collection of states and of processes with which, from 
 moment to moment, each one of us is, in his own case, very directly or 
 immediately acquainted, while, on the other hand, it is impossible that 
 any one else besides the original observer, whose mental life tliis is, should 
 ever get this immediate sort of acquaintance with just this collection of 
 states and processes. Herein, then, lies the essential characteristic of our 
 mental life. Others may learn, from observing our acts and our words, 
 a great deal ahout this our own mental life ; but each one of us is the 
 only being capable of becoming directly aware of his own mental states. 
 On the other hand, however, our physical life, in its ex- 
 ternal manifestations, may be observed by any one who 
 gets the opportunity. And thus the fact that the mental life of each one 
 of us can be directly present, as a series of experienced facts, to one person 
 only, may well be used as a means of defining the difference between our 
 physical and our mental life. Thus physical facts are usually conceived 
 as "' public property," patent to all properly equipped observers. All 
 such observers, according to our customary view, see the same physical 
 facts. But psychical facts are essentially "private property," existent for 
 one alone. This constitutes the very conception of the difference between 
 ''inner" psychical or mental and physical or "outer" facts — a conception 
 behind which, in the following discussion, we shall not seek to go. 
 
 § 3. It is this fundamental difference that leads us often to speak of 
 the mental as the " internal life " or the " inner world," and to oppose it 
 both to our own physical life and to the "external physical world." This 
 way of expressing the distinction between mental facts and all others is 
 fairly good, but must be carefully guarded against misinterpretation. The 
 physiological processes of our bodies are physical, but are indeed also 
 often viewed as " internal," since they go on w^ithin our bodies, and are 
 in general mainly hidden from direct external observation. But our 
 mental life is " internal " in quite a diffei-ent sense. Digestion, circulation, 
 and the changes of our tissues are processes which are actually altogether 
 liidden from many forms of outer observation, and which, at best, can 
 only be observed very partially, and for the most part very indii-ectly, by 
 observers Avho view us from without. But, on the other hand, these pro- 
 cesses, in case of each one of us, are also very ill known to us ourselves, 
 and are in large part not even indirectly represented by any of our own 
 
GENERAL DEFINITIONS. 173 
 
 conscious mental states. So tliat, when we speak of onr pliysiolopical 
 processes as internal, the word "internal," although it here generally im- 
 plies " hidden, in whole or in part, from actual outer observation," does 
 not imply " directly felt by us ourselves." But when we speak of a pain 
 as an "inner" mental fact, we mean tiiat while nobody but tlie sufferer 
 can possibly get any direct acquaintance with its presence, the sufferer 
 himself can do so, and is aware of the pain. Furthermore, the fact that 
 other observers cannot directly watch our iimer physiological processes, 
 is itself something relatively accidental, dependent upon the limitations of 
 the sense organs, or upon the defective instrumental devices of those who 
 watch us. But the fact that our mental states are incapable of observation 
 
 by anybody but ourselves seems to be not an accidental. 
 
 An Essential Char- ^^^ ^^ essential character of these mental states. Were 
 
 States physiologists better endowed wuth sense-organs and with 
 
 instruments of exact observation, we can, if we choose, 
 conceive them as, by some now unknown device, coming to watch the very 
 molecules of our brains ; but we cannot conceive them, in any possible 
 case, as observing from without our pains or our thoughts in the sense in 
 which physical facts are observable. Were my body as transparent as 
 crystal, or could all my internal physical functions be viewed and studied 
 as easily as one now observes a few small particles eddying in a glass of 
 nearly clear water, my mental states could not even then be seen floating 
 in my brain. ISTo microscope could conceivably reveal them. To me 
 alone would these states be known. And I should not see them from 
 without; I should simply y^e^ them, or l)e aware of them. And what it 
 is to feel, or to be aware, I alone can tell myself. 
 
 § 4. Mental life has thus been defined by pointing out its contrast 
 with all that is physical. !Now, psychology is to undertake the study of 
 
 mental life for the sake of trying to describe and, in a 
 „ p , , measure, to explain its facts. But this undertaking 
 
 may, for the first, appear to be quite hopeless. How 
 can one describe, with any sort of accuracy, where the facts to be described 
 are in any case open to the inspection of one observer only ? Successful 
 description, made with any scientific purpose, seems to involve the possi- 
 bility of comparing together the various attempts at description made by 
 different observers in view of the same facts. When astronomers observe 
 celestial objects, they compare the results of the various observations of 
 different astronomers. In the multitude of trained observers, occupying, 
 upon occasion, widely different positions on the earth's surface, but all 
 looking at the same heavenly bodies, the possibility of the growth of as- 
 tronomical science seems to depend. How, then, shall psychology progress 
 if, in our various mental lives, no two observers can ever take note of 
 precisely the same facts ? Is it not as if there were as many real moons 
 
174 OUTLINES OF PSYCHOLOGY. 
 
 as there are astronomers observing the heavens, and a different real moon 
 
 for each astronomer, which nobody but himself could ever see i In such 
 
 a case one may ask, AVhat would become of astronomy ? 
 
 iJ 5. AVithout in the least going into the extended and interesting 
 
 philosophical problems suggested by these questions, it is enough here to 
 
 point out at once that, while no two persons among us 
 
 „ '^" can ever observe the same series of mental facts and 
 
 Uxpression. 
 
 processes, psychological study is nevertheless made 
 possible by the fact (a fact of the most fundamental importance) that 
 we all of us not only have our mental states, i)ut also a})pear to ff/'ve theise 
 menial states a physical expn'ssiofi in certain bodily acts — viz., in what 
 may be called our expressive functions. The mental states themselves 
 each one of us observes for himself alone. Their physical expression is 
 something that, like any other physical fact, is patent to all observers. 
 Now, anyone of us can often observe for himself what sort of physical 
 expression some given sort of mental states gets in his own case. Thus 
 one can sometimes observe how, by cries or by groans, he himself gives 
 expression to his own pain ; or how, by appropriate bodily attitudes, he 
 expresses the mental states of attentive interest which we call " looking," 
 '' listening," " watching," and the like ; or, finally, how he adapts the 
 familiar words of his mother tongue to the expression of multitudinous 
 inner moods, and other personal experiences, for many of which, in fact, 
 we have no definite and conscious bodily expression at our voluntary dis- 
 posal except such words as chance to occur to us as appropriate at the 
 moment when these states are passing. Cries, groans, sighs, tears, 
 gestures, attitudes, words, and other far less easily observable expressions — 
 some voluntary, some involuntary — are thus found to accompany our men- 
 tal processes. But all these expressive movements are themselves facts 
 in the physical world, and are, as such, matters both for common observa- 
 tion and for exact scientific scrutiny. Most of these expressiv^e acts 
 show marked similarity, either in several, in many, or in all men. And 
 meanwhile, what states in each one of us they express, the individual ob- 
 server experiences for himself. In attempting to describe our mental 
 experiences to one another we therefore constantly make use of the names 
 of familiar expressive functions, such as laughter, weeping, and the like. 
 Some of our expressive acts, like the ones just named, viewed apart from 
 their names, are of instinctive origin and are only partially under the in- 
 fiuence of conventions. Other expressive acts, like the use of the woi'ds 
 of our mother tongue to embody or to describe our mental states, are of 
 purely conventional origin, and have only become moulded by slow de- 
 grees to a certain sort of uniformity as regards their relation to similar 
 mental states in many people. Whether one person means by the word 
 " love " a state very closely similar to the state that another person means 
 
PHYSICAL RELATIONS OF MIND. 175 
 
 bj the same word may be, and often is, a very diflicult question to de- 
 cide. Yet the use of the words of our common mother tongue to express 
 our mental states, guided as this use has been since childhood by tlie 
 effort to conform our expressions to tlie comprehension of our felkjws, is 
 often brought to a point which enables us to be decidedly sure that the 
 states which many people agree in describing in given words are them- 
 selves in pretty close agreement. With some caution, the same may be 
 regarded as true, within limits, as to the states described in various lan- 
 guages by parallel words and phrases. While we are then unable to 
 make our mental states objects of common observation, in the sense in 
 which the astronomers are said to observe the same star, we nevertheless 
 can observe in common our natural and conventional, our simple and 
 complex, our voluntary and involuntary, our more subtle and our less 
 subtle motor expressions of our mental states, whether in our outward 
 deeds or in the permanent products of these deeds (as in works of skilful 
 art), or in our words, or in our momentary gestures, or, finally, in our 
 established habits of behaviour. The inner meaning of such expressions 
 each of us can, by more or less attentive scrutiny, discover for himself. 
 Their agreement in many persons enables mental facts, pi'ivate though 
 they be, to be indirectly submitted to a comparative study in many peo- 
 ple, and to some sort of generalisation, classification, and even explana- 
 tion. 
 
 § 6. AYliile this outward physical expression, which our mental life 
 gets, makes psychology, as a comparative and more or less scientific study 
 of mind, possible, our study itself is very greatly aided by a further con- 
 sideration — viz., that we not only express our minds through our move- 
 ments, but seem to ourselves to be dependent^ for at least very much of 
 our mental life, upon more or less definable physical conditions, which 
 we recognise, even apart from any special study, as mat- 
 
 ysica ^gj.g y^eW known in daily life, and as matters which we 
 
 Conditions. ^ "^ . 
 
 can study in common. Thus the private mental con- 
 dition is noticed by its one observer to vary with the presence or absence 
 of physical facts that he and his fellows can observe together. That one 
 cannot see in the dark, that one feels cold at a time when the ther- 
 mometer reveals the physical fact of a low temperature, that violent 
 physical exercise makes one weary — these are facts which have, at the 
 very same time, their psychical aspect manifest to one observer, and 
 their physical aspect manifest to all observers. A more scientific study, 
 moreover, shows us that not merely some, but all of our mental states vary 
 with physical conditions of one sort or another. IS^ow, this sort of union 
 of the public and the private, of the genei'ally accessible and of the purely 
 individual, gives us many means for indirectly comparing and classifying 
 mental facts and for studying their conditions in various people. 
 
170 OUTLINES OF PSYCHOLOGY. 
 
 § 7. But both the expres.^ive movements and the physical conditions 
 thus far mentioned prove, upon closer examination, to have a character as 
 
 plivsical processes that makes them still further the top- 
 
 The Nervous • j? • ^-ii ^- x . 
 
 „ , ics 01 a scientmc scrutiny : tor we possess, as a most 
 
 System. . ^ • ■, 
 
 important part ot our physical structure, oiir net'vous 
 
 systeins. And it may be sh(_)\vn that the expressive ])hysieal functions 
 (acts, gestures, words, habits, etc.) in wliich our mental life gets its ont- 
 ward representation and embodinient are all of them, as ]ihysical events, 
 determined hi/ physiological ^processea t/iat occur in our nervous systems. 
 In other words, the functions of tlie nervous system, Avhile they include 
 many other processes as well, still also include, as a portion of themselves, 
 precisely those functions by which, from moment to moment, our mental 
 states get expressed. Thus the scientitic stud}- of our expressive func- 
 tions becomes linked to the general study of nervous physiology. On the 
 other hand, however, those numerous physical conditions, both without 
 and within our bodies, which have been mentioned as appearing to de- 
 termine in some way our mental states, prove to be conditions that are 
 effective in so far as they at the same time physically influence our 
 nervous systems. Thus in two ways the scientiiic study of mental life 
 may get aid from the study of the nervous system. 
 
 § 8. Now, the physical functions of the nervous system are capable of 
 a very extended comparative and experimental investigation. Those of 
 the nervous functions wliich are not closely related (as apparent conditions 
 or as expressions) to our mental processes appear, in the light of such study, 
 to differ from those nervous functions which are so related, chiefly in respect 
 of the relative simplicity of the nervous functions which are not thus 
 closely related to the mind, when compared with the relative complexity 
 of those nervous functions which are more intimately related to mental pro- 
 cesses. But no one easily definable dividing line appears between the 
 two, except the familiar fact that the nervous functions most closely re- 
 lated to our mental life are localised, so far as concerns their central sta- 
 tions, in the cortex or grey matter at tlie external 
 surface of the brain, while the nervous functions that 
 liave no discoverable mental accompaniment are, for the most part, di- 
 rected from centres placed below the level of this brain cortex. Other- 
 wise, as we shall see from time to time hereafter, it is hard to prove any 
 essential difference in kind between the physical functions whose nervous 
 conditions are centred in the cortex and those which are centred lower 
 down. The higher functions are, indeed, often vastly the more complex. 
 They change much more during life, and under the influence of our ex- 
 perience, than do our lower nervous functions. They show more signs 
 of what is often called " spontaneity " — that is, of a certain relative 
 (although never complete) independence of the present external physical 
 
METHODS OF PSYCHOLOGY. 177 
 
 surroundings in which our body chunccs to Ix; |>l;u;cd. J>ijt. tlicise, althougli 
 large ditlerences, are differences of degree. J'*liysically speaking, and 
 despite vast differences in detail, the same general or fundatnental types, 
 both of structure and of function, are observable, both high up and low 
 down in the nervous centres. 
 
 § 9. Yet one must insist that the study of neurological facts lias. 
 
 although very great, still only relative value for the psychologist. For 
 
 one thing, what the psychologist wants to understand is 
 
 ^ZwZ^ical Study. "^^^^^^^ 1^^"®' ^"^ *« *^/« ^^^ ^^^ "«es all his other facts 
 only as means; and for the rest, any physical expres- 
 sion of mental life which we can learn to interpret becomes as genuinely 
 interesting to the psychologist as does a bi-ain function. A pyramid or 
 a flint hatchet, a poem or a dance, a game or a war, a cry or a nest, the 
 nursery play of a child or the behaviour of an insane person, may be a 
 physical expression of mental life such as the appreciative psychologist 
 can both observe and more or less fullj^ comprehend. The study of such 
 facts, and of their physical causes and results, throws light both upon 
 what goes on in minds and upon the place which minds occupy in the 
 natural world. To be a student of psychology thus involves three essen- 
 tial things : (1) To observe carefully the signs which express mental life, 
 and to explain these expressions as far as possible ; (2) to examine those 
 physical processes which in any case appear to condition mental life ; and 
 (3), with constant reference to the foregoing classes of facts, to analyse 
 by means of a close self-examination, or "introspection," the one series 
 of mental facts which can alone be directly observed by the individual 
 psychologist. Studies of the sorts (1) and (2) can be made by all properly 
 equipped observers together, and in presence of what are called the 
 " same " external facts. Studies of the sort (3) each psychologist must 
 make alone for himself ; but by the aid of the facts acquired through 
 studies of the sorts (2) and (3) he can indirectly compare his introspective 
 results with those of other psychologists. The first two sorts of study are 
 very greatly furthered by what we know of the nervous system, but are 
 by no means confined to this region of knowledge. Psychology is by 
 no means a branch of neurology. On the contrary, wherever, in the 
 physical world, any mind gets intelligible expression, or any physical 
 conditions appear to determine mental states, the psychologist finds what 
 he wants, in so far as he seeks means of comparing his introspective ol>- 
 servations with the experiences of other minds. 
 
 § 10. The foregoing conditions already serve to de- 
 Psvclioloav ^^^^ ^^^® principal methods of psychology, whereof we 
 
 may next name the most important. 
 (1) Our first method — the study of the expressive sigyis of mental life 
 — is in some forms extremely familiar to the popular mind. Every per- 
 14 
 
178 OUTLINES OF PSYCHOLOGY. 
 
 son of any experience is his own psycluiUii^ist in judging almost con- 
 stantly the ideas, moods, and intents of his fellows by watching not only 
 their faces, but also their whole range of voluntary and involuntary ex- 
 pressive movements. The relatively scientific use ol such study as a 
 nietlutd of more careful psychological investigation depends both upon 
 extending the range of its application and uj)on rendering mure minute 
 the scrutiny employed. 
 
 The naturalist employs this method when he studies the minds of ani- 
 iimls through an observation of their behaviour and of their skill. It 
 should l)e carefully remembered, however, that not merely the passing 
 functions of the moment, but the established habits and the permanent 
 physical productions of any animal are of importance as outwardly ex- 
 pressing its mind ; and a similar thing holds of physical facts and pro- 
 cesses that express the cooperative work of many intelligent beings. 
 Works of art, institutions, languages, customs, faiths, cities, national life 
 in general — all these things and processes are instances of complex ex- 
 ])ressions of mental life in outwardly observable physical forms. 
 
 The inevitable dangers and difficulties of this, the most constantly em- 
 ])loyed of all the methods of studying minds, are meanwhile, in part, well 
 known. The facts to be studied ai-e very numerous and complex, and 
 easily misjudged, especially in case of minds that are markedly different 
 from our own. A good example of this difficulty is the common failure 
 i)f even very intelligent men to understand a good many among the ex- 
 pressive functions of women, or the similar failure of women to com- 
 prehend a great many among those of men. The barrier of sex will 
 probably prove a permanent hindrance, in some important directions and 
 regions, to the progress of the scientific study of the human mind, so far 
 as that study seeks to make the mental life of one sex fully comprehen- 
 sible to psychologists who belong to the other. 
 
 (2) The second method of the psychologist begins by proceeding back- 
 wards from the study of the outwardly expressive functions, in which our 
 mental states get a sort of embodiment, to the scrutiny of their nervous 
 conditions. These, once found to be, as they are, centred in the organi- 
 sation and in the functions of the brain, this second method develops into 
 that of the study of the relationfi that exist hetioeen mental Vife and hrain 
 pi'ocesses. This method is necessarily an indirect one. It takes very 
 numerous special forms. One of these is furnished by the study of ner- 
 vous diseases with reference to tliose changes, in the expressive signs of 
 mental life, which are the result of whatever form of nervous disorder is 
 each time in question. In so far as the phenomena of insanity are already, 
 despite our defective knowledge, traceable to otherwise known and de- 
 finable physical disorders of the nervous system, the study of such phe- 
 nomena for the purpose of the psychologist also obviously belongs here. 
 
METHODS OF PSYCHOLOGY. 179 
 
 A further extension of the present method is offered ])y those experi- 
 ments upon the nervous systems of animals wliich involve any note- 
 worthy and intelligible changes in the signs of mind Avhich tliese animals 
 show. And it is thus that the functions of the brain have been frequently 
 and very fruitfully studied during the last twenty-five years, despite the 
 difficulty of drawing exact conclusions as regards the human Ijrain and 
 the human mind from the interpretation of such experiments. Isor does 
 the use of the present method cease here ; for, apart from disease and 
 from vivisection, we are able to perform an experiment ujjon tlie func- 
 tions of the brain whenever (as by stimulating our sense organs in par- 
 ticular ways) we can harmlessly bring about any physical change in a 
 living man, whose mental life can indirectly be studied through his own 
 accounts of it, while the physical effect that the experiment has upon his 
 brain functions is meanwhile capable of a more or less determinate esti- 
 mate. It is in this way that we study what is sometimes called " the 
 physiology of the senses." 
 
 § 11. (3) In close connection with the first, and in frequent connec- 
 tion with the second of the foregoing methods, stands the method of 
 
 introspection^ by which the individual psychologist un- 
 Introspedion. 7,7,7 7, 7 ?• t 
 
 aertakes to observe and to analyse his own mental states 
 
 and processes. If carried on alone, without constant reference to the 
 physical conditions of the mental life observed, and without a frequent 
 comparing of notes with one's fellows, introspection can accomplish little 
 of service for psychology. But, in union with other methods, introspec- 
 tion becomes an absolutely indispensable adjunct to all serious psycho- 
 logical study. The man who has never observed within will never be 
 able to interpret the minds of others. The student of neurology can 
 directly contribute to psychological science only in case he learns to scru- 
 tinise carefully his individual mental processes, even while he indirectly 
 learns about their nervous conditions. Introspection is, however, for the 
 scientific psychologist, despite its importance, rather to be used as an 
 auxiliary of the other methods than as a method capable of leading the 
 way. However expert a man may be in his own mental states, it takes a 
 wide intercourse with his fellows, an outwardly observant examination of 
 the signs of mind in others, and a careful study of the physical conditions 
 in which given mental states arise, to reach any conclusions worthy of 
 scientific consideration. The truly great "introspective psychologists" 
 of the past, from Aristotle down, were none of them, as psychologists, at 
 all exclusively devoted to the study of their own ]3ersonal experiences. 
 They were, for instance, greatly influenced both by the traditional views 
 of their social order and by the popular psychology which lay more or 
 less concealed in the languages that they used. 
 
 (4) An important modern method, which unites or may unite featui-es 
 
180 OUTLINES OF PSYCHOLOGY. 
 
 belonging to all the foregoing methods, is the method of psychological 
 
 ed'pei'hneiit in the stricter sense. This method involves hringing to pass 
 
 mental processes of greater or less complexity (acts of 
 
 sy<i ogxca attention, simple acts of will or of more complex acts of 
 
 Experiment. ... . 
 
 .choice, associations of ideas, processes of memory or of 
 
 computation, emotional states, etc) under cofiditioiis which can he exactly 
 controlled or determined. Then, according as he wishes, the psychologist 
 studies one or more of the various noteworthy aspects of the situation that 
 lias been experimentally brought to pass. Thus one can examine by 
 direct introspection what goes on in a single observer under the circum- 
 stance of a given experiment. Here one takes advantage of the deiinite- 
 ness which the experimental devices may give to tiie whole experience. 
 Or again, in a series of related experiments, one can iutrospectively note 
 how the mental states or processes alter as the physical conditions undergo 
 certain determinate variations. Further, through comparing the reports, 
 or the other expressive signs which various subjects give of what goes on 
 in their minds under similar experimental conditions, one can get results 
 as to the contrasts that exist between the mental life of various people. 
 In some cases it is also possible to determine, to a certain extent, what 
 physical changes in the central nervous system are produced by the ex- 
 periment, and thus our knowledge of the relations of particular nervous 
 and particular mental states may be furthered. 
 
 Very important results have also flowed from the careful noting of 
 the various time-relations of any or of all the foregoing classes of facts, 
 as they occur when exact experimental conditions have been established. 
 The problem, how long a given mental process takes, and how this time- 
 element varies with given variations in the situation, is one of great in- 
 terest to the psychologist. Experimental psychology is the most recent 
 of the branches of psychological work. In general it has to be carried 
 on in special laboratories, where there are instrumental means for measur- 
 ing time-relations, as well as for determining precisely the physical condi- 
 tions under whicli tlie mental processes to be studied take place. 
 
 II. TIIE PHYSICAL SIGNS OF THE PRESENCE OP MIND. 
 
 § 12. In view of what has now been said about methods, we may best 
 begin our analysis of the general characteristics of mental life by asking 
 what are the most general classes of expressive signs by which the living 
 beings that have minds manifest to us their mental life. IIow, then, do 
 those animals which ai-c Jiigh enough in the scale to show us that they 
 certainly possess mental life, difl'er from those living beings which, like 
 the plants, give us no sn<-h manifestations? 
 
 The most general answer to this question is, on the whole, not very 
 difficult. When a cat watches for a mouse, when a doi? finds his wav 
 
THE SIGNS OF MIND. 181 
 
 fiome over strai)2je country, we do not doubt that liei-e are real feigns of 
 the presence of mine]. Wlien a tree tliat is cut witli the axe shows no 
 sign of feeling tlie blow, we note that here signs of mind ai'(j absent. To 
 be quite certain just where to draw the line between living beings that 
 seem to have no miiuJs and living beings that j)ossess minds does indeed 
 
 involve us in great difficulties. But there are some 
 General Signs , . x- • n i • i n i • ■, 
 
 f M' d i^^"6ral signs oi mind wiiicii we all regard as unmistak- 
 able, and some cases of lack that seem to us to exclude 
 the presence of any functions such as the psychologist studies. The gen- 
 eral signs of mind may be defined as follows : 
 
 In the most general way of viewing the matter, beings that seem to us 
 to possess minds show in their physical life wliat we may call a great and 
 discriminating sensitiveness to what goes on in their environment. And 
 by this their sensitiveness we here mean something which, though a sign 
 of mind, is itself purely physical — viz., a capacity, observable from with- 
 out, to adjust themselves by fitting movements, or by their internal phys- 
 ical functions, to what takes place near them. This sensitiveness is called 
 discriminating because it is never a mere tendency to respond to every 
 sort of change at random, or to all effective changes in the same way; but 
 it is a tendency to respond to some changes («?. g.^ light or sound) rather 
 than to others, and to various changes in various fitting ways. To be 
 sure, plants also show very many signs of well-adjusted responses to the 
 changes in their environments. And, even so, those functions of animals 
 which need show no signs of any mental accompaniments {e. g.^ gland se- 
 cretions, or the regulation of the body's temperature) are also discrim- 
 inatingly sensitive, in the physical sense, to external conditions. But the 
 matter is here first one of degree. Greater, quicker, or else more highly 
 elaborate, is the sensitiveness of the beings that have minds, as it is shown 
 in their expressive functions. Duller, or slower, or else simpler, appears 
 the physical sensitiveness of the non-mental being or function when the 
 environment changes. 
 
 § 13. But it is not merely this very general difference in degree which 
 we note when we consider this discriminating sensitiveness as a general 
 sign of the presence of mind. If we come closer to the facts, we next 
 note that the 2:eneral sensitiveness of the beino-s that have minds deter- 
 mines itself, as we watch it, in three ways, and so appears in three im- 
 portant aspects, each one of which has its own special degrees of mani- 
 festation : 
 
 (1) The sensitiveness of the psychically endowed beings manifests 
 itself by what, with a ready sympathy, we easily interpret as signs of satis- 
 faction or of dissatisfaction, of pleasure or of pain, and 
 Signs of Feeling. „ . . „i • • ,i • • ■■ 
 
 ot various emotions. ihese signs, m their simplest 
 
 forms, are so well known that we need hardly describe them. Where, as 
 
182 OUTLINES OF PSYCHOLOGY. 
 
 in the eurtlnvoi'in, we ciiii detet't nothing that we ordinarily call intelli- 
 jjence, we seem clearly able to note the si<j^ns of pain. Wiithing, with- 
 drawal from a sonree of injiii-y, and other simple movements of an oh- 
 vioiislv i)roteetive character, are snch elementai-y signs of dissatisfaction. 
 Still other movements, even in very low forms of life, seem to indicate 
 satisfaction. Higher np in the animal scale we meet with reactions of 
 fear, of anger, of joy, of the more elal)orate forms of desire, and, in the 
 end, of nnmerous other emotional states. We may for the present class 
 all these as the Signs ok Feklixg. The beings that have nunds thns 
 seetn to us, from the lirst, to sJiow signs of more or less imDoediately 
 valumg, or esthnatiny, their own state, or t/ieir oion relation to their 
 environment. 
 
 (2) But a still more noteworthy aspect of animal sensitiveness, appear- 
 ing in sim[)le forms, decidedly low down in the scale, becomes, in certain 
 lines of evolution, rapidly more and more important 
 
 Sions of Inlelltft. ,., , , •i.i-ii 
 
 liigher up, and reaches its liighest expression in man. 
 
 The animal, and especially the vertebrate animal, in proportion to its 
 
 elevation in the mental scale, shows a disposition to he moulded, in its 
 
 actions hij its successive experiences. That is, it is not merely sensitive 
 
 in particular ways to particular changes; but it learns hy experience. 
 
 AVhat response it makes at any given time is determined not merely by 
 
 its inherited structure, nor yet by what is now happening to it, but, in 
 
 addition, hy ivhat has happened to it hefore, during its intercourse with 
 
 its world. This capacity to be moulded by experience greatly elaborates 
 
 the discriminating sensitiveness of the organism that is able thus to learn. 
 
 "Wherever this capacity appears in its higher and more complex forms. 
 
 the signs of such plasticity, of such power to be taught by the world in 
 
 which the animal lives, constitute, when taken together, the Signs of 
 
 Intkllpxt. 
 
 It is true that, in ourselves, nervous functions which seem to have no 
 
 mental as])ect, are still often moulded by experience. Not every case, 
 
 then, of this sort of plasticity is itself a sign of mental 
 
 Special Ma ric, life. In fact, all the so-called "acquired characters" of 
 
 of llujhar In- . '. , . , . , . 
 
 tellecfual LiO\ ammal organisms plainly involve, in some measure, a 
 
 capacity to be moulded by pliysical experiences. But, 
 
 once more, the matter is one of degree. The power to show the effects of 
 
 past experience is, in its more elaborate forms, the most convincing of all 
 
 the signs of the presence of mind. Especially convincing is this sign 
 
 when it appears as a power to apply the results of former experience 
 
 in the adjustment of an aiiimaPs actions to decidedly novel conditions. 
 
 When wild animals, after having experienced something of the nature of 
 
 traps, become especially skilful in detecting and avoiding new sorts of 
 
 traps, we never doubt that this is a sign of real intelligence. AVhen (as 
 
THE SIGNS OF INTELLECT. \Hy> 
 
 is narrated in an account quoted by Roniaue.sj an olcpliant, taught to pick 
 up articles and liand them to tlie man who is on liis hack, detects at once, 
 even in case of a novel article (e. (/., a sharp knif'ej, and hy virtue of some 
 subtler similarity of tliis novel article to previously known things, will 
 either pass up this article carefully or with a careless haste, w^e are sui-e 
 that this sort of acquired skill indicates the ])resence of mental life of a 
 highly developed sort. 
 
 Decidedly different is the case where the actions of an animal show 
 great skill in their successful adjustment to surrounding conditions, while, 
 nevertheless, the adjustment in question seems to be 
 largely an original function of the animal, which is only 
 in part, perhaps in very small part, moulded by the animal's own past 
 experience. In this case we call the actions that we observe cases of 
 Instinct. The signs of instinct cannot of themselves be regarded as signs 
 of what, from the psychologist's point of view, is identical with intellect. 
 The most marvellous developments of instinctive functions occur in in- 
 vertebrate animals, especially among the insects {e. g., ants, bees, and 
 wasps). While these instincts get adjusted to passing experience, thev 
 are sometimes remarkably perfect apart from the influences of any past 
 experience. The instincts of the higher vertebrates are generally a good 
 deal moulded by the experiences of the individual animal, so that although 
 a large part of the functions may be directly inherited, it is nevertheless 
 subject in its growtli to the laws of the intellect, and is here seldom free 
 from great modifications during the life of its possessor. In man the in- 
 herited instincts, although they lie at the basis of all our intellectual life, 
 get so much modified and moulded by our experience that we generally 
 fail to recognise their presence as instincts. Yet, as James and others 
 have sliown, man has at the outset an extremely large number of elaborate 
 and inherited instinctive predispositions to given sorts of conduct. 
 
 In so far, however, as we leave out of account these relatively unalter- 
 able inherited instincts, we can then say that by the signs of intellect we 
 mean those which show an fmimaVs plasticity in the presence of experi- 
 ence^ and especially its skill in adjusting the results of past experience to 
 the meeting of novel situations. This, then, is the second form of that 
 general sensitiveness which constitutes the sign of the presence of mind. 
 
 (3) In a third form the general sensitiveness of the beings that possess 
 minds shows itself when we consider, not now the conditions, but tJie 
 
 results of their actions and their own relations thereto. 
 Signs of Will. -\t j_ i n i i tit i • 
 
 JNot only do they respond to slight changes, but, in 
 
 many cases, their responses lead to highly important results, whose 
 
 elaborateness seems out of all proportion to the slenderness of the 
 
 causes that have set them into activity. For one thing, the higher 
 
 animals generally show an overwealth of activity. They not only 
 
184: OUTLINES OF PSYCHOLOGY. 
 
 respond in a titting way to tlioir environment, but they repeat or 
 elaborate their responses mure than is neeessary for adjustment. They 
 move about when they might, without loss or danger, keep quiet ; they 
 sing, as the song birds do, apparently often for the mere love of singing ; 
 or, in the form of play, they vent their surplus energy as kittens do, or as 
 children. On another side of their active life we find a great many of 
 them highly constructive or destructive. They do not leave their world 
 as they found it. They fashion their environment to their pleasure. 
 They build honeycombs, nests, houses, cathedrals. Or, as beasts of 
 prey, they destroy others, and so may alter the aspect of their environ- 
 ment very effectively. Now, when such activities, whether by their over- 
 wealth or by their elaborateness, or by their permanent or by their far- 
 reaching results,. so attract our attention as to seem to us to show that the 
 animals concerned take note of their own conduct, and more or less 
 clearly mean or intend its outcome., we regard these as Signs of Will. 
 The life of the will means the life of an animal, in so far as it involves a 
 more or less conscious directum of conduct. 
 
 In this way, then, we get three sorts of noteworthy signs of mind : 
 
 (1) The Skjns of Feeling — i. e., the signs of an animal's way of di- 
 rectly valuing or estimating its own state, or its relation to the environ- 
 ment. 
 
 (2) The Signs of Intellect — i. <?., the signs that indicate an animal's 
 tendency to learn by experience. 
 
 (3) The Signs of Will — i. e., the signs that an animal is taking account 
 of its own conduct and directing this conduct. 
 
 III. THE NERVOUS CONDITIONS OP THE MANIFESTATION OP MIND. 
 
 § 14. The organic conditions for all these manifestations of mind is the 
 
 presence of a nervous system. At all events, such signs of mental life as 
 
 some have believed to be present in organisms too low 
 
 ^ .. to show us any differentiated nervous systems are such 
 
 as to need here no further mention. The discriminating 
 
 sensitiveness which everywhere accompanies all the higher manifestation 
 
 of mind is, physically speaking, a property of nervous tissue. 
 
 Leaving to the anatomist and the physiologist every extended descrip- 
 tion of the structure and functions of our nervous system and of its in- 
 struments — viz., the sense organs and the organs of muscular movement — 
 the psychologist can here only try to show very summarily what charac- 
 ters of the nervous system most interest his own undertaking. 
 
 The nervous system consists, for our purposes, of a vast collection of 
 " elements," each one of which is a " nerve-cell " that, in addition to its 
 minute central mass, possesses prolongations which are either " nerve- 
 fibres " or else are other so-called "processes" — viz., minute and multi- 
 
THE NERVOUS SYSTEM. 185 
 
 formly branching extensions of tlic substance of tlie nerve-cell. These 
 
 processes, extending, in tlie centi-al nervous system, from one cell to tlje 
 
 immediate neighboui-hood of other cells, form an ex- 
 
 Strudure and tremelv complex network of finely divided threads or 
 
 Function of the ^•^ ,• , i , -. 1 1 • ,. , 
 
 Nervous System. ^* moss-like or of mould-like collections of short and 
 
 long threads and branchings. A current and author- 
 itative opinion holds that the processes of one cell probably never really 
 unite either with the processes or with the central substance of any otlier 
 cell. Thus each cell, with its processes, lies, it would seem, side by side 
 with other cells, whose processes, intertwining like the foliage of neigh- 
 bouring trees with its own processes, still never grow into its own sub- 
 stance, so that all these " elements" — i. e., cells, each with its own exten- 
 sions — are anatomically independent. The nerve-fibres proper, which grow 
 out of what are called the axis-cylinder processes of cells, run often for 
 long distances unbroken through the nervous system, either reaching their 
 various terminal organs in the outer or " peripheral " portions of the 
 body, or else coming to an end in tuft-like branchings in the immediate 
 neighbourhood of the cells whose functional relation to their own parent 
 cells they are destined to determine. ISTerve-fibres often divide into 
 branches of equal value, or else send off, in their course through the cen- 
 tral regions of the nervous system, many accessory branches, which may 
 terminate as does the main iibre, only at points often far removed from 
 one another. Thus any given fibre, with its branches and accessories, 
 may serve to bring its parent cell into some sort of relation to many other 
 regions of the central nervous system. On the other hand, the anatomical 
 independence of the elements which has thus been probably made out 
 suggests that every cell has some sort of relative and subordinate inde- 
 pendence of function. When it has once received any disturbances it 
 probably sends out, through its processes and its fibre, its own sort of ex- 
 citation ; but very possibly this excitation does not pass over from the ter- 
 minations of the cell branches to any other nervous element without con- 
 siderable alteration in form, and perhaps in degree. It has been suggested 
 by the experimental work of several neurologists that what a cell does to 
 its neighbours or to the more distant cells with which its fibres bring it 
 into relation must be somewhat analogous to '' induction " as known in 
 case of electrical phenomena. From this point of view the excitation of a 
 cell through the excitation of its nerve-fibre or by any other means may 
 " induce " other cells, with which the first cell stands in relation, to give 
 out, in their turn, their own form of excitement, which they then pass 
 over by induction to yet other cells. In any case, the known general 
 structure of the nervous system seems especially adapted (1) to the mani- 
 fold propagation of excitements in various directions, (2) to the constant 
 variation of the form of this excitement as it passes from element to ele- 
 
186 OUTLINES OF PSYCHOLOGY. 
 
 incTit of the nervous system, and (8) to the most complex iiilhience of the 
 
 excitations of one part of the nervous system upon the independently 
 
 aroused excitariuns which happen to he present in other ])arts of the 
 
 system. 
 
 § 15. The best-known (li\i>ioii that exists in the functions of the 
 
 nervous system is that between the sensory and the ni(»t(ji- functions. 
 
 lle<2;inning in the more external or ])eri])lieral re^-ions of 
 Sensory and ., " ^. r ^ i j. ..i • • 
 
 ,, , r- ,• the oro-anism, disturbances are coustantiv passin2: in- 
 
 wards from the sense organs, where the fibres of the 
 sensory nerves have their outward endin<is. These sensory fibres carry 
 physical disturbances of some still unknown form to the neighbourhood 
 of more centrally situated cells, which in their turn may, and in general 
 obviously do, send the excitation or its induced resultants to very various 
 parts of the still more centrally situated nervous tissue. The rate at 
 which the nervous disturbances are carried in nerves is in general known, 
 although not so accuratel}' in the sensory as in the motor nerves, and is 
 from thirty to forty metres per second. In the meantime, centrally in- 
 itiated physical disturbances are constantly passing outwards over motor 
 nerves to the terminations of these nerves in muscles, glands, etc., where 
 these disturbances produce complex effects upon the organs of voluntary 
 and involuntary movement, upon the circulation, and upon the secretions. 
 In general, the sensory nerves, in view of their actual relations to the rest 
 of the organism, are so disposed as to carry disturbances only inwards, and 
 the motor nerves so disposed as to carry only outwards, although this law 
 seems to be not al)solute, but only a resultant of the 
 usual conditions. The sensory nerves terminate out- 
 wardly, as has just been said, in sense organs, which are in general so 
 constructed as to expose their nerve-fibres to only one sort of physical 
 excitation (as the fibres of the optic nerve are normally exposed to the 
 effects which light produces upon the retina, the auditory nerve to the 
 effects of sound-waves, etc.). 
 
 This division between sensory and motor nerves is, in the first instance, 
 a purely physical matter, and does not by any means name functions that 
 must have any direct relation to our mental states. For disturbances trav- 
 elling inwards over sense-nerves need not be passed on through the nerve- 
 centres until they reach the level of the cortex of the brain ; and unless 
 they do reach the cortex we have no sensations, and the sensory-motor 
 process then goes on without mental accompaniment. Just so, very nu- 
 merous motor currents pass outwards from centres — i. <?., from groups of 
 cells situated wholly in the spinal cord or elsewhere below the level of the 
 cortex — and are in no wise due to excitations aroused in the cortex. In 
 such cases the motor processes in question have no relation to our will. A 
 j^igcon deprived of its brain hemispheres can fly, avoiding obstacles ; can 
 
ADJUSTMENT TO THE ENVIRONMENT. 187 
 
 perch, balance, walk, etc., when stimulated to such acts ]>y appropriate sen- 
 sory disturl)ances. It, liowever, no longer shows huiig(;r, fear, love, or 
 similar sorts of discriminating sensitiveness, and gives no sufficient signs 
 of such intellectual life as would characterise an nniujurcd pigeon. If 
 left alone, it rests in apparently absolute repose and indiii'erence to its en- 
 vironment. Driven from one perch, it merely flies till it finds another. 
 Thus the sensory excitations which reach the brainless pigeon's nervous 
 centres produce, probably apart from any definite mental life, physical 
 disturbances of cells, such as stimulate in an always rigidly determined 
 serial succession (through the intermediation of motor nerves) just the 
 right muscular fibres which are needed to produce each time the pigeon's 
 acts of balancing, flying, or perching. Yet all this appears, in the end, to 
 involve none of the watchful, often hesitant, tremulous, emotionally busy 
 sensitiveness of the normal pigeon. The brainless pigeon seems like a 
 delicate but absolutely determined machine, which never really seeks to 
 escape, and never shows the least normal concern for its own preservation, 
 but merely perches when it touches a perch, flies when it is in the air, 
 balances when it begins to fall — and all this with the stubbornness of a 
 steadily working clock. 
 
 So far, then, a sensory impression has appeared in our account as a 
 physical disturl^ance that passes inwards from a sense oi'gan over a sen- 
 sory nerve. In the central masses of cells such disturb- 
 Environment. ^"^®^' occurring, as they do, at any moment, in great 
 numbers, produce changes that are often far-reaching, 
 but that are usually determinate as regards their total outcome, and that 
 often are so quite apart from any signs of intellect, of feeling, or of will. 
 In any case, liowever, the outcome, if definite, is some sort of " adjustment 
 to the environment" — i.e., is of a nature to be, in general, serviceable to 
 tlie life of the organism. The adjustment is modified by tli,e endless inter- 
 change of excitations throughout the central nervous system, Avhose 
 enormous numbers of relatively independent "elements," mutually induc- 
 ing different forms of excitement in one another as soon as any of them 
 are disturbed, tend both to the multiplication and to the control of the 
 effects of every disturbance. The useful movements that result are such 
 as they are because, in the end, groups of muscle-fibres get excited in a 
 definite serial order for every complex act. And this serial order is de- 
 termined by the total structure and the consequent functions of the central 
 nervous system. 
 
 § 16. But now, where the signs of mind are definitely shown, the ac- 
 companying nervous processes are still of the same fundamental sort as in 
 „ . ^ the cases just discussed. The difference lies in the place, 
 
 in the complexity, and in the significance of the central 
 nervous processes involved. When, as in our own cases, the cortex of the 
 
188 OUTLINES OF PSYCHOLOGY. 
 
 brain is present and is actively function inij:, it functions as it does becanse 
 of the current sense disturbances which reach it. The result of the brain 
 process is always an outward-flowing but vei-y highly orderly — a serially 
 arranged — collection of disturbances which, acting, in general, through 
 tlie co-operation of lower centres, result either in actual external move- 
 ments, or in tendencies to movement, or, Anally, in the prevention of 
 movements which would be carried out, at the time, by the lower centres, 
 if the latter were not under the control of the brain. Intermediate be- 
 tween the ceaseless income of the sensory disturbances that reach the cor- 
 tex so long as it is active, and the equally ceaseless outgo of the motor 
 processes (or of the processes tending to the control of movements), that 
 leave the cortex all through our waking life, there are central processes 
 occurring in the form of an interchange of induced cellular disturbances 
 among the elements of which the cortex of the brain is composed. As 
 there are probably some hundreds of millions of these elements in the 
 grey matter which forms the surface of the brain, and as the intertwining 
 foliage of the branching forest of cell processes, together with the masses 
 of innumerable winding libres that wander from region to region of the 
 brain, must determine an august multiplicity of interrelations among 
 these elements, it is no wonder that these central processes should show a 
 simply inexhaustible complexity. Still more marvellous, however, from 
 a purely physical point of view, is the orderliness which reigns amid the 
 complexity. This orderliness is, in general, due to the great law of habit. 
 The hrain tends to do tJte sort of thin (j that it has al- 
 ready often, done. The brain is, meanwhile, persistently 
 retentive of its own once-formed habits regarding these interchanges of 
 the activities of its various elements whenever they are excited in particu- 
 lar ways. And it is thus persistent to a degree which we can never cease 
 to regard with more wonder the more we study the brain's functions. 
 On the other hand, the cortex remains, to a remarkably late period in life, 
 I)ersistently sensitive to a great variety of new impressions, and capable 
 of forming at least a certain number of specialised new habits — such as 
 are involved whenever we learn to recognise and name a new acquaint- 
 ance, or to carry out a new business enterprise. And all these things, it 
 must be remembered, the cortex accomplishes as a physical mechanism. 
 If we change — by experimental interference, by accident, by poisoning, 
 by disease — any of the physical conditions of the cortex, we interfere with 
 some or with all of these functions. Meanwhile, if we at any time were 
 to cut off all sensory stimulations, the brain, as many facts indicate, would 
 either soon cease to act at all, or would remain active only in a slight or 
 in an almost utterly insignificant way. On the other hand, so long as the 
 brain is active it sends out motor stimulations, or stimulations that tend 
 to control or to suppress the activities guided by lower centres. And it 
 
THE LAWS OF HABTT. 180 
 
 is precisely tlii.s motor out<^o of the brain that detei'iiiines tJie very h'i^uh 
 of mind wliich we discussed above. 
 
 Furthermore, while the brain is, duririiij waking life, full of general 
 activity, it is now well known that every definite outflowing process, as 
 well as every definite sensory stimulation, involves sharply localised re- 
 gions of the brain. Eye and ear, arm and leg, have definite centres in 
 the brain corresponding to the stimulation of the sense organ, or to the 
 movements of the limb. liaoh of the nuinerous hahlts of the brain raeanfi, 
 then, tendencies to the excitement of localised t/pacts and paths under given 
 ■physical conditions. An excitement passing over one set of paths leads 
 to one system of external movements — e. g., from eye-centre to hand-cen- 
 tre, when one sees and then grasps. If circumstances vary the paths, they 
 vary the motor results. It is possible to have, in cases of localised brain 
 disorder, the survival of a few very complex habits of movement in the 
 midst of the utter wreck of all the other related habits of the same grade 
 of complexity and of similar significance — as when a patient loses all 
 power to remember his native tongue except for a few surviving words, 
 chosen by the disease, as it were, either at random or in more or less tvp- 
 ical fashion, to outlast the rest. In this case a few definite and localised 
 habit-worn paths for the induction of activity remain after all the related 
 paths of the region in question have been destroyed. 
 
 Meanwhile, what the brain at any moment does, in answer to the cur- 
 rent sensory stimulations, is determined both by its entire past history and 
 by its inherited "temperament" or original type of structure. For bv 
 heredity the brain has come to be just this vast colony of functionallv 
 united cells. And, on the other hand, whatever has happened to the 
 brain in the past has meant some definite and usually sharply localised in- 
 terchange of induced activities among its elements. Every such inter- 
 change has altered the minutest structure of all the elements concerned, 
 has established localised paths between them for future inductions to fol- 
 low. They can never act again precisely as they would have done had 
 they not acted once in just this way. And this is w^hat is meant by say- 
 ing that the hvam forms its hahits. One must now, in addition, note that 
 this formation of habits occurs in the most subtle fashions. Parts that 
 have often functioned together tend to function more easily together 
 again. This is true down to the minutest detail of localised functions. 
 But what is still more significant for all our higher mental life is. that 
 general forms or types of activity, however siihtle or evanescent their na- 
 ture, when once they have resulted from a given exchange of induced 
 activities {due to serisory stiinulations), tend thereby to become henceforth 
 more easily re-excited, so that the habits of our brain come to be fixed, not 
 "merely as to the mere routine which leads to this or to that sj)ecial act. 
 but as to the general ways in ivhich acts are done. A given '' set** of the 
 
190 OUTLINES OF PSYCHOLOGY. 
 
 brain as a wliole, a given sort of preparedness to be inlhieneed in a certain 
 way — yes, even a given tendency to change, nnder particular conditions, 
 our more speciiie fashions of acti\iry — may tlius become a matter of rehi- 
 tively or of entirely li.xed habit ; so that, under given conditions, the brain, 
 so long as it remains normally intact, is sure to res])ond to certain sensoi'v 
 disturbances by assuming tliis '"set," by being ready for this relatively new 
 inrtuence, or by actually seeming to change even its sjiecilic past habits 
 themselves in a certain general but habitually pi-edetermined direction 
 whenever given sorts of stimulation are }tresented. It is known, for in- 
 stance, that '' fickleness " of conduct, irrational change of [)lan of behaviour, 
 can itself become a hopelessly tixed habit in a given brain. There is, then, 
 no type of activity so general tliat some brain cannot be trained to become 
 habitually and fatally predetermined to just that type of interchange of 
 internal functions, and so to that type of outward-llowing activity. 
 
 § IT. On the general relation of the activities of the cortex to those 
 of the lower nervous centres, and of the relations between various activi- 
 ties of the cortex itself, it still remains to say here a 
 
 r ^ ' few words. The brain cortex directs, by itself alone. 
 
 Lower Centres. . 
 
 and apart from the co-opei-ation of lower nervous 
 centres, few or no externally observable motor processes. AVhat it does 
 is partly to combine and elaborate, partly to guide by slight alterations, 
 and partly to hold back or to prevent, the activities which other centres, 
 left to themselves, would carry out in response to the sensory stimuli 
 which either reach them or for which the brain substitutes its own sort 
 of stimulation when it arouses the lower centres to act in its service. 
 The character of the cortex as an organ for preventing or "inhibiting" 
 the functions of lower centres is of very great importance, and well ex- 
 emplifies the sort of hierarchy which obtains among our nervous cen- 
 tres. Within the lirain itself a similar hierarchy exists, and a similar 
 system of mutual inhibitions gets formed on the basis of our experi- 
 ence. 
 
 Upon this process of "inhibition" — i.e., of the prevention or over- 
 coming of one form of nervous excitement through the very fact of the 
 ])resence of another — the organisation of all our higher 
 life depends. AVhat, in any situation, we are restrained 
 from doing is as important to us as what we do. Tension, the mutual 
 opposition and balancing of numerous tendencies, is absolutely essential 
 to normal life. The brain receives, at every waking instant, an enormous 
 overwealth of sensory stimulation. For instance, the habits of those por- 
 tions of the brain which receive the fibres of the optic nerve, and of those 
 portions which direct our eye-movements, are such that every object of 
 the least note in our field of vision actually acts as a stimulus to incite us 
 to look directly at itself. Consequently, if the eyes are idle, the presence 
 
THE LAWS OF INHIBITION. 191 
 
 of any one bright light in the otherwise indifferent field of vision is a 
 physical disturbance, to which the natural niot(;r response is the turning 
 of the eyes towards that light. And so, if the field of vision is full of 
 interesting objects, all of them thus tend to excite various motor responses 
 on the part of the eyes. In order to look steadily, for even a moment, in 
 any one direction, we thei'efore have to inhibit all of these tendencies ex- 
 cept the one whose triumph means seeing the preferred object. This is 
 only one among the countless cases where the accomplishment of a 
 given act means the inhibition of other acts to which the brain is mean- 
 while incited by the presence of some habitually effective stimulation. 
 
 As every normal stimulation that reaches our brains during our adult 
 years is likely to appeal more or less vigorously to some established brain 
 habit, the need of such suppression of possible motor processes is absolute 
 and continuous. The problem of the inhibition of those habits of move- 
 ment whose presence at any given moment would injure the useful adjust- 
 ment of our organisms to their environment is, despite its complexity, 
 solved, in case of all the higher nervous centres, by the presence of certain 
 general and very characteristic physical processes whose nature is still 
 very ill understood, but whose beautiful adaptation to their purpose we 
 can already to some extent estimate. We have before 
 spoken of what may be called the general " set," or 
 " sort of preparedness for a given kind of excitation," which the brain at 
 any moment may be brought to assume. This " set " is in general itself 
 the obvious result of a previous series of sensory stimulations, and of an ap- 
 peal to old habits, and it may come to pass either suddenly or quite grad- 
 ually. Once assumed, any given " set " of the brain manifests itself by 
 the fact that, for the time, one group of sense-experiences tends to arouse 
 the motor habits that have become attached to them in consequence of the 
 past experiences of the brain, while the motor habits to which all other 
 current sense-impressions appeal, are in great measure inhibited. Yet 
 these relatively ineffective sense-impressions certainly reach, in most cases, 
 their centres in the brain, for if altered a little from their current char- 
 acter they may at once assert their presence by calling out movements 
 that show concern in the alteration. A similar " set " may be given by 
 the action of the brain to a group of lower centres, which then proceed to 
 react automatically to external stimuli until the whole process is cut off 
 by external stimuli, or by a new signal from the cortex ; and while this 
 " set " continues all other motor habits of the centres in question are in- 
 hibited. 
 
 § 18. Examples, both of inhibition in general and of its relation to 
 the passing general " condition of preparedness " of the higher and lower 
 centres, are easy to give. In general, all higher intellectual processes are 
 accompanied by processes in the cortex which appear, when seen from 
 
192 OUTLINES OF PSYCHOLOGY. 
 
 without, cnonuousily inhibitory. One absorbed in writing or reading lets 
 pass without response countless impressions which pretty certainly reach 
 the brain, impressions to which, under ordinary circumstances, he would 
 respond by acts of looking, of listening, of grasping; or of other more or 
 less useful or playful types of adjustment. Let him cease the higher ac- 
 tivity, and he adjusts himself more vivaciously to the lesser matters of his 
 environment. An absorbed public speaker, an actor, or a man in a formal 
 social company, inhibits those movements, however habitual they are in 
 other company and however strong the momentary sensory solicitation to 
 them, which his habits have taught him to suppress as being here " out of 
 character." This word "character" here names the mental equivalent of 
 a given "set" of brain. So long as one assumes the "character" the 
 well-practised inhibitions triumph. If one goes home, or changes one's 
 company, those former reactions may vanish as if they never had been, and 
 it may be even impossible to reassume them, except in particular sur- 
 roundings. In case of the relations of higher and lower centres, the "set" 
 of a group of lower nervous processes is well illustrated by the activity of 
 walking, which consists of a regulated series of motor adjustments to 
 sensory stimulations — leg-movements, acts of balancing, etc. This series 
 is largely under the control of relatively lower centres, both in the cortex 
 and below. It may be initiated by a signal from above. Once begun, it 
 is continued, with a consequent inhibition of all inconsistent muscular 
 movements, and often little or no guidance from the more complex groups 
 of brain centres, until the signal to pause is given. Then other activities 
 of adjustment take the place of the ones that have come to an end. Thus 
 one pauses in a walk through a garden to survey more carefully the ap- 
 pearance of the flowers, to do a piece of work that requires the skilful 
 use of the hands, etc. The rule of inhibition, as regards the before-men- 
 tioned hierarchy of the nervous centres, seems to be that the higher a 
 given function is, the more numerous are the iidiil)itor3^ influences that it 
 exercises over lower centres. Intense brain activity of the highest sort is 
 opposed, while it lasts, to nearly all the simpler functions above the level 
 of the vital necessities, except the very few, such as reading or speaking, 
 which training may have brought into the direct service of the highest 
 activity itself. Excite a child's brain to anything approaching absorbing 
 activity {e. </., by telling the child an interesting story), and for the time 
 you "keep him quiet." Otherwise he runs about, looks here and there, 
 laughs, wriggles, kicks, prattles — all adjustments to his environment, ad- 
 justments either useful or playful, but of a simpler sort. These may cease 
 by inhibition when the story begins. The child may then sit for a short 
 time with moveless hands, with o]itic axes ]iarallel — i. e., with eyes 
 "gazing far off," with legs hanging loosely, with falling lower jaw — all 
 of them more or less inhibitory phenomena. 
 
THE RELATIONS OF ACTIVITY AND CONTROL. llj;; 
 
 § 19. The practical consequences of tin's general princijjle of the in- 
 hibitory character of the higher nervous processes are multitudinous. 
 Absence of inhibitions is a familiar sign of nervous dis- 
 order or degeneration, and also, in children, of imma- 
 turity. " Self-control " is an essential part of health. This principle 
 furnishes the reason why so much of our educational work has to 1)6 ex- 
 pended in teaching " self-control," whose physical aspect is always the 
 presence of inhibitory functions. The moral law has often been expressed 
 in the form of the well-known " 77iou shalt not^ Such negative pre- 
 cepts always presuppose that in the person who really needs to be taught 
 by the precept, a disposition or habit of brain pre-exists which involves, 
 when left to itself, a certain sort of response to a given environment — e. g.^ 
 in an extreme case a tendency to the expressive acts called, in human 
 social relations, theft or murder. Instead of telling such a man what 
 positive motor activity to substitute for such doings, the negative precept 
 undertakes to point out that, as a condition prior to any better adjusted 
 conduct, these motor tendencies, at least, must be inhibited. But their 
 inhibition is to be actually brought about, in case of the successful moral 
 precept, through the influence of what is called in psychological language 
 " suggestion." The physical efiicacy of such " suggestion " depends, how- 
 ever, upon its appeal to brain habits of a very high 
 level, which, like the otlier higher processes, have a gen- 
 eral capacity to act in an inhibitory sense, as against functions of lower 
 levels or of a more primitive simplicity. 
 
 But just as we often ti'ain habits of inhibition as a preliminary to the 
 more positive establishment of useful higher functions, it is even so true 
 that, whenever we can get higher functions of a positive sort established, 
 we thereby train inhibitory tendencies. And, on the whole, this is the 
 wiser course for the teacher of the growing brain to take where such 
 a course is possible. Inhibition is a constant means, but it is still but a 
 means to an end. The end is the right sort of motor process. You 
 teach a man to control or to restrain himself so soon as you teach him what 
 to do in a positive sense. Healthy activity includes self-restraint, or in- 
 hibition, as one of its elements. You in vain teach, 
 then, self-control, unless you teach much more than self- 
 control. The ISTew Testament statement of " the law and the prophets " 
 substitutes " Thou shalt love," etc., for the " Thou shalt not " of the Ten 
 Commandments. A brain that is devoted to mere inhibition becomes, in 
 very truth, like the brain of a Hindoo ascetic — a mere " parasite " of the 
 organism, feeding, as it were, upon all the lower inherited or acquired 
 nervous functions of this organism by devoting itself to their hindrance. 
 In persons of morbidly conscientious life such inhibitory phenomena may 
 easily get an inconvenient, and sometimes do get a dangerous intensity. 
 15 
 
194 OUTLINES OF PSYCHOLOGY. 
 
 The result is then a fearful, cowardly, heli)less attitude towards life — an 
 attitude which defeats its own aim and renders the sufferer not, as he 
 intends to be, "good," hut a i)ositive nuisance. 
 
 The practical ju-ohlein as to the de2:ree of inhibition which it is well 
 to establish in our nervous life is one which wholesome ])eo])le meet in 
 part 1)Y the device of a duly chan<,nnir or alternating activity of the central 
 nervous system. TJie drain of ahmrhlny intellectual 
 ana WHO y^orh is, in consicleruhle part, p)'ett[/ obviously eitJier 
 
 conditioned or intensified hij tiro factors : (1) The 
 actual 7ie}'vous expenditure in calved in the inJiihitory 2^1'ocesses thern- 
 ticlves : AVhile one works, countless excitations tend to set free lower 
 motor functions, and all these tendencies have to be held back by counter- 
 sifi^nals from hijrher nervous stations. This in itself involves a ffreat deal 
 of motor expenditure. " To sit still '' is itself, in general, a motor pro- 
 cess, and is often a very hard one — e. g., when one is in an exciting or 
 harassing situation, and when prudence says : " Do nothing ; wait and 
 see." (:3) The indirect effects of non-exercise of the inhibited functions : 
 to sit still and think, to restrain ourselves, means to condemn many groups 
 of muscles to inactivity. This means a tendency to disturbed nutritive 
 processes, and so in the end an unequal development or an actual degen- 
 eration of the whole organism. AVe relieve the strain as well as favour 
 the neglected organs when we substitute exercise for inhibition. Varia- 
 tion of labour is thus, in itself, and within limits, actual motor rest or 
 recreation. " To let ourselves go," within the bounds of propriety, duty, 
 and moderation, involves a rest from the heavy motor task of " holding 
 ourselves still." This is especially true in children, in whom the inhib- 
 itory processes are ill-formed, and therefore the more laborious. Young 
 children should never be asked to continue long any one type of inhibitory 
 process. With them any one persistent " set " of the brain becomes very 
 soon an injurious incident. 
 
 On the other hand, not every change of the " set " of brain is itself 
 restful. The phenomena of " worry " include many " changes of mind " — 
 i. <?., of more special " set " of the brain. Yet the result 
 is disastrous. But the effects of worry seem to be very 
 largely due to the strong tension existing in the w'orried person between 
 his abnormally numerous sensory incitations to particular acts and that 
 general "set" of his brain which, so long as he is worried, survives aH 
 his actual changes of special " set " or plan, and tends to inhibit all sorts 
 of definite or connected activit}'. Whether he rushes about or lies still 
 in pretended rest, whether his mood is this or that, he is all the while in- 
 cited to act, and is busy holding himself back from effective action. His 
 endless question, " What shall I do ? " his motor restlessness, his petty 
 and useless little deeds, all express his inability to choose between the 
 
THE CLASSIFICATION OF MENTAL LIFE. 195 
 
 nuniei'ons tendencies to niovenrient wliidi liis situation arouses. Countless 
 motor hal)its are awakened, and then at once suppressed. In liis despair 
 he tries to inliihit all acts until tJie plan — the saving plan — shall appear. 
 And so, accomplishing nothing, lie does far more motor woi-k than an 
 acrobat. But let the dreaded calamity over whose mere j^ossihility he 
 worries actually befall him. TJum,^ indeed, there is often but one course 
 of conduct, perhaps a very simple one, suggested by his new situation. 
 The useless inhibitions vanish. One definite " set " of brain is. indeed, 
 substituted for the preceding state, but the new one is free from the over- 
 numerous and violent special tensions between higher and lower centres 
 and functions which characterised the former. The recently worried man 
 may hereupon become cool, may wonder that he can bear the worst so 
 much more easily than he could the uncertainty, and may by contrast find 
 not only rest, but a kind of joy in the relief occasioned by the cessation of 
 useless motor processes. Where the man himself has worried, it is thus 
 often the part of the seemingly most cruel fate to rest him ; and this the 
 latter then does by cutting off the extra inhibitions in favour of an easily 
 accomplished response to definite stimulations. 
 
 Finally, in this connection, it may be observed that when a given 
 series of acts, involving a certain number of successive inhibitions, has to 
 
 be accomplished, much more mental strain is involved 
 Attention to -. . ,, ,. ,.,.,.. 
 
 Inhibitory Process. ^"^ ^OYQ weanness results, according as the inhibitions 
 
 themselves have to be made objects of a more definite 
 consciousness or volition. And the degree of strain increases very 
 rapidly with the attention given to the inhibitory side of the process. 
 Hence the hard labor involved in learning new adjustments, in acts of 
 voluntary attention, and in conscious self-restraint generally. 
 
 IV. THE CLASSES OF MENTAL PHENOMENA IN GENERAL. 
 
 § 20. A certain proportion of the foregoing functional processes are 
 
 attended by mental states. In general, our mental life, or, as it is often 
 
 called, our consciousness, attends those processes which, 
 
 Consciousness. i •! • ^ • ,^ , r- 1 • T Ti T 
 
 wnile involving the cortex, are oi a decidedly complex 
 grade and of a relatively hesitant character, or which come in conse- 
 quence of the grayer interferences on the pai't of our environment. Our 
 most perfect adjustments to our environment are accomplished uncon- 
 sciously, unless we chance to become aware of them through their rela- 
 tions to what is actually concerning our conscious life. Our mental life, 
 however, regularly attends (1) those of our habitual cortex functions 
 which are at any time considerably altered to meet novel conditions, and 
 which accordingly have, despite their skill, a relatively hesitant fallibility 
 about them ; (2) those of our functions which are considerably disturbed 
 in their normal flow by the intensity or the novelty of the external stimu- 
 
190 OUTLINES OF PSYCHOLOGY. 
 
 lation ; and {S) those of our functions wliieli, in relation to the other 
 functions present in the cortex, have a physical intensity that exceeds the 
 average of what is going on at the same time. For exami)le, we are con- 
 scious when we think out a new \)\i\u, Init we ])erform numerous acts of 
 mere routine without noticing tlu'in. ^\'hat we do very rapidly we fail 
 to follow, in its details, wirh our nuMital life. AVhat, as being somewhat 
 novel, we do with ''deliberation,"' we may follow very ade(pu\tely. ]>iit 
 the physical accompaniments of strong states of feeling, however swiftly 
 they bring some reaction to pass, still imply a change in our conscious- 
 ness. And intense experiences, such as disagreeable noises (the sound of 
 a hand-organ or of a hurdy-gurdy), may long retain a place in conscious- 
 ness which may be out of proportion either to the importance, or to the 
 novelty, or to the complexity, or to the deliberateness of the motor func- 
 tions which they arouse. ]\Ieanwhile, the precise conditions that mark 
 the boundary between those functions which have no mental equivalents 
 and those to which consciousness corresponds is unknown. What we 
 are sure of is that our consciousness is a very inadequate representative 
 of what goes on in our cortex. 
 
 § 2L The mental life which accompanies these functions consists of a 
 " stream of consciousness " in which we can generally distinguish many 
 
 " states " or different " contents " of consciousness. These 
 ^ . ■ '' contents" (or rather, as we shall see, certain distinffuish- 
 
 able aspects of these contents) we divide, as before indi- 
 cated, into three sorts : (1) Contents of Feeling ; (2) Contents of Intellect ; 
 and (3) Contents of Will. The contents of Feeling form whatever consti- 
 tutes the immediate value for us, of the passing experience, as satisfactory 
 or unsatisfactory. The contents of Intellect are such as have to do with 
 our application of past experience to the present facts. The contents of 
 Will are such as have to do with our direction of our own activities. 
 
 § 22. The " stream of consciousness " is the name frequently applied 
 to what passes in our mental life, because, mentally speaking, we live in 
 a state of constant inner change, so that no portion of our consciousness 
 ever remains long without some alteration, while most of our contents are 
 always changing pretty rapidly. On the other hand, the changes in our 
 iimer state are, in general, however swift they may be, still somewhat 
 gradual when compared with the swifter physical changes known to us. 
 A flash of lightning lasts very much longer for our sight than it does as 
 a fact in the physical world. This is ]mrtly due to the "inertia" of the 
 retina of the eye. Bat a similar " inertia " holds of all our central processes. 
 Every mental experience always joins on, more or less, to subsequent ex- 
 periences, and in general to previous experiences also. A new experience 
 gradually wins our attention, reaches its height, and dies away as our 
 attention is turned to the next ; and even in very sudden experiences this 
 
THE STREAM OF CONSCIOUSNESS. 19 T 
 
 relatively i^raduul character of the process can be noted, if not at the 
 beginning then at the end of the experience, as it slips away into a mere 
 memory. If one listens to any simple rhythm, such as the ticking of a 
 watch, one can note how the succession of separate ticks is viewed by our 
 consciousness in such a way that the successive beats do not stand as 
 merely separate facts, but are always elements in the whole experienced 
 rhythm to which they seem to belong, while the successive presentations 
 of the rhythm form a sort of stream of events, each one of which gradu- 
 ally dies out of mind as the new event enters. In consciousness there is 
 no such thing as an indivisible present moment. What happens in our 
 minds during any one thousandth of a second of even the busiest inner 
 life none of us can possibly make out. The contents of mind, as we know 
 them in the " psychological present," constitute at the vei-y least a con- 
 siderable and flowing series of changes, the least appreciable portion of 
 which takes up a considerable fraction of a second. 
 
 As for these "contents" themselves of the stream of consciousness, it 
 is well to say at once that they never form any mei^e collection of " ideas " 
 or of other simple and divided states. Consciousness is not a shower of 
 shot, but a stream with distinguishable ideas or other such clearer mental 
 contents floating on its surface. What we find in any passing moment is 
 a little portion of the " stream," a " pulse " or " wave " of mental change, 
 some of whose contents may be pretty sharply distinguished from the 
 rest, while the body of the stream consists of contents that can no longer 
 be sharply sundered from one another. If one listens to music, the notes 
 or the chords may. in their series as they pass, appear as sharply sepa- 
 rable contents. But these stand out, or float, upon a stream of mental 
 life which includes one's estimate of the time sequence of the music as a 
 whole, one's pleasure in hearing the music, one's train of associated memo- 
 ries, one's general sense of the current bodily comfort and discomfort, 
 and much more of the sort, which no man can analyse into any collection 
 of separate or even separable states. In consequence, we are never able, 
 by any device at our disposal, to tell with certainty the ivhole of what is, 
 or just w^as, present to any one moment of our conscious life. The old 
 question w^hether one can have "more than one idea at a time" present 
 to one's mind is a question absurdly put. Present at any one time to 
 one's mind is a small portion of the flowing stream of mental contents, 
 in which one can in general distinguish at least two, and sometimes de- 
 cidedly more, elements of content (perceptions, feelings, images, ideas, 
 words, impulses, motives, hopes, intentions, or the like\ while beside and 
 beneath what one can distinguish there is the body of the stream or 
 (to change the metaphor) the background of consciousness, where one 
 can no longer distinguish anything in detail, although in some other 
 moment one may easily note how the whole background has changed. 
 
198 OUTLINES OF PSYCHOLOGY. 
 
 § 23. As for the ditfercnt sorts of contents, it is also well to say at once 
 that they can be distinguished rather than separated. AVhen we distin- 
 guisli feeling — /. e.y the current direct sense of the present value of what 
 is liappening to us — from intellect — /. e., the mental process of profiting 
 by and using our. past experience in our present consciousness — and when 
 we say that contents representing both feeling and intellect continually })as8 
 before the mind, w'hat we mean is not that some of our distinguishal)le 
 contents [c. (/., ideas, such as one's ** idea of a horse ") belong exclusively 
 among the intellectual facts, while other coiitents {e. (j., pains, such as 
 the pangs of chagrin or of a toothache) belong among the facts of feel- 
 ing. On the contrary, all facts or contents of the inner life are facts of 
 feeling, and all are also facts of intellect. But some arc more exclusively 
 valuable from the one point of view and some from the other. Thus I 
 have pass before me the image of a number, say 500, or of a word, say 
 physiology. Such mental contents are undoubtedly to be called rather in- 
 tellectual facts than anything else ; for by virtue of such contents I ap- 
 ply my past experience to the interpretation of my i)resent needs. These 
 are what people usually mean by " pure ideas '' — cold, unemotional. But 
 a closer inspection shows that one never attends to such an idea unless, at 
 the time, it is " interesting" — i. <?., unless, as a fact in consciousness, it has 
 a sort of present value, a colour of feeling about it, which makes it worth 
 holding as it passes. In the worst case, even our relative " indifference " 
 to an idea that we reject from our present notice is itself an aspect of the 
 passing fact which we now feel or estimate. This fact, then, involves 
 some slight element of satisfaction or of dissatisfaction. Thus all those 
 mental contents by means of which we apply past experience to present 
 needs are also contents that have a present value for feeling. On the 
 other hand, however, no feeling, however intense, occurs to an adult mind 
 without being more or less viewed by us in its relation to past experience. 
 It is recognised, or regarded as strange, or is otherwise commented upon 
 as related to one's past. And thus, though sometimes in a very dim way, 
 it is regarded by ourselves as an intellectual fact. 
 
 V. THE FEELINGS. 
 
 § 24. We pass next to the special classes of contents, and first to the 
 
 feelings. Complex masses of very marked feelings present together are 
 
 called emotions. The feelings (compare § 13, § 21, and 
 
 Relation of Feeling ,, ... v x i ^ t j.i xx 
 
 . ,, : the section immediateiv i)recedinc; the present) are not a 
 
 to Consciousness. • ^ ?-< i / 
 
 separate or se])arable group of the contents of the mind, 
 but by this woi'd we mean all the contents of the " stream of conscious- 
 ness " in HO fa I' as. at t/ie nioinent of their passing, they have an immedi^ 
 ate value., either in themselves or in view of their relations to other con- 
 tents. Thus, again, feeling is another name, of course, for what is often 
 
THE FEELINGS AND THEIR TYPES. 100 
 
 said to give the passing states their inoinentary *' wortli " or to make them 
 "worthless." V>y virtue of sucli worth or worthlessness tliey Kcem, as 
 they pass, " satisfaetory " or " unsatisfactory." Now, some facts of con- 
 sciousness are " cold," and their colour of worth (the degree of feeling 
 which attends them, and which forms one aspect of them) is small. These 
 colder experiences are usually treated as if they wholly belonged to some 
 other class than the feelings — e. ^., to intellect. But, as a fact, these con- 
 tents, too, have an aspect which gives us a right to class them, precisely 
 in this aspect, with the feelings ; for, after all, the whole of consciousness 
 and every part of it has its passing value. Nor can one in any fashion 
 so separate out the feelings from their entanglement with the other aspects 
 of mental life as to treat them as if they could exist alone. The whole 
 stream of consciousness is coloured with interests, or with " what makes 
 life interesting," whether the particular contents be satisfactory or un- 
 satisfactory. Names which denote contents or masses of contents, so 
 far as they are contents of feeling, are such names as joy. grief, anger, 
 unrest, peace, happiness, unhappiness, surprise, misery, contentment, etc. 
 
 This general character of being momentarily satisfactory or unsatis- 
 factory is itself one which appears in our mental contents in the most 
 
 varied fashions. Psychologists usually attempt to sim- 
 and Pain. P^^^-^ ^^^® matter by calling what makes the passing colour 
 
 of feeling satisfactory its jjleasur able, and what makes 
 it unsatisfactory its painful tone or quality. In fact, the names jjleastire 
 and pain, suggesting, as they at once do, rather the stronger and simpler 
 experiences that we get in the world of feeling than the fainter and more 
 complex experiences, invite us to reduce our account of our feelings to a 
 relatively simple formula. Pleasures and pains are unquestionably, in at 
 least one aspect of their conscious existence, feelings — i.e., they involve as- 
 pects of passing experience such as give it momentary value for us, and such 
 are most obviously marked aspects of raanj'^ of the passing experiences that 
 we get through our sense-organs. A toothache is a pain. It is also, to 
 be sure, more than merely painful feeling. It has its intellectual aspect, 
 since one recognises it, relates it to past experiences, localises it in the lower 
 or in the upper jaw, and is led by its presence to think of its probable causes. 
 It has its volitional aspect, since it forms an essential part in one's con- 
 sciousness of the plan or act of trying to get rid of it, say by resolving to 
 visit a dentist. But regarded as mere feeling, this pain is a fact of pass- 
 ing consciousness, whose " colour " or " worth," distinguishable from all 
 its other characters, lies in the fact that it is not only unsatisfactory, but 
 " intolerable." If one failed to recognise or to localise it, if one could 
 get it into no relation to past experience, if one had no plan for getting 
 rid of it, if one could form no resolve about it, still (so one may by ab- 
 straction insist) there ivould remain the brute fact of its intoleral)leness — a 
 
200 OUTLINES OF PSYCHOLOGY. 
 
 matter of unretloctive ]^a>5ini!^ estimate — an intense eolouriniij of the pain 
 as a feeling. A similar analysis would hokl for the intenser pleasures, 
 except that they have about them the contrasting colour of immediate 
 satisfactoriness, or " attractiveness," or " aeceptaljleness." The intoler- 
 ableness of a violent ]xiin. the momentary attractiveness of a keen pleas- 
 ure, may also be said to be ]iresent in consciousness as possessing an in- 
 tensity — i. e., as being greater or less in a)nount. x\nd thus such feelings 
 are apparently quantities, and are sometimes spoken of by psychologists 
 as if they were measurable (juantities. And from this point of view some 
 have defined, on the basis of such facts, the general maxim of all our 
 ]M-udence as being the rule : '' So act as to get the greatest sum of pleas- 
 ures and the least total amouTit of pains," thus assuming that we can at 
 least roughly compute and sum up our quantities of pleasure and pain. 
 
 If such an analysis is to hold of the simpler cases, why not extend it 
 (so one may say) to the more complex and subtle experiences of feeling ? 
 The masses of feeling which constitute what we call " joy " M'ould thus 
 be nothing but groups or streams of pleasures. " Sorrow " would mean 
 a complex of many pains. " Surprise " is either mainly jileasurable in 
 colour or mainly painful, and, according to this view, would be, as a feel- 
 inf, made up of pleasure and pain more or less mixed, and so sometimes 
 of pleasures almost alone or of pains almost alone. Thus all feeling, as 
 such, would mean the pleasure-pain aspect of the contents of our con- 
 sciousness, and the whole theory of the feelings would ])e reduced to the 
 theory of the nature and the varying intensities and combinations of our 
 ]>leasures and pains. This, then, is a frequent theory as to the feelings. 
 
 But it may well be questioned whether such an account is uot a merely 
 artificial simplification of the enormously complex facts of the world of 
 feeling. Pleasures and pains, in the ty])ical case, are names especially 
 associated in our minds with the experiences of certain of our senses. A 
 burn or a toothache is a sensory experience, whose disagreeable or unsat- 
 isfactory tone is only one aspect of its nature. It has also its intellectually 
 important character, since, as just pointed out, it is usually pretty clearly 
 localised, and is, like any other sensory experience, referred by us to a 
 source outside of ourselves. Now, the clear and unmistakable character 
 of our more decided sensory pains — which are, not only in the just-men- 
 tioned respects, facts like the rest of our sensory contents, but also, like 
 our other disagreeable feelings, unsatisfactory — this very definiteness of 
 character, renders these more violent sensory pains poor examples to illus- 
 trate the peculiarly subtle and complex facts of feeling in general ; for 
 our feelings, while always either intensely, or vaguely, or in a relatively 
 indifferent way satisfactory or unsatisfactory to us, still show many other 
 characters present in them besides those of the sensory pleasures and 
 pains. Consider, for instance, the masses of feeling which make up won- 
 
FEELING IN RELATION TO PLEASUEE AND PAIN. 201 
 
 der, anger, reverence, our intellcetual interests in genei-al, or our feelings 
 of the "sense of humour." Conirnon to all these cases is the presence of 
 values — i. e., of objects of combined satisfactions and dissatisfactions. But 
 hov^r hard it is to be content with reducing, in all cases alike, the satisfac- 
 tion to pleasure, the dissatisfaction to pain ! That this can be done is a 
 mere dogma of certain psychologists. 
 
 Another consideration enforces this difficulty. In all our waking life 
 an element of dissatisfaction is in so far mingled with our experience as 
 it is true that we are always interested in passing on from any experience 
 to the next. If we have a satisfactory pleasure, m'c want it to be still 
 more intense, and so are at the same time dissatisfied. If we listen to 
 music, we are always expecting the next note or chord to the very end. 
 If we are attentive, we are looking for more clearness as to the object of 
 our attention. And so consciousness seems to be largely a concern in 
 what shall come next. But this universal inner restlessness of conscious- 
 ness, variable in degree, but apparently always present, however keen our 
 pleasures — is this mere restlessness itself a pain ? Yet it surely involves a 
 certain element of continual dissatisfaction w'ith the present. On the 
 other hand, whatever interests us, and so draws our attention, seems to be 
 an object of wdiich we in such wise want more that, Mdien we get this 
 " more," there is a certain element of relative satisfaction in the attain-- 
 ment. Yet a novel pang of any sort, painful in itself, may be an ol»ject 
 of just such interest. So far as we get satisfaction of this interest, we 
 accordingly get, for the time, more of the pain before our clear conscious- 
 ness than we should otherwise get. Shall one change the formula and 
 say that here the getting of a pain is a satisfaction ? An angry man, at 
 all events, often takes a keen satisfaction in dwelling upon thoughts and 
 deeds that are at the moment giving him great pain. Still further, in 
 brooding grief, a mourner, refusing to be comforted, finds what he him- 
 self calls a "■ gloomy satisfaction " in dwelling on his loss. The promise 
 of a cheerful or even highly pleasurable distraction he may then reject, 
 even when he begins actually to feel the coming pleasure, with the keenest 
 dissatisfaction. Very much the same is true of a man " in the sulks." 
 N'ervous troubles of many sorts, insistent ideas, forebodings, morbid ques- 
 tionings, and the like, include many cases where nothing so attracts the 
 sufferer as a content of consciousness which meanwhile gives him inner 
 pain. Even the tune that " runs in one's head " often illustrates this sort 
 of thing. 
 
 On the whole, then, it may well be affirmed that while there are many 
 pains which are always merely unsatisfactory, and many pleasures which 
 are always attractive, the terms satisfaction and dissatisfaction name a 
 character present in mental states which is of a much wider range than 
 the characters indicated by the words pleasure and pain. TTe may find 
 
202 OUTLINES OF PSYCHOLOGY. 
 
 some satisfaction in a pain, sonic dissatisfaction in a jdcasnrc, and mncli 
 interest in experiences Nvliich have little pleasure or ])ain about them. 
 Desire and aversion, attractiveness and distastefulness, a<2;recablcness and 
 disagreeableness — these are still other names for aspects or for cases of the 
 facts of feeling. But that pain is conunonly disagreeable, that pleasure 
 is eonnnonly attractive — this does not warrant us in saying that dissatis- 
 faction means pain, or that satisfaction means pleasure. 
 
 Feeling, then, is the valuation of the contents of consciousness, or the 
 presence of values in consciousness. And value means, primarily, satis- 
 factory or unsatisfactory character. The unsatisfactory, as such, we in 
 the end reject. It arouses devices to get rid of it, and so " spurs on 
 the will." The satisfactory, as such, we rest in and accept. Meanwhile, 
 the two coexist and are interwoven together ; and consciousness is never 
 without some element of dissatisfaction, and rather seldom, at least in 
 any fairly normal life, without some element of satisfaction in it. 
 
 The physiological basis of the feelings is still, in many regions, extremely 
 obscure. Pleasures and pains of a sensory type are dependent in part upon 
 the degrees of stimulation to which our sense-organs are at any time sub- 
 jected. Over-intense stimulation of any sense-organ produces pain. The 
 pleasures of sense are all of them the results of relatively moderate stimu- 
 lations. But there are many sensory nerves that never give any sharply 
 marked and well-localised sensations except painful ones {e. g., the sensory 
 nerves of the viscera, of the teeth, etc.). Altered organic conditions, such 
 as inflammation, also give rise to a high sensibility to pain. Both mus- 
 cular and nervous fatigue are, again, well-known conditions of painful 
 sensations, although the theory of the process is still obscure. On the 
 other hand, painful sensations may be eliminated by some anaesthetics, or 
 by some diseased nervous conditions, without the disappearance of other 
 forms of sensation {e. g.^ of touch-sensation) in the parts affected. The 
 painful sensations, when aroused through sensory stimulation, seem to 
 travel in part upon paths through the spinal cord which are different 
 from those travelled by other stimulations, so that pain does not always 
 reach consciousness as soon as do other sensations aroused at the same 
 time, and by the disturbance of the same region on the skin. If one 
 
 passes to other sorts of feeling, desires and aver- 
 •Physical Relations . ,, i ■ i , • ,• 
 
 f th F' r s sions express themselves m characteristic movements 
 
 (see § 13) ; and it is probable that the incoming mus- 
 cular sensations produced by these expressive movements (movements 
 whose causes lie in the hereditary and habitual nervous tendencies of our 
 organisms) form part in our very feeling of the desire or the aversion 
 itself. (Upon this view Prof. Miinsterberg has recently laid stress.) Our 
 more complex emotions are also doubtless deeply tinged by masses of 
 other internal sensations more or less indirectlv derived from the orji^ans 
 
THE PHYSICAL BAHIH OF THE FEP:L1NGB. 203 
 
 affected by the expressive movements, and tlius much of our conscious 
 feeling is actually secondary to what is called the expression of the feel- 
 ing. Thus our griefs alter their emotional tone according to the sort of 
 external expression that chances to be forcing itself upon ns. Tearless 
 grief is one thing, tearful grief another; and no doubt an important part 
 of the inner attitude of mind which constitutes the grief is determined 
 by our very sensory consciousness of how we are expressing ourselves. 
 This manner of expression is largely determined by our inherited instincts 
 and acquired habits. Reacting to a given environment in a given way, 
 we then feel our own reaction. In telling about the tone of one's own 
 emotions one often has to say, "My heart stood still," or " I felt a chok- 
 ing in my throat," or " I found myself gasping." The poets are accus- 
 tomed thus to remind us of emotional tones by mentioning their manner 
 of expression, and by so suggesting how this manner' of expression itself 
 feels to one who finds himself giving way to it. Thus Bayard Taylor 
 tells how, as the soldiers in the Sebastopol trendies sang " Annie Laurie," 
 " something upon the soldiers' cheeks washed out the stains of powder." 
 This importance of the instinctive or habitual expressive movement as a 
 primary reaction to a given environment — the emotion being the sec- 
 ondary result or feeling of this reaction — has been of late especially in- 
 sisted upon by Prof. James. 
 
 Meanwhile, however, there can be no doubt that, in addition to all 
 states of our organs of external and of internal bodily sense, purely cen- 
 
 „ . ^ . tral nervous conditions have much to do with the tone 
 
 Bram-fatigue. ^ • . •, c • t-v . » . ,. •,, 
 
 and mtensity or our emotions. J3ram-fatigue of all 
 
 degrees, from the lightest to the gravest, is likely to show itself in altered 
 emotional tones, even where it gives few other easily marked signs of its 
 presence. There are known diseases of the brain (such as the extreme 
 forms of nervous exhaustion known as melancholia and mania) whose 
 principal symptoms are profound alterations of emotional tone. The 
 phenomena of these disorders, as well as other known facts, have been 
 regarded by many as indicating that the current conditions of the blood 
 supply in the brain are direct causes of our emotional states. 
 
 § 25. The practical aspect of the life of the feelings, and in particular 
 of the masses of feeling called the emotions, is of great importance. 
 . Whatever their precise physiological explanation may 
 
 be, we are in any case warranted in saying that in the 
 feelings, and in their expressive signs, we have in general an especially 
 useful index of the current state of the nervous centres viewed as a 
 whole. The state of a man's present feelings may indeed, at first 
 sight, throw comparatively little light on his character or on his ex- 
 perience, except where one already knows what opportunities he has 
 had to cultivate or to learn to control just these feelings. It is noto- 
 
o,^4 OUTLINES OF PSYCHOLOGY. 
 
 riously unfair to jiulixo any man by bis momentary mood. Tbe now 
 violently angry man may be, in general, a person of amiable self-control. 
 Especially absurd, as well as uncliaritable, is, tlierefore, tbe babit of tbose 
 wlio regard a cliaracter as best to be read by considering tbe most pas- 
 sionate or otherwise marked emotional excesses, or tbe weakest or most 
 foolish moods which are known to occur in the life of its possessor. So 
 to judge is to commit what may be called the scandalmonger's fallacy. 
 But, on the other hand, for a good observer, an emotional reaction, re- 
 ararded with due reference to its external causes, does tend to indicate the 
 passing general nervous state in a way which is of great value for psycho- 
 logical diagnosis. Nervous exhaustion, mental over- 
 
 Emohonnl gtniin, show themselves (as lust pointed out) first of all 
 
 Variability. ' . , ... Ji • i i • ^ 
 
 in emotional variability, ihis the popular mind gen- 
 erally recognises. What is not popularly so well recognised is the fact 
 that this emotional variability of overstrain is not by any means always 
 equivalent to the tendency to " black moods " or to ill-temper, but may 
 show itself — and in grave forms, too — in emotions of a relatively cheerful 
 or benign seeming. The sufferer from nervous overstrain may have 
 hours, or even periods, of abnormal vivacity, when his friends, remem- 
 bering his former fits of gloom, feel that now he is surely restored to 
 himself since he is so ambitious and animated. But the symptomatic 
 value of an emotional state lies rather in the degree of its variation from 
 the normal mean of the individual temperament than in its agreeable or 
 disagreeable seeming. 
 
 If emotional variability is often a useful index of nervous overstrain, 
 
 the permanent common qnality at tJie basis of any vian's iiornial emotions., 
 
 if once made out, is indeed also an important index 
 
 mo lona ^^ ^^ ^j^^ fundamental type of his nervous temper Or 
 
 Undertone. '^ ax vi jt ^ 
 
 ment. By this one does not always mean m?, predomi- 
 nant emotions, which may be made predominant merely by his business or 
 his fortune. One means something deeper. The emotional ^indertone, as 
 one may call it, of any given individual is always one of the most interest- 
 ins; features of his character. It must be made out by observing him in a 
 number of sharply contrasted passing moods, especially when such moods 
 are determined by circumstances rather unfamiliar to him. One then 
 finds it henceforth curiously independent of fortune. The fundamentally 
 cheerful man is thus to be found, even in the midst of the keenest dis- 
 tress, and even when he cries out with his bitterest anguish, still, at heart, 
 not really despairing, but in possession of a certain fundamental sense of 
 satisfaction in living, which no mere fortune can overcome and which 
 only a serious brain disorder can set aside. There are other men, and 
 often very resolute men too, who have withal a deep-seated emotional 
 distrust of life, which never leaves them in the midst of tlie most joyous 
 
THE PRACTICAL ASPECT OB^ THE FEELINGS. 205 
 
 good luck. They may bo enduring, patient, even lici'oic, but they ai'e 
 never on decidedly good terms with tlieir own inner state. Such under- 
 tones of emotion, when one has learned to observe them in any individual, 
 remind one of the temper of an old violin, or of the quality of an indi- 
 vidual's voice — facts which remain amid the greatest varieties in the 
 music played or sung. Like the violin's temper and the voice's quality, 
 this emotional undertone is unquestionably the accompaniment of a per- 
 manent physical organisation. In case of the emotional undertone this is 
 the inherited temperament of the brain — a fact which, when once thus 
 diagnosed, may be henceforth counted upon with great assurance. The 
 emotional undertone appears to be noticeable in many cases fairly early 
 in childhood, although it is liable to great changes in the course of devel- 
 opment, particularly in early youth. 
 
 Abnormal emotions may occur in a great variety of forms. They 
 appear not only as variations from the normal intensity or steadiness of 
 the otherwise unobjectionable emotions, but as associa- 
 Emotions ^ions of emotions with objects, situations, or habits, with 
 which these emotions ought not to be associated in a 
 healthy organism. Our feelings, as we have seen, accompany certain 
 nervous conditions which colour, and in part determine, our whole " ad- 
 justment to our environment." If the feelings ai'e distorted, this indicates 
 a distortion of these nervous conditions, and so this whole adjustment 
 must tend to fail. Conversely, a failure of our adjustment, if determined 
 by nervous conditions which express themselves in signs of feeling, is 
 itself a proof that the feelings are worthy to be called abnormal ; for our 
 main test of the "normal" is the power of successful adjustment to one's 
 world. All violent passions in ordinary life are therefore relatively 
 abnormal emotional states. The man who adjusts himself well "keeps 
 his head," whatever the temptations to passing moods of confusion. Just 
 so, however, morbid fondnesses for dangerous objects or deeds {e. g., a 
 craving for intoxicants or a love for unwholesome reading) demonstrate 
 their unhealthfulness by the very fact that their results are instances of 
 moral or of physical failure to adjust one's self to one's environment. 
 But the morbid emotion need not be either a violent or a special experi- 
 ence. The whole emotional undertone of any " perverse " character is, in 
 its own degree, an abnormity ; and such an abnormity may calmly outlast 
 years of training and thousands of broken and spasmodic resolutions. In 
 fact, what is called "perversity" of character generally means simply an 
 abnormity of the emotional undertone, and is as hard to alter as the latter. 
 
 Yet, of course, great and enduring emotional abnormities can be the 
 result, not of heredity, but of training. Some of our emotions {e. g., our 
 cheerful or gloomy undertone) are principally due to heredity ; but others 
 are very much moulded as they develop in our early lives. Hence the 
 
206 OUTLINES OF PSYCHOLOGY. 
 
 iniportance of care as to guarding the growth of such sorts of emotion as 
 are subject to the greatest degree of development during childhood and 
 youth. 
 
 A striking and critical instance is here the whole world of tlie sexual 
 emotions, including the romantic and the " sentimental '' tendencies. 
 These, normally absent or only sporadically hinted at in the emotional life 
 of childhood, develop with great rapidity at puberty and for some years 
 afterwards. They normally occur at first as the ])henomena of reaction 
 to particular series of facts in the environment, and they occur both with 
 and apart from more doiinite acts. But they also normally tend to spread 
 through and colour gentlv one's whole life to its vei-y hio-hest and noblest 
 levels. Keligious emotion, for instance, has deep relations to them. It is 
 the business of parents, teachers, and other guardians of youth, to see to 
 it that these more subtle emotional reactions are controlled by duly con- 
 trolling both this environment and the youth's sentimental and passionate 
 relations thereto. The laws of brain habit determine the principle that 
 when experiences are keen and novel, any reaction then accomplished de- 
 termines the brain's whole future to a degree never later equalled by other 
 actions of the same sort and number. Does one early form an association 
 between certain objects and certain vigorous emotional responses, one's 
 emotions are thenceforth given what may prove a permanent " set." 
 This, as recent investigations have more and more shown, is peculiarly 
 the case with the sexually emotional reactions. Whether a youth is to be 
 a libertine at heart or not, and whether or no his sexual imagination and 
 feeling are to be definitively perverted even while they grow (perverted 
 in fashions that are sometimes horribly grotesque and mischievous), is 
 often determined by the earliest stages of his sexual experience, wherein 
 must be psychologically included most of his youthfully sentimental ex- 
 perience, together with even his religious emotions. However convention, 
 or resolution, or morality may later teach him to control his more definite or 
 more external acts, the " set " of his inner sexual consciousness, and of all 
 that more or less unconsciously gets built up thereupon, the purity or im- 
 purity of his feeling as a whole, his capacity for honourable love, the 
 whole colouring of even his highest social emotions, his love of honour, 
 his truthfulness, his humanity of sentiment, may be established for life by 
 the emotional responses that he makes to a comparatively few situations 
 in his early world of ignorant youthful sexuality — a world to him uncom- 
 jjrehended, and one where too often, alas, he is wholly unguided. It is 
 one of the saddest of psychological blunders that even wiser guides often 
 leave the young to fight this confusing battle of these inner emotional 
 states alone, and so such guardians, entrusting the young to the mere 
 chances of foolish companionships, subject some of tlie most delicate and 
 momentous emotional functions of the 3'outhful brain to a treatment that 
 
THE PEACTICAL ESTIMATE OF FEELINGS. 207 
 
 no man of sense would give to liis watch, or even to his boots. 'J'o be 
 sure, ■& false liglit, a deceitful guidance, an ignorant soi-t of terror at pos- 
 sible mishaps, would in these matters itself determine or even constitute a 
 perversion. Guidance does not mean mere random meddling. And even 
 a cheerful indifference accomplishes far more than a morbid anxiety. 
 I )Ut one need not ask for a false artiKciality of instruction, only for a cool 
 and reasonable "symptomatic guidance" of the young, given confiden- 
 tially and treated as a matter of course, by watchful guardians ; given, 
 moreover, just when the charge is seen actually to need it. There is, 
 meanwhile, no one routine of instruction as to such matters. P^ach case 
 ought to be watched for itself. 
 
 The mention of abnormal emotions leads to the practical problem of 
 estimating their significance when once they are present. Kegarding the 
 phenomena of any given morbid emotional state, whether permanent or 
 transient, it is a general rule that, of two morbidly emotional moods or 
 individuals, viewed in general, and apart from special causes : the cheer- 
 fully morbid is likely to prove worse than the painfully morbid. False 
 despair, within limits, is, psychologically speaking, much more benign 
 than false confidence or than vainglory. One sees classic instances of this 
 in the case of the before-mentioned fundamentally " perverse " charac- 
 ters. Such persons, in case their abnormal emotional " undertone " is one 
 of dissatisfaction (of gloom, or self-distrust, of morbid conscientiousness), 
 may be indeed, in the strict sense, incurable, since one cannot provide them 
 with a new heredity. But they can often learn, within their limits, how 
 to get a very effective sort of self-control, and to live tolerable or even 
 nobly useful lives, simply because they suffer for their frailties, and con- 
 sequently strive for some sort of salvation. But the cheerfully perverse, 
 whose undertone is often one of vainglory, and who accordingly revel in 
 their own perversities, are much more hopeless cases. You may give 
 them the clearest sort of knowledge, and they may have a high order of 
 intelligence with which to grasp it, to restate it in their own words, and 
 even to preach it ; yet at heart they understand their own perversity only 
 in secret, or openly, to admire it. The sole hope lies in getting them where 
 they keenly suffer, not, to be sure, any external or arbitrary penalty, but 
 what they can come to view as the natural result of their own characters. 
 Even then, however, it is a ceaseless marvel to the onlooker how much 
 they can suffer without either losing their false optimism or essentially 
 mending their evil ways. They may change numerous special habits of 
 conduct, but they still cling to the central enemies of their life. Self- 
 induced anguish is often their only possible medicine, yet they tolerate it 
 in simply enormous doses, and often go on as before to their doom, per- 
 sisting that they have learned wisdom, but daily manifesting that they 
 are fools. 
 
208 OUTLINES OF PSYCHOLOGY. 
 
 A similar rule holds, as said above, regarding the judgment of even 
 passing moods. A state of nervous fatigue whieh is extremely disagree- 
 able is in general nearer to the normal than a condition in which we are 
 actually very tired, but feel extraordinarily vivacious. Cheerful insomnia 
 is far worse than even a decidedly painful sense of weariness when ac- 
 companied by sleepiness. Even anger that is uncontrollably violent, 
 and that causes the keenest suffering to the angry individual, is less abnor- 
 mal than that lucid type of fnry which its possessor fairl}' enjoys and nurses. 
 Temper of the Urst sort quickly wears itself out in pathetically helpless 
 reactions. Temper of the cheerily malicious sort may make its possessor 
 a criminal before it lets go its hold. After great calamities people are 
 often '* dazed " into an ominous insensitiveness. The return to the nor- 
 mal is then marked by an anguish which the sufferer himself welcomes as 
 a sign that he is again " coming to his senses. " Thus in general good 
 observers are not easil}' appalled by the mere appearance of suffering. 
 Mental anguish, viewed as a psychological phenomenon, and apart from 
 any otherwise known and serious external cause for sorrow, is always an 
 abnormal incident; but it is frequently, in its consequences benign, in its 
 direct indications relatively insignificant. 
 
 VI. THE INTELLECT, OR THE ORGANISATION OF EXPERIENCE. 
 
 § 26. All the contents of the stream of consciousness, in so far as 
 they constitute experience — i. e., in so far as we learn from them — are 
 contents of Intellect. AVhen we viewed these contents as feelings we 
 found in them, everywhere present, a certain colour of passing estimate, 
 an immediate sense that they were worth something to us at any given 
 moment, or that they then had an interest to us. When we view these 
 same contents in another light we observe that not merely their passing 
 interest, as such, has a real importance for us, but that this momentary 
 value, as we feel it, is but a hint, and sometimes a poor one, of the real 
 place that they have in relation to our adjustment to our environment. 
 Not only that given states now pass, hut that certain former states have 
 heen^ guides us in our deali-ng with the world. In so far as we either 
 recognise or' otherwise j^^'ofit hy this relation hetween our present and our 
 former states^ or in so far as, hy virtue of such a relation to the past 
 states, we are led to expect any future state, our mental states are said to 
 he experiences, and they then have, in addition to their direct value as 
 feelings, an indirect value as indications of truth, as sources of 
 knowledge, or, once more, as intellectual conditions. This "indirect 
 value" we shall henceforth call their " intellectual value." 
 
 The life of the intellect is far too rich a field to be even fairly sketched 
 in this study. What here follows is limited by the purely practical aim 
 before us. 
 
THE BASIS OF INTELLECT. 200 
 
 Our past experiences are now of use to us in our adjustment to our 
 
 environment, because they were associated with nervous changes w^hich 
 
 tended to mould our conduct into conformity with ex- 
 
 „ ' ternal pliysical facts, and which have estabhshed certain 
 
 more or less fixed habits of brain. Our present expe- 
 riences, as such, now serve to guide us, in so far as their physical accom- 
 paniments appeal to these established brain habits ; or again, in so far as 
 these new experiences tend to modify the old habits. 27te jjower to learn 
 hy experience is founded upon the power of the hrain to acquire and to 
 retain habits, (Cf. § 16.) At any moment a disorder of brain whicli 
 suspends or destroys the nervous conditions of habit impairs in the same 
 degree the intellectual powers. These considerations are fundamental in 
 the whole theory of the psychology of the intellect. 
 
 On the other hand, by no means the whole of our experiences are of 
 equal value for our process of learning by experience, or for arousing us 
 to make use, at any moment, of what we have formerly learned. Many 
 inner facts are of great passing importance for feeling, which are of little 
 intellectual concern. One eats three meals daily and should enjoy them 
 heartily ; but since one has come to mature years one has learned com- 
 paratively little by such experiences, unless one is a housekeeper, a gour- 
 mand, or a cook. But one may have seen but once a given landscape, or 
 scientific experiment, or man, and may have learned a life's lesson from 
 that experience. An experience is intellectually valuable in proportion 
 as it either moulds our habits or calls them into action. It is sometimes 
 said that the value in feeling of a given experience is universally in 
 inverse proportion to its intellectual value. This, as thus universally 
 stated, is not true. Dante's first boyish meeting with Beatrice moulded 
 his whole intellectual life, but was full of the deepest feeling at the mo- 
 ment of the meeting. But one can indeed say that the value in feeling 
 of a given experience bears no sort of constant relation to its intellectual 
 value. A burn is an intellectual experience, when it teaches a child to 
 dread the fire. But so is a light touch, say of a new fabric, if it teaches 
 a blind man to recognise henceforth that fabric. In general, violent 
 internal bodily pains {e. g., the colic or a headache) have comparatively 
 little intellectual value, because we too seldom rightly associate them with 
 their causes, so as to learn easily how to avoid them in future. More- 
 over, they last longer than they are needed for purposes of warning, and 
 our memory for their intensity is poor. On the other hand, very gentle 
 experiences, say the memories of past scenes, reproduced in the form of 
 very faint images, are, in all persons, of great intellectual importance. 
 as being connected with old habits of action. Pains of the external 
 sensory organs (burns, bruises, dazzling lights, etc.) play a great part in 
 our earliest intellectual education, but are normally of far less moment 
 IG 
 
210 OUTLINES OF PSYCHOLOGY. 
 
 later unless we learn some new art (^c. </., bie'vciing, or handling electric 
 apparatus). 
 
 So far for the vaguer variations in intellectual values. l)Ut now for 
 more precise rules. These are : 
 
 1. An experience is of intellectual value in proportion as, through the 
 laws of habit, it becomes linked with other experiences. jVo ea'pe/'ience 
 I H of 111} 1/ inh'Ilectnal importance in i^o far ax it stands alone. Its ner- 
 vous accompaniments in the central nervous system must be functionally 
 linked to processes that have been the accompaniments of former expe- 
 riences if it is to prove effective for intellectual ])urposes. This usually 
 haj)pens as follows : Let a new experience, «, resemble, in some delinite 
 fasliion, a former one, A. Then its nervous accompaniment will also 
 reseml)le and nearly reproduce functional processes formerly present in 
 the cortex. The law of habit runs that an old function, when once re- 
 produced, tends to induce those other processes which it induced, or with 
 which it was linked when it was before present in the brain (§ 16). The 
 new experience, «, resembling the former one, A, will therefore be accom- 
 panied by a process — viz., the reproduced A-process, that tends to pass over 
 into certain other definite and localised processes. These other processes 
 will somewhat correspond, however, in general to still other former ex- 
 periences which of old actually accompanied or immediately followed A, 
 since the A-process of old passed over into these other processes. Let 
 these other former experiences, as they originally were, be B, C, D. 
 Then a will now tend to be followed by experiences 5, c, <7, which more 
 or less resemble the former B, C, D, res])ectively. In this case a is said 
 
 to he linked hy association with these other experiences — 
 viz., J, c, d. For here the result of « is a tendency 
 (which may or may not at any one time prove effective) to the appear- 
 ance in our minds of experiences J, c, fZ, more or less resembling what 
 those other experiences (B, C, D) originally were. So, when I see an 
 apple-tree in winter, I may be reminded of the apples that were growing 
 there last summer. That is, the present experience of the tree is accom- 
 panied by central nervous processes in the cortex which (by habit) tend 
 to induce some of those nervous functions that were induced last summer 
 when I saw the tree in full leaf with the apples groM-ing. The latter 
 functions can never be wholly reinduced, but the result is a state which 
 includes something resembling, at least, a portion of them. This asso- 
 ciation of our experiences in groups is the primary condition of their 
 (jetting any intellectual importance. And here we meet with the psy- 
 "chological expression of the fact above observed, that intelligence espe- 
 cially shows itself in the adaptation of old habits to new needs. 
 
 2. The "background" of consciousness at any moment (see § 22) is 
 always of relatively small direct intellectual value for that moment, 
 
THE LAWS OF INTELLECT. * 211 
 
 altliougli, in case it supports the general "set" of our attention, it has 
 an indirect value ; and in case it long retains any definable character, 
 this character may slowly acquire an importance through its relation to 
 our habitual brain functions. Those states which stand out (or "float") 
 with a marked relief above or upon the general stream of consciousness 
 are of relatively great intellectual importance. Or, in other words, 
 experiences are of intellectual importance in propjortion to the marked 
 or definite character which they have in relation to the exjjeriences that 
 accompany them. Definite conscious experiences stand for markedly pre- 
 dominant functions of the cortex at the moment in ques- 
 tion. The more sharply localised the function in the 
 brain, the more definite is the brain habit which tends to be formed. 
 This principle lies at the basis of all effective attention. 
 
 3. In order that our states, viewed as a whole, should become at any 
 moment definite, and therefore intellectually valuable experiences, they 
 mMst possess, in a certain degree, unarTted differences from the sum total, 
 of the states which have immediately preceded them. It is this " shock of 
 difference " which accompanies the whole play of consciousness and makes 
 every intellectual process possible. Even when we long attend to one 
 object, we are busily " changing our minds " about it — questioning, con- 
 jecturing, observing various aspects, making use of dif- 
 
 Discrimination. '.. , ^ ^ -, , • • ,• m i ,, 
 
 ferent habits, trying various assertions, io liave one 
 
 idea" is to have no idea at all. Discrimination is thus an essential func- 
 tion of intellect. 
 
 4. But discrimination itself never stands alone. A mental state, in 
 order to be of relatively immediate intellectual importance, must not only 
 stand out in consciousness as against its background, and must not only 
 differ from what has preceded, but must further, as we have seen, stand 
 in connection with similar past experiences, since otherwise it appeals to 
 no habits of brain. These similar past experiences, when " represented " 
 
 at any moment, resemhle the present mental state. And 
 Identification. ,, . . -.i i , i • 
 
 they join with whatever else m present consciousness re- 
 sembles this new state, to help us to assimilate it. To know is to note not 
 only difference, but also resemblance ; not only contrast and variety, but 
 identity and harmony. An utterly strange state is of small intelltecual 
 value. And so, in addition to its associative connections, an intellectually 
 important state maist have relations of resemblance to its context in our 
 consciousness. Knowing is thus discrimination plus identification. This 
 is still another expression of the principle that intelligence means adapta- 
 tion of familiar facts to novel needs. 
 
 § 27. The classes of intellectual states are numerous. First in order, 
 and in importance as regards the original genesis of the intellectual life, 
 are the sensations. These are our momentary experiences, in so far as 
 
212 OUTLINES OF PSYCHOLOGY. 
 
 thev correspond to tlie excitations of the organs of sense. They therefore 
 accompany the inconiini>; stream of sensory disturbances of §§ 15 and 10, 
 above. ISo exh;iu>ri\(.' and iierft't-tlv satisfactory classifi- 
 cation 01 our sensations is yet possible, llie popular 
 division according to the "live senses " is certainly inadequate. From 
 our internal bodily organs vre receive many masses of ill-defined sensa- 
 tions of the "common sensibility." What is often confused together un- 
 der the name of " the sense of touch " involves numerous strongly con- 
 trasted experiences. Simple pressure, heat, cold, muscular sensation 
 pro]icr, joint-sensations — all tlicse need, for psychological puri)oses, to be 
 discriminated in what has sometimes been vieM'cd as " touch," while the 
 pains of touch-sensation have already been mentioned. In addition to the 
 foregoing, one must mention sensations which have a special organ in the 
 semicircular canals of the inner ear, and which are aroused by the mere 
 fact of the movement in space of the head or of the whole body. The 
 feelings of " dizziness" often accompany an extreme form of these sensa- 
 tions. Then come the popularly w^ell-recognised sensations of smell, taste, 
 hearing, and sight. But even here, in the sense of sight, some psycholo- 
 gists have been disposed to distinguish the sensations of movement in the 
 field of vision from the others, just as a similar division has been proposed 
 in case of the sense of touch itself. 
 
 AVe must leave, however, to special treatises the discussion of the 
 classes of sensation. Our interest lies in the general value of the sensa- 
 tions as experiences. This value depends upon the fact that the nervous 
 accompaniments of sensation — viz., the incoming streams of sensory im- 
 pressions — are the causes which excite and sup])ort that whole series of 
 interchanges of induced activities upon which the motor functions of the 
 brain depend, and by virtue of which our brain habits are formed. With- 
 out series oj" definite 6-<'»so?'y experiences no habits of hrain or of mind : 
 this is the great principle of the source of our experience. On the other 
 hand, in any given " set " of brain (cf. §§ 16, 17), those already-formed brain 
 habits are excited to which the incoming sensations favoured by that " set" 
 then and tlioi-e a]ipeal. As they are excited, the habits tend to become, 
 in their tiii'ii, in(»(liliL'd by the new sorts of sensory disturbance which 
 awaken them. In early experience this alteration is often very decided. 
 Later it tends to become often inappreciable. The principle of association 
 (§ 26) determines the result that sensations directly tend to arouse those 
 habits which were formed in the past by the action of sensory disturbances 
 similar to the present ones, in so far as the current iidiibitory "set" of 
 the brain does not interfere to prevent this result (§ 17). And the rule 
 thus holds : Without present sensory support^ no use of ohl hrain habits 
 — a rule which governs the whole current employment of our experience. 
 As a fact, even in the most absorbed meditation, we are constantly sup- 
 
THE INTELLECTUAL PROCESHEB. 213 
 
 ported by masses of fitting extei-iial (or internal bodily) sensations. One 
 thinks best on a given subject while reading certain books, sitting in a 
 given study, listening to a given speaker, holding a pen and writing, or 
 while getting whatever other experiences habit has made effective. 
 
 § 28. Of the enormously complex processes which follow upon sensa- 
 tion we can give only a hint. Our sensations never stand alone in the 
 maturer mind. They are effective only in so far as their nervous accom- 
 paniments awaken habits. But, as a fact, the habits of the brain have at 
 all times been moulded by great masses of sensory disturbances acting to- 
 gether. The results of current sensation are then, in genei-al, mental ex- 
 periences which more or less resemble past experiejices belonging at once 
 to many senses. The brain habits accordingly tend to a complex restora- 
 tion of former conditions. What we see reminds us not only of former 
 sights, but of former touches. The colour of an orange suggests its odour 
 and taste. The sound of a word may recall the appearance of the word as 
 written or printed. Now, these recalled experiences, usually rather faint 
 unless we dwell upon them, first tend, by reason of their swiftness and 
 faintness, to coalesce with the present experience, which then stands be- 
 fore us as a whole mental state, a group of interpreted sensations — a per- 
 ception. A perception, then, is a group of present 
 sensory experiences interpreted in terms of our past 
 experience of those outer objects which were similar to the one that has 
 aroused this group of sensations in us. The nervous process accompany- 
 ing the perception depends wholly upon our brain habits. The brain 
 tends to do again what it has done before. Just so, in our accompanyino- 
 mental life, we tend to recognise in the new what we have already experi- 
 enced in the old. Such habits of recognition may often lead us astray 
 — as -when we fail to note typographical errors, or fall prey to optical 
 illusions. 
 
 Upon a similar process, however, all our higher intellectual life de- 
 pends. Our memories are determined by associative functions. What 
 has been connected in experience tends to be connected 
 Imagination. ^" ^^®^- "^^^^ series of remembered experiences, again, 
 runs parallel to the reawakening of already-established 
 brain-habits. Our trains of inner imagination, even in the case where we 
 seem to ourselves most fantastic, are themselves the accompaniment of 
 reawakened brain functions whose results, instead of coalescing with our 
 sensations (as was the case with our perceptions), stand apart, so that we 
 often fail to note the ever-present support which our current sensations, 
 derived from the organs of external sense or from our internal bodily or- 
 gans, give to even our freest imaginative processes. Tet one has only to 
 note how the imagination of a dyspeptic, or of a sufferer from headache, 
 or of a person listening to an organ played in church, or watching moon- 
 
214 OUTLINES OF PSYCHOLOGY. 
 
 lii;ht sparkle on water, varies with the current sensations, to see how im- 
 aijination also involves brain-habits determined by current sensory im- 
 pressions. 
 
 Our organised relation to past experience is still more obvious in our 
 thoughts, which are everywhere interpretations of sen- 
 sations, of images, or of masses of other ideal contents, 
 by virtue of their relation to our former experience. 
 
 § 29. These higher modes of intellectual life — Perception, Imagina- 
 tion, Memory, Thought — recpiire, however, another set of considerations 
 to make even their general character at all intelligil)le. 
 
 Our sensations, we have said, suppui't our intellectual processes l>y 
 awakeninff brain-habits. But the brain is an organ that directs move- 
 
 ments, and the habits of the brain get their effective 
 Motor Tendencies. • • i • ^ i T • j. 
 
 expression eitiier m actual movements or m motor pro- 
 cesses which, although inhibited, are none the less present as tendencies. 
 Xow we actually have states of mind which correspond to such motor 
 tendencies, even when these are existent in an almost wholly inhibited 
 form, and merely as tendencies. 0\ir jperceptions as well as our higher 
 inteUecUtal process are in large jyart made up of mental material which 
 corresponds to more or less completely suppressed movements — movements 
 which we image^ in ahhreviated forms, even when we do not make them, 
 or movements whose residts we image even when we do not carry them 
 out. The motor aspect of the intellectual life constitutes one of its most 
 signiiicant features. Thonght is the correlate of present but suppressed 
 muscidar tendencies. These tendencies, aroused by sensory impressions, 
 woven into series by our past habits, adjusted to our present situation in 
 the most delicate fashions, by virtue of the similarity existent between 
 present and past experience, altered also by our present discriminations, 
 and inhibited, or at least reduced to very faint motor tendencies, by the 
 present " set " of the brain — these constitute the physical accompaniment 
 of our most abstract thinking, as well as of our perceptions, of our trains 
 of imagination, and of our memories. 
 
 For example, I hear a sudden sound. My perception of the direction 
 whence the sound comes is identical with my consciousness that, in order 
 to hear the sound better, I must turn my head to the right or to the left. 
 This consciousness accompanies an actual motor tendency (the result of 
 long-established brain-habits) to turn my head thus. To judge direction 
 is here to recognise that this noise meaiix this useful movement of adjust- 
 ment in so far as the sound will be better heard thereby. Even so, to 
 perceive in the iield of vision that a given object is to the i-ight or to the 
 left, and so or so far away, is to have certain motor tendencies of the eyes, 
 of the grasping hands, or of the general locomotor organs of the body, 
 appealed to and more or less visibly aroused. To perceive where an 
 
THE INTELLECT AND THE MOTOR PROCESSES. 2ir> 
 
 object is, is to remember how to reacli the place wliere tlie object appears 
 to be; and this memory of "how to reach" is itself the idea correspond- 
 ing to the actual tendency to move thus. Unle.'is .nick raovenherds are 
 inhihited they actimllij get carried out. One watching an object intently 
 may visibly begin to move towards it ; for every idea of any movement, 
 or of the known result of any movement, tends, in proportion to its clear- 
 ness, to be accompanied by that movement. This principle is the one 
 constantly used in the parlour game of " willing," or by public exhibitors 
 of " mind reading." What is usually " read " in such cases is the motor 
 expression which a person absorbed in watching, or in otherwise imaging 
 an object, inevitably and involuntarily gives to his tendencies to approach, 
 or otherwise to adjust himself to the object, as he perceives or images its 
 place, or its other tangible characters. 
 
 Abstracter thoughts, however, have in a similar way their still less 
 visible, but none the less real, motor accompaniments. Much of our 
 thinking runs parallel to an " internal speech " whose expression is an 
 actual series of motor adjustments of the vocal organs. Unless one in- 
 hibits these, one " thinks aloud." Deaf-mutes may sometimes be seen 
 " thinking with their hands." Our " general ideas," or " abstract ideas," 
 or " conceptions," of even the highest grade, while they partly consist of 
 a wholly sensuous imagery (mental " pictures," etc.), are acquired in the 
 first place in connection with definite (on higher grades uniformly imita- 
 tive) motor processes. These processes we usually first repeat after our 
 teachers. Thus one learns what a circle or a straight line is by learning 
 how to make one according to a definite rule. One learns what ten means 
 by counting one's fingers, etc. All these processes were originally actual 
 series of movements, which had to become habitual before the ideas in 
 question were at all familiar. Thereafter, at pleasure, we can represent 
 to ourselves the ideas by repeating the corresponding movements. The 
 definiteness of the idea precisely corresponds to the definiteness of the 
 habitual motor process. Where we do not actually repeat such move- 
 ments while we think, we nevertheless hold and comprehend the ideas by 
 beginning the familiar movement and then inhibiting it, or by "feeling 
 as if we could " repeat the movement if we chose — a feeling which cor- 
 responds to a mere tendency to begin the movement in question. AVhere 
 we symbolise ideas by other ideas, as the number ten by the word ten^ we 
 may then wholly substitute for the original motor tendency, whose cor- 
 respondent was our abstract idea, a motor tendency to speak the word 
 that is said to " express " this idea. And thus, by continual substitutions 
 and resubstitutions of simpler motor processes for more complex ones, we 
 may come to survey, as it were, years of carefully acquired motor habits 
 by means of a momentary impulse to utter a single sound or to make a 
 single gesture. But in no clear thinking is the motor element really 
 
21t) OUTLINES OF PSYCHOLOGY. 
 
 absent. Xobody can think without knowing how to do. The real ex- 
 j)ression of a thought is an imitative motor process intended to repeat or 
 to reconstruct what we liave perceived. All true thought has thus its 
 practical tendency. There is no such thing as the '' pure intellect " out 
 of relation to activity. One understands what one can reconstruct or 
 imitate ; and one learns by accomplishing — a fact which is of the first im- 
 ]iortance for all teachers of the young. The more abstract the ideas are 
 which one is to teach or to learn, the greater the need for constructive 
 motor processes to accompany the work of the learner. Kobody gets 
 ideas without responding to one's environment, and our mental images, 
 however rich, are of no intellectual importance except where they are 
 linked to definite brain-habits, which somewhere run out in action. The 
 one distinguishing feature of the motor processes which express our 
 thoughts is that they are all twjdieitly imitative movements, although the 
 imitations are often highly symbolic. 
 
 There is here only time to say further : (1) That, among the pro- 
 cesses of the higher intellectual life, what is called the activity of judg- 
 ment (as logicians use the term) is, in general, the mental 
 aspect of an effort to imitate the structure and relations 
 of things by means of combinations of words. In judging we try to com- 
 bine our words as, in reality, the objects or characters named by the words 
 are combined. And thus our judging is as much the mental accom])ani- 
 luent of an imitative motor process as is the activity of drawing pictures. 
 A judgment that satisfies our own ideals as to how judgments should be 
 made is accompanied by a familiar feeling called Belief. 
 
 r> ■ • Belief, then, is a feelino- of satisfaction in our own activ- 
 
 Keasoning. ' _ ' " 
 
 ity of judgment. (2) That what is called reasoning is, 
 in general, a process which involves judging {i. e., again, imitating in a 
 new act) the result which has followed from some exact constructive pro- 
 cess which we ourselves have just accomplished. Consequently, what 
 judgment is to its objects — viz., an imitation of them by means of an 
 order which we give to our words — such is our reasoning process to the 
 results which have followed from our processes of judging. To reason is 
 usually to judge about the outcome of former judgments. And so reason- 
 ing also runs parallel to motor processes of an imitative, although highly 
 complex and symbolic, type. 
 
 Thus the mind of a man engaged in abstract intellectual activity is no 
 exception to the rule that the intellect shows itself, more or less overtly, 
 in the adaptation of our movements to our situation, u))on tlie l)asis of 
 our experiences. Whoever thinks, moves, or tends to move. And intel- 
 ligence on the highest as upon lower levels shows itself in the power to 
 adapt former habits to the present situation, old rules to new cases, and 
 new deeds to established modes of conduct. 
 
THE NATURE OF INTEREST. 217 
 
 § 30. It remains to speak of tlie process by vvliicli our inoinentary 
 mental states get the clearness or the "relief" upon which (§ 26) their 
 intellectnal value so largely depends. As we learned (also in § 26), in so 
 far as we profit by the relation between our present and our former states, 
 our mental states are said to be experiences. On the other hand, in so 
 far as we are directly satisfied or dissatisfied with our passing mental 
 states (§ 24), they are contents of feeling. But now, as it happens, we 
 often find present in ourselves feelings of satisfaction and dissatisfaction 
 in the very fact that given present states have some sort of relation to 
 former states {e. g., are novel or familiar, are puzzling or comprehensible, 
 have obvious relation to our past habits, or need new adjustments, etc.). 
 But thus our experiences come to have a new and important relation to 
 our feelings. An experience has (§ 26) its "intellectual value," over and 
 above the value for passing feeling of what, as a momentary mental state, 
 it contains (as, for example, pleasure or pain). But now, as a fact, v)e 
 are able to have feelings which once more express an immediate, a pass- 
 ing, and, of course, often a mistaken, estimate of this intellectual value 
 
 itself. Such feelings are called our current " feelings 
 Feelings of Interest. n . , , ^ mi ^ • i • • i t i 
 
 01 interest. J- hey have a curious and invariable char- 
 acter, which often brings them into sharp conflict with our other feel- 
 ings of the same moment. A pain or an agonisingly perplexing problem, 
 although we hate it keenly, may interest us intensely, because we want to 
 dwell upon it until we have understood its cause or nature. When such 
 interests are those of predominant satisfaction they lead us to dwell on 
 the experience for its own sake, as a familiar or comprehended fact. 
 Thus a young child may love to have its known stories told over and 
 over, or to find picture after picture of familiar objects {e. g., men), and 
 to say triumphantly " Man," " Man," on viewing each picture. Here the 
 mere familiarity of the experience is itself what satisfies. But even if the 
 predominant interest in the experience is one of dissatisfaction (as when 
 one is pained or puzzled), still, the only way to satisfy the current intel- 
 lectual interest in the pain or puzzle {i. e., to reduce the dissatisfaction) is 
 again to dwell on the experience until its relation to the past has been 
 altered (<?. g., until it has become familiar or has been " made out "). So it 
 is peculiar to the feelings of interest, or to the " intellectual feelings," that, 
 whether they are cases of satisfaction or of dissatisfaction, the only way 
 to hold the satisfaction or to diminish the dissatisfaction is, in any case, 
 to dwell for the time on the experience as an experience. For, as we 
 have here defined our term, the interest is not a feeling of satisfaction or 
 of dissatisfaction with what the mental state in itself alone chances to con- 
 tain {e. g., with its pleasurable or painful tone as such), but with its rela- 
 tion to other states or to one's habits. Hence in states of intellectual 
 interest one questions, analj^ses, compares — does whatever tends to relate 
 
218 OUTLINES OF PSYCHOLOGY. 
 
 tliis object to other tibjects. One is seekiiiji; to know "what to do with 
 it," or is rejoicing in tlie faet that one does know M'hat to do with it, 
 
 Now. atti'ntion is the ^^rocixs of undertal'lmj to mtisfy such an intel- 
 lectual interest In/ (hcelling on its object, or, in other Avords, attention is 
 the process of furtherituf our current interest in an eor- 
 j}ertence when luetrca just as an exj)er<ence. >V hen 1 
 attend to a tiling I either try to recognise or to understand it, or T take 
 contentment in an ah'eady existent recognition or untlers anding of it, and 
 dwell upon it accordingly. 
 
 If our attention succeeds in any case — /. e., if our passing feeling of 
 current interest is furthered — the object of this interest grows clearer in 
 our ininds ; that is, it grows more definite and gets a better " relief " 
 upon its background. This is the one sure result of the furthering of the 
 temporary and passing intellectual interest, as this interest has here been 
 defined, "What we attend to may, as a mental state, be faint in content, 
 but as an experience it grows important. It is discriminated better from 
 whatever goes along with it, is more effective in arousing a.ssociations, is 
 recognised more readily, if already somewhat familiar, and tends to be 
 more effective in modifying our already existent habits. Attention in- 
 volves, of course, by definition, feelings. But these feelings from their 
 nature have, even as feelings, their intellectual value. And attention is 
 the conditio sine qua non of all important intellectual processes. 
 
 The less artificial and adventitious are our passing interests, the easier 
 and more effective is their satisfaction. Accordingly, it is difficult to 
 attend long to anything merely because we abstractly think that we ought 
 to attend. AYe must have our interest prettj- spontaneously, or we can 
 never hope to satisfy it. AYhat already pleases us for itself is therefore, 
 in general, the more readil}^ attended to in regard to its interest as an 
 experience. The relatively familiar is also more closely attended to than 
 the incomprehensibly strange, unless the latter, by its painful or its por- 
 tentous aspect, or by its sensuous or other direct charm, arouses our long- 
 ing to comprehend its significance. Children often wholly neglect what- 
 ever is not yet comprehensil)le to them in their lessons, although some 
 uncomprehended things, such as fairyland, or the doings of their elders, 
 may arouse their keen interest by appealing to their love of beauty, or by 
 awakening their imitative instincts. Interest in objects because of their 
 familiarity or their comprehensibility has been called "derived" interest, 
 and its furthering " derived attention " ; but, as a fact, all current interests 
 are, as already shown, more or less secondary feelings. 
 
 The physiological accompaniments of attention seem to be of three 
 sorts : (1) Adjustments, of a motor type, whereby our sense-organs are 
 brought into better relations with the object of our interest, or are brought 
 into positions tliat habit has associated with clear attention, while our 
 
THE PRACTICAL ASPECT OF THE INTELLECT. 219 
 
 organisms are also rendered otherwise luoi-e iinpressible. ('ei-tairi cliar- 
 acteristic attitudes, gestures, and alterations of hreHthing and of circula- 
 tion belong in this category. (2) The assumption of a "set" of brain 
 that tends especially to favour those habits which are of most use in com- 
 prehending objects of the kind wherein we are interested. The control 
 wliicli attention displays over our trains of association belongs in this 
 category. (3) In close connection with (2), the assumption of a " set " of 
 brain which tends to inhibit all movements and habits such as would inter- 
 fere with the satisfaction of the ruling interest. Hence tlie stillness, the 
 " absorption "' of the attentive person. Attention is always a highly in- 
 hibitory function. Hence its fluctuating character in children and in 
 many of our states of weakness. 
 
 § 31, The practical study and proper guidance of the intellectual life 
 constitutes one of the principal problems of civilisation. All efforts to 
 deal with the problem must set out from the fact that 
 T-f the intellectual life is precisely the " Organisation of 
 
 Experience," and that, on the other hand, both the ex- 
 pression and the very existence of the intellect are dependent upon the 
 formation of rational habits of conduct, useful motor adjustments. 
 
 The first principle is itself twofold. It means that the intellectual life 
 depends, as to its genesis in each of us, upon experience, and that, apart 
 from experience, we have no sound intellectual guidance. It also means 
 that no experience is of importance unless it is organised, and that chaotic 
 or irrationally ordered experience is useless, and may be worse than use- 
 less. The second principle shows, in general terms, how experience is 
 organised. It is organised by teaching certain fitting habits of conduct 
 (imitative processes, constructive activities, language functions, habits of 
 attentive observation), such as are at once constant, familiar, and accurate 
 as to their general types, and at the same time plastic, adaptable, and 
 controllable, with reference to the novel circumstances that may arise. 
 'That this complex object may be attained in case of healthy brains is 
 itself a matter of experience. IIow to attain it belongs to the art of the 
 teacher — an art whose rules, so far as they can be stated abstractly at all, 
 must be founded on the laws of habit, of interest, and of inhibition — all 
 of them laws which can best be stated in terms of the physical functions 
 of the brain. At all events, he teaches in vain who does not in some way 
 organise the activities, the intellectually expressive deeds of his pupils. 
 Thought is either action or nothing. 
 
 The abnormities of the intellectual life are more manifold and sharply 
 definable than are those of the emotional life. The common formula for 
 them all is a failure of due imitative adjustment to the environment, con- 
 ditioned either by defective sense-organs or by defective or by hindered 
 intellectual habits of brain. This failure, whether its cause lies in hered- 
 
±20 OUTLINES OF PSYCHOLOGY. 
 
 itary teinperamcnt, or in early training, or in acute or in e-lironic disease, 
 is very generally a matter that shows itself more or less plainly to every 
 closer observer. The intellectually abnormal person seems " queer," or is 
 called a '* fool " or a " crank," or makes a *' failure of life," or, in cases of 
 acute acquired malady, " becomes stupid," or " loses his memory," or 
 otherwise '* breaks down." Such things, in a general way, one constantly 
 hears. Intellectual defects and disorders, if considerable, do not easily 
 escape notice, because the keen struggle for existence sets every man 
 busily adjusting himself to his environment, and a serious failure of the 
 brain to display useful habitual functions is sooner or later pretty unspar- 
 ingly exposed. 
 
 On the other hand, the diagnosis of what is the actual failure present 
 in any individual case is much more difficult. There is, one must remem- 
 ber, no such thing as '' foolishness " in general, unless, as in case of the 
 extreme idiot or of the patient suffering from advanced dementia, one 
 means thereby simple absence of all significant cortex functions. Other- 
 wise, what gets called " foolishness " or '' crankiness " is some particular 
 group of defects ; and then the question is, each time, what group ? It 
 is regarding this question that careless judgment, in general, hopelessly 
 errs. 
 
 Here it must l)e noted, in the first place, that many intellectual defects 
 and disorders are but secondary phenomena, due to disorders whose 
 primary manifestation lies rather in the realm of the feelings. The grief- 
 stricken, the anxious, the worried, the exhausted man, or the victim of 
 violent physical pain, may have, for a longer or shorter period, an almost 
 complete suspension, or else an extensive degradation, of all the higher 
 intellectual functions. This sort of thing, in case of sufferers from acute 
 nervous exhaustion, may assume an outwardly very 
 
 „ , .. formidable aspect, and may give the sufferer and his 
 
 friends numerous fears of impending insanity, even 
 where the whole trouble is of relatively very superficial character. The 
 nervously exhausted are likely not only to be, for the time, intellectually in- 
 efficient, but to be keenly aware of the fact, so that their fears of disorder 
 may often tend to aggravate what disorder they have. It is important, 
 therefore, to distinguish the false fire from the real mental danger in 
 these regions. 
 
 In cases of simple nervous exhaustion the attention is usually one of 
 the most easily affected intellectual functions. It grows unequal — spas- 
 modically intense as to some matters, uncontrollal)ly hel])less as to others. 
 A sense of confusion overtakes one in the midst of business complica- 
 tions or of other intellectual tasks. One's favourite mental work grows 
 unaccounta])ly distasteful, or else morbidly engrossing in its portcntous- 
 ness, so that one cannot lay it aside during the hours of rest. One for- 
 
INTELLECTUAL DEFECTS AND DIBORDERS. 221 
 
 gets in the middle of a sentence wliat one was going to say, and is terri- 
 lied accordingly. One then talks of entire mental collapse. Memory 
 may become more or less unequal or helplessly uncontrollable before the 
 case has progressed far. A complaint of the " total loss of memory " — 
 a complaint, to be sure, often absurdly unfounded — is very common with 
 nervously exhausted patients. Over all these things, howevci', " the sense 
 of inefficiency," a collection of feelings, may easily be seen to preside if 
 one observes more closely. And a noteworthy characteristic of this 
 whole state is that .the nervously exhausted man can actually do all, or 
 nearly all, that he declares himself unable to do, can peii'oi'm nearly all 
 the brain functions that he regards as impaired, can speak coherently, can 
 avoid confusion, can attend closely, can remember very fairly, if only, 
 without his express expectation, you engage him in a conversation that 
 gets him for the time " out of his ruts," and that so temporarily frees his 
 essentially intact brain from the emotional cloud that is hindering his 
 habits from their natural expression. This is, of course, an objective 
 proof that the clouded functions are not yet destroyed. So that the ques- 
 tion of mental diagnosis is here not what the nervous patient can not do 
 (when he is left to his anxiety or confusion), but what he still can do 
 when for the time you get his thoughts " out of himself." 
 
 This may serve as a suggestion of the nature of a secondary impair- 
 ment of otherwise intact intellectual processes. But we must proceed to 
 exemplify the intellectual disorders proper. A striking 
 
 Hallucinations. , p -,• ^ -,- ^ • ■^^ 1 • • 
 
 example of disorders directly intellectual m type is 
 furnished by the morbid phenomena, of a sensory character, called " Hal- 
 lucinations," or false perceptions, which have no foundation in external 
 facts. These occur normally in our dreams, often also on the border- 
 land of sleep, and in a great variety of mental disorders. Sporadically, 
 as single brief waking experiences, they occur also in the lives of healthy 
 people. But they are never present in any considerable number or per- 
 sistence in a wide-awake person without a decidedly serious nervous cause. 
 This may be a cause seated in part in the external sense-organs, but it 
 generally involves those portions of the brain where the sensory nerves 
 of the sense affected have their central stations. An hallucination is, in 
 any case, jpriina facie evidence of an abnormal form of central excite- 
 ment. Yet hallucinations, as morbid phenomena, may occasionally exist 
 for a good while in a comparatively isolated form in the mind. The 
 patient may then be quite cool about them, may reason correctly that they 
 are only hallucinations, and may be in all other intellectual respects ap- 
 parently unimpaired. But this clearness can seldom thus last long. The 
 strangeness of the hallucinatory experience fixes attention upon it. The 
 physical cause of the trouble is usually pi-etty general. In the further 
 development of the case either a general delirium follows, or the intel- 
 
2'2'2 OUTLINES OF PSYCHOLOGY. 
 
 lectual luibits, if tliev remain relatively intact, are gradually but pro- 
 foundly modified by these sensory intruders. The delirium of fevers and 
 of a number of other nervous conditions of toxic origin is largely char- 
 acterised by the ]n'esence of manifold and massive hallncinations along 
 with o-rcat emotional disturbances. 
 
 The hallucination, in itself alone considered, is a fair example of a special 
 disorder of the intellectual life. But another form of intellectual impair- 
 ment appears in what are technically called delusions. 
 Delusions are morbid derangements of one's habits of 
 judgment. These may be, like sporadic hallucinations, phenomena con- 
 tiiied to a decidedly limited region of the intellectual life. Ihit this seems 
 to be seldom the case. If a man suffers from one delusion he commonly 
 falls a prey to more than one, although then his delusions may still relate, 
 for the most part, to some one class of topics. Yet the psychological 
 mechanism is such that delusions, from their nature, tend to influence all 
 of the sufferer's intellectual habits, and nobody can be trusted to remain 
 long " insane on one topic only." One can never tell when the false habit 
 may not show itself in some unexpected region, 
 
 "While the phenomena of insanity proper belong elsewhere, this sketch 
 mentions delusions simply because of the practically interesting psycho- 
 logical problems of diagnosis which they suggest. As to the name, the 
 psychological usage differs somewhat from the popular usage. The latter 
 often co7ifounds hallucinations with delusions. The psychologist means 
 by delusion a morbidly defective type of opinions, while hallucinations 
 are false perceptions. When a man groundlessly and morbidly accuses 
 his family of trying to poison him, this is a case of delusion. When a 
 patient hears unreal voices talking about him, this is a case of hallucina- 
 tion. Of course, phenomena of both kinds may be combined, and in some 
 forms of insanity they always are combined. The distinction, however, is 
 important ; because, from a purely psychological point of view, a delusion 
 is, in general, the sign of a deeper derangement than is a mere hallucina- 
 tion. The latter may be due to transient conditions of cerebral excite- 
 ment. The former, the delusion, stands at once for the distortion of one 
 of the most significant of our habitual functions — namely, the function of 
 judging our relation to our environment. And it is a universal rule of 
 psychological diagnosis that the more general the habit of brain which has 
 been really deranged (and not merely hindered by temporary emotional 
 disturbances), the worse is the abnormal indication. To forget a familiar 
 name is possibly an abnormal, but is so far a decidedly superlicial incident. 
 To hear a voice when none is really speaking may be a very grave matter, 
 if it becomes chronic ; but of itself, as a single incident, it indicates merely 
 a state of excitement which may soon pass away. But coolly to insist, 
 without any objective ground, that you are indubitably aware that your 
 
THE ESTIMATE OF INTELLECTUAL DEFECTS. 223 
 
 wife means to poison jon — this indicates an established "set" of Ijrain 
 which (unless the cause is an acute and transient delirium) is likely to 
 prove serious in pi'oportion to the number and the generality of the altered 
 habits which must lie at the basis of the perversion. (On the "general" 
 habits of the brain, compare what has been said in § 16 near the end.) 
 
 On the whole, other things being equal, the cooler and less emotional 
 a delusion is, in the tone with which it is held and expressed, the worse is 
 the indication, because the more does this state of things indicate a direct 
 perversion of the more general "set" of the brain. The delusions of a 
 fever delirium are largely secondary to violent emotions, and so in their 
 contents they are confused, and they may soon pass away, when the tem- 
 porary brain poisoning is relieved. The wild, fleeting, and scarcely utter- 
 able delusions of an ether-intoxication are as massive as is the stormy, 
 emotional outburst of the intoxicated condition, and they vanish with re- 
 covery. But an experienced insane patient may hold to his chronic de- 
 lusions with considerable coolness and clearness of head. His power to 
 do so may of itself indicate the hopelessness of his state. Especially grave 
 is the tendency of cooler delusions to get thought out, or " systematised," 
 by the patient. For thus all of a man's habits of brain get wrought over 
 into the service of his delusion, and then he can never even conceive the 
 way out. All of the foregoing indications must of course be modified by 
 the circumstances of individual cases, but these suggestions may serve as 
 hints of the principles of psychological diagnosis. 
 
 A morbid delusion, for the rest, is by no means the same thing as a 
 foolishly false opinion. When one gets superstitions, or other absurd 
 views, by hearsay, and from the tradition of the social order to which one 
 belongs, the process of acquiring the false belief is then normal, however 
 false the faith. There is no view so ill-founded that perfectly sane men 
 may not hold it, given a sufiicient weight of social tradition and of popu- 
 lar ignorance. But the peculiarity of the morbid delusion is that a man 
 does not get it by normal methods — e. g., by accepting current social tra- 
 ditions — but comes upon it alone, as a matter of his private experience. 
 The exceptions to this rule are, for our present purpose, insignificant. 
 Moreover, the morbid delusion has always a characteristic reference to the 
 patient's own private fortunes or dignity, instead of being, like the socially 
 acquired tradition, a matter which concerns others quite as much as him- 
 self. A morbid delusion may, indeed, assume a philanthropic seeming, 
 but a closer inspection always shows that the deranged man is to an ab- 
 normal degree at the centre of his false world. It is he who, of all men, 
 is most persecuted or exalted. 
 
 So much must here suffice as a mere hint as to the greater intellectual 
 abnormities. Yery common, however, is another problem — viz., that of 
 the diagnosis of mere eccentricity of intellectual life, apart from any spe- 
 
2-24: OUTLINES OF PSYCHOLOGY. 
 
 cificallv luanifest perversions. It is iiui'uuil lor us to acijuii-e the most of 
 
 our intellectual habits, by imitation, ivom the society to whicli Ave bc- 
 
 lonix. ^^in- social experiences are norniallv the most po- 
 Eccentriciiy. ^ 1 r ^^ • o i • ' i- 
 
 tent 01 all our experiences. Speaking, reading, writing, 
 
 investigating, the .knowledge of our profession or business, the thoughts 
 of our daily life — these are all determined for us, in great measure, by our 
 guardians and teachers in early life ; by our friends, comrades, rivals, and 
 other fellows in later life. Hence the most of our intellectual habits 
 ought to be of a sort that we have in common with many of our fellows. 
 AVhen one's intellectual life varies, however, from the average intellect of 
 his tribe or of his class, then, according to the degree and the noticeable- 
 ness of the variation, one is called " striking," " individual," " original," 
 '' independent," " a man of parts," " a genius " ; or, in less kindly speech, 
 one is declared '' eccentric," " queer," '* quaint," " odd," " a fool," or " a 
 crank." Now, it is manifest that variations from the average intellectual 
 type are, within certain degrees, advantageous to both the individual and 
 the community. The best communities cultivate certain types of origi- 
 nality. One ha1)it that ambitious young people often catch by imitation is 
 the very habit of seeming not to imitate — /. e., of striving to be original. 
 On the other hand, there is a good deal of intellectual originality in the 
 asylums ; and certain forms of eccentricity are of themselves abnormal. 
 The question of diagnosis often offers itself : Is this particular sort of 
 intellectual eccentricity [e. g.^ in this 3'oung man) a mark of wholesome 
 talent or of dangerous crankiness ? 
 
 The answer must be founded upon principles, some of which can easily 
 be stated. Conformity to one's environment is, as we must insist, in the 
 end the test of normality. But some original men first win their environ- 
 ment over to conform to them ; and herein they show, even through an 
 early conflict with the environment, their higher sort of capacity to find 
 a place in their world. Moreover, all young men have to spend some 
 time in learning what they are fit for before harmonious life becomes 
 possil)le. Thus the test of the conformity of a given intellectual life to 
 a given environment must be applied, especially in early life, very cau- 
 tiously. Some eccentric young men are so because they are " ugly duck- 
 lings " who will turn out swans. Still others, however, are rather geese 
 among swans. The psychological observer is therefore not afraid of 
 the mere show of eccentricity even where it is great in degree. It is the 
 sort of eccentricity that such an observer tries to consider more carefully 
 before he judges. And now% a general test of the abnormally eccentric 
 intellectual life, where it involves as yet no graver disorders — no delu- 
 sions, no violently morbid emotional states — is to be found in much the 
 game region as the one in which the morbid cliai-acter of true delusions 
 was just seen to manifest itself. The moj-bidly eccentric intellect is one 
 
THE WILL DEFINED. 225 
 
 in which tlie interesting experiences are to an extraordinary degree cen- 
 tred about matters which have too little social concern, and too much pri- 
 vate concern for the morl)id individual liimself. This test is not appli- 
 cable, of course, in childhood, since all young children are extremely- 
 self-centred.' But it is, despite the normal selfishness of youth, already 
 fairly applicable in the later years of youth. A young man may indeed 
 be very extremely and grossly " self-centred " and intellectually common- 
 place at once without much mental danger ; for he then belongs to his 
 herd, and his herd will take care of him. His socially submissive instincts 
 may, and probably will, offset the selfish grossness of his conscious aims. 
 He will live, like the rest of his kind, a poor intellectual life, but a nor- 
 mal one. He will think mostly about his private concerns, but still society 
 will, after all, determine what he shall think about them, Not so, how- 
 ever, is the eccentric or "original" mind fatally protected by the instincts 
 of the herd. And where an intellectually eccentric or original mind is 
 extraordinarily devoted to thinking over, dwelling upon, planning, the 
 private success, the exalted dignity, the selfish preferment, of just this 
 individual, then, in the combination of intellectual eccentricity and selfish 
 nari'owness of personal aim^ there are strong marks of danger. To be 
 sure, even such a being might have the brain of a Kapoleon ; but that 
 is, to speak mildly, uncommon. On the other hand, a naive eccentricity 
 of intellectual life, sincerely, not falsely, devoted to objective concerns 
 (mathematical problems, scientific pursuits, the study of nobler literature, 
 the pursuit of a modest but effective philanthropic career), is consistent 
 with a true promise even where the anomaly is relatively great. A note- 
 worthy test, then, is whether the anomalous young person really looks 
 rather without than within. One need not add that to apply such a test 
 needs often a pretty close scrutiny. Selfish greed may wear many cloaks 
 and may use noble phrases. 
 
 Vir. THE WILL, OR THE DIRECTION OF CONDUCT. 
 
 § 32. The life of the Will has already been defined, in certain of its 
 aspects, in the foregoing discussions of the facts of feeling and of intel- 
 lect. It is therefore possible to be here especially summary in our 
 method of treatment. 
 
 The Willis the sum total of our mental states in so far as they involve 
 attentive guidance of our conduct. How such guidance is possible we 
 have therefore next to explain. 
 
 All definite brain-processes tend to express themselves without in 
 
 movements by which we adjust ourselves to our envi- 
 Expression of ^nvrj-^i ^ i 
 
 T> ■ ' ronment. JMany oi these movements pass more or less 
 
 xSram-processes. ^ •' ^ ^ 
 
 unnoticed by ourselves. But all of them, in propor- 
 tion as they are marked and effective movements, tend not merelv to 
 17 
 
220 OUTLINES OF PSYCHOLOGY. 
 
 result from braiii-processcs, but to influence, in tlieir turn, the very brain 
 whose processes liave initiated tlieni. If one's arm moves, the movement 
 is itself a fact in the world outside the mind, and, like any other outer 
 fact, it may be once more perceived and remembered. One sees the arm 
 move, feels the sensations of muscular contraction, and is in still other 
 ways advised through one's sense-organs of the processes which the arm's 
 movement involves. Moreover, if the arm, by moving, accomplishes some- 
 thing definite, such as an act of grasping, one perceives the resulting move- 
 ments of the object grasped. If the arm is engaged in writing or in draw- 
 ins^, one sees on paper the lines which the moving hand traces. In all 
 such cases one observes, then, the results of one's doings. And so, in 
 short, ones own activity constantly becomes itself a part of one's expe- 
 rience. If an experience is any mental state in so far as its relation to 
 past states guides our present thoughts and deeds, and 
 .ipenence of .^ ^^^ ^^ ^^^j. mental life accompanies those expressive 
 
 our own Activity. . ' i • i i i • 
 
 movements, or tendencies to movement, winch the bram 
 
 initiates and guides, it follows that every mental state has an aspect in 
 which it may he regarded as involving an experience of our own fash- 
 ions of action., or of our own attitudes, towards our world ; for at every 
 instant we are acting, or tending to act, and so at every instant we are 
 experiencing the results of our own activity, or of our own tendencies 
 tt) action. So far, then, there is an aspect in all of our mental life which 
 constitutes this life a series of experiences of our own doings., a series 
 which can take on, by the laws of intellectual growth, a highly organised 
 and rational character in proportion as our habits of conduct become 
 themselves regular, uniform, and complex, and are observed by ourselves 
 for what they are. 
 
 But just as our activity has its intellectual aspect, in so far as we con- 
 stantly learn what w^e have done and are doing, so, too, this activity has 
 also its passing value for us in our direct feelings. What we are doing 
 at any given moment is satisfactory or nnsatisfactory to us. Action 
 which, by virtue of its passing character as a felt mode of action, rela- 
 tively satisfies us, we call an expression of our desires. When an action 
 is such that the feeling which accompanies it is one of 
 predominant dissatisfaction, the act opposes our ruling 
 desires, and tends to be inhibited accordingly. TJius, then, every mental 
 state tends to home, as a fact of feeling, an aspect tohich embodies our 
 current relative satisfaction or dissatisfaction with our ov^n momentary 
 doings. A desire ■means a tendency to action, experienced as s^ich, and 
 at the same time felt as a relatively satisfactory tendency. 
 
 So far, then, we see : (1) That our own activity forms constantly a 
 part of our experience ; (2) that this same activity constantly results in 
 a modification of our feelings of satisfaction and dissatisfaction in what 
 
IMPULSE, DESIRE, AND WILL. 227 
 
 we are doin^. If one combines these two aspects of our inner Jifc, one 
 can say that together tliey involve a vast ea'jjerience of our ovm deairea 
 and aversions^ of our own doings and inJuhitions, and of the inner re- 
 sults of these doings and inhihitions^ together with a constant ^^«;y of 
 feelings of inner content and discontent vrlth our own motor j/roceHses^ 
 and with the tendencies or attitudes which acconqxing our jjartially sup- 
 2)ressed movements. 
 
 Thus we briefly characterise so much of our inner life as constitutes 
 the world of desire. and of its outcome. Thus viewed, our minds appear 
 as full of passing impulses, of tendencies to action, of passions, and of 
 concerns for what we take to be our welfare. All these impulses and 
 concerns get woven, by the laws of habit, into systems of ruling motives, 
 
 which express themselves without in our regular fash- 
 The Will in the . n i , hm i i j- • t i- • 
 
 xjr-j . o ions ot conduct. Ine whole oi our inner Jite, viewed 
 
 in this aspect, appears as the active side of our con- 
 sciousness^ or as the will in the wider sense. 
 
 But it remains to lay stress upon one further aspect, by virtue of 
 which the world of the more or less organised impulses, concerns, pas- 
 sions, and other desires, gets its fully developed character as the world of 
 the will in the stricter or more proper sense. We not only observe and 
 feel our own doings and attitudes or tendencies as a mass of inner facts, 
 viewed all together, but in particular ice attend to than with greater or 
 less care^ selecting now these., now those tendencies to action as the cen- 
 tral topics in our experience of our own world of desire. The process 
 of attention (§ 30) often has as its objects not only external facts, or facts 
 of sense-perception, but also desires, actions, inhibitions, tendencies to 
 action, concerns, feelings, passions — in brief, whatever constitutes the 
 active side of our nature. But to attend to anything is to emphasise that 
 object, to give it " relief " as against the rest of what is in our minds. 
 To attend to any action.^ or to any tendency to action., to any desire., or to 
 any passion, is the same thing as " to select," or " to choose," or " to pre- 
 fer," or " to take serious interest in," just that tendency or deed. And 
 such attentive preference of one course of conduct .^ or of one tendency or 
 
 desire, as aqainst all others present to our minds at 
 An Act of Will. ,: ■ jj J ^ ^ -77 
 
 any time, ts called an act of wdl. 
 
 The Will is, when viewed from within, the attentive furtJiering of our 
 interest in one act or desire as against another. The act or desire is in 
 itself something of more or less interest to us. If we attend to this act 
 or desire (§ 30) we further our interest in it. The furthered interest re- 
 sults in a clearer consciousness of the act or tendency in question. But 
 the very existence of such clear consciousness implies (by the principles 
 indicated in § 20) that the condition of brain which naturally expresses 
 itself in just this form of outward activity is, at the moment of clear 
 
22S OUTLINES OF PSYCHOLOGY. 
 
 consciousness, a predominant condition of the brain. The furthered in- 
 terest, if intense enough, therefore means, on the physical side, that tlie 
 form of activity in wliich we are interested gets an actual outer expression 
 jtfsf as soo)i as ou?' attention snjfjcienthj j-irrfvrs tlw tJioiujJit of this act to 
 the thoi/(/ht of any other act. 
 
 To think of any sort of activity, therefore, already implies a tendency 
 to this form of activity (cf. § 29). And actually to will a given act is to 
 think attentively of that act to the exclusion or neglect of the representa- 
 tion or imaging of any and all otluT acts. AVhenever one idea of action 
 or one tvj)e of desire becomes really predominant in consciousness 
 through attentive consideration, then the action or desire in (piestion at 
 once firets carried out until some restraining idea arises and in its turn 
 gets attended to. Choice bears, therefoi-e, the same relation to actions that 
 intellectual attention bears to images, ideas, or thouglits ; and in discuss- 
 ing the phenomena of attention we have already discussed all tliat is 
 essential to the comprehension of an act of will. Upon the physiological 
 accompaniments of the will we need, therefore, say nothing further at 
 this point. 
 
 It remains to note here only one or two considerations of no small 
 
 practical moment. The first is that, strange as the statement may seem, 
 
 we can never will any really novel course of action. 
 
 " „ . . , AVe can directly will an act only when we have before 
 7iot Origutal. -^ •{ 
 
 done that act, and have so experienced the nature of it. 
 The will is as dependent as the intellect upon our past experience. One 
 can indeed will an act which is sure to involve, in a given environment, 
 al)>olutely novel consequences ; but the act itself, so far as one wills it, is 
 a familiar act. Thus a suicide can will an act which results in his own 
 death, and so far he seems to be willing something which wholly tran- 
 scends his past expei'ience. But, as a fact, the act itself which he makes 
 the direct object of his will {e. </., pointing a pistol and pulling a trigger, 
 or swallowing a dose) is itself an act with whicli he is long since de- 
 cidedly familiar. One can will to visit a far country, to engage in a new 
 sort of speculation, to choose a still unfamiliar profession, to marry, or to 
 do anything else whose consequences one cannot foresee. But it is the 
 consequences that are novel ; the act which one directly wills is not novel. 
 What one does at the decisive moment is to l)uy a ticket, to sign one's 
 name, to say " Yes," or otherwise to repeat deeds whose contents are 
 already perfectly familiar, while the circumstances under which they are 
 willed may make them to any extent momentous. But, on the other 
 hand, one cannot will to fly, because one has never learned liow. We 
 can thus will to do only what we have learned to do. " Control yourself," 
 says the stern adviser to the spoiled child. But the adviser upbraids in 
 vain. How can the spoiled child will to control himself if nobody has 
 
THE EVOLUTION OF THE WILL. 229 
 
 ever shown him, by an appeal to his imitative instincts, what self-control 
 
 means ? Our will, psychologically viewed, is thus an absolutely unoriginal 
 
 power. It gives back what experience has taught it. Hut, on the other 
 
 hand, viewed with respect to its outer consequences, the will, if not in 
 
 itself original, may be to any extent originative, because to repeat such 
 
 an unoriginal act as signing one's name, or saying " Yes," may, under 
 
 given conditions, begin a new life for the doei-, or even for the whole 
 
 world in which he moves. 
 
 Closely connected with the foregoing consideration is tlio fui-tliei- 
 
 principle that, before we can come to possess a will, we must first ]>erfoi-m 
 
 numerous and complex acts by virtue of the inherited 
 Basis of the Will. , i . x- i i • / -, ^ r, • t ^ 
 
 tendencies oi tlie orain (see § lb, m the latter portion). 
 
 Such original tendencies of the brain are the source of our human in- 
 stincts (§ 13, 2). The will is based upon instincts. These get moulded 
 by experience. The resulting acts, gradually organised by the laws of 
 habit, come at last to our notice, in so far as our doings are themselves a 
 part of our experience. The accompanying feelings colour our acts so that 
 they are also expressions of desire. Then attention fixes now on this, now 
 on that conceived act, tendency, or desire, according as our interest plays 
 over the whole series of such experiences of our activity. The emphasis 
 which attention gives, in the end, to the ruling idea of action is the inner 
 and psychological aspect of our current act of will or of choice. 
 
 The growth of language in any child is an excellent example of the 
 
 evolution of the will. Inherited instinct expresses itself in the infantile 
 
 actions known outwardly as cries, and later as more 
 
 ^ou) Of vocal sounds — babblings, primitive efforts at wholly 
 
 Language. . rrn i i -i • 
 
 meaningless articulation. Then the child begins to ob- 
 serve these acts of his own, to feel satisfaction in them, to desire their 
 repetition. The result, so far, is the development of a chaos of vocalised 
 expressions, but not yet anything resembling true speech. However, 
 long before this process is completed another inherited instinct inter- 
 venes. The child is imitative. This instinct involves complex processes 
 which result in making the child's vocal noises tend to resemble those 
 which he hears from other people. This resemblance, once more noticed 
 by the child, also becomes a much-desired ideal ; and hereby the child 
 first gradually learns and then definitely wills to reproduce the utterances 
 of others. Then there is added, while these processes are still under way, 
 the intellectual experience that many of the sounds uttered by other peo- 
 ple mean something : are names for things, or for feelings, or for pur- 
 poses. This, erelong, shows the child that he too can express his mean- 
 ing by using the right sounds. Now he becomes selective, attentive to 
 speech as such, desirous of harmonising what he says with what others 
 say or understand ; and finally, upon the basis of all these elaborately 
 
230 OUTLINES OF PSYCHOLOGY. 
 
 inoukled instincts and habits, the intL'llii:;cnt will to talk takes form, and 
 iienceforth the child says whatever he predominantly and attentively de- 
 sires or chooses to say, whenever he is thinkiiip^ vi speech rather than of 
 any other mode of activity. 
 
 § 33. While the expression of our minds in and by our conduct is the 
 
 one great tendency upon which all knowledge of mind from without, 
 
 and all the serviceableness of our mental life for the interests of society, 
 
 depends, it is nevertheless the case that the practical study and training 
 
 of the will are almost always regarded as secondary to the practical study 
 
 and training of the feelings and the intellect. The reason for this is 
 
 obvious. Apart from intellectual training, the life of our desires is 
 
 mainly the expression of our inhei-ited instincts, M'hich 
 
 nobody can hope to eradicate altogether, or to enrich by 
 
 the addition of any entirely novel instincts. What can be done for us is 
 
 to organise ctur planlessly numerous inherited instincts in such fashion 
 
 that there shall result valuable and consciously directed habits. The 
 
 devices for accomplishing this aim are largely appeals to our universal 
 
 human love of social imitation. Hereby we " learn 
 
 Training tlw Will. , ,, ^ ^ • i ^ i i i u^ i 
 
 how to act aright ; and unless we have learned 
 how," one appeals to our will in vain. Hence what appears as an intel- 
 lectual acquisition — a " learning how " to be good, industrious, skilful, 
 self-directing, etc. — is always prior to the successful moulding of the will 
 as such. As every such " learning how " involves interests, the feelings are 
 appealed to at every point. But the will itself, whose proper moulding 
 is indeed in one sense the goal of all education, seems to be capable of 
 only this indirect approach. Or, again, to teach one to will involves teach- 
 ing him first to take note of his own conduct. But to teach him this you 
 nmst first establish in him the desired conduct. You must get him to do 
 before he has consciously willed this particular sort of doing. The in- 
 voluntary conduct must precede the voluntary; but the right sort of in- 
 voluntary conduct you can only establish through appeals to the feelings, 
 and through presenting the fitting objects of knowledge to the intellect. 
 For the same reason disorders and defects of the will never exist 
 alone. The}' always involve alterations either of the feelings or of the 
 
 intellect, and must be studied in connection therewith. 
 n ft f th Wll ^^ '^^ noteworthy that insanity, in the popular mind, is 
 
 usually conceived as primarily an intellectual defect 
 rather than as primarily a defect of the will, and this despite the noto- 
 rious fact that insanity can only manifest itself through some sort of 
 " queer " or *' wrong " exjiressive action. 
 
 Nevertheless, it is often important to consider mental defects or dis- 
 orders from the side of the will. So viewed, the " disorders of the will " 
 may be said to manifest themselves in thi'ce general types. The first 
 
THE DEFECTS OF THE WILL. 231 
 
 type is that of tlie absence or serious impairment of the abihty to carry 
 out important voluntary acts, when such acts have already been in the 
 past learned as well as often performed. This first defect is often known 
 by the rather vague name of " weakness of will." A technical name is 
 " Aboulia," or morbid will-lessness. The second type of defects of will is 
 that of the chaotic or '' segmented " will, whose plans do not hang to- 
 gether, whose action is morbidly impulsive, capricious, inconsistent, or 
 inwardly anarchical. The third type of defects of will appears in those 
 morbidly perverted persons {e.g., in morbid criminals) whose activity, 
 without being confused or chaotic, is still steadfastly such as fails of any 
 tolerable adjustment to the enviroimient, and especially to the civilised 
 social environment. 
 
 The first type, Aboulia, is sometimes a manifestation of the tempera- 
 ment as such. In such cases one naturally looks for its cause in the 
 emotional " undertone " (cf. § 25). The deeply hesitant 
 or morbidly indecisive man who, despite having learned 
 how to do a given thing, and despite his clearly knowing that it is to his 
 interest to act, still remains permanently fast bound in a Hamlet-like in- 
 capacity to will anything for himself at the important moment, has become 
 a favourite topic for literary portrayal. Hamlet notoriously refers his 
 own defects of will to intellectual causes. His " native hue of resolution " is 
 " sicklied o'er with the pale cast of thought." But such defective will may 
 appear with a less obvious intellectual basis than in Hamlet's case. Then, 
 however, the defect would probably be definable, in emotional terms, as 
 the pretty constant presence of some emotion of painful timidity or 
 scrupulosity, in the presence of which all very decisive action seems in 
 general unsatisfactory. " Apathy " of temperament — i. e., an enduring 
 state of abnormally depressed emotional sensitiveness — might have the 
 same effect. 
 
 But Aboulia is a frequent acute symptom in cases of more or less 
 transient nervous exhaustion. In a measure, every one can occasion- 
 ally notice such a defect of will as an incident of normal weariness. At 
 such times we may find it especially hard to make a decision, even when 
 we seem to ourselves clearly able to see just what decision ought to be 
 made, and even while we feel that, as we say, we " want " or even " long " 
 to decide. The feeling of helplessness is then itself often extremely 
 painful. If by chance we actually begin a decisive course of conduct, 
 then the feeling that we are " committed " gives a great sense of relief, 
 and the defect of will may at once, for the time, vanish altogether. 
 
 In cases of nervous exhaustion, such Aboulia is an inconvenient com- 
 plication, in so far as it tends to set a habit of indecision which may long 
 survive the period of exhaustion itself. In itself, however, this acute 
 Aboulia is apparently no very alarming incident. The nervously exhausted 
 
232 OUTLINES OF PSYCHOLOGY. 
 
 man sliould be carefully relieved, so far as possible, tVoin every necessity 
 of making difticiilt choices, lie should, therefore, if possible, " resign his 
 will " into the hands of some one, or at most two or three competent and 
 harmonious advisers, and he must be protected from every confusing 
 variety of plans.. On the other hand, whenever decisions are really 
 necessary, he should always be gently but iirndy helped to a quick and 
 irrevocable choice, since hesitancy is a very exhausting incident in his 
 experience, and since even a poor choice is often better for liim than 
 doubt. But if such care is taken, the Aboulia itself is no very serious 
 symptom. Sometimes one meets with light cases of weariness where such 
 Aboulia is, in fact, almost the only discoverable morbid symptom, and 
 these cases are actually encouraging as to the outlook for quick recovery. 
 Much more manifold are the chaotic disorders of the morbidly incon- 
 sistent or capricious will. Temperaments abound which are characterised 
 by ])henomena of this kind, and in both acute and 
 egmen e i . q]^yqi^[q disorders the disorganised will is a well-known 
 symptom. This, for example, is especially true in hysterical disorders. 
 But ordinary nervous exhaustion is frequently burdened with enemies of 
 the kind. One often sees, for instance, the man who forms morbidly 
 one-sided resolutions for the conduct of this or of that portion of his life. 
 He means to permit only this or this train of thought, or to exclude wholly 
 this or this possibility of temptation. Over the well-meant but possibly 
 useless resolution he grows morbidly conscientious, and upbraids his 
 friends for not sufficiently appreciating and aiding his efforts. Mean- 
 while, however, he freely indulges himself in graver defects than the one 
 which he is so elaborately correcting, and inconsistently encourages even the 
 very tendencies which he is fighting by giving them a false importance 
 through his over-wrought self-scrutiny. In more hysterically disposed 
 cases such defectively insistent broodings will be subject also to vast 
 changes of plan, so that the sufferer alters his religions faith, or the 
 whole ideal of his life, without any clear reason, and throws to the winds 
 a whole system of good resolutions in favonr of some other equally use- 
 less scheme. The habit of mere fickleness may thus become finally 
 prevalent over all other habits (cf. § 16, at the end). One thus finds peo- 
 ple who acquire a " mania " for changing their religious faiths or their 
 callings. 
 
 Simpler, but often very stubborn, are the phenomena of disorganisa- 
 tion of will in case some one more or less generalised motor habit becomes 
 
 rebelliously insistent — e. g., the habit of counting or of 
 - DisorqaniHation . . " • . ^ ^ . . i .1 .i 
 
 i „..,, examinmg gas jets, locks, etc., to see whether they 
 
 have been safely adjusted, or of asking useless ques- 
 tions about some sort of topics. Disoi-ganisations of this kind appear in 
 many patients on the basis of a defective hereditary constitution. But in 
 
THE DEFECTS OF CHARACTER. 233 
 
 children and quite youli<^ people they ure also often present as mere dis- 
 orders of development, which pass away witli maturity. And nervous 
 exhaustion can brinij^ them on as acute syinptoms in otlierwise unljurdened 
 people. A surj)risini^ly large number of such morbid habits can often 
 exist without destroying or even seriously endangering in other respects 
 the general capacity of the brain that suffers from them ; and the fears 
 of an impending general insanity which they often arouse are therefore 
 very frequently unfounded. On the other hand, they are certainly 
 grave inconveniences, and are not to be trifled with. They are best 
 treated, apart from the medical care of the patient's general health, 
 through a discreet moral support, given by a competent adviser, who 
 can often help the patient to or towards a relatively effective and 
 cheerful ignoring of his enemies. 
 
 In estimating all such defects the rule holds here, as in case of the 
 defects of the intellect, that the stronger the attendant emotional col- 
 ouring of the disorder, the more hopeful, other things being equal, is 
 the outlook. The cooler the emotional tone of the sufferer from a 
 defective will, in so far as concerns his immediate feeling about his 
 disorder, the fewer are the means of influencing his morbid state. And 
 
 this finally suggests why the morbidly perverted char- 
 31orJ)id Perversioii. , -u -\ ,• ^ ^'^ • i r- 
 
 actei's wiiose wills are relatively well organised, firm, 
 
 and cool, but whose behaviour is intolerable, are in general incurable. 
 In consequence, we may as well here abandon the task of further de- 
 scribing such characters, whose mission in the world seems to be to 
 illustrate the variability but not the healthy docility of our human nature. 
 
 NOTE BY THE EDITOR ON 
 THE PRACTICAL APPLICATIONS OF PSYCHOLOGY. 
 
 It is a common mistake to suppose that psychology is a branch of 
 science which has little bearing upon the practical affairs of daily life — 
 that it is a matter of pure theory, which has its place among the abstruse 
 studies of philosophers far above the heads of ordinary people, and as far 
 removed from ordinary business as are the higher mathematics or phil- 
 ology. The aiticle by Prof. Royce shows clearly that psychology has a 
 most intense " practical " importance ; it is concerned with every phase 
 of human thought, and therefore of human action. It deals not only 
 with the human mind in the abstract, but with the mental development of 
 
234 OUTLINES OF PSYCHOLOGY. 
 
 every iudividual liuinau being. Upon the application of its principles to 
 the growing child depends to a large extent that child's whole future — its 
 moral character, its mental ability, and its happiness. It simplifies many 
 problems connected with education by showing definitely how children 
 learn and why they learn. It shows the ways in which habits of mind 
 are acquired, and enables us to try in a rational manner to guard against 
 the formation of those which are bad, and foster and strengthen good 
 habits already existing and to estal)li>h new ones. 
 
 Every one who has to estimate the character of his fellow-men (and 
 who has not to a greater or lesser extent i') consciously or unconsciously 
 must draw his conclusions — if they be correct conclusions based upon 
 logical processes, and not mere guesses — by applying psychological meth- 
 ods. The best training of children can only be carried out by one who 
 understands the relations of cause and effect in the mental world so far 
 as these relations can be understood. Psychology does not pretend to 
 explain what thought is ; it deals with the phenomena exhibited by the 
 thinking being, and tries to learn the nature of these phenomena and 
 their relations to one another. The psychologist can no more explain 
 the exact nature of thought than can the physicist explain the nature of 
 energ}'. The latter studies the various objective forms of energy — such 
 as heat, light, electricity, gravity, and motion — with a view of learning 
 the laws which determine their behaviour and relations ; the former does 
 the same with phenomena of energy exhibited by the brain when in 
 action. 
 
IV. 
 PHYSICAL TRAINING. 
 
 By JOSEPH HAMBLEN SEARS, A. B. 
 
 INTRODUCTION. 
 
 The life of an ordinary man or woman, boy or girl, of to-day is very 
 different from what it was a hundred years ago. Every boy or girl who 
 wishes to grow up well educated and prepared in every way to take his 
 or her part in the world has a much more difficult task than his father or 
 mother had. There is more to learn, more that must be known before a 
 start can be made ; and at the same time the development of the modern 
 city offers far less opportunity for the maintenance of a vigorous mind 
 and body. We have to do more, and are in poorer physical condition to 
 accomplish it than our parents. 
 
 For both these reasons it is the more necessary that a boy or girl, a 
 man or woman, of to-day should set for himself or herself regular and 
 systematic work that shall tend to strengthen the physical body and fit it 
 to furnish a constitution capable of doing what the mind requires. 
 
 As it is neither wise nor possible to lessen the work laid out for us. 
 the only other course is to find a means of preparing our bodies to with- 
 stand the greater strain, to supply that physical educa- 
 Increasing Neces- ^.^^^ ^^ ^j^^ muscles and tissues, which is to fit them to 
 sity for Physical . -. , . . i -t • c ^ ^ 
 
 Trainina keep pace With the increasing capabihties oi the human 
 
 mind. And the fact that such men as Gladstone, Bis- 
 marck, and hundreds of others carry the weight of enormous responsi- 
 bilities and retain the capacity for extraordinary amounts of work far 
 beyond their threescore and ten years is proof enough that this can be 
 done. 
 
 The body is nothing more nor less than a beautiful machine. It is 
 well made at the start — that is, if there are no hereditary weaknesses of 
 moment. The machine simply needs care, attention, and proper use, to 
 make it run smoothly and accomplish infinite tasks. If it is imperfect in 
 any part from whatever cause, and yet not so poorly made as to preTvent 
 use, the machine can be improved b}' careful study of the imperfect parts, 
 
 235 
 
230 PHYSICAL TRAINING. 
 
 and svstematic'work to correct their fault.-^. Thi^ macliiiie, like any other, 
 needs rest — rest in its true sense, not lack of use ; for, like a ])iaMO, it 
 will soon get out of tune if it is not constantly used ; but, like the piano, 
 too, it will get out of tune if you drum on one note constantl}^ if you 
 maltreat it or do not watch it. Whatever philosophers may say to the 
 contrary, the brain and the mind are just as much machines as the body, 
 all three being so closely connected that when one is out of tune it can 
 not be played in harmony with the others. "Wherefore ])hysical training, 
 as treated in this article, is not only exercise of body, but, to a certain 
 extent, of the mind and brain also. 
 
 Naturally, theory and practice do not always run the same road in 
 
 amicable companionship, but these little disputes by the way do not 
 
 in the least alter the correctness of the theory, nor fur- 
 
 Pomble for Every i^igii argument or excuse for the total disregard of it. 
 
 One to take Some ^,. -, n. t i ^i ^ ^i 
 
 Exercise. Circumstances may, and oiten do, make the theory in 
 
 part impossible to put to practical use. Then, for the 
 time, the best that can be had must be taken without a murmur; and, 
 keeping the theory before us, we must endeavour to come as near it as 
 circumstances will allow. The commendable advantage of physical train- 
 ing over analogous subjects is that the theory can be put into actual prac- 
 tice here far more frequently and far more perfectly than elsewhere. 
 Ev^ery one can bathe ; every one can eat moderately and judiciously ; and 
 every one can play and exercise twenty minutes in a day. And, after all 
 is considered, what more is there in physical training ? 
 
 It would be impossible in this short article to go into an exhaustive 
 treatise on all the branches and theories of physical training. There are 
 books upon books that do this as well as it can be done, and any one who 
 cares to, or who cultivates a desire to do so, may find all he wants to 
 know in these, or from the hundreds of trained instructors in this im- 
 portant subject. The purpose of this article is rather to show, if pos- 
 sible, the importance of physical training itself in everyday life, and if 
 the result of its perusal creates that desire in the reader, leading him to 
 go further into the study and give his mind and body that attention 
 which so beautiful a machine deserves, the purpose of the author will be 
 accomplished. 
 
 It is a law of life that nothing really great is accomplished suddenly ; 
 
 nothing is achieved by single feats of any kind, but by slow, persistent 
 
 endeavour, by constant practice, and by that steady, 
 
 r^ . gradual movement toward the accomplishment of a 
 
 Exercise. ^ ... . . 
 
 great result, which is like the building of a mansion 
 
 bric]v u})on brick. And if this is a law of life, it is most certainly a law 
 
 of health, that no complete physical or mental power is attained by single 
 
 isolated instances of training, but by the aid of the most regular, steady, 
 
THE THEORY OF PERFECT PHYSICAL CONDITION. 2.'iT 
 
 persistent, and constant physical exercise, always temperate, never exag- 
 gerated, tlie judicious placing of one small brick each day on the build- 
 ing of physical health. The theory is clear enough ; and that theory 
 should be stated at tlie start, as if it were entirely possible in all cases, 
 since, as I have said, it is jiossible to him who will but have the courage 
 to undertake it and cai-ry it out. Still, as hundreds of matters interfere, 
 and, most important of all, as it is so difficult for human nature to be 
 regular and methodical, it will be necessary, after briefly stating the 
 theory, to offer in quite as brief a form some suggestions as to the best 
 courses to pursue, where, for the moment at least, circumstances appear 
 to be too firmly set to allow one person or another to follow it in detail. 
 
 Every result in physical training has its reason for being what it is ; 
 and the best way to learn how to accomplish a result is to search out and 
 study its cause. The cause — that is, the theory of perfect physical condi- 
 tion — can be stated in half a dozen words : exercise moderately and tem- 
 perately for a short sjMce of time reyularly at the same relative hour 
 every day of your life. 
 
 The regularity of the exercise accustoms the l)ody to a certain stimu- 
 lus at a certain time ; the habit is acquired, and the exercise adds just so 
 much healthy strength and vitality to the frame, increasing the muscles 
 moderately to a healthy development, where they are maintained at a 
 normal standard. If an unusual or unnatural physical exercise is taken, 
 the result is a shock instead of a normal addition to the body's strength, 
 and hence the result is injurious. The heart is overtaxed, or the lungs 
 are congested, or the muscles are fatigued, or a hundred other injurious 
 effects are accomj)lished instead of the one correct thing — steady physi- 
 cal advance. 
 
 Manifestly this temperate, regular daily exercise should be taken out 
 of doors. The air is purer under the sky than under a dusty ceiling, 
 which, when jarred even in the slightest degree, drops 
 ,. " "• thousands of particles that go into the lungs to produce, 
 we may be sure, no salutary results. There is more 
 room out of doors in which to perfect the exercise. There is a stronger 
 movement of the atmosphere that stimulates respiration. The springy 
 ground is quite different from a wooden floor. Most important of all, 
 some of the finest physical exercises are, from their very nature, impos- 
 sible within doors. It should be remembered, also, when out of doors is 
 mentioned, that it is the country and not the city pavement whicli is 
 meant. 
 
 Furthermore, it is quite as manifestly true, after a moment's con- 
 sideration, that this daily exercise should be undertaken in the daytime 
 rather than at night, if for no other reason than that God meant men to 
 work in the light and sleep in the dark. But it has been too often 
 
238 PHYSICAL TRAINING. 
 
 ])roved to need ariiument liore tliat jtliysieal exercise inuler the rays of 
 
 the sun is quite another thing from night work of the same sort. The 
 
 sun warms and stimuhites the body, makes a pleasure 
 
 Ej-ernsein the ^^^^^ ^_^^. ^^.j^,^^ j^ ^^^ ^^ done, and in evi'i-v wav serves as 
 
 Uaytime. , i • i ' i ' • • 
 
 a lielp toward the result for which tlie exercise is 
 
 undertaken. Then, too, many of the best exercises re(]uire light, and 
 
 j^ood light at that, for their accompli.shment — for examjile, most 
 
 games. 
 
 It may not seem at lirst glance (juite as necessary as the foregoing 
 
 laws of exercise to say that all general exercise should be in the form of 
 
 a game rather than in some especial series of physical 
 
 .dercuse iu (c im^vements ; but, upon reflection, this will be found to 
 I orm of Crames. , ' ^ i i i ■ , tkt 
 
 be quite as true as what lias already been said. We 
 
 have all seen men, and perhaps some of us have been through the same 
 process, who firmly believed they were exercising and relieving the ten- 
 sion of mind and body after a long and close application to work when 
 they went through a series of dumb-bell movements, whereas, in reality, 
 their minds not being required in the course of this exercise, only the 
 bodv was receiving its training, and that merely in a perfunctory manner. 
 To make exercise beneficial, the mind and 1 train must be as much em- 
 ployed as the body, and this can only be done, except in a few isolated 
 cases, by making the exercise itself some form of game requiring brain 
 work and embodying the idea of victory and defeat. 
 
 Let no middle-aged, no old man think that the time has gone by for 
 him to receive any good from physical exercise. One of the most satis- 
 factory features of the whole practice of training is the immediate results 
 it shows in persons of any age. A few short weeks of this temperate, 
 regular development makes a different human being of the octogenarian. 
 And, in like manner, the popular prejudice, now fortunately disappearing, 
 that women and girls are in some way different kinds of beings from 
 men and boys, and do not require any physical exercise, is as absurd as it 
 is disastrous. If anything, women should give more thought to their 
 exercise than men, more thought to the determination of the method and 
 the duration of their exercise ; for having, in a certain sense, more deli- 
 cate organizations, they require that more thought and more care be put 
 into the question of their physical training. 
 
 Finally, the question of physical training is not for the good of the 
 body onlv. It is proba]>le that exercise of a healthy sort is a great pre- 
 ventive of crime and of intemperance in all forms, one of the greatest 
 strengtheners of the moral sense that exists. But this subject is too ex- 
 tensive even to be touched upon here. There is only room for the state- 
 ment of the fact that college authorities unanimously declare that our 
 modern American college athletic games, and all the training that accom- 
 
TO MAINTAIN HEALTH OR STRENGTHEN WEAK PARTS. 239 
 
 panies theni, liave dono tlic community an inestimable servicf; in raining 
 the standard of morality and temperance arnoiif^ our youn<^ men to a 
 point that has never been reached in the United States before. 
 
 OUTDOOR EXERCISES. 
 
 It is important to remember, in discussing the question of physical 
 training, that two distinct sides present themselves, and that the distinc- 
 tion of one from the other must be carefully borne in 
 Two Ohjeets of • i i i ^i i • , • i . •, 
 
 Exercise ' iw^^d wJien any work on the subject is under considera- 
 tion, as well as wdien tlie subject of individual develop- 
 ment is to be discussed. Exercise is taken up either as a means of main- 
 taining already good health in a normal body, as a means of counteracting 
 the influence of sedentary life in which little or no physical movement 
 bears a part, or to develop constitutionally weak parts of the body, or 
 muscles, or organs that have been rendered chronically weak by the par- 
 ticular occupation of the individual in question. The ordinary city office 
 work, which means constant sitting at a desk six days of the w^eek, the 
 similarly ordinary occupations of a woman within the house and in the 
 midst of her domestic duties, require general action of the body as a 
 whole in order to counteract the lack of exercise in themselves. Lungs 
 which are constitutionally weak, which are only employed within doors 
 cramped over a desk or sewing table, a stomach and digestion that are 
 chronically out of healthy working gear — these and a thousand others are 
 special parts of the body that require special attention and special athletic 
 exercises, not only to restore them to normal condition, but to prevent 
 them from developing into incurable diseases. 
 
 A large part of this article will be given necessarily to the former, 
 since a special weakness is different in its details in individual cases, and 
 should have the direct personal care of a physician or some one who un- 
 derstands physical culture. Few principles can be given for the improve- 
 ment of these special weaknesses, and those only the most general. As, 
 however, exercise for general purposes of health is what the great ma- 
 jority of persons require, and as any one who is really ill is likely to go 
 to a physician of his own accord, the practice of general athletics is the 
 subject to be discussed here. 
 
 OUTDOOR GAMES. 
 
 Outdoor games are, without question, the best methods for maintain- 
 ing normal health for such persons. The first principle to be laid do-wn 
 is that no man or woman should allow a day to pass while he or she is 
 well without taking exercise in the form of some game — that particular 
 game which contains the largest amount of general exercise and which is 
 
240 PHYSICAL TRAINING. 
 
 available when the facilities of the individuars surroundings, the time at 
 his disposal, and the size of his purse are taken into consideration. 
 
 Naturally one can not play polo every day in the year. It would not 
 only grow wearisome, but would overtax the strength, and in time injure 
 tlie health instead of beTieiiting it. Most real athletic games present the 
 same difficulty. But it should be borne in mind that one who plays polo 
 or tennis, or anything else of the sort, once or twice a week is from this 
 very fact stimulated to keep himself what is called " in training " all the 
 time. On the days when he does not play his games his exercise should 
 be taken in something more temjierate, involving less time, less prepa- 
 ration, and consisting perhaps of nothing but special development 
 exercises. The latter alone will not accomplish what is intended by 
 physical exercise. Combined with a vigorous game, they do much, 
 perhaps nearly as much as the daily practice of some easily undertaken 
 games. 
 
 There is little doubt that polo as played at present contains a greater 
 amount of physical exercise distributed over every conceivable muscle of 
 the body than any other sport, at the same time that it 
 occupies the mind to the exclusion of all else. Every 
 one of the leg, back, abdominal, chest, shoulder, and arm muscles are at 
 work all the time. The player is using his lungs in the freest possible 
 way, and he has the added exercise of keeping himself on his horse, 
 which is constantly charging in every direction, which must be guided, 
 steadied, and controlled with one hand while the other is engaged in 
 managing the mallet. And through it all the player's mind and brain are 
 busy with the pony as well as with the course of the ball and the prog- 
 ress of the game. There is never the same movement repeated a second 
 time. The whole principle of the sport is infinite variety, bringing every 
 part of the body into play, bringing every faculty of the mind to bear. 
 Yet, though precise and accurate repetition is absent, the amount of skill 
 required can be understood only by him who has played the game for 
 years. Polo is, however, beyond the reach of most men. It is very ex- 
 pensive ; it is impossible for a man beyond middle age, on account of the 
 extraordinary quickness required ; it is impossible for one whose weight 
 is over about one hundred and seventy-five pounds, as a pony can not carry 
 even that weight with the degree of quickness and ease necessary to the 
 game. Furthermore, polo, like all the most vigorous exercises in the 
 form of games, is dangerous to life and limb, for a collision of two men 
 on their ponies often results in serious injuries. For him who has the 
 time, the money, and the physique to play it, polo, nevertheless, is without 
 a peer in atliletic sports. As an exercise pure and simple it should not 
 be played oftener than three times a week, and only during that part of 
 the year when the turf is in a soft condition. 
 
POLO GAME IN PROGRESS. 
 
 241 
 
242 
 
 PHYSICAL TRAINING. 
 
 Football as played in college to-day— that is, either the American 
 
 game of llugby Union (Fig. 2) or the English Association — has all the 
 
 points brondit out in polo, excei>t that the pony is 
 
 ° " ' wanting, and with him goes some of the completeness of 
 
 the exercise. Football is more exhausting, and can only be played at its 
 
 best for a short time in the year when the temperature is warm enough 
 
 IN GOAL 
 
 TOUCH 
 
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 160 FEET 
 
 
 
 
 
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 Fig. 2. — Diagram of football ground. 
 
 to furnish soft turf but not so warm as to exhaust the body. It embod- 
 ies, however, all the points which make exercise beneticial. Every muscle 
 of the body is constantly in use during the game, and at the same time 
 the sport trains the mind in many of its most valuable cpialities. It is 
 
PREJUDICE AGAINST FOOTBALL MISPLACED. 
 
 243 
 
 distinctly a young man's and boy's game, but as sucli it lias done an in- 
 estimable amount of good, ])oth morally and physically, to the youth in 
 colleges and schools. Fig. 3 gives a good idea of the game at its lieight. 
 The difficulties of football as a systematic exercise are great, liowever, 
 since twenty-two men are required to make up the two elevens, and the 
 better part of an afternoon is required for the playing of a single game. 
 For schoolboys in towns and cities there is hardly a liner and more manly 
 sport to be found, and the popular prejudice against it as an ungentle- 
 manly game is misplaced ; for while, like boxing, it offers opportunities 
 for vicious natures to revel in, it is a magnificent school in self-control, 
 courage, self-reliance, keen, quick thought, and the habit of instantane- 
 ous decision. The infinite variety of a game, or even of an afternoon's 
 practice, is what places it above most sports as a general physical trainer. 
 
 Fig. 3. — Football : a successful '' tackle." 
 
 An important consideration in both polo and football is that they 
 should not be played by any one who has a tendency to heart or lung 
 trouble. Such a tendency is often not discov^ered until one of these vig- 
 orous sports is taken up. But as soon as it is discovered a phvsician 
 should be consulted. Either game should be played only after consid- 
 erable athletic training. Indeed, they are only for the naturally healthv, 
 who have time and money to devote to some extraordinary exercise. 
 
 In lacrosse (Fig. 4) there are many of the points that commend the 
 physical exercise of football. Extreme skill, delicacy, cleverness, and quick 
 wit, added to the general muscular training, make the game one of the 
 best of exercises and one of the most beautiful sports known. Lacrosse 
 
24:4 
 
 PHYSICAL TRAINING. 
 
 Jjiirrosse. 
 
 can be ]ilayed also by many men wlio tind football too severe; but it is 
 nevertheless a fact that with the disappearance of the jiersonal-contact 
 feature in football there goes some of the muscular train- 
 ing about the shoulders, chest, and back. Lacrosse de- 
 velops the leg, side, and abdominal muscles ; but if a ]ilayer in good train- 
 ing will spar for half an hour with a boxing teacher he will lind the 
 next day that all aronnd the upper part of his body the muscles are stili 
 and lame, which is a proof of the fact that in his lacrosse he has had no 
 use for some of these, and that they are consequently not being devel- 
 
 
 it 
 
 
 FiG. 4. — Laukusse. 
 
 Lawn Tennis. 
 
 oped. It should be said in passing, however, that lacrosse onglit to be 
 played far more than it is, since it surpasses all but two or three sj)orts 
 in mental and physical training. 
 
 Lawn tennis is, perhaps, as good an exercise as any outdoor game 
 which comes within the sphere of the average man and woman. Tlieo- 
 retically the game requires a perfectly level turf of 
 rather extensive proportion, which is impossible for 
 most people to procure ; but practically any group of persons, in town 
 or country, may, by clubbing together, form a tennis club at a cost of but 
 a few dollars a year apiece. The game requires little time, and is feasi- 
 ble for seven or eight months of the year out of doors, and for the whole 
 year if during the winter it be played under cover. A moment's consid- 
 eration will show, however, that tennis has not the merits of any of the 
 
TENNIS, BASEBALL, AND CRICKET. 245 
 
 foregoing games as an exercise. In the first ])luce, it develops the right 
 side at the expense of the left. In the second place, there is no personal 
 contact, which, while it always makes a sport more dangerous, gives a 
 greater variety of exercise to the muscles and introduces qualities of men- 
 tal training that are totally wanting in tennis. At the same time and for 
 this very reason tennis is more practicable, less exhausting, and therefore 
 includes among its players men and women of all ages. For a business 
 man, who can get a good half hour of tennis each evening after his 
 work, there is scarcely a better or more feasible exercise when all things 
 are considered. The playing of men and women together is distinctly a 
 mistake, of which more is said hereafter. 
 
 It may be as well to note here that no game should be taken up super- 
 ficially. If exercise is Avorth undertaking at all, it is worth undertaking 
 seriously. The player should always do his best. If he is tired out he 
 should stop; for ten minutes of tennis or anything else wlien you are in 
 a wearied condition will do a definite amount of harm. One should in- 
 variably prepare for his game in costume, should play with study and care, 
 should never sit about after stopping without carefully wrapping up, and 
 should invariably bathe in hot and then cold w^ater as soon as possible 
 after stopping, for these are the laws of the athlete to the ends of the 
 earth, and the manner in which games are played is far more important 
 than the games themselves. 
 
 Baseball as an exercise is peculiar. There are certain points about it 
 that make it valuable both as a mind and body trainer, but it is more of 
 a game than an exercise. The sudden movements, the 
 sometimes protracted periods of inaction, with the con- 
 sequent nerve tension, make an otherwise admirable sport for the young 
 and middle-aged only a secondary exercise in physical training. The 
 real value of such a game is in the training it gives one while he is pre- 
 paring for it. And here again is a proper moment to urge old and 
 young who take np such a game to play it systematically. The ordinary 
 " knock up," or " scrub," or desultory choosing of sides, have no trace 
 of physical training in them, except the fact that the players are in the 
 open air. To make baseball beneficial the nine should be carefully chosen, 
 each man studying his position, regular practice being taken each day 
 and games played periodically. With all the accompanying rules, such 
 as dressing properly, bathing after practice, and eating carefully, the 
 hour of exercise is of course beneficial. When all is said, however, base- 
 ball is not as complete an exercise as any of the games that have already 
 been mentioned. 
 
 Cricket is as yet hardly an American game, but in general the same 
 may be said of it as of baseball. It is a good sport if systematically kept 
 up, but there is an amount of sameness to it, a lack of general develop- 
 
240 
 
 PHYSICAL TRAINING. 
 
 ililiffiiiiEMi^^ 
 
THE MERITS OF GOLF. 
 
 247 
 
 Cricket. 
 
 ment in the exercise that makes it hardly a garuo to bo undertaken as a 
 means of accomplishing physical culture, though both these games as games 
 have few equals. As in baseball, one should always avoid 
 the desultory, unsystematic game. Cricket requires 
 eleven men to a side, and there can be no real game unless twenty-two 
 men are at hand. AVithout the complete nuinber the game is weak, no 
 systematic team play can be put into it, and the players get none of the 
 mental good to be obtained from it. With the full number, however, 
 there are few games where more skill is involved. The bowler has an 
 intinite variety in his work, and the chance for individuality is extraordi- 
 nary. So also in the case of the batsmen. With a full field they have to 
 judge the ball and at the same time pick out a hole in the field where they 
 may send it, and, finally, they have to know the use of the bat so well 
 that they can direct the ball to within a few feet of the spot at which 
 they aim (Fig. 5). All this involves study long and thorough, and all 
 this is lost in desultory, half-hearted games, while bad habits are easily 
 learned. 
 
 The disadvantages of football, baseball, and all such games are, how- 
 ever, present in cricket also — namely, so many men are required that it is 
 not every one who can bring so many men together and get daily practice 
 in the game. 
 
 Golf has been recently introduced into America from England and 
 
 Scotland. The enthusiasm which has characterized its devotees is a 
 
 siffn of its merits. 
 Golf. T % 
 
 Like cross-country 
 
 riding, it was generally considered 
 
 an English fad, and very likely some 
 
 attempt at aping the English was 
 
 the cause of its introduction here. 
 
 But the game has merits that few 
 
 other sports can pi-esent, and for 
 
 this reason it is worthy of careful 
 
 attention as an exercise. In the 
 
 first place, golf can be played by 
 
 both men and women as well as by 
 
 boys and girls. A boy of fifteen 
 
 and his grandfather may play it and 
 
 neither give the other a handicap. 
 
 At the same time that the club 
 
 swinging (Fig. 6) is an admirable 
 
 exercise for most of the muscles of 
 
 the body, the game has none of the drawbacks that come from sudden 
 
 movement. The whole course of the sport is steady yet vigorous, and it 
 
 Fig. 6.— Golf 
 
 ACT OF DEIVIXG. 
 
24S PHYSICAL TRAINING. 
 
 can be plavcd for nine months in the year in the northern part of the 
 United States and for the entire year in the South. The expense is hglit 
 after the Hnks are laid, and these ran be ])re[)arfd, after the organization 
 of a chib, anywhere in the country that there are open fields. For busi- 
 ness men in middle and old age and for their wives there can scarcely 
 be found a better outdoor sport, and the amount of interest and skill con- 
 nected with the game are almost infinite. 
 
 In England the game is much better understood than in America, and 
 a practice has grown up in the former country which might Mxdl be 
 adopted in the United States in connection with golf. This is that fre- 
 quently in Scotland and in England business men take an hour and a half 
 to two hours and a half at lunch time. They not only get lunch, but they 
 liave time to go the rounds of the links once perhaps, and come back to 
 work braced for the rest of the day. This could not be done, of course, 
 by a man out of training without tiring him so thoroughly as to make 
 Ins afternoon work useless ; but in a short time he learns to come back to 
 Ins work ready to cover twice as much as before. This practice of taking 
 a long noon hour and working later at night is an admirable one, and it 
 would do Americans a great deal of good if they could break away thus 
 entirely from business in the middle of the day. Such a respite has an 
 extraordinary influence in quieting nervous temperaments, and relieves 
 the muscles and starts the blood just when both are growing dull and 
 sluggish. 
 
 Ice sports, including skating pure and simple, as well as games played 
 upon the ice, such as hockey and ice polo, are natural and healthy kinds 
 of amusement out of doors. In a large portion of the 
 United States, however, they are impracticable, or 
 nearly so, since the climate is not cold enough to furnish the ice. They 
 do not, therefore, play an important part in physical training. Their 
 great use is in supplementing some other sport that has been kept up for 
 ten months of the year and, perforce, dropped on the first fall of snow. 
 Ice sports, too, except straight-away skating, are confined largely to boys 
 and young men. 
 
 Track athletics, which include long-distance and short-distance running, 
 high and broad jumping, hurdle-racing, hammer-throwing, and shot-put- 
 ting, are sports that require more care from an instruct- 
 Track Athletics. ^, r ^ ■. -i - ^ c 
 
 or than any of the games already mentioned, so far as 
 
 purely athletic exercise is concerned, for in long-distance and short-dis- 
 tance running, for example, one may do himself far more injury than 
 good, unless he runs in the proper way. The same is true of the other 
 track- athletic sports mentioned. Running is neither easy nor healthful un- 
 less undertaken in the right way; 100- (Fig. T), 220-, or 440-yard dashes 
 should never be undertaken suddenly, practice being required before the 
 
THE VALUE OF TRACK ATHLETICS. 
 
 249 
 
 lungs and heart are rendered capable of undergoing the strain. Jiut, on 
 the other hand, steady training of tlie right sort for these events is an ad- 
 mirable method of preserving healtli. In long-distance running — that is, 
 from two to ten miles — the runner, dressed in suitable light costume, 
 should begin with five-minute " jogs." These short runs may be extended, 
 as days go by, to ten-, fifteen-, and twenty-minute runs, two weeks being 
 given to each period. In time this can be extended again, until the runner 
 can easily keep up a slow run for one or two hours without undergoing 
 any greater strain than he sustains in the first five-minute run. It is this 
 steady preparation in all track athletics which, if carried out in the right 
 
 Fig. 7. — One hundred yard dash. 
 
 way, makes healthy muscles and good spirits ; for at the same time that 
 one prepares oneself properly for a contest, one prepares oneself also for 
 a healthy body. The value, then, of track athletics is in the daily hour 
 of practice for some event, not in the event itself ; and hence that hour 
 of practice should be maintained religiously as long as the weather per- 
 mits. Indeed, if the practice could be maintained without the contest, it 
 would be fully as well for the health of the athlete, since hard-fought 
 contests are in themselves apt to be injurions. 
 
 Rowing, when studied as it is in the colleges, or in singles, pair oars, 
 four, six, or eight oars (Fig. 8), is a questionable exercise. It has its merits, 
 of course, and they are well known ; but it is certain that four-mile races, 
 such as those rowed between the American and English universities, are 
 
250 
 
 PHYSICAL TRAINING. 
 
 injurious, for the reason that they not only overtax the heart and lungs, 
 but pros-e too great a strain on a man's nerves. Aside from the question of 
 contest, however, rowing is a doubtful means for phjsi- 
 ioivin(j. ^_^^ training. It only brings into play certain muscles. 
 
 It develops these at the expense of others, and the very merit uf it — the 
 precision and absolute repetition of stroke after stroke — renders it too 
 precise, too unvaried and methodical to be a perfect ])hysical exercise. 
 We liave all seen many an example of this. I remember a rowing man 
 in perfect training making the attempt to play a game of polo. He found 
 himself the next day as lame as any one would have been who had taken 
 no exercise for a long time. On the other hand, no one ever knew a polo 
 player or a football man in good condition to be lame in any way after a 
 day of rowing. In other words, these two games exercise every muscle 
 alike, while rowing gives practice only to a chosen few. 
 
 Fig. 8. — Rowing: eight oaks. 
 
 From this short consideration of the more important outdoor sports 
 — which nnfortunately, for obvious reasons, can not be more extended 
 and thorough— it will be seen that no game is a perfect physical exercise 
 and at the same time open to old and young of both sexes ; and indeed 
 there are drawbacks to all from the theoretical point of view. It is for 
 this reason that so many people have grown into the error of recommend- 
 ing special-development exercises as better for the average person. This 
 is a false theory for many reasons. There are bad points about all sports, 
 but sports put vitality and spirit into the man or woman who takes them 
 up, and they afford something that is never supplied to a man by years of 
 practice on the pulley weights. They bring into play the mind, the brain, 
 and the qualities of courage, self-reliance, and confidence which are totally 
 absent from all special-development exercises, but which have more to do 
 in making a healthy mind and body than any amount of large muscles. 
 Furthermore, though match games, races, and prize contests are, as a rule, 
 not advisable from the trainer's point of view, they are tolerated, so to 
 
GAMES PEEFERABLE TO SPECIAL EXERCISES. 251 
 
 speak, for the good they do in .stiimilating a man to train long and faith- 
 fully in preparation for them and in educating by the force of example 
 the desire for athletic prominence among others. With all their faults, 
 then, games, rather than special exercises, should be chosen as the medium 
 for securing and keeping physical health, wherever and wlienever any 
 one of them is feasible. 
 
 There are, however, men and women who, for many reasons, can not, 
 or believe they can not, take up any game systematically, and for these 
 special exercises are tlie only, and therefore the important, subjects to 
 study. 
 
 OUTDOOR SPECIAL-DEVELOPMENT EXERCISES. 
 
 The whole question of exercise is, in other words, one of degree. 
 Every one should take some exercise. A law should therefore be laid 
 down setting forth what are the best methods and what the best forms for 
 exercise. This being done, it is the business of the individual to fit one 
 of these methods or forms to his particular circumstances. Finding none 
 of these available, it is his physical obligation to himself to turn the 
 printed page of physical training and find some plan wdiich, though less 
 useful in theory, does suit itself to his surroundings. If no game is 
 feasible, then he should iindei'take some special exercise. It does not 
 alter the fact that outdoor games are the best educators of health, that 
 they are better than meaningless exercise ; yet, at the same time, it does 
 not mean that there is no good to be attained from this second form in 
 athletic training. The outdoor special training is thus better than the 
 third or fourth page — that is, indoor games and special exei-cises — just as 
 they are better than no exercise at all. 
 
 For one reason or another, therefore, games may not be open to the 
 individual in question. His entire day may be taken up with work, and 
 
 hence the night is the only time when his exercise can 
 
 Overeating and n ^ ^ rm i.-"xix £ • j. \ • • -r\ 
 
 ^ , ^ „ . find a place, ihe question that confronts him is, Does 
 Lack oj Jixercise. . . . . 
 
 it behoove him to exercise some particular part of his 
 body, or should he merely try to keep an already healthy frame in work- 
 ing order ? That is, should his outdoor work be special or general in its 
 form ? In most cases it is the general that is needed. Men of the city, 
 of the town, and often of the country, as a rule eat too much and take 
 too little exercise. If the body is reasonably healthy its possessor has a 
 large appetite, he enjoys his food, and he does himself no apparent injury 
 by eating three good meals a day. If there is little or no time for ath- 
 letics he gives no attention to them. The result is that several times a 
 year he has throat trouble, or perhaps once a month he comes home from 
 work and o-oes to bed with a bad headache. His wife or mother verv 
 
2") 2 PHYSICAL TRAINING. 
 
 likely sends for a doctor. Xext day he begins work again, a little weaker 
 perhaps, but still not ill enough to be sick in bed, and in a week the large 
 appetite has returned. 
 
 I venture to say that this is the history of most men and women in 
 the United States who are, to all appearances, perfectly well. ^luch of 
 it is due to overeating and lack of exercise, and any one who stops a 
 moment to think of it will confess that to overload a machine like the 
 liuman body and then not keep it working will clog it, set all its parts by 
 the ears, and then, as the strain grows greater, some little portion of the 
 mechanism will break — that portion, of course, which may be naturally 
 weak or have a flaw in it. Hence, if your throat is naturally sensitive, 
 you have a cold wliic-h rcipiires a physician's care. The most glaring ex- 
 ample of this that has come to my attention, and which in its denouement 
 would have been comical if the whole history of it had not been sad, was 
 of a man who suddenly found himself atHicted with heart disease. He 
 could not walk. He could not go up a flight of stairs. He was treated 
 for heart disease of a certain kind, because he had once, ten years before, 
 been troubled with the working of the valves of liis heart. Day by day 
 he grew worse, until finally a shrewd physician stopped his eating any- 
 thing but meats, and ordered him to drink hot water. The third day 
 afterward he went upstairs for the first time in months. In four weeks 
 he was nearly as well as ever, and now, instead of weighing two hundred 
 and twenty-five pounds, he weighs one hundred and eighty, takes some 
 regular exercise daily, and eats carefully and lightly. The history of it 
 was that he liked good food, ate heartily, took no exercise, clogged the 
 machine given into his charge, and the one point in his mechanism that 
 had a flaw in it — the heart — gave way for the time being, fortunately not 
 so completely that it could not be repaired, when the whole machine was 
 running smoothly again. Outdoor special exercise, or, in fact, any exer- 
 cise, will to a certain extent lessen the tendency to overeating, though the 
 eating should always be kept under careful control. 
 
 One of the best means for general muscular exercise, and especially so 
 because it can be practised at night as well as in the day, is walking. 
 
 Walking is one of the most abused exercises known to man. Under- 
 taken in the correct way, it affords capital physical training, and, as far as 
 it goes, as good as any. It does not equal any of the 
 sports already mentioned, because walking can be un- 
 dertaken without forcing the mind to drop the work of the day. Theo- 
 retically, walking requires a great deal of mental attention. Practical!}'', 
 one may brood over the troubles of the day while trudging along a road, 
 and if the gait is steady and the movement solid and heavy, the walker 
 may return home after an hour and not have received any more exercise, 
 except to his lungs perhaps, than if he had stayed at home. Once carefully 
 
WALKING AND RIDING. 253 
 
 studied, on the otlicr liaiid, walking turns out to be ii diflicult matter. 
 There is a distinct position of the body for it, and any one who decides to 
 take it up as the only half hour of physical training open to him, should 
 learn this correct position and always take it. In the first ])lace, he should 
 dress for walking, wearing light clothing, no suspenders; if on a track, 
 nothing but light walking shoes, short cotton walking trousers, and a 
 light flannel shirt; if through the streets and in the country, an ordinary 
 suit, large, loose, flat-heeled shoes, and a felt hat. The shoulders should 
 be thrown back, head a little forward and chest out, the arms bent a little 
 at the elbow, the fists clinched, and a vigorous movement of the shoulders 
 developed, which not only carries the body in a long stride, but enlarges 
 the chest, shoulder, and back muscles. The stride should be long, steady, 
 and quick, and made from the shoulder and hip, not from the knee alone. 
 This can be acquired by rising on the toes of the right foot, leaning for- 
 ward, and at the same time swinging the left hip forward — partially turn- 
 ing to the right, in other w^ords. Then, placing the left foot upon the 
 ground as far in advance as possible, the whole body should be swung 
 forward until the right hip and shoulder are in a like manner advanced 
 and turned a little to the left. While this adds to the length of the stride, 
 and brings all the side muscles into play, it gives opportunity for the 
 puUing-back movement and thrusts the body forward with a quick, vigor- 
 ous action that adds springiness and vitality to the exercise. The 
 step itself involves the rising upon the toes of each foot alternately to 
 their fullest extent, each step ending in a vigorous spring from the ball of 
 the foot. The foot itself should point directly forward, being neither 
 " turned out " nor " in," in other words. A four- or five-mile walk of 
 this sort each afternoon before sundown is an admirable, inexpensive, and, 
 for most people, a feasible exercise, and not the least of its good points 
 is that it can be undertaken every day in the week. Nevertheless, it 
 must be remembered that it lacks mental exercise and relaxation for the 
 brain. 
 
 Riding has the great merit over walking that it does furnish this re- 
 laxation for the mind. That relaxation is the companionship of the 
 horse, wdiich requires the attention of his rider to such 
 a degree that it is at least easily possible to find rest and 
 change of thought thereby. For any one who is so situated that he is 
 either in or can get into the country for a half hour or an hour a day, 
 riding is a capital trainer, especially riding to hounds. Hiding after 
 hounds is increasing in the United States, and it is a mistake to believe 
 that the sport must be confined to the wealthy and the aristocratic. Any 
 dozen persons in a town can easily secure a few hounds who will follow 
 the scent of an aniseed bag if foxes are not to be had ; and, indeed, 
 hounds are not necessary so far as the exercise is concerned, for one may 
 
254 PHYSICAL TRAINING. 
 
 lay out a cross-country course for his run and follow that as well without 
 hounds as with them. The exercise given the nuiseles during such a ride 
 is general, and for that reason alone it is valuable. 
 
 In the heat of the summer walking and riding can hardly be supple- 
 mented by a better all-round general exercise than swimming (Fig. '.)). In 
 swimming, however, as in all other exercises, there is 
 one correct and many incorrect ways, iliere should be 
 no desultory paddling about, no occasional sea bath once or twice a week, 
 but a systematic plan involving a short swim eat-h day. The particular 
 man or woman who is near the seashore and takes up swimming for the 
 hour's daily physical training through June, July, August, and Septem- 
 ber, should choose the most suitable time of day for it and then keep to 
 that same hour each dav throuirh the four months. Often before break- 
 
 FiG. 9. — Swimming : proper position. 
 
 fast is a good time, or late in the afternoon, before supper or dinner. 
 The body should be cool before going into the water, and the stomach 
 should not be occupied in digesting food — that is, the man should have 
 eaten at least two hours before bathing. If possible, swim without bath- 
 ing clothes of any kind. Once cooled off, go down to a pier and plunge 
 into the water by diving head foremost. Thus the blood in the head 
 receives the first shock. Come to the surface and swim directly for some 
 definite point as far away as your capacity for swimming will allow. 
 Xever swim, however, after you become aware of a feeling of weariness 
 and exhaustion. A swimmer may be out of breath and not tired. Hard 
 breathing is not in itself a bad thing. It shows that the lungs are being 
 distended and exercised. Having reached the desired point, swim back 
 with long, slow, complete strokes to the pier, come out of the water at 
 once, rub yourself thoroughly, and dress. Afterward sit or lie quietly 
 for from fifteen minutes to lialf an hour. During the course of this 
 swim, which can be extended as the powers of endurance increase, every 
 
ADVANTAGES AND DISADVANTAGES OF BICYCLING. 255 
 
 Bicycling. 
 
 Fig. 10. — Bicycling : incorrect posittox. 
 
 conceivable muscle of tlie body is used, and four months of such work 
 will make your daily duties easier than ever before. 
 
 We now come to an important exercise that requires special attention. 
 Bicycling can be enjoyed so easily at any time of the day or night, and 
 the expense is relatively so small, that the bicycle is be- 
 coming extremely pojDular for both sexes and all ages. 
 And there is much in it that is good. It is distinctly an error, however, 
 to ride a bicycle too f re- 
 qiTtently, or too much at 
 one time, or at any and 
 all times of the day and 
 night, especially if physi- 
 cal training is one of 
 the reasons for riding. 
 Here, as elsewhere, a 
 regular scheme for each 
 day's exercise should be 
 followed. There should 
 be the half hour, or 
 hour, of steady long-dis- 
 tance riding, and the fif- 
 teen minutes, or half hour, of speeding at its close. Care should be taken 
 as to costume, as to the bath and rub-down immediately after the return, 
 but more especially as to the correct way to ride. There is no necessity 
 
 for the wheelman to bend over 
 the handles (Fig. 10). This 
 compresses the lungs, strains 
 the back, and not only develops 
 what are called " round phoul- 
 ders," but slowly and surely 
 displaces the chest and abdomi- 
 nal muscles in a way that is 
 sure to produce ill health in 
 time. The constant jar in rid- 
 ing is also an injury to the 
 liver and other parts of the 
 body. To avoid this as far as 
 possible, the rider should never 
 allow his muscles to become 
 Fig. 11.— Bicycling : correct position. rigid. For example, when a bi- 
 
 cyclist becomes a little wearied 
 he will straighten his arms, thrust his chest forward, and allow his shoul- 
 ders to be pushed backward until the shoulder blades almost touch each 
 
256 PHYSICAL TRAINING. 
 
 otlier beliiiid liiiii. His neck will protrude and he will sway from side 
 to side on each pedal in turn, sending tlie machine with the weight of 
 his body instead of the force of his muscles. If you ever get into this 
 position as a result of weariness, the only thing to do is to dismount and 
 rest until the weariness has in a measure disa]i]x\arcd. Ihit no i-ider 
 should ever allow himself to get into such a posirioii. In the first place, 
 it is actually injurious, and in the second, it renders the exercise without 
 merit as a physical trainer. The proper position is to sit erect with the 
 arms a little l»ent to allow some s])riiig, with the legs moving at thigh, 
 knee, and ankle with each revolution, and with tlie whole body uj)right 
 and stationary to avoid swaying from side to side (Fig. 11.). AVhen this 
 position cannot be maintained it is time to stop. 
 
 I might go on bringing out the points in other similar outdoor exer- 
 cises that are general in their nature and yet are not games in the strictest 
 
 sense, but this is sufficient to suggest to the readers "who 
 
 Outdoor Exercises n • i . , i • xi i n 
 
 ^ really wish to take up some exercise, the good as well 
 
 as some of the drawbacks of such forms. They will 
 soon find many other sports like these if they care to search for them. 
 None of them are as good as games, but they have one great merit over 
 special-development exercises — i. e., that they do not exercise the same 
 muscles in precisely the same way all the time. Walking uphill is quite 
 different from walking downhill, as any one will soon learn who ti-ies 
 both ; and walking along a level road is neither of these two. In like 
 manner, riding, jumping, and running a horse are all different one from 
 another ; swiniming on the stomach, on the side, on the back, employ 
 each its own set of muscles, or rather all the muscles in a different way. 
 These or otlier exercises should be taken by every one throughout the 
 3-ear day by day, the object being to preserve health by furnishing some- 
 thing in contrast to the regular occupation of the individual. 
 
 There are, however, certain occupations which, involving as they do 
 the use of certain muscles at the expense of all others, or requiring that 
 the bod}' be held in more or less cramped positions each day, make it 
 necessary that the other muscles of the body be given a superabundance 
 of exercise to make them equal these and keep the body normal. Fur- 
 thermore, many persons are chronically Aveak in one portion of the body 
 or another. Their legs are strong wdiile their chest muscles and shoulder 
 muscles are weak, or both may be vigorous at the expense of the abdomi- 
 nal muscles. Exercises tending to correct these inequalities are available 
 at every turn, but it should be invariably kept in mind that all special- 
 development training is to be carried on in the open air if possible, and 
 in the daytime as well. If daylight is impossible, they should be under- 
 taken at night, but still out of doors, and finally, if not out of doors, then 
 under cover, but in the vicinity of open windows and doors. 
 
EUNNING AS A SUBSTITUTE FOR GAMES. 257 
 
 I remember the case of an individual who docs not live a liundred 
 miles from New York. His life was a sedentary one, and lie was com- 
 pelled to sit at a desk durin<( tlie hours of the day. 
 Special Exercises /-..i £ j.\ ^ ,-\ r 
 
 J, ,, r Outdoor o'aines were lor the moment therefore not to 
 
 jor the Legs. , ^ 
 
 be considered. Yet he found his leg muscles growing 
 so weak and his lungs so out of condition that he had difficulty in going 
 up four flights of stairs. The chief difficulty was with the muscles of 
 the calf, tije thigh, and the back thigh. Finally, he hit u{)on the follow- 
 ing plan, and this happened to be in the winter too: Immediately upon 
 arriving, at six o'clock, at his home in the suburbs of New York, he went 
 to his room and stripped. Then he put on " sneakers," a pair of cotton 
 drawers cut off at the knee, and an undershirt not only without sleeves, 
 but with most of the shoulder cut out. Over this he wore what is called 
 a " sweater." This was all his clothing. He then went out on to a long, 
 straight road, which was not much used at night, and began to trot 
 slowly along through the three inches of snow. He had studied how to 
 run. His shoulders were thrown far back, his arms swung across his 
 chest in a bent position, each hand grasping a large piece of cork cut in 
 the shape of a banana. His chest was thrown painfully (at first) forward 
 and his head back, so that he could look up at an angle of about thirty 
 degrees. His abdomen was thrown far forward and his back bent in. 
 He ran on his toes, never letting his heels touch the ground. In three 
 minutes he was not only perspiring freely, but he had to stop from sheer 
 muscular exhaustion. Kealizing that he must not stand in the cold, he 
 turned and ran back. The whole time w^as not over ten minutes from 
 the start to the moment when he got into a bath of lukewarm water. This 
 was followed by a cold-water sponge, and then, rubbing his skin with a 
 hard towel, he dressed, and was sitting at dinner at a quarter before seven, 
 and found himself struggling not to eat too much. 
 
 For a man of almost any age who can not play a game in the daylight 
 I know of no better exercise if his occupation involves desk woi"k. The 
 •chief good of it is in the muscles of the legs — by running on the toes. 
 If the heels are allowed to touch, neither the muscles of the calves nor 
 of the thighs are effectively used. The lungs received as complete an 
 exercise in their way as the leg muscles, simply from the position in which 
 the shoulders were held and the long, deep breathing that was necessary. 
 
 There are many such exercises within the reach of every one. Broad 
 or high jumping, which can be carried on in the back yard of any subur- 
 ban or counti'y house ; hammer-throwing, shot-putting, or high kicking, 
 and many others that will naturally suggest themselves. 
 
 For the waist and abdominal muscles there are several of the more 
 common athletic sports that are admirable exercise, all of which can be 
 adapted to the use of a single man in or near his house and without the 
 19 
 
2:)S 
 
 PHYSICAL TRAINING. 
 
 Waist and Alnlomi 
 7ial Muscles. 
 
 need of mueh prepavatioii or expense. There is hardly a better move- 
 ment to bring in the siile muscles — in fact, all the muscles about the waist 
 — than tlirowini:; the hannner {Viy:. 
 I'l) and putting the shut {V\g. !>)). 
 One needs but to swing around the 
 
 head at ai-nis' length a sixteen-pound shot attached 
 
 to the end of a pole three and a half feet long a 
 
 dozen times to lind this out. Any open lot with a 
 
 liundred feet clear is suitable for these exercises. 
 
 The former should be treated gingerly at first, as 
 
 should shot-putting with a sixteen-pound shot, for 
 
 the strain to unaccustomed muscles is prodigious. 
 
 The swinging of a hammer and the practice in the 
 
 movement required in the putting of the shot should 
 
 be carefully studied at first, attempts at record throw- 
 
 inor not beins taken into account at all. Between 
 
 five and six o'clock at night, or early in the morn- 
 ing, half a dozen careful " throws " or " puts " should 
 
 be made, and then some other general-development 
 
 exercise taken. As time goes on the number of 
 
 throws should be increased, and if the movements 
 
 are correctly made the number is not to be limited 
 
 except by the feeling of weariness, which is the tell- 
 tale of what a man can do and the signal 
 for stopping the work for the time being. 
 Six puts and throws a day are better than 
 a thousand once a week. Other exercises 
 there are and their name is legion, but we 
 can only suggest the principal here and 
 leave the individual to find what is best 
 suited to his needs. If he is anxious to 
 find it, there are hosts of books to tell him 
 where and how to search. And if he feels 
 Necessity urging him on to exercise, that 
 maternal parent will set her child at work 
 to invent a way for himself. 
 
 For the shoulders, chest and back mus- 
 cles such exercises as tree-chopping are the 
 kinds needed. Here, again, however, there 
 is one right and many wrong ways. Chop- 
 ping to be reall}' effective must be studied 
 
 carefully. The chopper should stand a short distance from the tree and 
 
 strike so that the blade will enter the trunk at a height from the ground 
 
 Fig. 12. — Throwing 
 the hammkr. 
 
 FlO. 13. PlTTINO THE SHOT. 
 
TO EXERCISE SHOULDERS, CHEST, BACK, AND ARMS. 259 
 
 a little greater than his own waist. At the end of a stroke, with the 
 
 blade sticking fast in the tree, the chopper stands erect on both feet, 
 
 knees and heels a little apart, head up and shoulders 
 The Shoulders, \ ^ £ miai • ii. 
 
 CI i d B 1' ^^^^ ^s lar as possible. As he swings around on his 
 
 right side the knees should bend, the whole body sway, 
 
 and the whole physical system, especially shoulders, cliest, and upper 
 
 back, be brought up with a quick, strong movement. Having given the 
 
 right side of tlie tree a dozen steady strokes, stand in the same position 
 
 and follow this with another dozen on the left side. Never fall into the 
 
 error of thinking that you are getting proper exercise by chopping always 
 
 on one side, and do not worry too much about cutting the tree down. 
 
 That is a minor point. Splitting wood that lies upon the ground is 
 
 another good movement, bringing the back muscles into effective use. 
 
 For the arm muscles, the biceps, the triceps, and those of the forearm 
 
 and hand, ordinary rowing such as a man or boy may get if he lives 
 
 near the sea or a river in an ordinary rowboat, is effect- 
 The lliiscles of . . , . 
 
 the Arm ^^'^" '^^^^^ rowing is not the same as the training of an 
 
 eight-oar boat. It is the individual pulling of one man 
 who does not use his back as much as a professional, wdio sits upright 
 and pulls with his forearm and biceps, grasps the oar firmly with the 
 hand, slackening the hold a little with each stroke, and throwing the oar 
 back on the recover with his triceps. All these motions should be com- 
 plete, steady, and strong, stretching and contracting the muscles in turn 
 to their utmost extent, a necessary part in all effective muscular exercises. 
 This was well illustrated once by a famous trainer in speaking of some 
 of the chest, shoulder, and arm movements in rowing as being like what 
 is called stretching, meaning the motions which a man makes after sitting 
 or lying in one position a long time. " In fact," said he, " stretching is 
 nothing more than an involuntary attempt of the muscles to exercise 
 themselves." It is for this reason that slow walking, running on the 
 heels, rowing in short, unperfected fashion are not good. 
 
 It is health which we should strive after. Many a ti-ainer has made 
 the mistake of thinking that his pupils were striving for large muscles or 
 the ability to excel in some particular branch of sport. For those who 
 do look toward one of these accomplishments this article will have no 
 interest, for its writer neither believes in the importance of their objects 
 nor that health is insured or induced by them. The highest accomplish- 
 ment of physical exercise is to make a healthy and symmetrical body. It 
 may be well, therefore, in this connection, to suggest in a few words the 
 best outdoor exercises likely to produce this symmetrical body in the case, 
 first of a man, then of a woman, and finally of a boy and girl. 
 
260 PHYSICAL TRAINING. 
 
 SPECIAL OUTDOOR TRAINING FOR MEN. 
 
 The average American is pretty badly oil so far as a normal condition 
 of muscular development is concerned. In the first place, a man of forty 
 in America, as a rule, lias not exercised the muscles of the lower part of 
 his body sufficiently. lie is undeveloped below the waist. Furthermore, 
 the same American is more than apt to be one-sided above the waist, and 
 round-shouldered besides. The reason for this is that in the United 
 States men work too long and too hard from day to day, and do not think 
 of physical exercise as a part of their labours. It is safe, therefore, to give 
 the following suggestions for the guidance of the average man from 
 thirty to sixty years of age. What athletic work he does — and he has 
 little time for it — must be to counteract desk work and lack of move- 
 ment on the feet. It should be as vigorous as he can stand, and must 
 be discontinued the moment it becomes wearisome. It should be vig- 
 orous enough to produce a normal amount of jar to the body and 
 stimulus to the blood in a day and offset the long hours of sedentary 
 work. The exercise must be a little greater than natural steady move- 
 ment would furnish, in order to make a general average at the end of 
 the day. 
 
 If possible, the man should play something like polo twice a week. 
 
 If that is, however, impossible for lack of time, of money, or of physique 
 
 lawn tennis, played for a short time daily, should be 
 
 In Middle Age. ,, . • j t^ j- .^ . ^ ^ 
 
 the next in order. Dress for the sport and play every 
 afternoon from one half to three quarters of an hour — at most an hour — 
 from the middle of May into November. From the middle of November 
 to May, either play tennis indoors, or, when feasible, hockey, ice games, 
 or something equally vigorous, for the same length of time and at the 
 same time each day. If it is impossible to do this except on Saturdays 
 and Sundays, play tennis an hour or more (always depending on the feel- 
 ing of weariness) on these two days during the summer half of the year, 
 and on the evenings of the other days of the week get the same amount 
 of exercise by running at first half a mile each evening, gradually increas- 
 ing this to three or four miles. In the winter play an ice game on Satur- 
 days and Sundays and on the other evenings run or skate or take some 
 equally vigorous exercise. This may, and very likely does, seem impos- 
 sible to most men between the ages named, but it is astonishing how 
 much work can be done and how regularly, if the individual really tries 
 to do it. 
 
 It would be a mistake to try to replace tennis by rowing as a daily 
 exercise. Rowing can not be beneficially so undertaken. Bicycling is 
 good in its way, but not equal to tennis. It is too precise, too little of a 
 
TENNIS SUPERIOR TO ROWING OR BICYCLING. 201 
 
 really stirring exercise greatly to Ijcnofit cither iriind or body, and there is 
 some question whether bicycling is not likely to be injurious. Bicycling, 
 however, is a good example of what a man can do in the way of exercise 
 if he makes up his mind to it, for there are many who would say that it 
 was impossible for them to find time for running or for tennis who, nev- 
 ertheless, spend the same amount of time in wheeling. In other words, 
 one can usually find time for what he really wants to do. Yet, if tennis 
 is impossible, fall back on bicycling, always remembering to finish the 
 ride with a reasonably long and hearty spurt, followed by a batli and rub 
 down. If in winter, ice exercise, running out of doors, and all other such 
 exercises are impossible — but only then — fall back on indoor or gym- 
 nasiumx exercises. Finally, remember that for men from thirty to sixty 
 years of age, unless they are in the best of condition, violent games are a 
 mistake. The change from the sedentary hours of the day is very sudden 
 for any one over forty, and is rather dangerous. 
 
 For men approaching sixty the nightly run may be, to all intents and 
 purposes, impossible. Tennis is also slowly creeping beyond their reach, 
 and they will say to you, perhaps, that all games are 
 too vigorous for them. This is not so. Easily within 
 their reach is golf, which, while it is capital physical training, and not 
 less to the lungs than to the muscles, is also a sport that admits playing 
 by men of sixty — even seventy — while the preparation for it is simple 
 enough, provided the open country is at hand. Nowadays almost every 
 city has its golf clubs in the suburbs, where for reasonably small amounts 
 a man may have plenty of opportunity to play. Apart from games, there 
 are many general exercises, such as wood-chopping or tree-chopping, 
 riding, or walking. I have seen many men working in gymnasiums 
 under the impression that they were doing the best possible for them- 
 selves physically, when half the time spent in cutting down a large tree 
 or taking some outdoor exercise would do them much more good. 
 
 SPECIAL OUTDOOR EXERCISES FOR WOMEN. 
 
 As men's exercise in general should be to counteract ofiice work, so 
 women's exercise should be to counteract housework. In general, there- 
 fore, the object in view should be to practise something involving agility, 
 without too sudden or too vigorous movements. The same general prin- 
 ciple of light but regular and periodic exercise should be borne in mind 
 and followed to the letter. It is of the utmost importance that womeiv 
 should rememher to stop exercising^ whether at games or special-develop- 
 inent raovenients, the moment they feel the slightest weariness or strain 
 growing upon them. One of the best games for them is golf ; important 
 
262 
 
 PHYSICAL TRAINING. 
 
 here, as in the ease of men, because it can be played fast or slow, and the 
 amount of exercise thus graded to suit the player. But it still remains an 
 exercise which is, in its way, as good sport as any to be liad, and which 
 calls for a screat deal of skill and attention. 
 
 Fig. 14. — A woman playing golf. 
 
 Oolf and Tennis. 
 
 Golf (Fig. 1-1) is open to women of almost all ages, while tennis is 
 confined to the young and middle-aged. There is, too, a danger in tennis 
 that one may play too long, forgetting the feeling of 
 weariness in the excitement of the sport. If it is begun 
 lightly, however, and played with a certain amount of coolness and atten- 
 tion to labour-saving, there is no finer outdoor game for women. It 
 would be far better if the costume could be arranged in accordance with 
 the needs of the game, for much energy which is now spent in manag- 
 ing the skirts might be put to better use if the player wore bloomers. It 
 must, however, be borne in mind that women should never play tennis 
 with men. There is more of the athlete in a man, and the woman 
 
SPECIAL OUTDOOR EXERCISES FOR WOMEN. 203 
 
 naturally tries to compete with liiiri when 2)layin^ tlic game. This causes 
 
 an unnatural exertion on the part of the woman, fuid tlio re.suh, is that 
 
 the exercise is overdone. 
 
 Walking and skating, especially straight-away skating, a little each 
 
 day, are both admirable physiciil training for women if the rules for 
 
 these exercises already laid down are upheld. A 
 Walhinq and . • , £ r r ,j2tiim 
 
 C.J ,. mountain tramp ot from lour to nve hundred miles 
 
 bicattng, _ ^ ^ _ 
 
 in the summer, taken during an outing of eight or 
 ten weeks, stores up an amount of health in a woman that will carry 
 her through the rest of the year. But to gain physical health when 
 the individual does not possess it, ten weeks is not enough. She should 
 make it her business to be out of doors at least one hour a day through- 
 out the year, doing something in which physical exercise and training 
 bear an important part. Golf or tennis for a good part of the year, 
 with walking (not less than three miles at a time) interspersed,' with skat- 
 ing in the winter — any one of these, carried out theoretically, is sufficient 
 not only to keep a person well, but to restore to normal condition many 
 bodies that are sadly in need of restoration at the start. 
 
 Then come the three doubtful exercises for women — much-vexed 
 questions : riding, rowing, and bicycling. There are certainly good 
 points in all these, but at the same time there are bad 
 ones. If any or all of them should prove to do you no 
 harm after a generous trial, there is probably no reason why you should 
 not keep them up in moderation. But they are all, in a measure, ill- 
 advised. Riding, bicycling, or rowing may be carried on temperately, but 
 the limit for a woman is usually less than that for a man, and it varies 
 more among women than among men. Each girl and each woman should, 
 therefore, either have the advice of some one competent to give it on 
 these subjects, or she should study herself to learn what her capacity is in 
 any one of these exercises she takes up. It should be borne carefully in 
 mind that the best horse for a woman is the one wuth the smoothest mo- 
 tion, that the rider should use a three-pommel saddle, and should avoid, as 
 far as possible, trying to make the lower part of the body move absolutely 
 in unison with the horse, while from the waist up she allows herself to 
 swing backward and forward. This is a common fault, and it is com- 
 mitted through an almost 'involuntary tension of the muscles of the legs 
 against the pommels. It not only causes weariness from long tension, 
 but swings the upper part of the body about in a way that is enough to 
 wrench all the muscles of the abdomen and lower back. Riding, in the 
 case of women, should therefore be studied first, and then, when the 
 equestrienne can sit with all her muscles relaxed and keep on her horse 
 by balancing herself with the reins (her feet and the pommels being 
 thrown out of the question), she may begin to think of it as a suitable 
 
264 
 
 PHYSICAL TRAINING. 
 
 Bicficling and 
 Ruwing. 
 
 form of training to undertake systematically if the vigorous exercise is 
 not too severe for her particular case. 
 
 In the same way bicycling and rowing have their bad points, more 
 especially the former. AVomen should have wide, flat saddles to their 
 bicycles and should sit on them in an upright position, 
 merely using the handles for steering, as I have already 
 explained (Fig. 15). Furthermore, they should never 
 ride Nvith men more than ten miles. In fact, it is safe to say that, as a 
 rule, men and women should not ride together, since a man naturally 
 
 takes faster and more vigorous 
 exercise, and thus stimulates 
 the woman to equal him, and 
 paves the way for her to in- 
 jure herself, and the same may 
 be said of rowing. 
 
 Indeed, the exercise of 
 women might well till a volume 
 by itself. It is most important 
 and is most frequently passed 
 over. Hardly a work on physi- 
 cal training mentions women's 
 exercises, much less considers 
 them carefully, and yet the 
 grace, ease, and physical bear- 
 ing which make a woman not 
 only healthy, but attractive to 
 both her own and the other 
 sex, all lie in the hand of physi- 
 cal training. Steady, light, not 
 too vigorous, but supple and 
 general exercise — that is what is needed. Costumes, too, play an impor- 
 tant part, and when exercising, when walking, playing tennis or golf, 
 women should wear no stays, and should avoid, as far as possible, any 
 skirts. Fortunatelv this is now being: recognised here and there, and in 
 time the whole question of women's exercise is sure to receive the atten- 
 tion it deserves. 
 
 Fig. 15. — Bicycling : correct position for a 
 
 WOilAN. 
 
THE IMPORTANCE OF ORGANIZED GAMES. 205 
 
 OUTDOOR EXERCISES FOR GIRLS. 
 
 No society girl, no fartn o-irl, no girl of the ofliee or factory, the 
 shop, or the home, should be without some daily outdoor exercise, a game 
 — and that one involving exercise most in contrast to her ordinary life — 
 being the best foi"m in which to take it. In general, what has been said 
 of women's exercise applies to girls, though the latter can and should take 
 much more of it. They may also enter into somewhat moi'e vigorous 
 games. They ought always to avoid sports involving personal contact, 
 however, for such sports tend to wrench the frame too much to admit of 
 girls indulging in them. Tennis, riding, golf, skating, bicycling, croquet, 
 in a moderate way running and rowing — all are as suitable for girls as 
 boys, and yet all, if not practised in the correct way, may become in- 
 jurious. 
 
 OUTDOOR EXERCISES FOR BOYS. 
 
 The physical training of boys is perhaps the most important part of 
 this large subject. Unfortunately, it can only be suggested to parents 
 here how important a part of their son's life manly physical training is. 
 If a boy is kept well at physical exercise until he arrives at manhood, not 
 only will he be so well and healthy physically as not to need the care of 
 doctors, but he will have formed the habit of treating his body w'ith care ; 
 he will have his full share of common sense, reasonable confidence in him- 
 self, and a moral and physical nature that will carry him safely over many 
 a hard road. There should be in every school — and fortunately there is 
 in many already — a compulsory course in regular phj'sical training ; not 
 only wooden dumb-bell work, but honest, thoroughbred, outdoor games. 
 If you chance to visit a school where the head master or the assistants go 
 out during recesses and pla}'- baseball, football, cricket, and all the other 
 games with the scholars, you are likely to find not only vigorous bodies 
 all around you, but a healthful spirit of good-fellowship between master 
 and pupil, and a high standard of scholarship and dignity pervading the 
 whole school. 
 
 The importance of games to boys is almost beyond measure. In their 
 
 sports organization plays an important part. They should take up games 
 
 involving "sides," each including several individuals. 
 
 Or^miizedO°me ^^^^ object of this is that the players secure a more 
 
 comprehensive physical training, and at the same time 
 
 learn what organization, subordination, authoritj', and system mean. For 
 
 grown men this is neither necessary nor always possible ; but for boys 
 
 the mental training is valuable, since they have much of this to learn, 
 
266 PHYSICAL TRAINING. 
 
 and tliey will take it more to heart if they learn it through the means of 
 a sport which they enjoy. Personal contact of one contestant with an- 
 other is feasible here, since the body of a boy can stand the strain better 
 than that of a man, and all the qnalities that go to make up manliness, 
 courage, and self-control arc brought into play the moment the game 
 beo-ins. This is a much-misunderstood subject, and we are constantly 
 liearing ct)mplaints of parents against the roughness of their boys' games. 
 Many of the sports are rough, and more or less serious injuries occasion- 
 ally result ; but while the injuries are to be sincerely deplored, it Ayas 
 lonir ago demonstrated that the yaluable qualities of mind Ayhich are what 
 make a man worthy of his Maker can be taught a boy in no other way 
 more effectually than in these games of his youth. They are quite as 
 beneficial to older men, but the man's time can not, as a rule, be given to 
 such matters, and his physique ^yill not bear the strain. 
 
 Where there are several members in the contest, ranged in two oppo- 
 site sides, the presence of two leaders is necessary. Hence the beginnings 
 of organization, of discipline, of command and obedience, and of study 
 in the theory of what is termed "team play," and perhaps, most im- 
 portant of all, of emulation. This kind of training of youth is valuable 
 beyond all estimate. It is proved day by day in the schools and colleges, 
 and no school, however small, should be without its organized athletic 
 association in football, baseball, rowing, tennis, track athletics, lacrosse, 
 cricket, and all the other games which are played to-day. Far from 
 detracting from the boy's studies, all this supplements them, training not 
 only the body to iit the mind for study, but strengthening the qualities 
 of mind ^yhich are as important in athletics as they are in mathematics. 
 The only objection to the present athletic systems in certain schools is 
 that but half the scholars receive this athletic training, whereas all should, 
 in one form or another, be admitted to a part of the education it fur- 
 nishes. 
 
 Every boy who can, should take part in some one of the games men- 
 tioned in winter and in summer, practising it each day of the week. 
 This makes it quite unnecessary for him to go into any special-develop- 
 ment training, unless there is some organic or chronic weakness which 
 a physician thinks that physical exercise of a s])ecial nature can rectify. 
 The system should be briefly as follows : Each day at four o'clock, rain 
 or shine, during the entire year, Sundays, of course, excepted, he should 
 dress for the particular sport in season. Then, going out, he should take 
 part in and study this game from one to two hours, depending upon the 
 nature of the game itself. After this the player should return to his 
 home or gymnasium, at once go into a bath — shower, if possible — and 
 bathe first in warm water and then in a cold shower, lie should then 
 dress and go to his meal within an hour. 
 
DESULTOEY PLAYING OF ANY GAME OP" NO VALUE. 207 
 
 Desultory playing of any game is of no value. Tlic " scrub " game 
 of ball, the sudden sprint race of boys in ordinary costume, the desul- 
 tory kicking about of a football, are in a measure, dis- 
 VI s oj esu ory ^jj^^^^jy injurious. Nothing of value is learned, time is 
 wasted, and the habit of doing a thing by halves is 
 easily formed in this way. On the otlier hand, a thoroughly business- 
 like organization, with a commander chosen from among themselves by 
 the boys, involves the beginnings of a systematic and careful study on 
 the part of both captain and men. It means a study of the correct way 
 of doing what is in liand, and consequently the development of all mental 
 qualities worth cultivating. And it means, also, correct physical training 
 and greater pleasure. 
 
 It may not be out of place to add here that military training in 
 schools serves much the same purpose, since it brings into use practically 
 the same matters, physical training occupying, however, a much less im- 
 portant part. It is to be hoped, therefore, that military drill will soon 
 be introduced into the schools of the United States both for the good 
 that it will bring and for the preparation it will afford the Government 
 for an army in time of war. 
 
 INDOOR EXERCISES. 
 
 Nothing has been hinted at so far except outdoor exercises, and for 
 this reason much that I have said may have seemed incomplete. In a 
 measure this is true ; but the method used illustrates one of the most 
 important points in physical training, and one in regard to which many 
 teachers have fallen into an error. It is proper to explain this here. 
 
 The highest aim of physical training is healthy which can he amj)lijied 
 to include the restoration and the maintenance of health. It is in this 
 sense that the subject is treated here. There is, however, a common error 
 frequently committed by instructors on the subject to the effect that the 
 purpose of physical training is to increase the size of the muscles of the 
 body. While this is in a measure true, its very truth is what causes the 
 error. Exercise does increase the size of muscles during the process of 
 making them healthy and vigorous. The increased size, however, is a 
 secondary result, not by any means the purpose or cause of the training. 
 Large muscles, unusual dimensions of calf, thigh, biceps, chest, etc., are, 
 for many reasons, not to be desired. In the first place, they are often 
 unhealthy. All really healthy men and women have normal-sized muscles ; 
 but the converse is not true, for many a man with large muscles has been 
 made unhealthy because of them. Mr. Ferris, the famous Hercules of 
 Boston, and for a long time a gymnasium superintendent there, developed 
 his chest, stomach, and back muscles to such an extent that he took off 
 
208 
 
 PHYSICAL TRAINING. 
 
 all his flesh, which meant the loss of strength, and died suddenly of con- 
 sumption at less than fifty years of age. There are many such cases, but 
 
 Fio. 16. — The FAKNKbE Hekcules. 
 
 it is enough to say that famous athletes usually die at middle age, and are 
 not healthy human beings. Sandow, wonderful as he is to look upon, is 
 
THE FAENESE HERCULES AND APOLLO BELVIDERE. 209 
 
 not to be emulated, for he is not a normal m^i. Compare the wonderful 
 statue of the Farnese Hercules (Fig. 10) with the Apollo iielvidere (Fig. 
 
 Fig. 17. — -Apollo Belvidere. 
 
 17), or the Hermes of Praxiteles, and you at once see that the two latter 
 represent healthier men. 
 
270 PHYSICAL TRAINING. 
 
 Aside from tlie fact that games out of doors in the daylight furnish 
 better air for the kings and hglit for the body to work in, aside from the 
 fact that special-development exercises out of doors fill the same condi- 
 tions, except as concerns mental training, both of these systems can 
 scarcely be used except to maintain health in general. Indoor exercises, 
 on the other hand, with their dumb-bells, their pulley weights, and their 
 other apparatus, have nothing of this training, and in searching for some 
 end to work for in connection with these, the individual discovers that it 
 lies in the endeavour to lift the heaviest load, to pull the body up and 
 down the greatest number of times, to add a half inch to the circumfer- 
 ence of the biceps, and so on ; all of which might be well enough in 
 itself if it did not tend, when carried too far, to injure the health, and 
 thus defeat the purpose of physical training. 
 
 On the other hand, it must not be understood by this that all indoor 
 
 exercise is injurious. It is not. It is certainly not as helpful as the 
 
 same amount of exercise out of doors, but in many 
 Gt/mnasium and - . , •, • -i .. -^^ .^ ^ 
 
 T-r r- • cases, lor special purposes, it is better, JN evertneless, 
 
 Home Axercise. . . . . 
 
 the danger of losins; sio-ht of health in the desire for 
 
 unusual strength is greater when indoor training is taken up than when 
 the question only involves work out of doors. 
 
 Indoor exercise can be divided into work in the gymnasium and work 
 at home. The first is for men and women who have some chronic 
 physical weakness which can be best corrected by delicate, precise work 
 under the eye of an instructor, or for men and women who can not find 
 the time or the place in which to take physical exercise out of doors, and 
 who are therefore presented with the alternative of exercising indoors 
 or not at all. In such cases gymnasium work is manifestly the better 
 course. The second course — that is, exercise indoors in your own home 
 — is the last resort, and to be taken in hand when, for any of many rea- 
 sons, you can neither exercise in any way outdoors nor in a gymnasium. 
 Human nature is naturally unsystematic. The tendency when one is 
 well is to take no exercise. It is hard to make time for a game out of 
 doors, or for an hour in the gymnasium, and hence indoor home exercise 
 includes another class of individuals — a very large one, unfortunately — of 
 men and women who might get any kind of exercise but who do not take 
 the trouble to seek it. They can at least take ten minutes after rising 
 and ten minutes before retiring ; and such is the l)eautiful completeness 
 of our bodies that even this, if carried out regularly, will keep health at 
 hand and ward oU disease. 
 
SPARRING AND WRESTLING. 271 
 
 INDOOR GAMES. 
 
 With this in view wc can turn to indoor exercise, bearing in mind 
 that it is the first downward step from ideal exercise. Naturally, the 
 best form of indoor exercise is to be found in some indoor game, for 
 the reason that a game involves the use of the brain and mind as well 
 as the body. In so far as it does it makes the health-giving quality of 
 the training greater. Many of the games open to us 
 might be, and indeed are, played out of doors. They 
 are discussed in this connection only as indoor sports, though, of course, 
 where it is possible, they should be carried on out of doors. Sparring, 
 for example, which is one of the finest educators 
 
 of health, strength, courage and quickness, cool- ^ ■^ [^ 
 
 ness, decision, accuracy and self-control — all the ^, '^f ^HBir^% 9^ 
 qualities a mother hopes to see in her son, a wife 
 in her husband, a sister in her brother — is more 
 healthful if carried on out of doors (Fig. 18). 
 As it admits of indoor practice, how^ever, it is 
 generally considered an indoor game. Sparring Fig. is.— Sparrino. 
 
 is often called a brutal sport. This is as much 
 
 an error as to call football prize-fighting, or gunning murder. Sparring 
 can be and often is brutal, and football, unfortunately, has occasionally 
 been made to look like prize-fighting. Certainly a man may go gunning 
 with murder as his object. But none of these contains the evil in itself 
 unless brought out by the person using it. 
 
 In other words, it is what lawyers call the animus which makes evil 
 or good out of them, and it would be no more just to stop sparring be- 
 cause Sullivan and Mitchell fought than to stop bird-shooting or deer- 
 stalking because one man shoots another. Sparring brings into play every 
 muscle of the body, and not only educates endurance and strength, but 
 adds quickness and vitality to its other good points, qualities which are 
 so often wanting in indoor exercises. A man or youth can scarcely do 
 better — and from here on the question of outdoor games is not considered 
 — than to spar half an hour a day with either the gymnasium instructor 
 or some friend. . But the sparring should be studied, scientific, and thor- 
 ough — like all other games played for the good there is in it. 
 
 Wrestling, in much the same way, is a capital trainer of both mind 
 
 and body. The teacher is, however, an important factor in wrestling. 
 
 No one should take up the sport without some prior 
 
 mg. instruction ; for it is one of the easiest and simplest 
 
 ways of straining muscles, nerves, and tendons. In the heat of a contest 
 
 any wa-estler would rather strain a nenve than allow both his shoulders to 
 
272 PHYSICAL TRAINING. 
 
 go down on the ground together, and for this reason a somewhat long 
 apprenticeship with an instructor is advisable. A man or youth, wlio 
 is so built that more complex games are impossible, or who can not get 
 more than one other to join him in his athletics, may make up a capital 
 scheme for physical training by alternating with his friend between 
 wrestling and sparring, taking one one day and the other the next. They 
 offset each other admirably. Sparring, while it employs every muscle of 
 the body to a certain extent, makes the upper part of the frame work a 
 little harder than tlie abdomen and the legs. "Wrestling, on the other 
 liand, though general in its muscular development also, uses the legs and 
 abdomen, the side and back muscles more than those about the chest and 
 arms. Both these sports have the great merit of involving no expense. 
 
 Kackets, in a way, is one of the most complete rests and exercises a 
 
 busy city man can undertake, and while it requires an extremely agile 
 
 frame, it does not exclude older and stouter men. The 
 
 Rackets, Court .^^ earroming of the balls, and the general move- 
 
 Tennis and Lawn ^ ■ ^ ,• ^^ ^ • • *" ^ c 
 
 Tennis meut required to lollow them, is exercise not only for 
 
 the muscles and the mind, but for tlue circulation of the 
 blood, which is one of the most important features for men employed in 
 sedentary occupations to bear in mind. Rackets, up to the present, has 
 had the disadvantage of being expensive. It requires an expensive court, 
 and courts are only to be had in clubs. But it is to be hoped that in time 
 racket courts will be put up in many of the Y. M. C. A. gymnasiums 
 that are constantl}'' increasing in the different ])arts of the world. In 
 good time both this and court tennis promise to become more feasible for 
 the average mortal. There is, however, one thing to be said concerning 
 such games. The racket held in the right hand cultivates the right side 
 at the expense of the left. This should be avoided, not by special-de- 
 velopment exercises for the left side, but by playing at least half the time 
 with the left hand. It can be done equally well with a little ])ractice and 
 a little persistence. As this danger is a constant one, however, these 
 games are not as general in their development as sparring and wrest- 
 ling. 
 
 Court tennis and lawn tennis played indoors are both admirable exer- 
 cises, though court tennis and rackets are probably better than the other. 
 The indoor lawn tennis necessitates a very large room without posts, and 
 this is expensive even for a club to build. 
 
 Handball has many of the qualities of rackets, and it is much more 
 
 within the means of the average man. It requires but a small court, and 
 
 „ these are now being put up in most Y. M. C. A. gym- 
 
 Handhall. . ,. *= ^ , ,,. n . . . . 
 
 nasiums. it you can get halt an hour six days in tJie 
 
 week in a handball court, you will find that your muscles are being very 
 
 thoroughly and very generally used, and that by the end of two months 
 
HANDBALL AND BASKET BAL^. 273 
 
 you liave a most vigorous circulation. Handball, indeed, is becoming a 
 favourite game for young and middle-aged men. Many newspaper men — 
 who work at night, sleep late in the morning, and only have their after- 
 noons to themselves — are apt to play handball in the early afternoons. 
 This " sets them up " for the evening's work at a small expense, and gives 
 them a great deal of pleasant enjoyment. It is as important here as else- 
 where to remember that both hands must be used in hitting the ball, or 
 the sides of the body will not be developed equally. If this is strictly 
 adhered to, the shoulders, back, side, waist, and abdominal muscles receive 
 a most thorough shaking up before the half hour is over. The legs come 
 in for their share of the work also ; but if more is desired for them, a 
 mile jog around the track of the gymnasium at the end of the handball 
 game will equalize the practice of all the parts of the body. Perhaps, 
 everything considered, there is nothing more feasible for the middle-aged 
 and older man in gymnasium work which furnishes so much normal and 
 healthy exercise for a small outlay. 
 
 There has been introduced into America within the last few years a 
 new game that has many of the attributes of both lacrosse and football, 
 so far as that is possible within doors. This is basket 
 ball. For the benefit of those who do not know the 
 game, it may be said that it is played on the gymnasium floor. There 
 are two sides of eleven, or any given number, each. The object is to toss 
 a large leather or rubber ball into a basket about the size of an ordinary 
 peach basket, which hangs from the ceiling fifteen feet above the floor. 
 The game is very exciting and the exercise is general in every way, in- 
 volving an amount of skill which precludes any idea of inattention on 
 the part of the players. A team of basket-ball players can be easily 
 organized wherever there is a gymnasium, and half an hour of play three 
 times a week, with some other light special exercise, forms a good substi- 
 tute during the winter months for the more vigorous outdoor games. One 
 of the great advantages of the game is that it can be played by girls. In- 
 deed, it is played at present at such institutions as Smith College. Hand- 
 ball is also within the sphere of women, although it does not seem to have 
 acquired the popularity of basket ball. When played by girls, basket 
 ball should receive its due like other sports, and be an oi'ganized con- 
 test, the girls practising in regular teams. Girls, however, should not 
 play with boys in this or any other indoor game involving such exer- 
 cise. 
 
 These sports are in the main general and equally distributed physical 
 exercise, with the exception of tennis and rackets, which, as has been in- 
 timated, are apt to develop the right side at the expense of the left, unless 
 care be taken to avoid it. We now come to two representative games 
 that have not the merit of general development. 
 20 
 
274 
 
 PHYSICAL TRAINING. 
 
 Fig. 10. — Fkxcino. 
 
 Fencing has hardly an equal among physical exercises in the develop- 
 ment of grace, agility, and quickness (Fig. ll>). It recjuires more Jin I'sse, 
 more delicate skill than almost any other sport, and as 
 encDhj. ^xn.\i it is a beneficial exercise. It, however, develops 
 
 onlv the right side unless the fencer can ])lay the rapier with either the 
 right or the left hand ; but this is so unusual that it is practically im- 
 possible. Any one undertak- 
 ing fencing must for this 
 reason finish off his hour of 
 exercise with some special 
 movements to bring the left 
 arm and shoulder up to the 
 standard of its mate. If this 
 is thoroughly done, there is 
 no danger of unequal develop- 
 ment. Bearing this in mind, 
 girls and young women may secure grace and health by fencing a short 
 time each day — fifteen minutes to half an hour, with fifteen minutes 
 added for special work on the left arm. So far as women's fencing is 
 concerned, it should be confined to the rapier ; but men may take up any 
 of the other forms, such as the fencing of the German duellist, sabre 
 exercise, or any of the other sword sports. The rapier is, however, the 
 l)est physical exercise of all in its general as well as its special results. 
 The other of these two one-sided sports is single-stick play, which can, 
 though with difficulty, be practised with the left hand. 
 It bears a close resemblance to fencing so far as the 
 general exercise it furnishes 
 goes, but fencing requires 
 more skill (Fig. 20). 
 
 These last, though they 
 exercise the muscles of the 
 legs, do not give them as great 
 or as universal development 
 as they do the upper part of 
 the body, and to counteract 
 this the boy or young man 
 may to advantage add other 
 forms of exercise which can 
 still be said legitimately to 
 
 l)elong to games. These are such sports as high jumping, high kicking, 
 and tumbling, all bringing into good play the lower muscles of the body, 
 and yet retaining the idea of defeat and victory. None of the latter, how- 
 ever, are sufficient in themselves, and no one searching for some single 
 
 Fig. 20.— Single stick!?. 
 
AT THE GYMNASIUM AND IN THE H<^ME. 275 
 
 sport wliicli ]ic may go into for the general iiiaint(;iiuiice of a liealtliy 
 body should rely on these alone. If, liowever— and tliis may Ijo said (jf 
 most Americans — the upper body is more fully develojjod than the mus- 
 cles of the legs, it may be well to adopt the plan of trying at high jump- 
 ing certain times during the week after the general-development game 
 has been given its required time for the day. This is true also of such 
 games as bowling, which do not go far to keep up physical culture, and 
 at best act oidy as a stimulus to the circulation. 
 
 Indoor games are naturally limited almost entirely to the gymnasium, 
 
 since it is there alone that the necessary apparatus and room are to be 
 
 found for carrying out the details of the different sports. 
 
 Badminton and rpj^^ ^^^^^ ^^^ ^^^^^^^ ^^.^ ^^^ without athletic games. 
 
 Battledore and , i-\ ^ -, ^ o ' 
 
 Shuttlecock. however. One would scarcely believe how much 
 
 physical exercise there is in such a game as badminton 
 or battledore and shuttlecock until one has played either steadily for 
 half an hour. The difficulty with such sports always lies in the fact that 
 tile players do not look upon them as anything more than pleasant amuse- 
 ments ; and whereas a man or woman would never think of going to a 
 gymnasium to exercise unless dressed in athletic costume, both will play 
 badminton in evening dress. The result is hard exercise in cramped 
 clothing, natural perspiration without being followed by a bath and a 
 change of clothing, and finally a cold which will more than take away the 
 good effects of the exercise. As they are generally played, therefore, 
 the^e two games are not as beneficial as some of the special exercises 
 which can be taken up at home as well as in the gymnasium. And this 
 brings us to the much-vexed question of special-development exercises 
 themselves, and to the great field of usefulness which the gymnasium fills. 
 
 SPECIAL INDOOR EXERCISES. 
 
 Indoor special exercises, as has several times been intimated, are make- 
 shifts for want of something better. They are at the same time the 
 poorest form of general physical training, the best method for bringing 
 up an organic or chronic weakness of particular parts of the body, and 
 the most common method of systematic exercise among men, women, 
 and children for the reason that all classes find themselves more apt to 
 keep regularly at work in this way under the eye of an instructor than 
 when left to themselves. Gymnasiums, therefore, are filling a most valu- 
 able place in the community, and as cities grow in size and it becomes 
 impossible for human beings to get into the open air for systematic exer- 
 cise, gymnasiums are sure to become important means for maintaining 
 the health of the community. Having looked at the question from one 
 
270 
 
 PHYSICAL TRAINING. 
 
 side and urged that the individual should plav games out of doors in the 
 sunshine, Ave may also, without contradiction, say that special detail exer- 
 cises indoors and at night are far better than no exercise at all. 
 
 One of the best gymnasium trainers is the punching bag. It consists 
 of a superstructure similar to a circular sounding board, still seen occa- 
 sionally over the pulpit in a church. From the centre 
 of this hangs a leather bag about the size of a football, 
 tilled with air, so tiiat it swings from its rope at about the height of a 
 man's head above the floor (Fig. 21). By giving it a quick blow it swings 
 out and upward until it hits the sounding board, when it rebounds again 
 with added velocity. The person practising with it must then give it a 
 
 Punch in;/ B(tg. 
 
 Fig. 21. — Pl>ciiixo ba 
 
 second blow before it swings beyond the centre of its arc. Otherwise it 
 will itself give him a severe blow. In a moment the bag is swinging hither 
 and thither, and the puncher must be indeed quick and active to catch it 
 squarely each time it approaches. This bag exercises the muscles of the 
 arm especially, but in reality the chest and back muscles are getting severe 
 work, and those of the leg and waist are coming in for a reasonably good 
 share of the exercise. In the meantime the mind has been employed to 
 the exclusion of all else for the time being, which is most uncommon in 
 exercises not involving a game. Half an hour a day at this lively bag is 
 a wonderful chest " opener."" In striking, the blows should be of all 
 kinds — direct from the shoulder, round arm, upper cuts, and all the vari- 
 eties known in boxing. In fact, it is a species of solitaire boxing, and 
 comes as near reaching the real thing in its good points as any imitation 
 can. 
 
 Another capital chest and arm developer is Indian-chib swinging, 
 M'liich is familiar to every one. The position should be 
 a rigidly upright one, heels and knees together, chest 
 out, shoulders back, and head up. In all the evolutions of the clubs the 
 
 Indian Clubs. 
 
INDIAN CLUBS, ROWING, RUNNING, AND TUMBLING. 277 
 
 whole body except the arms should be as nearly ri<^id as possil)]o. These 
 exercises are especially beneficial to the hand, forearm, biceps, triceps, 
 and pectoral muscles, and so far as they go they are admirable. The 
 great advantage of Indian clubs is that one may keep them at home and 
 swing them night and morning. The exercise is general so far as the 
 upper part of the body is concerned, and it admits women among its 
 devotees. The clubs themselves should not weigh over two pounds 
 apiece, and one and a half is far better. 
 
 The rowing machine, which is simply a mechanical imitation of an 
 oar, gives the body the same exercise that rowing does. It develops the 
 
 arms and the chest and back, besides incidentally using 
 Rowing Machine. ,^ ^ ^ ^ ^• -^ ^ . . hm 
 
 the leg muscles to a limited extent. I he swaying mo- 
 tion also exercises the abdominal and side muscles, but, as in rowing it- 
 self, the machine is too precise to allow one to use it extensively without 
 poor results. IS^o exercise that has for its object the absolute repetition 
 of the same movement an indefinite number of times can be as valuable 
 as something involving variety of movement. A short practice each day 
 on a rowing machine, with some other irregular developer, such as jog- 
 ging around the track, or jumping or wrestling, may, on the other hand, 
 produce good results. The objects to be sought when using this machine 
 are to assume and preserve the correct rowing position, to then go thi-ough 
 the movements of a stroke, bending the knees, moving the sliding seat 
 forward, letting the body sink between the knees, and then " catching " 
 the oars in the (supposed) water and pulling the stroke through by 
 straightening the back, thrusting the knees down, and pulling the oar in 
 to the body. To use a rowing machine properly it is necessary to learn 
 the stroke first from some competent person. 
 
 To ofifset these special developers of the upper part of the body there 
 is jogging around the gymnasium track. Here, again, the person adopt- 
 ing this particular exercise must learn the one right way 
 
 Running %n the ^^ carrying it out. Running in the gymnasium is only 
 Gymnasium, ^ o o .-.^ 
 
 and Tumbling. different from running outdoors m that one must go 
 much slower on account of the frequent turnings. 
 Otherwise the position of the chest, head, and arms is the same, and the 
 runner must here, as well as outdoors, run entirely on the ball of his foot. 
 It is always a good plan to close the day's exercise in the gymnasium 
 with a mile or more on the track, done at this slow, swinging jog. The 
 action fills the lungs, starts profuse perspiration, and prepares the individ- 
 ual for his bath, which should follow very soon after the run is over. 
 Tumbling is another good leg exercise to counteract the punching bag, 
 Indian clubs, and rowing machine. But tumbling is a science in itself, 
 which must necessarily be practised under the eye of a teacher for some 
 time before it becomes an exercise to be indulijed in to anv great extent. 
 
978 
 
 PHYSICAL TRAINING. 
 
 Parallel bars, the vaulting and horizontal bars, the flying rings, and 
 
 the other general arm and chest developers are familiar to any one who 
 
 has been inside a gvm- 
 
 ParalM Bars, etc. . ■, , , j ' i 
 
 nasium, and tliey do not 
 
 need discussion here. They are all spe- 
 cial in their nature, as are the differ- 
 ent apparatus known generally as pulley 
 weights. The larger and more com- 
 plete gymnasiums become, the more ex- 
 tensive are these different special appa- 
 ratus.* 
 
 All of these have their value in aiding 
 individuals to bring up to the standard 
 different muscles of their bodies at pres- 
 ent below the average. For the reader' 
 of this article it is enough to say that if 
 he is merely seeking general exercise in 
 this way the proper course is to learn the 
 ol)ject of each apparatus and use it a short 
 time every day as a part of the develop- 
 ment course he has prescribed for him- 
 self. See that all the muscles have some 
 exercise each day, whether all the ap- 
 paratus are used in so doing or not. If, 
 on the other hand, any particular part of 
 the body is under developed, if the shoul- 
 ders are " round " or the right side higher 
 than the left, or any other defect is visi- 
 ble, one should go to the gymnasium 
 
 instructor or use Dr. Sargent's charts and add this special exercise to 
 the general work of each day. 
 
 Fig. 22. — Ordinary pulley weights 
 fob home ok gymnasium use. 
 
 * Dr. Dudley A. Sargent, the director of the Hemenway Gymnasium, Cambridge, Mass., 
 has invented a large number of these pulley weights, each intended to exercise special 
 muscles, and he furnishes descriptions of them to any one. Indeed, many of these have 
 been adopted already in other gymnasiums to great advantage. In his carefully arranged 
 anthropometric charts, Dr. Sargent shows graphically what after years of research are 
 found to be the normal measurements for a boy, a girl, a young, middle-aged, or old man 
 or woman ; and the man of thirty, for example, can procure the particular chart that 
 shows the normal measurements of a man of that age and compare it with his own mus- 
 cular measurement. Then in one of Dr. Sargent's books he will find careful descriptions 
 of the different gymnasium apparatus, and can proceed to exercise with those which are 
 intended to develop the muscles he finds in his case below the average. 
 
HORIZONTAL AND PARALLEL BARS. 
 
 279 
 
 THE HOME GYMNASIUM. 
 
 Home Horizontal 
 Bar. 
 
 But none of these apparatus are to be found at home, and many per- 
 sons can not, or think they can not, afford a gymnasium membership, or 
 the time required for the exercise there. It is thus that the qnestion of 
 home development asserts itself, where, without apparatus, the individual 
 wishes to keep his healthy physical condition. If you have a garret you 
 can fit it up as a little gymnasium without much expense. A pair of 
 pulley weights (Fig. .22) can be purchased, or a rowing machine, or dumb- 
 bells. Or, if there is no garret, the door of the closet in your room may 
 be turned into a small gymnasium itself by having nailed at either side 
 of the frame on the inside of the door about three inches 
 below the top a piece of wood an inch thick by several 
 inches square, having on its upper side a socket or 
 groove. In these two grooves 
 rest a stout round bar perhaps 
 an inch and a half or two inches 
 in diameter, cut to a length 
 which permits it to fit between 
 the two sides of the door frame 
 and rest on the grooves (Fig. 
 23). Here is a horizontal bar 
 which you may grasp, and by 
 which you can pull yourself up 
 to the chin as many times as 
 possible. Another pair of these 
 grooves, or supports, may be 
 nailed in a similar manner three 
 feet above the floor, and if the 
 bar be transferred to these it 
 offers an opportunity for a lim- 
 ited practice of horizontal-bar 
 w^ork. 
 
 At another small expendi- 
 ture a capital parallel -bar effect 
 
 can be produced. Have the carpenter make a small apparatus similar to 
 what painters attach to the windows of a house (but in 
 the reverse position) to hold up the plank on which they 
 stand while painting the outside of a house. It consists of two horizon- 
 tal poles, two inches in diameter and about three feet long, running out 
 of the window on the sill, and being clamped outside under the sill each 
 by a piece of iron. Six inches from the ends (which extend into your 
 
 Fig. 23. — The home GTiiNAsiuji : hoeizo>"tai bar. 
 
 Home Parallel Bars. 
 
280 
 
 PHYSICAL TRAINING. 
 
 bedroom) braces run to tlic lloor, wlierc it meets the -vviish board, and at 
 this lower end the two braces are joined by a stout piece of plank (Fig. 24). 
 This apparatus can be taken out and in without any inconvenience, and, as 
 
 it necessitates keei>in>5 the window open 
 while it is in j>lace, you are sure to exer- 
 cise in fresh air, which is one of the 
 necessaries of the home gymnasium. In 
 fact, all such exercise taken in a room 
 should begin with the opening of all the 
 windows. Mr. Blakie '•' suggests simpler 
 but not quite so suitable parallel bars, 
 lie has two short two-inch-diamcter 
 poles, not more than six inches in length, 
 each fastened to the inside of the door 
 frame about three feet from the floor, 
 by wliich you can push yourself up and 
 down by grasping the ends of the short 
 poles. Dr. Sargent has also invented 
 several apparatus for use in the house, 
 which can be prepared at small expense 
 if the room admits of it, all of which 
 are admirable. 
 
 It is not necessary, however, to have 
 these if a man wants to go into training 
 to that extent, since he can become a 
 member of some Y. M. C. A. gymnasium or athletic club, paying less in 
 fees than he would in having the apparatus constructed. If you have 
 these apparatus you can do somewhat more thorough work, but if not, 
 there is still enough left to make half an hour a day of most beneficial 
 exercise, and it is this which must interest us most now. First comes the 
 development of the arm. 
 
 Fio. 24. — The home oymttasium : 
 
 LEL BARS IN THE WINDOW 
 
 THE ARM. 
 
 The muscles in the arm are, from the point of view of training, four: 
 The biceps in front of the upper arm, the triceps behind the biceps, the 
 forearm between wrist and elbow, and the wrist and hand muscles. In 
 developing the arm one should carry in each hand a dumb-bell which 
 should not weigh under any circumstances over a pound and a half to 
 two pounds — that is, at most these two dumb-bells should not together 
 weigh over four pounds. There is never a greater mistake made than 
 
 * In his How to get Strong and stay so, an admirable book, but too much devoted to 
 muscular development alone. 
 
TO EXERCISE THE BICEPS AND TRICEPS. 281 
 
 the use of eight- or ten-pound iron dunil)-l>e]!s, or even five-pound ones. 
 They do not add to the stimuhis i^ivcn to circulation by tlie difl'ci-cnt inovo- 
 inents, and they strain the muscles unless one liappens to be an old and 
 experienced dumb-bell user in good condition. Even then th(;y do not 
 add to the healthfulness of the exercise, the sum total of the good in them 
 being simply that they increase the size of already big muscles, for only 
 large muscles should use them. And to gather a big set of muscles on 
 the chest or about the bones is, as I have said, rather a low ideal for am- 
 bition to look up or down to. 80 far as health is conGerned, tvx) pounds 
 apieoe is the outside weight of dumb-hells^ and they should he of wood. 
 
 To exercise the biceps, grasp these dumb-bells one in each hand. Put 
 all the muscles of the arms at tension — that is, strain tliem to liarden 
 
 „„ „. all the muscles in them as much as possible. To begin 
 
 with, the arms are hanging straight down at the side, 
 the fingers pointing to the rear. Now gradually and very slowly raise 
 the dumb-bells by bending the elbows, keeping up the tension all the 
 while, and gradually turning the wrist so that when the dumb-bells are 
 close up with the shoulders the fingers are still pointing to the rear. 
 Then, without stopping, without a jerk of any kind, when the upward 
 movement is finished, lower the hands again, turning the wrist until the 
 arms are once more at the side, fingers pointing to the rear. Begin the 
 same movement again without relaxing the muscles. This should not be 
 repeated over twenty-five times at first, and in any case it should be con- 
 stantly borne in mind that the moment a feeling of weariness appears 
 that particular movement which is causing it should be stopped for the 
 time being. This is the best movement to begin on, though anything 
 which brings the hands in toward the shoulders by bending the elbows 
 is good for the biceps. 
 
 If pulley weights are in the house, use them in the general motion of 
 rowing, or as described above. Or, if you have a rowing machine, that 
 will give the biceps along with other muscles much the same exercise. 
 After practising at this some days, until the lameness has gone out of the 
 biceps, it is well to put the horizontal bar in the lower of its two posi- 
 tions, and then, sitting on the doorsill, to pull yourself just clear of the 
 floor with your arms. The whole movement should not be more than 
 three inches upward. Later still the practice of " chinning the bar " can 
 be tried. 
 
 The triceps are the muscles behind the biceps at the back of the 
 
 upper arm, and they do the pushing for the arms. Every time one 
 
 . pushes against anything by straightening the arms out 
 
 this muscle is brought into play. To exercise it, begin 
 
 by thrusting the two-pound dumb-bells straight up over the head with the 
 
 same slow, regular movement as already described, keeping the muscles 
 
282 
 
 PHYSICAL TRAINING. 
 
 tense all the time bv gripping the bells hard. This alone will strengthen 
 and keep strong the triceps, but in time more vigorous pushing move- 
 ments can be taken up ; for example, lean against a wall and push 
 your body back and forth on the toes as a pivot. Several weeks later, 
 when the triceps are in better training, lie flat on the chest, and, 
 touching only the "toes and the palms of the hands to the floor (Fig. 25), 
 slowly push the rigid body upward until the arms are straight. This is a 
 
 Fig. 25. — Developing the triceps and siioili>er muscles. 
 
 The Forearm. 
 
 severe test, and should only be done two or three times at the start. 
 Finally, grasp the ends of the parallel bars set into the window as de- 
 scribed, and lower yourself between them, then sloM-ly push the body 
 up till your arms are again straight. This is the most severe exercise of 
 all for the triceps, and is only to be practised after long training. If 
 taken up earlier, there is great danger of rupturing a tendon or injuring 
 the muscle in some other way. 
 
 The forearm was somewhat exercised when the dumb-bells were being 
 raised to the shoulders by the turn given the hand. And in fact it is dif- 
 
 licult to develop the biceps and triceps M-ithout also 
 
 developing the forearm, i^nother plan is to hold the 
 arm straight down at the side a little away from the body, and to then 
 "twirl" the bells — that is, twist the hand to the right as far as it will go 
 without bending the arm, and then reverse the movement as far to the left 
 as possible, all the time grasping the bells firmly. Still, again, grasp the 
 bells vigorously, palms up and arms out in front horizontally a little bent 
 at the elbow. Tlien turn the hand at the wrist up and toward the face as 
 far as it will go without moving any other portion of tlie arm. Kepeat 
 this, and in a moment you will feel the forearm muscles. As a matter 
 of fact, however, the forearm is always exercised with the biceps and 
 triceps. 
 
 The hand can be exercised by continually opening and shutting it 
 
 firmly, and b}' alternately grasping and letting go of 
 
 anything. 
 It should be remembered, in connection with the arm exercises, that 
 
 The Hand. 
 
TO EXERCISE THE MUSCLES OF THE LEG. 283 
 
 "weights are neither proper nor necessary. As lias been said, after a long 
 practise of a year or more, if weights are used they will increase the size 
 of the muscles, but they never add one iota to the health or symmetry of 
 them, and there is the constant danger of rupture. Indeed, the idea of 
 weights of more than two pounds should be given up in connection with 
 this home gymnasium. 
 
 THE LEG. 
 
 The leg is divided, so far as exercise is concerned, into the muscles of 
 the calf and the front and back thigh, those of the foot being exercised 
 at the same time with the calf. One of the best ways 
 to bring the calf up to the normal standard is to stand 
 upright, knees together, and to then rise slowly on the toes as far as pos- 
 sible, the muscles of. the legs being at tension, as already descriljed in the 
 arm. This movement also should be slow and steady, and care should be 
 taken not to rest the body on the heels when you come back to your 
 original position. In order to avoid losing the balance, stand near a wall 
 and steady yourself by touching it with one hand. Once you have become 
 accustomed to doing this fifty times without stopping — and it will be some 
 time before this will be the case — try the same movement first on one 
 foot alone and then on the other. Xaturally, any general leg exercise 
 brings in the calves as well as the thighs; but for indoor, at-home devel- 
 opment this one movement is quite sufficient, with perhaps the added 
 action of hopping lightly on one foot up and down without touching the 
 heels at all. 
 
 The muscles of the thigh are twofold — front and back. The front mus- 
 cles are best exercised by standing erect, holding two-pound dumb-bells 
 
 in either hand at the sides, and then bendinff the knees 
 The Thigh. , , ■ .^ ^ i Ji .-i i n , i 
 
 and lowering tlie body until the bells touch the ground. 
 
 The return to the upright position will tax these muscles hardily at first. 
 This movement should be done carefully, otherwise the muscles will stiffen 
 and be lame for days. But in time the same motion can be gone through 
 on one leg alone. It is also a homely but a capital exercise to go up and 
 down (backward) a flight of stairs for six or eight times at the start, and 
 more later, always slowly, in order that each leg may have as complete a 
 movement as possible, Ko one can imagine what an extraordinary exer- 
 cise this is till he tries it, moving on the toes entirely and giving the ]eg 
 muscles all the exercise possible in the process instead of trying to save 
 them. 
 
 The back thigh muscles have some little exercise in all this, but it is 
 well to invent some special work for them. One of the best movements 
 for this purpose is high kicking. Hang a tamboureen ©r anything of the 
 
2S4: PHYSICAL TRAINING. 
 
 sort from a chandelier at about the height of the shoukler ; then, standiiio; 
 on the left foot, swing the right leg quickly up and hit the taniboureen. 
 Without allowing the right foot to touch the ground, repeat the kick, and 
 continue for ten or iifteen times. Then do the same with the left leg. 
 Tiie same result is obtained by trying to touch the hands to the ground 
 without bendinff tlie knees. 
 
 SHOULDERS. BACK, AND CHEST. 
 
 The muscles about the shoulders, back, and chest are so closely con- 
 nected that almost any general exercise suggested here for any one of 
 them will necessarily give practice to the other two. 
 
 Some are naturally better for one than the other, and hence, for the 
 
 shoulders, grasp the dumb-bells lirmly, the hands and arms hanging 
 
 naturally at the sides. liaise both arms straight and 
 The Shoulders. ■ .v , c i i i -1,11 1^ ^ 
 
 Still out from tlie body until they have gone above tlie 
 
 horizontal line as far as they will go without bending the elbow. Then 
 lower slowly and with the muscles always at tension. In other words, go 
 through the motion of flapping wings ; but of course this should be done 
 slowly. You will soon notice that the muscles over the top of the 
 shoulders are growing tired. Again, with the arms hanging as before, 
 raise them slowly (parallel to each other) out behind the body as high as 
 possible. This brings in the muscles just above the shoulder blades, as 
 well as those below and under the shoulders. Then, if you have a rowing 
 machine, use it temperately. If not, sit on the floor as if on a rowing 
 machine and go through the movements, holding the dumb-bells in the 
 hands. In doing either of these movements, remember that line in the 
 old English boating song, and "• keep your body between your knees " ; 
 that is, as you come forward open the knees and force both the chest and 
 abdomen far forward, bending the back concavely and holding the 
 shoulders as far back as possible. Another general exercise for the 
 shoulders may be described in the following way : Suppose two wheels 
 with a radius the length of your arm were set upon a short axle, the axle 
 lying across the shoulders behind the neck. On either side of you there 
 would then be a large wheel. Grasp with each hand the tire of one of 
 these imaginary wheels, and, moving from front upward over the head 
 and back, turn the wheels around very slowly. This makes a rotary mo- 
 tion with both arms holding the dumb-bells and onl}' bending the elbow 
 a little at the point where it is necessary to do so to complete the curve 
 downward behind you. It is an extraordinary shoulder and chest devel- 
 oper, and should be executed very slowly, with the muscles at tension and 
 the chest inflated. Try it three or four times, and the shoulders will 
 fairly ache. 
 
SHOULDERS, BACK, AND CHEST. 285 
 
 It should be remembered in all these shoulder moveirionts that the 
 slightest feeling of weariness is a sign that it is time to stop. 
 
 The back, during these last exercises, has been receiving some devel- 
 opment, especially during the rowing movement. Any stooping motion 
 
 is a good back developer also. But one should never 
 The Back.- , . -y.^.r:.- -• xi • • i -i • , 
 
 try weiglit-lirting tor tins purpose, since, while it does 
 
 exercise the back muscles, it tends to pull them out of shape, deadens 
 
 them, and in time makes a man muscle-bound and round-shouldered. As 
 
 a rule, the average man needs back-muscle less than chest-muscle training, 
 
 since most manual occupations involve work for the back. On the other 
 
 hand, not only are the chest muscles not so much used, but they need to 
 
 be more fully developed than the back, because during the process of 
 
 exercising them the individual is " opening " his lungs, and the lungs are 
 
 the organs of the body that need the most gentle care, for they do the body 
 
 an inestimable service every instant during life, whether their possessor 
 
 be sleeping or waking. 
 
 For the chest muscles themselves, one of the best, perhaps the best, 
 
 exercise is to have two poles set up in the room in some such manner as 
 
 the two poles in an ordinary cow's stall, between which 
 The Chest. 
 
 the unfortunate animal is obliged to keep her head. 
 
 Placing these poles far enough apart to allow the shoulders to pass 
 between — say twenty-four to thirty inches — the exercise consists in 
 grasping each pole with a hand at about the height of the shoulder and 
 then allowing the chest, head, and shoulders (with the head as far back as 
 possible) to swing between the bars. Then force the body back again on 
 the toes as a pivot, and continue for perhaps twenty times at first. The 
 chest muscles soon begin to show they are being used. I remember a 
 man who developed these muscles at his home where he had no poles — not 
 even a cow's stall — by simply opening the door of his room about two 
 feet and placing one hand on the end of the door and the other on the 
 door frame. This exercise also develops the back between the shoulder 
 blades. 
 
 If the person who is going through all these exercises in his room in- 
 variably keeps his head thrown back and his chest well out, while keep- 
 ing his lungs full of air — if he does all this, he sufficiently exercises the 
 lungs themselves, and need think of no special work for them. One of 
 the most convenient as well as the most thorough exercises for chest, shoul- 
 ders, upper back, biceps, and triceps was told me once by Dr. W. S. 
 Williams, of New York, who has made physical exercise a careful study 
 for years. The great merit of it is that it can be practised anywhere — at 
 the office without rising from the desk, in the cars on the way home, at 
 the theatre, even in church, if necessary. It consists in grasping the back 
 of the left hand with the right hand. This brings the two hands asrainst 
 
286 
 
 PHYSICAL TRAINING. 
 
 the chest bone. Tliey should not touch tl)e body, hovccvcr, but be held 
 about two inches from it. The elbows should be held a little lower than 
 the hands and not quite so close to the body. In other words, the line 
 from elbow to elbow along the forearms and across the hands should not 
 1)6 straio-ht, but should form a large obtuse angle with the hands for a 
 vertex. In this position stand upright or sit upright, chest out and head 
 thrown back, and pull as if trying to separate the hands. Pull steadily 
 for about two seconds. Then reverse the tension and push as hard and 
 steadily, without changing the position in any way, for another two sec- 
 onds. Repeat this twenty-five times, and do it so hard that the muscles 
 quiver and the teeth '' grit." Whenever the back, arms, or chest ache 
 from leaning over a desk, at any time of the day or night, this simple but 
 extraordinary exercise, if tried for five minutes, will give one a complete 
 re>t, will till the lungs, and compensate the muscles for a long period of 
 unnatural position. 
 
 THE ABDOMINAL AND SIDE MUSCLES. 
 
 AYe have now to say a word as to the muscles of the abdomen and 
 side. The abdominal muscles are most thoroughly exercised by the per- 
 son lying flat on his back, clinching his feet under the 
 side board of the bed, and raising the upper part of his 
 body slowly and steadily to a sitting posture (Fig. 26). Then, without 
 
 Fig. 26. — Exeucising the abdominal and front thigh muscles. 
 
 making a stop or. jerk at the top, the body should be lowered again to a 
 horizontal position. During this movement the hands and arms may be 
 
THE ABDOMINAL AND SIDE MUSCLES. 
 
 287 
 
 either held at the side, folded across the chest, or locked behind the head. 
 
 Contirminij; this without letting the shoulders touch the floor at all, it will 
 soon be found that the muscles across the stonriach are having their share 
 
 
 Exercising the abdominal muscles. 
 
 The Side Muscles. 
 
 of work. A good variety on this movement is to raise the legs without 
 bending, except at the waist, and keeping the upper part of the body on 
 the floor by placing the arms, extended over the head, under the side board 
 of the bed (Fig. 27). 
 
 For the side muscles I have never seen a better exercise than to swing 
 both hands together, grasping the two-pound dumb-bells, from the left 
 side up over the head and down as far as possible on the 
 right side, the swaying movement itself beginning from 
 the waist, so that the body swings on the waist as a pivot. If the knees 
 are bent, or if the upper part of the body is permitted to lean forward, 
 the proper effect on the side muscles is defeated. 
 
 This slight suggestion as to what can be done at home for the muscles 
 of the body without apparatus is necessarily incomplete. Indeed, it is 
 only intended to be suggestive. There are many books which give ac- 
 curate and explicit directions for such exercises, and the individual him- 
 self can invent hundreds of different movements by simply going through 
 an exercise and with one hand feeling the muscle he wishes to develop. 
 Those exercises that cause this muscle to harden are, of course, the ones 
 he is seekinsr. But slio-ht as this discussion must necessarilv be, it can not 
 be dropped until something has been said as to the particular exercises 
 that are suitable for people of different sexes and different ages. 
 
 In the first place, as to the time when the home exercise should be 
 taken. It is difficult and practically impossible for the great body of work- 
 ing people to find time during the day for stopping work, changing the 
 clothes, and taking a systematic half hour for development exercises. The 
 
288 PHYSICAL TRAINING. 
 
 men of the family are at their offices all day. The women are full of tlie 
 
 labours connected with the honse. The boys are taking their exercises 
 
 out of doors when not in school, and the girls are either 
 
 le 'f"^.'^'' .jj. gciiool or attendins: to their share of the housekeep- 
 i^pecial jbxercittes. ^ . . ^ 
 
 ing. There are but two times in the day when exercises 
 
 of this sort can be taken, and these are innnediately after rising in the 
 
 mornino; and immediately before retiring at night. And, as it happens, 
 
 these two short periods of the day are the best that could be chosen for 
 
 the particular kinds of exercise to be undertaken. Immediately after 
 
 rising in the morning one has had a long rest, the mnseles are set and 
 
 numb, as witness the universal desire to stre.tch the moment one wakes. 
 
 Furthermore, one does not have to nndress to prepare for the exercise. 
 
 In like manner, just before retiring one is also ready, so far as costume 
 
 goes, and if all the mnseles are given a healthful stretching, the circulation 
 
 is stimulated in a way to give it a clear passage for the work it must do, 
 
 while its possessor sleeps, in bnilding up tissues worn out during the day. 
 
 For the man or woman who can take no other exercise, these two 
 
 quarters of an hour are the time in which they must save themselves from 
 
 sickness. 
 
 SPECIAL INDOOR EXERCISES FOR MEN. 
 
 The average person to whom we may consider this section as ad- 
 dressed would be a man at work either in a city or town, or near one or 
 the other. This might extend on the one side to the farmer and the 
 miner, and on the other to the bank clerk and merchant. In all cases the 
 order of the trainer would be to exercise out of doors — at some game, if 
 possible. For the moment, however, we are oidy considering indoor ex- 
 ercise. Under the circumstances, therefore, the next order would be to 
 play a game in a gymnasium ; and if that were impossible, to exercise in 
 a gymnasium ; and if the gymnasium were not at hand, to carry on the 
 home exercise. 
 
 For the city man who is at or beyond middle age, and wlio is almost 
 certain to be at his desk all day, the day's exercise should be as follows : (1) 
 
 Itise at 7.30; (2) strip entirely ; (3) take two two-pound 
 In Middle Age. , , i / n i /,. " -, /• ^^ -, 
 
 wooden dumb-bells and (4) stand erect (m all these ex- 
 ercises keep the lungs full of air, and have the head and chest out); (5) 
 rise on the toes fifty times (but only execute these movements as long as 
 you are not wearied; in two weeks you will be able to do fifty without 
 feeling a strain on the muscles — begin with ten or fifteen); (6) then bend 
 the knees, let the body fall and rise again, first ten or fifteen times and 
 finally fifty ; (T) kick a tamboureen with each foot twenty times, at first 
 only five times ; (8) sway the dumb-bells, arms extended, in an arc from 
 
SPECIAL INDOOR EXERCISES FOR MEN. 289 
 
 left to right, and revorBC over tlio lioad twcnty-fivc times, beginning witli 
 five times ; (9) lying on the back, feet under the bed, rise to a sitting pos- 
 ture ten times, at first only two or three times; (10) reverse the move- 
 ment and raise the feet the same number of times; (llj "curl "dumb- 
 bells thirty times, beginning with ten at first; (12) thrust dumb-bells 
 straight up over the head the same number of times; (13) stretch them 
 out behind as high as possible, the arms being parallel, the same number 
 of times ; (14) raise them from the vertical position at the side, till the 
 arms form a horizontal line, the same number of times ; (15) swing the 
 rotary motion from tile front up over the head backward, both arms going 
 together, the same number of times. 
 
 It should be noticed that any man from middle age up can do all these 
 exercises easily except, perhaps, those intended to develop the abdominal 
 muscles ; but in a short time these will become as easy as the others. 
 Furthermore, there is no expense required except for the purchase of 
 dumb-bells. Even this small expenditure was saved by a friend of mine, 
 who took a pair of his heavy shoes, weighing together four pounds, and 
 used them in place of dumb-bells. 
 
 If expense is not too important an item, two or three apparatus will 
 add to the interest of this work as well as to the benefit to be obtained 
 
 from it. For example, there is nothing better for home 
 Suitable Apparatus • ,^ i • i -rJ•^ j_ 
 
 %; . exercise than a puncmno; bag. li you liave a garret or 
 for Home, Axercise. . . . . 
 
 store room with timbers instead of plastering for the 
 
 ceiling, have part of this ceiling boarded over to look like the sounding 
 board of a pulpit and the rest of the punching-bag apparatus made as 
 already described. Or a rowing machine may be purchased, and a set of 
 pulley weights, Indian clubs, and any of the other common apparatus that 
 the individual's pocketbook will permit him to purchase. 
 
 For a man under thirty the exercise can naturally be a little more 
 severe. He should in a short time take one foot off the ground and go 
 through the exercises on the other alone. These exer- 
 oung en. ^^^^^ include those given above under ISTos. 5, 6, and T, 
 the latter involving a leap, and these being accomplished on one foot, the 
 same should be repeated with the other. Then exercises 9 and 10 should 
 be doubled, and the movement (already described) of lying flat on the 
 stomach and, with only palms and toes touching the floor, pushing the 
 body up till both arms are straight, can be included. Also, jnen under 
 thirty ought to run a little each day, or at least several days of the week. 
 This can be done in light clothing in back streets after dark, if not in the 
 daytime ; and Indian clubs are quite sufficient to take the place of the 
 dumb-bell exercises. Indeed, only the merest suggestion can be given 
 here, and what novel-writers call " the intelligent reader " must use his 
 intelligence and invent various systems for himself, only bearing in mind 
 21 
 
200 PHYSICAL TRAINING. 
 
 that anv e.\erci.-^e wliich strains or wearies is perhaps not bad, but at any 
 rate unnecessary, and in the absence of some experienced person had 
 better be omitted. 
 
 Dnrins: the day five-minute exercises can often be taken, wherever you 
 
 may be, in some sucli form as described above for the shouklers, chest, and 
 
 arms. All these exercises should be begun very easily, 
 
 tive-minute _^^^^^ should never be over fifteen to twenty minutes, the 
 
 Exercises. . . . , i • • i "i • ^ . 
 
 reader bearinii: in mind tliat it is tlie regularity and not 
 
 the extent or long continuance at any one time that brings the result we 
 are all striving after — health. 
 
 SPECIAL INDOOR EXERCISES FOR WOMEN. 
 
 In the case of WDnien there is a great deal more to be said than can 
 be said here. The principle is, however, that women must employ mod- 
 erate exercises, and must stop the moment weariness comes on, even in 
 the slightest degree. The calf, thigh, abdominal, and chest-muscle exer- 
 cises must be carried out to a less extent than suggested above until at 
 least several months have passed. A woman, however, like a man, should 
 rise at a certain hour each day and go through her development exercises 
 at once, following these with a bath. All violent movements should be 
 avoided. For this reason such exercises as those numbered 7, 9, and 10 
 should be avoided until part of the year has gone by and the frame is 
 well seasoned for such things. But, on the other hand, movements tend- 
 ing to open the chest, such as that involving the use of the two upright 
 poles, already suggested, are capital for women. To give a scheme for a 
 woman from twenty years of age upward, the following might be sug- 
 gested : (1) Rise on the toes ; (2) bend the knees and lower the body ; 
 (3) with the knees stiff, bend forward and touch the floor with the fingers 
 or palms, if possible — each of these fifteen times for the first month ; 
 then gradually increase till each can be done fifty times without the least 
 weariness : (4) execute the swaying movement with one- or two-pound 
 dumb-bells, making the arc over the head as described ; (5) thrust the 
 dumb-bells straight over the head, (6) out behind and upward, (7) out at 
 the sides and upward, forming a cross with the body ; (8) "curl " dumb- 
 bells. Above all, swing Indian clubs weighing not over a pound and 
 a half apiece. It is easy to purchase some pamphlet describing the sim- 
 ple movements ; and they develop the shoulders, chest, and upper back 
 in a way that not only adds to a woman's beauty, but, what is far more 
 important, to her health and breathing powers, for it may not be gener- 
 ally known that not one woman in a hundred knows how to breathe. It 
 should also be borne in mind that no wonum exercises liecause she wishes 
 
SPECIAL INDOOR EXERCISES FOR WOMEN. 291 
 
 to be muscular, for a inusfuilar woinau Kliould confine herself to a circus. 
 
 Hence exercise that involves graceful movements is better than detailed 
 
 development exercise. Indian-club swinging, fencing, and that latest 
 
 fad of the day — which is fortunately a capital fad when carried on in 
 
 private — skirt dancing, are better than dumb-lx-lls or pulley-weight work. 
 
 Whatever the exercises are, they should be repeated on retiring at 
 
 night, followed by a dry rub Math a towel all over the body. 
 
 ■ Only a word can be said here as to the Swedish system of exercise. 
 
 Any one who desires to study it practically can easily purchase books 
 
 and pamphlets giving clear and practical instructions 
 
 Swedish System. ^^ .^ . r^ • ra • j. j. i ^.i ^ 
 
 regarding the system, it is surhcient to say here that 
 
 the Swedish-movement or calisthenic system is in direct contrast to all 
 games and similar exercises such as we have mentioned. In games it is 
 impossible to estimate, as I have already said, the exact amount of phys- 
 ical exercise any particular muscle has received. The exercise is generally 
 healthful in the main, though perhaps containing some possible injury. 
 The Swedish system, on the other hand, is in a measure an exact science. 
 That is, the teacher can tell precisely how much physical exercise each 
 and every muscle of his scholar's body is at any time receiving. The 
 Swedish system, therefore, is a physical exercise adapted to therapeutic or 
 curing purposes, while games and sports in general are for those who are 
 already healthy, as the word goes, and who merely need exercise to keep 
 them well. 
 
 If an arm broken by some accident is finally healed, but remains weak 
 from lack of use, certain movements taken from the Swedish system will 
 in a short time bring it up to the same standard as the other arm, and so 
 on. Whereas no game would be suitable for this purpose. The Swedish 
 system and tnassage treatment are therefore well adapted to cures. The 
 former, in calisthenic form, is used in schools to some extent, but the 
 extent is pitiable when one realizes how many scholars are not given any 
 thorough systematic exercise. The system itself, in brief, involves, first, 
 five positions : Standing, sitting, kneeling, lying, and suspending. Then, 
 secondly, from these positions the inventor of the system — a Swede 
 named Ling— evolved what he called derivative jyositioiis, which include a 
 large number of varied positions. After the derivative positions come 
 movements^ which include all the motions the body is capable of, whether 
 carried out by the person taking the exercise or by another person, while 
 he sits, stands, lies, hangs, or kneels, and allows his body to remain 
 impassive. 
 
 The study of these positions and movements is so complex that a chap- 
 ter would be required to suggest satisfactorily their practical value to the 
 reader. It must be sufficient to repeat that in the event of some serious 
 trouble with particular parts or muscles or nerves of the body, which 
 
292 PHYSICAL TRAINING. 
 
 renders it impossible for the person to take general exercise, these muscles 
 or nerves may be strengthened and brought up to standard by the adop- 
 tion of the Swedish system. 
 
 The Delsarte system is practically little more than a branch of the 
 Swedish system, though its theorists would deny this. It is the fcsthetic 
 
 "side of physical exercise, and consists of the use of 
 Delsarte Sustem. i . i • , i ^ j> 
 
 physical exercise to produce grace, charm ot figure, 
 
 and to give the most graphic physical demonstration of the different 
 
 emotions. 
 
 SPECIAL INDOOR EXERCISES FOR BOYS. 
 
 Boys, on the other hand, do not need these iifteen-minute exercises at 
 morning and night. They are out of doors taking natural exercise con- 
 stantly, more than either men or women, and for them pulley weights 
 and dumb-bells are a dangerous thing. Every healthy, normal boy is con- 
 stantly getting a great deal of the best help from old Mother Nature. 
 She is building him up in her own way, and he only needs to keep up 
 quick, vigorous movement of one kind or another. He need not fear 
 jumping, running, and all the other rapid sports in moderation, and, as 
 boyhood is short and we all lose it too soon, we should bespeak for him 
 games in the open air under the sky. Nevertheless, these games should 
 be regularly undertaken. The boy must rise at the same hour each day 
 and retire at the same hour, lie must take his cool bath and his hard 
 rub immediately after rising, and the exercise that he has should be taken 
 at the same relative hour each day. Habit is the greatest as well as the 
 worst thing in human nature. Form good haluts for the boy's body, and 
 liis body will do anything he asks of it in reason. That is a difficult thing, 
 however. No boy naturally wants to be regular, and it is a hard struggle 
 for him to form these habits. Once acquired, however, they are as hard 
 to break as bad habits, and the end is proved to l)e worth the struggle. 
 If detail exercises are, for one reason or another, advisable in individual 
 cases, there is nothing better than the army and navy "setting-up" 
 exercises, which are as follows : 
 
 ARMY SETTING-UP EXERCISES. 
 
 First Exercise. 
 
 1. Arm, 2. Exercise, 3. Head, 4. Up, 5. Down, 6. Raise. 
 
 At the command exercise, raise the arms laterally until horizontal, palms 
 upward. Head : Raise the arms in a circular direction over the head, tips of 
 fingers touching top of cap over the forehead, backs of fingers in contact their 
 full length, thumbs pointing to the rear, elbows pressed back. Up: Extend the 
 arms upward their full length, palms touching. Down : Force them obliquely 
 
ARMY SETTING-UP EXERCISES. 293 
 
 back, and gradually let them fall by the sides. Raise : Raise the arms lat<3rally 
 as prescribed for the second command. ContiniK; by r(;p(!atii)g- haad^ up, dovnt, 
 
 raise. 
 
 Second Exercise. 
 
 1. Arm, 2. Exercise, 3. Front, 4. Rear. 
 
 At the command exercise, raise the arms laterally, as in First Exercise. 
 Front : Swing- the arms, extended horizontally to the front, palms touching, 
 heels on the ground. Rear : Swing the arms extended well to the rear, inclin- 
 ing them slightly downward, raising the body upon the tfKiS. Continue by re- 
 peating, front, rear, till the men, if possible, are able to touch the hands beliind 
 the back. 
 
 Third Exercise. 
 
 1. Arm, 2. Exercise, 3. Circle. 
 
 At the command exercise, raise the arms laterally, as in the First Exercise. 
 Circle : Slowly describe a small circle, with each arm upward and backward, 
 from front to rear, the arms not passing in front of the line of the breast. Con- 
 tinue by repeating circle. 
 
 Fourth Exercise. 
 
 1. Arm, 2. Exercise, 3. Shoulder, 4. Front, 5. Rear. 
 
 At the command exercise, raise the arms laterally, as in First Exercise. 
 Shoulder : Place the tips of fingers lightly on top of the shoulders, keeping 
 upper arm horizontal. Front : Force the elbows to the front. Rear : Force 
 the elbows back as far as possible. Continue by repeating front, rear. 
 
 Fifth Exercise. 
 
 1. Hand, 2. Exercise, 3. Close, 4. Open. 
 
 At the command exercise, raise the arms laterally, as in First Exercise. 
 
 Close : Close the hands with force. Open : Open the hands quickly, spreading 
 
 the fingers and thumbs apart as much as possible. Continue by repeating close, 
 
 open. 
 
 Sixth Exercise. 
 
 1. Forearms vertical, 2. Raise, 3. Up, 4. Down. 
 
 At the command raise, raise the forearms until nearly vertical, fingers ex- 
 tended and joined, palms toward each other. Up : Thrust upward with force, 
 extending the arms to their full length. Down: Force the arms obliquely 
 back, and gradually let them fall by the sides. Continue by repeating raise, 
 
 up, down. 
 
 Seventh Exercise. 
 
 1. Forearms horizontal, 2. Raise, 3. Front, 4. Rear. 
 
 At the command raise, raise the forearms to the front, until horizontal, 
 elbows forced back, hands tightly closed, backs down. Front : Thi'ust the 
 arms forcibly to the front, turning the backs of the hands up, arms horizontal. 
 Rear -. Bring the arms back quickly to the first position, forcing elbows and 
 shoulders to the rear. Continue by repeating front, rear. 
 
 Eighth Exercise. 
 
 1. Trunk, 2. Exercise, 3. Down, 4. Back. 
 
 At the command exercise, raise the hands and place them on the hips, 
 fingers to the rear, thumbs to the front, elbows pressed back. Down : Bend the 
 
204 PHYSICAL TRAINING. 
 
 trunk forward at tlie liips as far as possible. Back : Raise and bend tlie trunk 
 to the rear as far as possible. Execute both motions slowly, without bendin*; 
 the knees. Continue by repeatinjr down, back. 
 
 Xi II til E.ve re ise. 
 
 1. Trunk. 2. Exercise, S. Right, 4. Left. 
 
 At the coiuuKind e.i-ercisc, place the hands on the hii)s. as in Eiyhth Exercise. 
 Right: Bend the trunk to the I'ig-ht without twistinj; it or raising- either heel. 
 Left : Bend the trunk similarly to the left. Execute both motions slowly. 
 Continue by repeating- right, left. 
 
 Tenth E.vercise. 
 
 1. Trnnk. 2. EXERCISE, 3. Circle Right (or Left). 
 
 At the connnand exereii^e. i)lace the hands on the hii)s, as in Eighth Exercise. 
 Circle right: Bend the trunk to the right as in Ninth Exercise; turn the 
 trunk to the rear and bend to the reai', as in Eighth Exercise ; turn the trunk to 
 the left and bend to the left, as in Ninth Exercise ; turn the trunk to the front 
 and bend forward, as in Eighth Exercise. Continue bj^ repeating circle right. 
 
 Eleventh Exercise. 
 
 1. Arms vertical, jjalms to the front. 2. Raise, 3. Down, 4. Up. 
 
 At the command raise, raise the arms from the sides, extended to their full 
 length, till the hands meet above the head, palms to the front, fingei-s pointed 
 upward, thumbs locked, right thumb in front, shoulders pressed back. Down : 
 Bend over till the hands, if possible, touch the ground, keeping arms and knees 
 straight. Up : Straighten the body and swing the arms, extended to the vertical 
 position. Continue by repeating down, up. 
 
 Tivelfth Exercise. 
 
 1. Arms foricard, palms doivn, 2. Raise, 3. Down, 4. Up. 
 
 At the command raise, raise the arms to the front, extended to their full 
 length, till the hands are in front of and at the height of the shoulders, palms 
 down, fingers extended and joined, thumbs under forefingers. Down : Bend 
 the trunk forward at the hips as far as possible, and swing the arms backward, 
 knees and arms straight. Up : Straighten the trunk and swing the arms to the 
 forward position. Continue by repeating down, up. 
 
 Thirteenth Exercise. 
 
 1. Ley, 2. Exercise, 3. Half bend, 4. Down, 5. Up. 
 
 At the command exercise, place the hands on the hips, as in Eighth Exercise. 
 Down : Lower the body, separating the knees and bending tliem as nmch as 
 possible, heels on the ground, head and trunk erect. Up : Raise the body, 
 straightening and closing the knees. Continue by repeating doicn, up. 
 
 Fourteenth Exercise. 
 
 1. Leg, 2. Exercise, 3. Fall bend, 4. Down, 5. Up. 
 
 At the command exercise. ])lace the hands on the hi];)s, as in Eighth Exerci.se. 
 Down: Lower the body, separating the knees and bending them as much as 
 possible, head and trunk erect, heels raised, weight of body resting on the balls 
 of the feet. Up : Raise the body, straightening and closing the knees, and 
 lower the heels to the ground. Continue by repeating down, up. 
 
SPECIAL INDOOR EXERCISES FOR GIRLS. 295 
 
 FifteenUi, Exercise. 
 
 1. Leg,2. Exercisb:, 3. Left (or right), 4. Fohwakj>, 5. Rear, or 5. Ground. 
 
 At the command exercise, place the hands on tlie hips, as in Eitchtli Exer- 
 cise. Forward : Move the left leg to tiie f'njnt, knee straiglit, ho as to advance 
 the foot about fifteen inches, toe turned out, sole nearly horizontal, body- 
 balanced on right foot. Rear : Move the leg to the rear, knee straight, toe on 
 a line with the right heel, sole nearly horizontal. Continue by repeating for- 
 ward, rear. 
 
 When the recruit has learned to balance himself, the command foricard is 
 followed by Ground. Throw the weiglit of the body forward by rising on the 
 ball of the right foot, advance and plant the left, left heel thirty inches from 
 the right, and advance the right leg quickly to the position of forward. Con- 
 tinue by repeating ground when the right and left legs are alternately in the 
 position of forward. 
 
 Sixteenth Exercise. 
 
 1. Leg, 2. Exercise, 3. Up. 
 
 At the command exercise, place the hands on the hips, as in Eighth Exercise. 
 Up : Raise the left leg to the front, bending and elevating the knee as much as 
 possible, leg from knee to instep vertical, toe depressed. Up : Replace the left 
 foot and raise the right leg, as prescribed for the left. 
 
 Execute slowly at first, then gradually increase to the cadence of double 
 time. Continue by repeating up when the right and left legs are alternately in 
 position. 
 
 Seventeenth Exercise. 
 
 1. Foot, 2. Exercise, 3. Up, 4. Down. 
 
 At the command exercise, place the hands on the hips, as in Eighth Exer- 
 cise. Up : Raise the body upon the toes, knees straight, heels together. Down : 
 Lower the heels slowly to the ground. Continue by repeating up, down. 
 
 All of these should not be executed in succession. In fact, a rest of a 
 few moments should be taken after doing any one of the exercises ten 
 times, and it is never necessary to go through the whole seventeen at one 
 time, four or five comprehensive ones being often sufficient. 
 
 SPECIAL INDOOR EXERCISES FOR GIRLS. 
 
 In the case of girls, it should be said at the start that an instructor is 
 almost necessary, and they are so easily obtained that I should unhesitat- 
 ingly advise that all girls should be put under the care of one, whether at 
 school or elsewhere, almost as soon as they are old enough to go to school 
 at all ; for it is quite impossible to estimate the good derived from light, 
 simple, quiet, regular physical exercise, such as is furnished either in the 
 Delsarte or the Swedish system for girls between the ages of four and 
 twenty. There will soon not be a school, private or public, in the United 
 States that will not put all girls through some form of special-development 
 
296 PHYSICAL TRAINING. 
 
 exercises. Tlieii people will look baek with wonder at the time when 
 school teachers and superintendents were so short-sighted as to allow 
 j)hvsical exercise to be slighted. In the meantime whatever exercise is 
 taken should never be anything violent ; no weights over a pound or so 
 should be used, and, if nothing else offers, there is always the home train- 
 ing at hand. In fact, one of the best sights in all the iield of physical 
 traininrc is to see a little girl in her gymnasium suit going through a care- 
 fully studied routine of short exercises with her mother, morning and 
 night ; and when one thinks how many doctor's bills, how many hours of 
 sleeplessness and pain, can be saved her — both of them, in fact — by this 
 quarter of an hour morning and night, it seems marvellous that it is not a 
 more general custom. 
 
 TRAINING. 
 
 In the process of discussing outdoor and indoor games and special 
 exercises I have used the word "■ training " many times synonymously 
 with exercise. This is a popular custom, and is perhaps correct. Strictly 
 speaking, however, training means more, and the title of this article sig- 
 nifies something more than development exercises. It includes this, and 
 includes also the daily life of the person taking the exercise, his manner 
 of eating and the things he eats, his general plan of life from day to day, 
 the time of rising and retiring, the hours of sleep, the dress, and the 
 arrangement of all these for regular life or for some coming contest. It 
 is not my purpose to enter here into a discussion of tlie proper food for 
 different individuals. I merely give below a sketch of the general subject 
 of training, which includes as one part exercise, as another food, and so on. 
 
 Training for a contest is quite different from training for general 
 health in the ordinary walks of life. Contests are not ideal health pre- 
 servers by any means. As has been already said, they 
 
 "^ .'". '^ • could be readily dispensed with theoretical! v, but prac- 
 Iraimng. . . ' . . 
 
 tically we should have little or no athletic life in the 
 
 community if a match of some kind was not either indirectly or directly 
 in view in most cases. There are probabilities that the young man may 
 injure himself at football or polo. People have permanently disabled 
 themselves by playing tennis. Many a man bears the mark of his base- 
 ball days, and all these and many more casualties are to be found in most 
 personal-contact games. "While, therefore, there is reason in the objection 
 n)ade by parents and others that the sports of children are dangerous to 
 life and limb, the same parents should keep in mind the benefit only to 
 be derived from such games, and they should distinguish betM'een serious 
 injuries and the commonplace knocks of childhood and youth. There is 
 born with ever}' vigorous boy or girl a natural and commendable desire 
 
THE VALUE OF AND TRAINING FOR CONTESTS. 207 
 
 to surpass others, to win wliat is wortli having, and the liui-dci- thci struggle 
 becomes, the moi-e pleasure and glory there is in the victory. Siicli desires 
 are not only natural, but necessary. They are the springs tliat force the 
 world and civilization forward, and he is but a despicable youth who does 
 not feel them stirring within him. Like everything else, they may be 
 carried too far ; but this does not make them useless nor oblige us to dis- 
 courage them. I should regret the want of them in a child or a friend of 
 mine, and if a careful canvass of the community were made there is little 
 doubt that we should find every one of the same opinion. 
 
 Contests, then, with all their faults, are valuable — nay, necessary. 
 And this for two reasons : while they stimulate the individual to prac- 
 ^ tise faithfully for his coming match, teach him thorough- 
 
 ness and discipline, they also furnish a standai-d for the 
 community and the country, constantly raising it, and inducing many a 
 person who might never think of exercising otherwise to do so merely 
 in emulation of those who succeed so well. One can, for instance, hardly 
 deny that American yachting has received a most extraordinary stimulus 
 directly from the international yacht races of the last ten years. It would 
 be as difficult to deny that intercollegiate athletics have increased the gen- 
 eral practice of athletic exercise among students, even among hosts of 
 men who never hope or care to belong to 'varsity teams. This has now 
 grown to such perfection that schoolboys all over the country are actu- 
 ally studying the science of physical exercise under able instructors solely 
 in emulation of college athletics, induced by intercollegiate contests. 
 
 To prepare for one of these contests, a far dift'ei-ent method must 
 be employed when nothing more than the maintenance of health is the 
 object of exercise. 
 
 First of all, sleep is more necessary, because the individual is under 
 
 greater nervous strain and is taking more exercise. For a boy or man 
 
 preparing for any personal-contact s:ame eight hours 
 Trainmgfor . [. ^. . n ^ . . . ,^ , 
 
 Contests "^^ *^ minnuum of sleep, and nine is far better. 
 
 This sleep should be between 10.30 at night and 7.30 
 
 in the morning. The individual should retire at ten and breakfast at 
 
 eight, and the more regular he is in keeping exactly to these hours the 
 
 better will be his condition. Most races or matches are won by the man 
 
 who has the greatest powers of spurting and endurance, depending, of 
 
 course, on the sport. That is, any one can, with a little study, run a race 
 
 and come in a good third. Many can run neck and neck with a trained 
 
 runner until the last lap or the last ten yards ; but the power to outdo 
 
 himself in the last stretch, to add to his speed at the last moment, is only 
 
 obtained by the man who puts his body into such admirable condition that 
 
 it responds to the added strain easily and quickl}', who keeps his digestion 
 
 in such good condition that there is no weakness there at the critical time. 
 
298 PHYSICAL TRAINING. 
 
 Indeed, tliou*i-li it uiiw seem of the earth earthy to say it. eourairc and 
 will-power depend a great deal upon digestion. An army will tight better 
 after eating than before, for many a man is braver with a full stomach 
 than an empty one. 
 
 That, however, does not mean that an athlete should go into the mile 
 run just after dinner. Far from it. After rising at T.ot> he should take 
 a plunge bath, if possible ; if not, a sponge or shower in cold water — not 
 the cold water of winter, but water at the temperature of the air during 
 about eight months of the year, which can be tempered during the other 
 four by a little warm water. ]>reakfasting at eight, he should then go 
 about his regular work. Taking the college man as the example for the 
 moment, he should go to his studies or recitations. Atone o'clock comes 
 luncheon, and then more work. At three he should go to the gynmasium 
 and dress in his running suit. Suppose he be a contestant in the mile 
 run : lie dresses in costume already described and goes out on the 
 track. For an hour he practises at the details of the exercise prescribed 
 for long-distance runners, and, while not hurrying, he never stands about 
 listlessly, doing nothing but catching cold. At the end of the hour he 
 mav start out on a two- or three-mile jog. At any rate, by live or later 
 he returns to the gymnasium warm, perspiring, tingling all over, and 
 goes at once into the shower bath, first warm and then cold. A careful 
 and complete rub-down follows by one of the gymnasium rubbers ; and 
 then dressing, the mile runner walks over to his dinner at six o'clock. 
 In the evening he does not stand out of doors, but, if he goes out at all, 
 he remembers that after such exercises and such a bath one may easily 
 take cold, and he accordingly has a care as to his dress. By ten he is 
 ready to go to bed, and by eleven, at the latest, he is asleep. While this 
 is training for athletics in a manner not possible to one whose day is 
 occupied with other matters, it nevertheless sets a good standard for those 
 who wish to give themselves as much physical training as is possible. 
 
 A word as to food. Much has been said and written as to training- 
 table food — from the " raw-meat " diet down through the gamut to the 
 eating-anything-you-like theory. Both are wrong. The 
 average college athlete, when in training for a severe 
 contest, such as football, eats for breakfast oatmeal, or rice, or hominy, 
 dry toast, steaks or chops and eggs, boiled or mashed potatoes, perhaps a 
 little tea or milk, and drinks as much water as he wants. For lunch, toast, 
 steaks, chops, chickens, or birds of any kind, boiled or mashed potatoes, 
 perhaps some simple vegetable, such as stewed tomatoes, prunes, rice and 
 milk, with milk and water to drink. For dinner, plain soups, roast beef, 
 lamb or mutton, tui-key or chicken, simple vegetables and potatoes as 
 described, toast, milk or water, plain puddings, such as rice or tapioca, 
 and occasionally ice cream. This is simple fare enough, and within the 
 
TRAINING FOR HEALTH. 209 
 
 reach of every one, wlietlier in oi" out of (;oll<';^(i. TIk; tnost iinportuiit, 
 part is in the cooking, for all the viands Hhould be well and thoroughly 
 cooked, though not dried np. It will be noticed that nothing fried is 
 eaten by men in training, that nothing is higldy seasoned, and that tliere 
 is no great variety in the food. Almost everything furnishes solid tissue, 
 and nothing adds fat to the system, though all these articles are easily and 
 quickly digested. For any boy or man who is working from two to four 
 months to prepare himself for some contest in baseball, football, tennis, 
 rowing, track athletics, or lacrosse, this skeleton of a training-table diet is 
 good ; but to follow it religiously and eat between meals, sleep only after 
 twelve at night, or do anything else contrary to the rules set down, is as 
 bad as to " break training " at the table whenever the spirit moves. 
 
 Stimulants at the training table are sometimes prescribed by trainers. 
 Often men who have lost appetite and weight, who lose their nerve and 
 grow moody and melancholy— become "overtrained," 
 in other words — are given ale, or claret, or an egg in 
 sherry once or twice a day. If a man trains correctly, however, and does 
 not exercise beyond his powers, he will not overtrain, and hence it is un- 
 wise to give him stimulants. For a perfectly healthy man liquors of any 
 kind are silly. You can not put vigour and courage into a j)layer by dos: 
 ing him with alcohol. I remember seeing it tried once. A football 
 player had been ill, and should not have played when he did. He was 
 necessary to the team, however — or so, at least, thought the captain — and 
 he was dosed with cocaine wine. He played well for half an hour,* and 
 then began to feel ill again. He was given more cocaine wine. Twenty 
 minutes afterward he stopped playing for a moment, and the next thing 
 he knew it was four hours later, and he found himself in bed with a 
 doctor feeling his pulse and trying to bring him to. 
 
 Training for the ordinary exercise of a business man or woman who 
 does not look forward to any contest is quite a different affair from train- 
 ing for some athletic contest. The principle is practi- 
 ^ fr"7fh ' cally the same — simple, easily digested food — but it 
 should be carried out in a more limited way. In the one 
 case, a college man training for a match is permitted to eat about as much 
 as he wants. The sedentary life of the latter makes it wise for the indi- 
 vidual to avoid eating too much, or too many vegetables, but at the same 
 time the monotony of his bill of fare can be varied with greater latitude 
 than in the stricter contest training. Fried foods are bad for both, how- 
 ever, and should be avoided. The business man does not need, nor can 
 he usually take, as much sleep. Seven to eight hours, according to the 
 person, is usually enough, and there is not the absolute necessity of re- 
 tiring so early as in the student's case. If a man can do his work better 
 in the evening than early in the morning, there is no reason why he 
 
3(>0 PHYSICAL TRAINING. 
 
 should not retire at twelve or later, and rise at eiulit, ])rovided he can 
 sleep soundly until that hour in the morning. Busy men often acquire 
 the habit of sleeping lifteen minutes to half an hour during the day, or 
 just before the evening meal ; and this, if the slumber be sound, is a re- 
 nuirkable rest both to mind and botiy. Such people, rising at eight and 
 breakfasting between half-[)ast eight and nine, if not earlier, should either 
 put themselves through the lifteen-minute exercises already described, or 
 lav out in the afternoon some one hour to be devoted to the playing of a 
 game. Then follows breakfast, the lighter the better, often consisting of 
 oatmeal or hominy, coifee, eggs, and toast, or perhaps a small amount of 
 meat. Lunch at noon or a little after, and at six or later, after the hour at 
 rackets or tennis or running, riding, rowing, or what not, a hearty meal. 
 Smoking among stmlents or men training for contests is a mistake. It 
 not only alfects the '" wind," but relaxes the nerves in a way to make 
 them less vigorous for the coming contest. It is not that it is an injury, 
 or an important feature of training ; but. like fried foods, it shows its 
 results at once, and where the athlete is trying to do his best to win he 
 will do well to avoid it. Try to walk up a long liill while smoking a 
 cigar, and you will soon see what smoking can do to make you uncom- 
 fortable. In the case of a business man, if smoking in moderation dues 
 him no harm, there is no reason why he should stop it. Every one is, 
 however, inclined to overdo it, unless he has some limit, and one of the 
 safest of these is to make a rule not to smoke until after the six-o'clock 
 dinner. Constant puffing at a cigar brings no pleasure. One merely 
 misses it when one stops. Indulged in occasionally, smoking is a pleas- 
 ure, a rest, and a recreation, and as such there is no reason why it should 
 be discontinued, providing it does no injury to the individual. 
 
 The business man should take his plunge bath and rub himself down 
 every morning after rising, breakfasting at once after dressing. His 
 lunch should extend over the full sixty minutes. It is useless to hurry 
 through this meal or eat a sandwich at one's office desk, for the work goes 
 no faster afterward, since one can not work as well during the afternoon 
 after such a meal. Then between five and seven there should be an hour 
 out of doors at some exercise as vigorous as the individual can stand, 
 followed by a warm and cold bath and a hearty dinner. 
 
 All this is very general. There are many cases M'here men can not 
 stand two baths — or rather a plunge and a Ixitli — each day. Still others 
 are too stout for games, and others, again, are too slight to liv'e healtli- 
 fully on a diet composed of such a large proportion of meat. The gen- 
 eral rule, however, for a normal man is correct, and each person must 
 regulate his particular day according to his own body, as well as according 
 to his own conscience, besides securing the aid of his physician to help him. 
 
ADAPTATION OF EXERCISES TO INDIVIDUAL NEEDS. 801 
 
 OONOLUSIOK 
 
 It may not be out of place, therefore, to close this article with a sug- 
 gestion of a plan for the daily life of men and women of different ages, 
 which will in a measure be hardly more than a recapitulation of what 
 has already been said. 
 
 Nothiug more specific to apply to all cases can be suggested here than 
 
 has already been mentioned, and it must be understood that each person 
 
 must mould that particular form of exercise which 
 Age, Sex, and j_ ^ i • i n • t , i . 
 
 f, ,., . comes nearest to his or her needs in order to make it 
 
 ijOHCl'111071, 
 
 lit his or her particular case. There are, nevei-theless, 
 certain well-marked divisions. Men and w^omeu need different forms of 
 exercise ; so do boys and girls. Men of the city require quite different 
 development exercises from farmers, society women from farmers' wives, 
 city girls from country girls, and sclioolboys from boys of the plains. 
 In all these it must be borne iii mind that each and every muscle is to be 
 used, and that each and every day's practice is to be followed by a bath. 
 
 In the first place, clothes have a great deal to do with training. The 
 individual, rising in the morning at his regular hour, should, after bath- 
 ing, put on absolutely dry clothing. The underclothing 
 should not, in a healthy person, be very thick. Indeed, 
 it is not really necessary to change the thickness of underwear from one 
 year's end to the other, and it is probable that more colds are encouraged 
 by these many changes of material than in any other single way. In 
 winter the house is usually as warm as the atmosphere is in the summer, 
 except on the hottest days. Clothing which is worn all the time, there- 
 fore, need not be changed in thickness. The extra warmth necessary for 
 the cold winter days is to come from overcoats and thick outer clothing, 
 which are worn only in the winter outdoors, and not at all in the 
 summer. 
 
 This underclothing should be fresh every day. That entails seven 
 sets a week, and though the average person thinks this is extravagance at 
 first, it is not so in reality. It is not only a much more healthful method, 
 but this, combined with the daily bath, is an extraordinary rest to a hard- 
 worked body. If seven changes a week are considered impossible, the 
 man may have two sets in use, one for the day and another for the even- 
 ing ; but in any case the thing to avoid is putting on clothing not thor- 
 oughly dry after yon have taken exercise, or in the morning after rising. 
 The following suggestions will explain themselves. They are differ- 
 ent schemes for informal but healthful exercise for different types. This 
 list might be far more complete, but the method employed in this article 
 has not been so much didactic as suggestive, and, furthermore, there is 
 
302 PHYSICAL TRAINING. 
 
 not space at my disposal to go into the matter more thoroughly. For 
 
 a man occupied with city work, w'ho can not get out- 
 
 pecijic f.N .«. . or J exercise, the followins; suo-ijestions might be made, 
 
 Exercising. . ' , , ? . i i 
 
 it being understood that the exercise takes place some- 
 where between five and seven at night, and occupies an hour : 
 
 In a gvniiia-imn. eirlier ( 1) play rackets or court tennis, ending up 
 with Indian clubs, especially with the left hand ; c»r (2) play handball, 
 ending with the mile run around the gymnasium track ; 
 I y . an. ^^ ^^^ ^^^^^_ \\\x\\ the instructor half an hour, including 
 rests, then jump or wrestle, and end uj) with a mile run around the 
 track ; or (4) give a few minutes each to the high jump, the parallel bars, 
 Indian clubs, punching bag, and run a mile — in all an hour's work ; or 
 (5) distribute the above through the week — that is to say, take up num- 
 ber 1 on Monday, 2 on Tuesday, 3 on Wednesday, 4 on Thursday, and 
 then begin again, or make up a fifth and sixth scheme for exercise as 
 different from these and each other as are the above. There will thus be 
 different- schemes for exercise for each day in the week. 
 
 If the gymnasium is impossible, set aside fifteen minutes at morning 
 and at night, and either (1) go through the army setting-up exercises, 
 giving each of the movements ten repetitions ; or (2) prepare the " home 
 gymnasium " after the manner already suggested, and make out a routine 
 from the apparatus at hand e(pial to the setting-up exercises, as, for ex- 
 ample, a few minutes each on the horizontal bar in the doorwaj', punch- 
 ing bag, rowing machine, Indian clubs, and parallel bars in the window ; 
 or (S) use light dumb-bells and go through some of the movements, as 
 suggested in the earlier pages of this article. 
 
 A man who M'orks outdoors in the country should take exercise for 
 straightening his body and for opening his lungs, since most employ- 
 ments connected with work in the country involve 
 
 ., , , r ,• stooiiing; and development of the shoulders and back at 
 Suburban Lije. ^ » ' 
 
 the expense of chest muscles and lung power. For 
 such occupations there is nothing better than the army setting-up exer- 
 cises and those house exercises which open the chest, tend to throw the 
 shoulders back, and exercise the arms. A subm-baiiite, on the other hand, 
 should invariably take up outdoor exercises. lie is in the country, and 
 can join a countr}' club. Tennis, therefore, golf, perhaps baseball, possi- 
 bly bicycling carried out in moderation, are the kinds of exercise he needs. 
 In other words, the farmer works outdoors and needs quickness, erect- 
 ness, vivacity. For him special development exercises are necessary. 
 The suburban resident works in the city, but lives in the country. His 
 ^exercise should be, therefore, out of doors. 
 
 For women in the city life is unnatural enough, but there is much 
 that can be done in the way of exercise if they w^ill only give the time to 
 
FOR WOMEN OF TOWN AND COUNTRY. 303 
 
 it. Every such woman sliould eitli(;r join a gymnasiurn, oi', if tlio neces- 
 sary funds arc at hand, ride ]ior.sel)ack, or liave her own lionie gymna- 
 sium. She should eitlier (1) ride from a half to three 
 quarters of an liour a day on an easy, quiet horse in parks 
 or suburbs, and at tlie same time go through the development exercises 
 already mentioned ; or (2) join a woman's gymnasium and put herself 
 under an instructor in the Delsarte or Swedisli systems, exercising at this 
 three times a week at least, or not more than an hour at a time. Here, 
 as elsewhere, however, the slightest feeling of weariness should be the 
 sign for stopping exercise ; or (3) set aside an hour in the late afternoon, 
 and walk three or four miles through parks or the neighbouring country 
 at a quick, vigorous gait. There is no question that most women, if they 
 really want to do this, can find the time for it ; or (4) study out the army 
 setting-up exercises and make selections from the list, repeating six or 
 seven times half a dozen of the most distinct movements, especially those 
 developing the chest. This should be done before going to bed at night 
 and just after rising. These exercises are usually supposed to be for 
 men, but man never made a greater mistake than in thinking that the 
 woman who bore him could give him a vigorous body if she were physi- 
 cally weak herself. There may be cases where strong children have come 
 from weak parents, but it is strictly and practically true that the " strength 
 of the mothers of the nation makes the strength of the nation itself." It 
 is unfortunate that we can not give more space to woman's physical 
 training. Perhaps some student of physical health will some day write a 
 book on physical training for women, and then I, for one, shall recom- 
 mend it to all men and women. 
 
 For women who live in the country, the best exercise is riding, or 
 playing some game at regular intervals and for short spaces of time out 
 
 of doors. They should join all the country clubs they 
 For Women of the . 
 
 ^ , can, play tennis or golf, walk, skate, and row ; but they 
 
 should do all these, except, possibly, golf and riding, 
 alone or with other women, and not with men, for the reasons already 
 mentioned. 
 
 It is impossible to do justice to children here. Their exercises should 
 be the study of parents. They should be kept in the open air, in the sun 
 
 durins: both cold and hot weather, and brouo^ht up with 
 
 Children. ... » r 
 
 the idea that it is necessary that they should take some 
 little exercise each day so impressed upon them that they Avill never for- 
 get it. Daily baths, fresh clothing, short, vigorous, systematic exercises at 
 regular times, will do much, not only to make them healthy, but to make 
 them quick in their studies and well supplied with common sense. All 
 children's exercises should be in the form of games in q.\qv^ conceivable 
 instance. 
 
3Q4 PHYSICAL TRAINING. 
 
 Let mo say, as a last word, that if all the mothers \vere thorough 
 physical exercisers, and if all their children were brought up to take 
 re-ular exercise daily, ^ve should have the United States tilled with a 
 tiMitiuij race of men and a tine, womanly, healthy race of women. As 
 Mr. Carlyle niii^ht have said, it only needs '* an infinite capacity for 
 takincr pains"' with vour little simple daily exercises. Only in this 
 instance it would be enough if the capacity were merely finite instead of 
 infinite. 
 
HYGIENE. 
 
 By SAMUEL TREAT ARMSTRONG, M. I). 
 
 INTRODUCTION. 
 
 Hygiene is the science that has for its object the preservation of 
 
 health and, as a corollary, the prevention of disease. On the latter 
 
 account it is often termed preventive medicine^ to dis- 
 
 rT • tino;nish it from the other branches of medical science 
 
 Hygiene. * 
 
 that are devoted to the treatment and cure of disease. 
 In the course of time experience teaches us the verity of the old 
 adage, " an ounce of prevention is worth a pound of cure," but we are 
 not always informed when and where the prevention may be best applied. 
 The conditions of life have changed so essentially during the past half 
 century, so many inventions and discoveries have been made which have 
 for their object the furtherance of business or comfort, but often without 
 consideration of their influence on health, that it is necessary for us to be 
 aware of their dangers and be cognizant of the best methods of avoiding 
 them. 
 
 Almost a century ago the French savant, Marie Frangois Xavier 
 Bichat, whose investigations materially assisted in creating the science of 
 physiology, said that Z-^y^ is the consensus of the func- 
 tions that resist death. While death can not be 
 ultimately avoided, recent discoveries have proved tliat many die pre- 
 maturely, and that such mortality is the consequence of the faulty hygi- 
 enic arrangements of cities, of houses, of food, and of water supply. 
 Daily there are adventitious and avoidable factors that are affecting and 
 involving the functions that resist death, and this is true notwithstanding 
 the fact that the mean duration of human life has increased. The general 
 adoption of vaccination, the improved character of municipal water sup- 
 ply, the inspection of food stuffs and the greater variety in dietaries, the 
 isolation of patients with communicable diseases, have served to diminish 
 the prevalence of sickness. 
 
 It is a fundamental assumption with the citizens of America — an 
 22 305 
 
306 HYGIENK 
 
 assumptiuii that is entertained by the iiihal)irant6 of all civilized lands — 
 that men have an inalienable ri«iht to life, liberty, and the pnrsnit of 
 happiness. But life itself is not worth living to one who is atflieted with 
 some chronic disease ; there is no liberty when disability or intirniity inci- 
 dent to sickness limits all eli'ort; and the pursuit of happiness is a figment 
 of the imagination to the sufferer. Modern research has proved that in 
 a last analysis the old Ivomans were right when they spoke of a sound 
 mi nil in a sound body. 
 
 Slight perversions of the functions of the human organism suffice, 
 
 when unrelieved, to produce disastrous mental and physical aberration ; 
 
 for the organism, in health as well as in disease, is a 
 
 Causes oj iM'ase. j-gggp^-^de and laboratory of poisons that are received 
 Obitct of llmiiB)iB */ 1 
 
 in the food, created by bad assimilation, and formed in 
 
 secretions. As Prof. Charles Bouchard has said, man is living constantly 
 under the chance of being poisoned ; he is always working toward his 
 own destruction, his own suicide, by intoxication due to products he ere-, 
 ates within his body. These injurious substances may, in people m'Iio are 
 in good general health, be produced superabundantly or destroyed insuf- 
 liciently, in consequence of excesses, late hours, mental anxiety, or as a 
 result of the influence of dampness, cold, or dwelling in places that are 
 badly ventilated and badly lighted ; all of these causes affect the body by 
 first acting upon the central or the peripheral nervous system. Besides 
 these causes of disease that are innate in the individual, there is a pre- 
 disposition to certain diseases in consequence of heredity and of indi- 
 vidual peculiarities. Then there are the extrinsic causes of disease, 
 either physical, mechanical, chemical, or bacterial. Some of these causes 
 may be restricted and controlled, and it is the object of hygiene to 
 determine what are the factors which produce disease, and what is the 
 prevalence of a disease ; from these data it is possible to determine the 
 methods which must be adopted to avoid or to prevent this production 
 or prevalence. 
 
 The article on Diseases in General will indicate the specific organ- 
 isms that are the cause of disease, or pathogenic, and the micro-organisms 
 that are non-pathogenic. It will l)e seen that these 
 Pathogenic and ^.^^^g^. . ^ ^ important role in disintegrating 
 Non-pathoqenic , . , . , ,. . t i i 
 
 Micro-orqanisms. higher organic bodies into lower compounds ; that they 
 are omnipresent in the air we breathe, the food we eat, 
 and the water we drink ; that they exist in the soil, in the vegetation of 
 the fields, and in the trees of the forest ; that were it not for their offices 
 life would probably be impossible. It will also be seen that the patho- 
 genic micro-organisms gain entrance into the body by the digestive or 
 respiratory trac-ts, or through certain mucous membranes or the skin ; 
 that their entrance is materially assisted by the existence of lesions of 
 
INFECTION AND IMMUNITY. 307 
 
 these parts; and that tliey may remain restricted to tlio site of infection, 
 or they may develop within certain ])articular tissues of the body. 
 
 There are some facts, however, that bacteriology does not explain and 
 
 that must be noted. For example, the bacillus that produces diphtheria 
 
 has been found in the secretions of the nose and throat 
 
 uscepi ii'V ^£ iiealthy ])ersons ; so with the coccus of pneumonia 
 and Immunity from i • i i i 
 
 Infection. ^"^ ^^^^'^ Other pathogenic micro-organisms. This being 
 
 true, it is evident that some other factor must exist in 
 order that a specific microbe may produce its disease. If a person in 
 good health, in wliom some sucli organism exists, is exposed to any influ- 
 ence that lowers his resistance, so as to permit the introduction into the 
 tissues of the germ or of the poisonous principles (toxines) that it pro- 
 duces, then the disease ensues. But many paradoxical facts have been 
 noted in regard to this subject. 
 
 A child is susceptible to many diseases during infancy, such as whoop- 
 ing cough, diphtheria, scarlatina, etc., yet if it escapes an attack of any 
 of these diseases at that period of life it is less hkely to become infected 
 therewith in adult life. Or two children almost of the same age, having 
 the same parents, Uving in the same environment, having to all appear- 
 ances similar constitutions, are exposed to the same infective disease and 
 one is affected while the other escapes, or one recovers quickly while the 
 other has a protracted or even fatal illness. These facts are as inex- 
 plicable as the reason for one animal being indifferent to a microbe that is 
 rapidly fatal to another animal of a different species ; but there is a 
 fundamental truth that can not be lost sight of, and that is, that in a 
 healthy human organism there is a power, independent of extrinsic re- 
 medial agents, that disposes of the germs of disease, and that this power 
 can hest he conserved and developed hy the hest hygienic conditions. 
 This expression must not be understood as a pessimistic view of medicine, 
 for the medical man of to-day is far from deserving Voltaire's criticism 
 that a physician is a person engaged in pouring drugs, of which he knows 
 nothing, into a body of which he knows less. Rossbach has said mankind 
 has endeavoured for thousands of years to discover specific I'emedies for 
 diseases, and the result has been the discovery of but four remedies for 
 three diseases ; and while the idea that it would be necessary to wait sev- 
 eral thousand years more to detect four other remedies would be distress- 
 ing, our knowledge of the fact that almost two thirds of mankind die of 
 diseases caused by germs, and our increasing knowledge of the various 
 features pertaining to the growth and multiplication of these germs, leads 
 us to infer that it will not be necessary to discover remedies, but rather 
 measures to further the best development of the individual and to restrict 
 all that is inimical to such development. 
 
 In the effort that has been made to surround the individual with all 
 
308 HYGIENE. 
 
 the precautions that may avert or cure disease and conduce to longevity, 
 
 and in the multiplication of hospitals, the invention of new medical and 
 
 surgical procedures, and the general endeavour made to 
 Stirrinil of the ^^, -,• i i • xi ^ • v • i i •■• 
 
 ,, ,./ ixitch up diseased and innrm individuals, some critics 
 
 Until. ^ ^ ^ . . , . . 
 
 have discovered misdirected effort that interfered with 
 the processes of Nature in eliminating the unfit — that is, a class unable, 
 through physical or mental intirmity, to support themselves or to con- 
 tribute to the general Avelfare. The statistics of hospitals and asylums 
 have been pointed to as affording evidence of an increased demand upon 
 their resources, and it has been said that too often the surgeon has saved 
 a life that was neither useful to itself nor to humanity. So, it has been 
 alleged, has the physician striven to nourish and preserve the lives of 
 children whose infantile ailments })roved the existence of a deteriorated 
 physical and mental endowment, and who, as they developed into matu- 
 rity, would evidence abnormal mental as a consequence of abnormal phys- 
 ical conditions. These " stepchildren of Nature," as they have been 
 called, comprising the constantly increasing defective class, are the 
 products of centuries of faulty conditions. That man is his brother's 
 keeper is beyond dispute ; and for all the wrongs that erroneous hygienic 
 measures have imposed upon humanity society is responsible and must 
 atone for. Complaints are constantly and universally heard in reference 
 to increased expense to the community for the maintenance of the classes 
 herein referred to. The investigations of the bacteriologist have shown 
 the truth of the psalmist's words, that the pestilence walketh in darkness, 
 for all the pathogenic micro-organisms thrive best in least light, and the 
 researches of the hygienist and sociologist have shown that the pestilence 
 of the defective class is best developed in the dark, squalid, ill-ventilated 
 homes and in the ignorance of the working classes — conditions that are 
 too often fostered by the greed or indifference of landlords and by the 
 rapacity of employers. 
 
 CHAPTER I. 
 VITAL STATISTICS. 
 
 To determine the prevalence of any particular disease, which is a 
 
 preliminary necessary to the study of the means by which it is to be 
 
 restricted or prevented, it is necessary to have recourse 
 
 Statistics ^^ ^ system of vital statistics. From properly collected 
 
 statistics we deduce facts in relation to the sanitary life 
 
 of the individual, of the community, and of the State. Such statistics 
 
VITAL STATISTICS. 809 
 
 should afford trustworthy data for detcrinining tlie expectation of life of 
 each newborn child ; for indicating the diseases to which the child would 
 be most liable in its growth to manhood ; for correcting faults in the con- 
 struction and arrangement of dwellings, by the permanent i-ecord in the 
 office of the Board of Health of the sanitary history of each house in a 
 community, so that it would be as feasible for an intending tenant or 
 purchaser to search its sanitary record as it is for him to search its title in 
 the office of the Register of Deeds. Such statistics should indicate the 
 efforts that must be made by the sanitary authorities in the correction of 
 faults in their inspection service and in their methods of segregating 
 communicable diseases, and in the remedying of errors in the drainage, 
 sewerage, and water supply. By such means it would be possible to learn 
 whether a house, a group of houses, a district, a wai'd, a town or city, a 
 county or a State, was in a better or worse sanitary condition than a 
 corresponding house or community. 
 
 The materials necessary to make such investigations include records 
 of births, deaths, and sickness, as well as accurate census returns taken at 
 
 recjular intervals. On the last will depend the utiliza- 
 Materials for . „ ,, ,. t * 
 
 Vital Statistics. *^^" ^* *^^^. P^'eceding. In America, as m many coun- 
 tries, a national census is taken decennially, while in 
 many communities a local census is taken quinquennially. Population 
 either increases, decreases, or remains stationary, so that between the first 
 and the tenth, or even the first and the fifth year of a census period there 
 is a variation in the number of inhabitants. The increase may be due to 
 a constant excess of births over deaths, as well as to immigration ; the 
 decrease may be due to an emigration that offsets any excess of births 
 over deaths, or the latter factor may be reversed ; and the stationary con- 
 dition may be due to the fact that there is neither immigration nor emi- 
 gration, and the births and deaths balance each other ; or if there is immi- 
 gration, that there is a decreased birth-rate or increased death-rate, or 
 both ; or if there is emigration, that there is an increased birth-rate and 
 decreased death-rate, or both. 
 
 The annual increase of population between census periods is ascer- 
 tained by the following method : Let P and P' represent the enumera- 
 tion in 1880 and 1890 respectively, assuming that the 
 How to estimate increment in every year is one tenth of that recorded in 
 Increase of ten years, the annual increase is obtained by subtracting 
 
 Population. /p' p\ 
 
 P from P' and dividing the remainder bv ten ( l 
 
 ^ • V 10 ; 
 
 A better method is to take a table of logarithms and subtract the logar- 
 ithm of the previous from that of the last census, and divide the 
 remainder by the number of intervening years, and the qnotient will be 
 the losfarithm of the ratio of annual increase. 
 
310 HYGIENE. 
 
 To liiul the ]iopuliition of any one year, multiply the latter logarithm 
 
 by the number of years elajised since the census, add 
 
 now 1o find ^jj^ product to the loi2:aritlim of the population, and 
 Popuhitnm of , ', - " , , , '■ \ ^i , , • 
 
 a Given Year ^"*-'" c^' reference to the tables tlie number that this 
 
 sum represents may be obtained. 
 
 AVhile such mathematical estimates are fairly accurate for very large 
 
 populations, as those of a nation, tiiey are liable to error in pro})ortion to 
 
 the smallness of the number that is dealt with. 
 
 , „i- y If the assumed (.bners from tlie true popuiatidu 
 
 such ±j»timntes. ^ ^ 
 
 by ten per cent., an assumed death-rate of twenty- 
 four per thousand will represent an actual rate of 2 TO or 2C"-i, in 
 accordance with the fact that the difference is an excess or a diminution. 
 It has been a frequent experience that the mortality rates of American 
 cities have been erroneous in consequence of overestimation of the popu- 
 lation, such overestimation having been made on account of a desire to 
 increase the prosperity and importance of the place, as w'ell as to show 
 salubrity and efficient sanitary supervision, England has had a similar 
 experience, population having been overestimated as much as thirty-three 
 per cent. The census of 1900, like its predecessors, will undoubtedly 
 show that not a dozen cities base their mortality rate on a correct estimate 
 of population. 
 
 In determining the population it is desirable to know how many 
 inhabitants there are in certain areas, how many of each sex, of each 
 group of ages, and of each occupation, for all of these influence the 
 tendency to sickness and death. 
 
 The number of inhabitants in certain areas is known as the density of 
 
 population. In the United States in 1790 this was 4"75 per square mile ; 
 
 in ISIO, on account of the increase in area resulting 
 
 e/isi y q fj-Qin the purchase of the Territorv of Louisiana, the 
 
 Population. ' 
 
 density had decreased to S'O^ ; but every decennium 
 
 since that year there has been an increase, until in 1890 the density was 
 20" To. But this density is not evenly distributed. In 1790 the popula- 
 tion in the cities was 3'35 per 100 of total population, while in 1890 it 
 was 29"20 per 100 of total population, or an increase in density in the 
 cities from one thirtieth to one third of the population. So in other 
 countries there is this increase in urban population ; in 1801 London con- 
 tained one eleventh of the population of England and AVales, and in 1890 
 it contained one seventh of the entire population of those countries. The 
 density in the United States is small in comparison with that of other 
 countries. In England and Wales the last census returns showed that 
 there were 503 persons to the square mile ; in Ireland, 14-1 ; in Scotland, 
 138 ; while in more recently settled countries the proportion is less than 
 here, as in Victoria there are only 13 to the square mile ; in New Zealand, 
 
DENSITY OF POPULATION. 
 
 311 
 
 C ; in Tasmania, 5-5 ; in New Soiitli Wales, 3-5 ; and in Queensland, 0*5 
 person to the square mile. 
 
 Coincident with this increase in the population of cities was an increase 
 in the number of persons in a dwelling, although in the entire country 
 there was a slight decrease. In 1850 the average for the United States 
 was 5*94, in 1880 it was 5*60, and in 1890 it was 5'45 persons in a dwell- 
 ing. But in New York city the average had increased from 16'37 in 
 1880 to 18-52 in 1890; in Brooklyn it had increased from 9-11 in 1880 
 to 9"80 in 1890; and in Chicago the increase was from 8*24 in 1880 to 
 8"60 in 1890. In the latter year 50'18 per cent, of the dwellings in New 
 York city contained from one to ten persons, and 49*82 per cent, con- 
 tained more than ten persons ; but the latter proportion represented 83"50 
 per cent, of the population, while the former represented 16'50 per cent. 
 In Chicago T5"46 per cent, of the dwellings contained from one to ten 
 persons, equal to 50"82 per cent, of the population of that city, and 24'54 
 per cent, of the dwellings contained more than ten persons, equivalent to 
 49*18 per cent, of the population. In Philadelphia 95*61 per cent, of the 
 dwellings contained from one to ten persons, equal to 87*21 per cent, of 
 the city's population, while 4*39 per cent, contained more than ten per- 
 sons, or 12*79 per cent, of the population. 
 
 This increase in the number of persons in a dwelling implies the mul- 
 tiplication of families therein, and an idea of the crowding of families, 
 with its consequent pernicious destruction of home life and sentiment, in 
 different American cities, may be gained from the following table, taken 
 from the Census Tleport for 1890 : 
 
 
 Population. 
 
 Families to a 
 dwelling. 
 
 New York 
 
 1,515,301 
 800.343 
 290,908 
 
 1.099.850 
 448,477 
 451,770 
 434,439 
 
 1,040,904 
 
 3-82 
 
 Brooklyn 
 
 2-08 
 
 Cincinnati 
 
 1-90 
 
 Chicago 
 
 1-72 
 
 Boston . 
 
 1-70 
 
 St. Louis 
 
 1-51 
 
 Baltimore 
 
 1-20 
 
 Philadelphia . . 
 
 1-10 
 
 
 
 The consequence of the concentration of population in towns and 
 
 cities is a deterioration of physical health and a higher disease-rate and 
 
 death-rate than in rural districts. Crowding favours 
 
 onseqiimce of ^^^^ development and spread of communicable diseases. 
 
 Concentration. ^ \ . • • i • i i • i 
 
 and while it is a fact that cities in which there is the 
 
 least crowding do not show that there is a correspondingly low death- 
 rate, or vice versa, yet investigation will generally reveal other detri- 
 mental factors that vitiate the advantages gained by domicile multiplication. 
 
312 
 
 HYGIENE. 
 
 BIRTHS. 
 
 Births should be registered. In no State or city of the United States 
 
 is the record of births accurate, tliougii it may be a matter of importance 
 
 to the individual in order to establish his descent and 
 
 liirth-rate. pj-^ve his claim to an inheritance. The census returns 
 
 of the United States for the year 1S80 gave a birth-rate of 30-05, and 
 
 those for ISOO a rate of 2G-Grf. 
 
 The statistics of all countries show a slight decrease in the birth- 
 rate during recent years. In the United Kingdom this rate has de- 
 creased from 35-0 in 1871 to 29-3 in 181)0; in Victoria it decreased 
 from 42-81 in 18G0 to 3807 in 1870, then to 30-75 in 1880, and in 
 1892 it was 32-54 per 1,000 of mean population; in New Zealand it 
 decreased from an average of 31*2 to 27*8 in 1892. 
 
 The number of births does not increase with the miinber gf mar- 
 
 riao-es, and it has been conjectured that the diminution is the result 
 
 of the increasing desire of married women to avoid 
 
 Limifatiouof ^^^^ responsibilities of motherhood. Dr. W. Balls- 
 
 Families. ^ . , , . ,. . . n r n- • 
 
 Headley considers that the hmitation ot lamilies is 
 due to the ditficulty with which civilized women bear children nor- 
 mally, and the strain, toil, and expense of rearing families; he has 
 forinulated the following interesting tal)le of the number of children 
 to each marriatre for a series of years in different countries : 
 
 Ireland '>-i6 
 
 New Zealand 5 ' ~''5 
 
 Western Australia 4-83 
 
 South Australia 4-73 
 
 New South Wales 4-70 
 
 Queensland 4-60 
 
 Italy 4-5G 
 
 Tasmania 4 • 51 
 
 AVhile in some countries the marriage-rate is decreasing and in 
 most countries it is stationary, the birth-rate is manifestly decreasing. 
 
 DEATHS. 
 
 The reo-istration of deaths is much more accurate. The existence 
 
 of laws maknig it a crime to bury a corpse without permission from 
 
 the sanitary authorities have accomplished this result. 
 
 liegistraaon of j^^^^^_^ records should include the age, sex, place of 
 
 residence and of death, the primary and secondary 
 
 causes of death and their duration, and the time of death of the deceased. 
 
 Mortality statistics are considered with reference to the magnitude of 
 
 the population concerned and to the length of time covered by the record. 
 
 For convenience it is customary to adopt fixed standards of time and popu- 
 
 Seotland 4-43 
 
 Holland 4-34 
 
 Vic-toria 4-23 
 
 Belgium 4-21 
 
 England 4-10 
 
 Sweden 4-01 
 
 Denmark 3 -55 
 
 France 2-98 
 
EELATION OF BIRTH-RATE TO DEATH-RATE. 
 
 313 
 
 Hoiv to esiimafe the 
 Death-rate. 
 
 lation. The rate is expressed as tlie rjurnber tljat lias occurred in oacli 
 thousand of population during a year, making the rate a tliousand per 
 annum. This is rouglily calculated by dividing the 
 number of deaths by the number of thousands of popu- 
 lation. Thus in Nevv York city in 18iK,> the census 
 gave a population of 1,515,301, and there were 40,103 deaths ; the rate 
 per thousand is obtained by dividing 40,103 by 1,515,301, wliich gives 
 20*45 deaths per thousand of population ; in that year the Board of 
 Health estimated the population at 1,631,232, which afforded a death-rate 
 of 25-97 per thousand. 
 
 The influence of nativity on the death-rate is shown in the data that 
 the death-rate for native whites in that year was 32'34 per cent., while it 
 was only 23'31 per cent, for foreign whites. This dis- 
 parity was largely due to the fact that the native white 
 death-rate was increased by the mortality of individuals 
 under fifteen years of age ; the mortality of native white children under 
 five years of age was 110*37, for coloured children it was 153"90, and for 
 foreign white children it was 74*28 per thousand of each group during 
 the six years ending May 31, 1890, Such figures suggest matters for in- 
 vestigation, to decide the reasons for the greater mortality among native 
 than foreign-born children or among coloured than white. There are 
 reasons for the existence of such facts, for there must be local and, 
 furthermore, avoidable conditions that make the death-rates of children 
 under five years of age per thousand of population of corresponding ages 
 so much greater in New York than it is in Brooklyn, as shown by the 
 following diagram, adapted from the census report for 1890 : 
 
 Influence of 
 Nativity. 
 
 Rate 
 
 1880 
 
 1881 
 
 1882 
 
 1883 
 
 1884 
 
 1885 
 
 1886 
 
 1887 
 
 1888 
 
 1889 
 
 1890 
 
 130 
 120 
 
 110 
 
 100 
 
 90 
 
 80 
 70 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 . 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ■^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 S 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 ^ 
 
 [v 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ^ 
 
 r-^ 
 
 
 
 ^ 
 
 
 
 
 
 
 
 
 
 
 I 
 
 
 
 
 
 
 
 ^ 
 
 
 
 
 
 
 k 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 
 y 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 / 
 
 
 
 y 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 
 
 
 \ 
 
 
 / 
 
 
 
 
 
 
 
 
 
 
 
 
 S 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 — 
 
 ■ 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 t-- 
 
 ■■' 
 
 
 -- 
 
 
 
 
 
 
 
 ^ 
 
 
 
 
 
 
 
 
 
 
 ,,' 
 
 
 
 
 
 
 
 
 f' 
 
 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 y 
 
 
 
 
 
 
 
 
 
 
 
 
 
 _^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 
 I — 
 
 — ■< 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 
 .' 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 y* 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 *'' 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •' 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Ar/?7ii Vnrk Brnnhlyn 
 
3U 
 
 HYGIENE. 
 
 
 MEAN ANNUAL DEATH-RATES IN 
 
 Yeaus. 
 
 Both 
 sexes. 
 
 Males. 
 
 Females. 
 
 IMl-oO 
 
 ISoMU) 
 
 18G1-7U 
 
 ISllSO 
 
 1881-yO 
 
 22-4 
 
 22-2 
 22-5 
 21-4 
 19-1 
 
 23-1 
 231 
 23-7 
 22*7 
 20-3 
 
 21 •« 
 21-4 
 21-4 
 20-1 
 18-1 
 
 The Highest 
 Death-rate. 
 
 The intiiienee of public sanitary measures on the death-rate is strik- 
 ingly showii by the tables prepared by Mr. 13. A. AVhitlegge from the 
 
 reports of the liegistrar-General of England, though 
 
 InfJttence of Public ^, . , i- -i. j ^ ^i i i ^i • i. S 
 
 .,• ., ■ this decrease was limited to tlie ai!;es below thirtv-nve 
 
 years in males and below forty-tive years in females; 
 beyond those periods there was an increase : 
 
 Unfortunately, the collection of 
 similar statistics in the United States 
 is not sufficiently general to aJl'ord a 
 basis for comparison with the results 
 obtained by ini[u\)vements in hygien- 
 ic conditions in England and Wales. 
 The tendency to the highest death- 
 rate is in infancy and old age, and 
 the rate is always lower among females than among males. It is higher in 
 towns than in the country, though in the United States 
 the cities have been gaining most in healthfulness, Dr. 
 J. S. Billings states, in consequence of the fact that sys- 
 tematic sanitary work has been carried on in them to a much greater 
 extent than in the smaller towns and villages. The larger urban mortal- 
 ity is mainly due to an excess of deaths in the earlier years of life. 
 
 In the United States the death-rate per thou.?and of living population 
 was, in 1860, 12-54 ; in 1870, 12-77 ; in 1880, 15*09 ; and in 1890, 13-98. 
 The former increased rate is not the consequence of increasing negli- 
 gence of sanitary measures, but rather the result of more complete mor- 
 tality returns secured by each census. And the diminution noted in 1890 
 was due, as Dr. Billings has stated, to the returns of that year being more 
 deficient than in 1880. As evidence of this fact it was shown that in a 
 population of 21,093,320 in which there were State registration returns 
 the rate was 20-27 per thousand, while in a population of 41,528,930, re- 
 turned by enumerators from districts in which there were no returns, the 
 mortality-rate was only 10-79 per thousand, a disparity that is inexplicable 
 l)y any probable fact. In the cities the rate was 23-58 and in the country 
 14-99 per thousand ; that of males was 20-08 and females 18-62, while 
 that of negroes was 19-57. 
 
 The most frequent causes of death are those from diseases caused by 
 bacteria, tuberculosis being first, then pneumonia, diphtheria, heart dis- 
 ease, cholera infantum, enteric fever, malarial fever, and 
 The Most Frequent , ^. ^ , ^ t- i ,1 • i r.o , ,. i .^ 
 
 Causes of Death scarlatina. In 1890 diphtheria cau.sed 33 -Ob deaths per 
 
 thousand, and in 1880 it caused 52-32 deaths; the rate 
 in cities was 37-70, and in the country, 22-63, Typhoid fever caused in 
 1890, 32-10 deatlis, and in 1880, 30-19 deaths per thousand. Consumption 
 caused in 1890, 121-49, and in 1880, 124-75 deaths per thousand. 
 
MORTALITY OF LARGE CITIES. 
 
 315 
 
 'J'ahij'; I. 
 
 Cities. 
 
 Altoona, Pa 
 
 Atlanta, Ga 
 
 Auburn, N. Y 
 
 Baltimore, Md 
 
 Binghainton, N. Y. 
 
 Boston, Mass 
 
 Brooklyn, N. Y. . . 
 Charleston, S. (-' . . . 
 
 Chicago, J 11 
 
 Cincinnati, Ohio.. . 
 Cleveland, Ohio . . . 
 
 Detroit, Mich 
 
 Erie, Pa 
 
 Fall River, Mass. . . 
 Galveston, Tex. . . . 
 Indianapolis, Ind.. 
 Kansas City, Mo.. . 
 
 Louisville, Ky 
 
 Memphis, Tenn . . . 
 Milwaukee, Wis . . . 
 Minneapolis, Minn 
 
 Mobile, Ala 
 
 Nashville, Tenn . . . 
 
 Newark, N. J 
 
 New Orleans, La. . . 
 New York, N. Y. . , 
 
 Pensacola, Fla 
 
 Philadelphia. Pa . . 
 
 Pittsburg, Pa 
 
 Portland, Me 
 
 Providence, E. I. . , 
 Richmond, Va . . . , 
 Rochester. N. Y . . , 
 
 St. Louis, Mo 
 
 St. Paul, Minn 
 
 San Diego, Cal . . . . 
 San Francisco, Cal 
 
 Toledo, Ohio 
 
 Washington, D. C. . 
 
 Population, 
 United Statics 
 cenBUH, 181J0. 
 
 35,000 
 
 (jr),r)i4 
 
 2.5,858 
 4:34.4:39 
 
 35,005 
 448,477 
 800,343 
 
 05,105 
 ,0JJ9,850 
 290,908 
 2G1,;353 
 205,870 
 
 40,634 
 
 74.398 
 
 29.084 
 105,430 
 132.710 
 101,129 
 
 50,313 
 204,408 
 164,738 
 
 31,076 
 
 76,306 
 181,830 
 242,039 
 ,515.301 
 
 11,750 
 ,046,964 
 2:38,617 
 
 36,426 
 132,146 
 
 81,388 
 133,896 
 451,770 
 133,156 
 
 10.159 
 298.997 
 
 81,434 
 230,392 
 
 ANNUAL BATE PKB l/lOO OF THE POPULATION. 
 
 1890. 
 
 15-3 
 24-6 
 22-1 
 23-3 
 10-0 
 22-9 
 24-3 
 27-9 
 19-6 
 22-3 
 19-2 
 18-8 
 
 22 -i 
 20-4 
 10-2 
 
 16- 
 
 21 
 
 26- 
 
 17 
 
 14- 
 
 26- 
 
 18-8 
 
 251 
 
 29-2 
 
 26-6 
 
 20-1 
 
 20-7 
 
 21-3 
 
 19-9 
 
 19-2 
 
 28-3 
 
 15-8 
 
 18-4 
 
 15-5 
 
 10-6 
 
 22-8 
 
 16-4 
 
 23-7 
 
 1891. 
 
 1892. 
 
 1893. 
 
 
 i9-8 
 
 22-5 
 
 25-3 
 
 24- 
 
 1 
 
 27-1 
 
 19-6 
 
 18- 
 
 2 
 
 20-1 
 
 23-1 
 
 24- 
 
 2 
 
 15-7 
 
 17-8 
 
 19 
 
 6 
 
 17-8 
 
 23-5 
 
 24- 
 
 8 
 
 25-9 
 
 26-4 
 
 25 
 
 6 
 
 25-9 
 
 29 
 
 29 
 
 2 
 
 27-9 
 
 24-3 
 
 23 
 
 7 
 
 24-7 
 
 22-3 
 
 20 
 
 2 
 
 19-8 
 
 12-3 
 
 19 
 
 8 
 
 20-0 
 
 19-3 
 
 24 
 
 
 
 200 
 
 
 20 
 
 4 
 
 17-4 
 
 24-3 
 
 25 
 
 3 
 
 23-4 
 
 23-9 
 
 24 
 
 
 
 20-8 
 
 18-4 
 
 18 
 
 8 
 
 19-9 
 
 12-3 
 
 12 
 
 4 
 
 
 19-1 
 
 19 
 
 4 
 
 . 
 
 27-9 
 
 25 
 
 
 
 21-3 
 
 22-9 
 
 21 
 
 7 
 
 21-2 
 
 13-7 
 
 15 
 
 5 
 
 13-5 
 
 28-4 
 
 25 
 
 3 
 
 27-2 
 
 23-6 
 
 20 
 
 7 
 
 20-2 
 
 28-3 
 
 28 
 
 1 
 
 26-8 
 
 28-3 
 
 30 
 
 9 
 
 28-9 
 
 28-8 
 
 29 
 
 1 
 
 29-4 
 
 21-8 
 
 24 
 
 5 
 
 20-6 
 
 22-0 
 
 23 
 
 1 
 
 22-6 
 
 24-4 
 
 22 
 
 ■7 
 
 22-3 
 
 17-2 
 
 21 
 
 •8 
 
 19-8 
 
 19-9 
 
 22 
 
 •3 
 
 24-6 
 
 26-6 
 
 25 
 
 •2 
 
 25-4 
 
 18-7 
 
 20 
 
 •3 
 
 19-3 
 
 21-0 
 
 20 
 
 •7 
 
 20-4 
 
 15-9 
 
 
 
 
 11-7 
 
 io 
 
 •7 
 
 9-7 
 
 23-3 
 
 21 
 
 •7 
 
 19-9 
 
 18-1 
 
 19 
 
 ■9 
 
 18-0 
 
 26-0 
 
 27 
 
 ■6 
 
 26-6 
 
 1894. 
 
 14-2 
 
 19-1 
 15-8 
 22-9 
 20-9 
 
 27-2 
 21-7 
 18-2 
 17-4 
 19-0 
 20-2 
 
 23-0 
 20-7 
 12-5 
 
 25-3 
 
 28-2 
 27-1 
 21-7 
 19-9 
 20-8 
 20-1 
 
 2i-i 
 
 16-2 
 19-2 
 
 12-5 
 20-7 
 12-5 
 25-4 
 
 Mortality of 
 Large Cities. 
 
 The mortality in certain of the larger cities of the United States is 
 given in Table I, that has been compiled from the Weekly Abstracts of 
 Health issued by the United States IMarine-Hospital 
 Service and from the annual reports of boards of health. 
 These rates do not correspond with those contained in 
 the reports of the boards, because the writer has made corrections for 
 population and ignored the estimates made in the reports. In an article 
 on mortality in the appendix to Quain's Dictionary of Medicine the 
 instance of Memphis, Tennessee, was cited by the writer as an example of 
 this tendency of overestimation of population ; the United States census 
 of 1890 gave the population of that portion of the city comprised within 
 the jurisdiction of the Board of Health as 50,313 ; but the Board asserted 
 
aio 
 
 HYGIENE. 
 
 that this estimate was erroneous, and in 1890, 1801, and 1892 calculated 
 their mortality on an estimated population of 00,000. In 1898, allo\vini>- 
 tor an increase in population duiinii; the three years that had elapsed 
 since the national census, a local census was made that returned a popula- 
 tion of 57,951, or more than 2,000 less than had been used to determine 
 the per thousand nmrtaliry of tlu' three ju-evious years. A numl)er of 
 Western cities, notably 8r. I.ouis previous to 1880, calculated their cen- 
 sus on a largely overestimated poj)uhition. Ko advantage accrues to a 
 niunici[)ality or townsliip from such ovei-estimations, as the inhabitants 
 are erroneously informed regarding their actual sanitary state, and the 
 data published for the information of sanitarians is receiv'ed with the 
 distrust it merits. Underestimation is infinitely less disadvantageous 
 than overestimation. 
 
 A factor that exercises considci-al)Ie inlluence in producing the high 
 death-rate of the Southern cities of the riiited States is the large negro 
 
 population. This race has a lessened resistance to 
 nj mnce j . 7 (jjg^^j^ge^ i]^q ii^faut mortality is quite high, and the 
 
 mode of life is indifferent to all, or almost all, hygi- 
 enic considerations. Dr. II. B. Horlbeck, of Charleston, South Caro- 
 lina, collected the following evidence afforded by Southern cities : 
 
 Cities. 
 
 White, per thousand. 
 
 Negro, per thousand. 
 
 C'liarlcston. 1880 to 1890 
 
 21-39 
 23-33 
 
 22-08 
 17-91 
 23-73 
 19-03 
 18-40 
 
 43-60 
 
 Memphis, 1876 to 1890 
 
 29-03 
 
 Mobile, 1876 to 1890 
 
 28-73 
 
 Xushville, 1875 to 1890 
 
 32-30 
 
 New Orleans 1881 to 1890 
 
 37-87 
 
 St. Louis, 1880 to 1890 
 
 34-10 
 
 Washington, 1876 to 1890 
 
 33-00 
 
 
 
 This increased mortality among negroes is not the fault of their 
 environment, for in almost all of our cities their death-rate is much 
 higher than that of the whites, as may be seen in Table II, compiled 
 from the census report of 1890. 
 
 For the purpose of comparing the vital statistics of cities with 
 
 those of States and countries Table III is introduced. It is in part 
 
 adapted from the annual report of the ]\[assachusetts 
 
 .ompartsonoj j>Qr^y(\ ^^f Health for 1893, and in part from the annual 
 T ital Statistics. ' ^ 
 
 reports of the boards of other States. It is to be recalled 
 
 that the density of ]')0])ulation varies in the different countries and States 
 herein included, and the methods of living are also different. Holland 
 and Belgium, for example, are densely populated, and yet their death- 
 rates are markedly less than those of Hungary and Italy, M'hile compara- 
 tively sparsely populated Denmark, Norway, and Sweden have quite low 
 death-rates. 
 
COMPAEISON OF VITAL STATISTICS. 
 
 317 
 
 Tahm.; II. 
 
 Cities. 
 
 New York .. . . 
 
 Chicago 
 
 Philadelphia.. 
 
 Brooklyn 
 
 St. Louis 
 
 Boston 
 
 Baltimore . . . . 
 San Francisco 
 Cincinnati.. . . 
 (.'leveland . . . . 
 
 Bu£falo 
 
 New Orleans.. 
 Pittsburg . . . . 
 Washington. . 
 
 Detroit 
 
 Newark 
 
 Jersey City. . . 
 Louisville . . . . 
 
 White. 
 
 38-47 
 
 23-28 
 25-41 
 •18-15 
 24-03 
 23 -(il 
 28-57 
 31 -9:5 
 31 83 
 19-83 
 35-41 
 21-56 
 19-79 
 30-36 
 38' 67 
 37-48 
 19 61 
 
 Coloured. ' 
 
 37-46 
 
 23 
 
 30 
 
 33 
 
 43 
 
 34 
 
 99 
 
 34 
 
 65 
 
 33 
 
 39 
 
 36 
 
 41 
 
 24 
 
 06 
 
 33 
 
 04 
 
 31 
 
 63 
 
 34 
 
 33 
 
 36 
 
 61 
 
 39 
 
 16 
 
 38 
 
 32 
 
 33 
 
 45 
 
 44 
 
 48 
 
 39 
 
 50 
 
 31 
 
 98 
 
 Cities, 
 
 Rochester.. . 
 Providence . 
 Indianapolis 
 Alleghany. . 
 
 Albany 
 
 Syracuse.. . . 
 Worcester . . 
 Ilichmond . 
 New Haven . 
 Paterson.. . . 
 
 Lowell 
 
 Nashville. . . 
 
 Atlanta 
 
 Memphis . . . 
 Charleston.. 
 Savannah.. . 
 Galveston. . . 
 Mobile 
 
 White. 
 
 17-39 
 
 21 
 
 97 
 
 17 
 
 78 
 
 20 
 
 06 
 
 25 
 
 34 
 
 19 
 
 74 
 
 19 
 
 14 
 
 23 
 
 25 
 
 30 
 
 90 
 
 23 
 
 62 
 
 27 
 
 43 
 
 14 
 
 39 
 
 18 
 
 28 
 
 23 
 
 37 
 
 24 
 
 75 
 
 29 
 
 04 
 
 24 
 
 37 
 
 26 
 
 05 
 
 Coloured. 
 
 6-92 
 34-81 
 30-04 
 24-13 
 39-44 
 11-53 
 15-37 
 40-80 
 29-17 
 35-56 
 
 23-92 
 33-57 
 29-97 
 53-94 
 
 41-47 
 25-28 
 43-75 
 
 Table IIL 
 
 Summary of the Vital Statistics of the Principal Countries of Europe for Twenty Years, 
 and for 1891 and 1892, together with those of some of the United States. 
 
 
 1871 TO 1890. 
 
 1891. 
 
 1898. 
 
 
 
 
 
 »_ 1- d 
 
 
 
 
 tM t. »' 
 
 
 
 
 <M (-< ^3 
 
 States and 
 Countries. 
 
 Mar- 
 
 Birth 
 
 Death 
 
 >ot 
 
 Mar- 
 
 Birth 
 
 Death 
 
 m O S 
 
 Mar- 
 
 Birth 
 
 Death 
 
 ^ > '^ 
 ^ c - 
 
 
 riage 
 rate. 
 
 rate. 
 
 rate. 
 
 « t- cS 
 
 rate. 
 
 rate. 
 
 rate. 
 
 S55 
 
 rate. 
 
 rate. 
 
 rate. 
 
 
 Massachusetts. . . 
 
 18-1 
 
 25-7 
 
 19-7 
 
 6-0 
 
 18-9 
 
 37-4 
 
 19-7 
 
 7-8 
 
 19-0 
 
 27-8 
 
 20-6 
 
 7-2 
 
 Maine 
 
 
 
 
 
 
 
 
 
 
 
 17-1 
 
 21-2 
 
 18-4 
 
 2-8 
 
 New Hampshire. 
 
 18 
 
 6 
 
 i8-6* 
 
 i8-9 
 
 
 
 20 
 
 6 
 
 19-8 
 
 19 
 
 3 
 
 
 
 21-6 
 
 30-6 
 
 21-2 
 
 
 
 Vermont 
 
 15 
 
 6 
 
 20-3 
 
 15-1 
 
 5 
 
 i 
 
 17 
 
 
 
 30-0 
 
 16 
 
 9 
 
 3 
 
 1 
 
 17-5 
 
 19-7 
 
 18-6 
 
 1-1 
 
 Rhode Island . . . 
 
 18 
 
 7 
 
 33-7 
 
 18-0 
 
 5 
 
 7 
 
 18 
 
 8 
 
 35-9 
 
 18 
 
 7 
 
 7 
 
 2 
 
 19-4 
 
 24-7 
 
 20-5 
 
 4-2 
 
 Connecticut 
 
 16 
 
 
 
 33-6 
 
 17-1 
 
 6 
 
 5 
 
 16 
 
 8 
 
 34-8 
 
 19 
 
 2 
 
 5 
 
 6 
 
 16-6 
 
 24-7 
 
 19-0 
 
 5-7 
 
 Michigan 
 
 17 
 
 5 
 
 23-8 
 
 9-5 
 
 13 
 
 2 
 
 18 
 
 
 
 33-7 
 
 10 
 
 3 
 
 13 
 
 4 
 
 18-4 
 
 21-2 
 
 9-9 
 
 11-3 
 
 New Jersey f . . . 
 
 
 
 30-0 
 
 18-4 
 
 1 
 
 6 
 
 
 
 30-7 
 
 32 
 
 1 
 
 -1 
 
 4 
 
 
 20-9 
 
 19-8 
 
 1-1 
 
 Minnesota 
 
 
 
 24' 7 
 36-9 
 
 11-1 
 19-0 
 
 13 
 
 7 
 
 6 
 4 
 
 
 
 36-1 
 
 11 
 
 3 
 
 14 
 
 8 
 
 
 
 
 
 Japan \ 
 
 
 
 
 England and 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Wales 
 
 15 
 
 6 
 
 34-0 
 
 20-3 
 
 13 
 
 7 
 
 15 
 
 6 
 
 31-4 
 
 30 
 
 2 
 
 11 
 
 2 
 
 15-4 
 
 30-5 
 
 19-0 
 
 11-5 
 
 Scotland 
 
 13 
 
 9 
 
 33-6 
 
 20-4 
 
 13 
 
 3 
 
 13 
 
 9 
 
 31-2 
 
 SO 
 
 7 
 
 10 
 
 5 
 
 14-1 
 
 30-7 
 
 18-5 
 
 12-2 
 
 Ireland 
 
 9 
 
 15 
 15 
 
 
 6 
 
 2 
 
 34-9 
 
 37-3 
 31-7 
 
 18-0 
 28-6 
 19-0 
 
 6 
 
 8 
 12 
 
 9 
 
 7 
 7 
 
 9 
 
 15 
 13 
 
 2 
 
 6 
 
 23-1 
 37-3 
 31-0 
 
 18 
 26 
 20 
 
 4 
 
 2 
 
 
 
 4 
 11 
 11 
 
 7 
 1 
 
 
 9-3 
 15-0 
 13-6 
 
 22-4 
 36-3 
 29-5 
 
 19-4 
 36-3 
 19-4 
 
 3-0 
 
 Italy 
 
 10-1 
 
 Denmark 
 
 10-1 
 
 Norway 
 
 13 
 
 7 
 
 30-7 
 
 16-9 
 
 13 
 
 8 
 
 13 
 
 3 
 
 30-9 
 
 17 
 
 5 
 
 13 
 
 4 
 
 12-6 
 
 29-6 
 
 17-7 
 
 11-9 
 
 Sweden 
 
 13 
 16 
 19 
 
 1 
 3 
 1 
 
 39-8 
 38-6 
 44-0 
 
 17-6 
 30-6 
 33-7 
 
 13 
 
 8 
 
 10 
 
 3 
 
 3 
 
 11 
 15 
 
 17 
 
 6 
 
 4 
 
 3 
 
 28-3 
 38-1 
 42-3 
 
 16 
 
 27 
 33 
 
 8 
 9 
 1 
 
 11 
 
 10 
 
 9 
 
 5 
 2 
 2 
 
 15-6 
 
 36-2 
 
 28-8 
 
 
 Austria 
 
 7-4 
 
 Hungary* 
 
 
 Switzerland 
 
 14 
 
 7 
 
 39-4 
 
 22-1 
 
 7 
 
 3 
 
 14 
 
 3 
 
 28-2 
 
 20 
 
 7 
 
 7 
 
 5 
 
 14-7 
 
 28-6 
 
 19-3 
 
 8-7 
 
 GermanEmpire|| 
 
 16 
 
 4 
 
 38-1 
 
 26-0 
 
 13 
 
 1 
 
 16 
 
 1 
 
 37-0 
 
 23 
 
 4 
 
 13 
 
 6 
 
 15-9 
 
 35-7 
 
 24-1 
 
 11-6 
 
 Holland 
 
 15 
 
 1 
 
 35-2 
 
 22-6 
 
 12 
 
 6 
 
 14 
 
 2 
 
 33-7 
 
 20 
 
 7 
 
 13 
 
 
 
 14-4 
 
 32-0 
 
 21-0 
 
 11-0 
 
 Belgium 
 
 14 
 
 o 
 
 31-0 
 
 21-4 
 
 9 
 
 6 
 
 14 
 
 8 
 
 29-6 
 
 21 
 
 
 
 8 
 
 6 
 
 15-4 
 
 28-9 
 
 21-8 
 
 7-1 
 
 France 
 
 15 
 
 4 
 
 34-6 
 
 22-8 
 
 1 
 
 8 
 
 15 
 
 
 
 33-6 
 
 o-> 
 
 6 
 
 
 
 15-2 
 
 22-1 
 
 33-6 
 
 -0-5 
 
 
 
 
 
 
 
 
 
 
 
 
 
 * For seven years. 
 
 * Fifteen years. 
 
 f For fifteen years. 
 II Nineteen vears. 
 
 X For ten years. 
 
318 HYGIENE. 
 
 The almost universal decrease in the birth-rate is shown by this table, 
 as well as the uncertain relation between the number of marriages and 
 the number of births. 
 
 It is now proposed to consider those factors that enter into the preser- 
 vation and per])etuation of health, whether it be necessary to live in the 
 ~ city or the country. All men incur more or less risk in 
 The Maintenance gj^j.,^-, ^ living, and on a subsequent page the relation 
 of Health. » '^ -11 1 • 1 J i> 
 
 of occu])ation to disease will be considered. lint many 
 
 of the risks of occupations can be avoided ; the most frequent causes of 
 mortality should, with our increasing knowledge of bacteriology, be de- 
 cidedly restricted; and while it may not be possible to realize Sir Benja- 
 luiu Wai'd Richardson's sanitary Utoi)ia, with its death-rate of four or 
 five per thousand, involving a mean duration of life of sixty-five years 
 instead of less than forty years, as is the case in the United States, yet the 
 healthier man, living under a healthier environment, will derive more 
 enjoyment from life than he can at present. 
 
 CHAPTER II. 
 AIR. 
 
 Air is the gaseous envelope surrounding every part of the earth and 
 constituting the atmosi:»liere upon which the existence of animal life de- 
 pends. It partakes of the rotatory motion of the earth, 
 and its height has been estimated to be from one hun- 
 dred and ninety-eight to two hundred and twelve miles, although long be- 
 fore these distances are reached the air is so extremely raretied that it will 
 not support life. 
 
 Air is essentially a mixture of oxygen and nitrogen gases, its com- 
 position being : 
 
 Nitrogen 7845 
 
 Oxygen 20-03 
 
 Argon -04 
 
 Carbonic acid '04 
 
 Aqueous vapour 'S-i 
 
 100-00 
 
 The foregoing proportions may vary according to the locality wdiencc 
 the air is obtained. The percentages of nitrogen and oxygen are quite 
 constant, the latter never exceeding twenty-one per cent, even in the 
 country, nor falling below twenty per cent, in the streets of a large city. 
 
THE COMPOSITION OF AIR. 319 
 
 Nitrogen is an indifferent gas tliat lias no cfFect on animal Jifc in sucli 
 
 pro])ortions as it exists in air ; if a gaseous mixture is 
 Nitrogen. , . , . , ... ^- ' r i i • ■ 
 
 made in wincli a similar proportion or hydrogen is sub- 
 stituted for the nitrogen an animal can live in it. 
 
 Oxygen is absolutely essential for the support of life, an adult absorb- 
 ing in twenty-four hours at 32° Falir., and at mean barometric pressure, 
 more than twenty-four ounces of oxygen. Muscular 
 
 0XUOGTI •/ *-) 
 
 and energetic persons use more oxygen than less active 
 persons of the same weight ; and there is a greater consumption of oxygen 
 in a bright light than in the dark. 
 
 There is an exchange of gases between the inspired air and the blood 
 in the air vesicles of the lungs, the oxygen from the air in the alveoli 
 being absorbed by a chemical process by the venous blood of the capillary 
 blood-vessels of the lung. Physiological investigations have shown that 
 the oxygen diffuses from the air cells into the blood plasma, where it 
 reaches the blood-corpuscles, the reduced hsemoglobin of these takes up the 
 oxygen to form oxyhsemoglobin ; in its circulation through the arteries 
 this oxyhsemoglobin comes into relation with tissues poor in oxygen, 
 whereupon the latter is dissociated from the corpuscles aiid supplied to 
 the tissues, while the blood freed from oxygen returns by the veins to the 
 right heart, whence it passes to the lungs to take up new oxygen. 
 
 Animals breathe in a normal way in pure oxygen, the quantity of the 
 latter that is absorbed, as well as the amount of carbon dioxide excreted, 
 being independent of the amount of oxygen present. But if the respired 
 air is deficient in oxygen, prolonged and severe difficulty of breathing 
 occurs, with eventual excitement, spasms, and death. Experiments have 
 proved that animals can breathe quietly an atmosphere containing 14:'8 
 per cent, of oxygen, but in one containing seven per cent, they breathe 
 with difficulty, in one containing 4*5 per cent, there is marked difficulty 
 of breathing, while if the oxygen percentage is reduced to three there is 
 rapid suffocation. 
 
 The temperature of the surrounding medium affects the consumption 
 of oxygen. As a result of some yet unknown reflex mechanism, increased 
 cold increases the processes of oxidation within the body, the number and 
 depth of the respimtions increase, and more oxygen is taken in. In Jan- 
 uary, in a temperate zone, a man uses an ounce of oxygen an hour, in 
 July less than an ounce. 
 
 Argon is a gas, the discovery of which was reported to the Koyal 
 
 Society by Lord Rayleigh and Professor Ramsay, on January 31, 1895. 
 
 It forms one two-hundred-and-fiftieth part of the air, 
 
 and in a year it is estimated that fifty pounds of the gas 
 
 enter the lungs. It is intimately mixed with nitrogen, and whether it has 
 
 any influence on respiration has not been determined as yet. 
 
320 HYGIENE. 
 
 Carbonic-acid gas, or carbon dioxide, arises from the respiration of 
 animals, the decomposition of organic substances, and the processes of 
 combustion. It is produced in such immense quantities 
 that It miglit be supposed that tlie composition oi tlie 
 air would vary ; but such is not the case, for in the process of vegetation 
 plants decompose this gas, assimilating the carbon and restoring the 
 oxvgen to the atmosphere. This cycle of analysis and synthesis pervades 
 Nature. During ordinary respiration more oxygen measured by volume 
 is absorbed than carbon tliuxide is given olf ; for while some twenty-six 
 and a half ounces of carbon diuxitle are expired in twenty-four hours, it 
 must be recalled that it is a heavier gas than oxygen, and an equal vol- 
 ume of the latter weighs less than the former gas. 
 
 The amount of carbonic-acid gas given oS is proportionately greater 
 before the body is fully developed than it is after the bodily energies 
 decay. In young persons the relative amount of oxygen absorbed is 
 greater than the quantity of carbon dioxide given off, and the absolute 
 amount of the latter gas given off is less in children than in adults ; but 
 if a calculation is made with reference to body weight, then, weight for 
 weight, a child gives off twice as much carbon dioxide as an adult. After 
 the eighth year males give off more of this gas than females. During 
 sleep the excretion of carbonic acid is diminished almost one fourth in 
 consequence of the absence of muscular activity, abstention from food, 
 darkness, and the retention of heat by the bedclothes. Muscular exercise 
 and the taking of food produce an increase in the excretion of carbon 
 dioxide, while more of the latter is excreted in a bright light or a bluish- 
 violet lio;ht than in the dark or in a i-ed liMit. 
 
 In the blood this gas is in com]>ination with the salts of the plasma, 
 and it is so diffused through the walls of the capillaries as to reach the air 
 vesicles, its separation being favoni-ed by the oxygenation of the haemo- 
 globin in the blood-corpuscles. In air overcharged with carbon dioxide 
 there is difficulty of respiration and eventually death. Breathing in a 
 limited space causes a gradual diminution in the oxygen contained in the 
 air of the apartment, a simultaneous increase in the amount of carbon 
 dioxide, and as the latter accumulates, that formed in the body is not 
 excreted, and eventually there are diminished excitability, lessened tem- 
 perature, loss of consciousness, and death. 
 
 Aqueous vapour is always present in the air, varying in quantity, but 
 generally increasing with an increase of the air's temperature. Breathing 
 is most comfortable in an atmosphere that is not com- 
 pletely saturated with aqueous vapour. Air that is too 
 dr}' irritates the mucous membrane of the respiratory tract ; air that is 
 too moist causes a disagreeable sensation, and if too warm there is a feeling 
 of closeness. Therefore it is a matter of importance to be sure that the 
 
THE VITIATION OF AIR 321 
 
 necessary amount of moisture is present in the air of sittin^-rooins, hcd- 
 rooms, and hospital wards. The direction of the wind, the season of the 
 year, and the height above sea level produce variations in the al^solute 
 amount of moisture ; in towns it increases with an elevation and decreases 
 with a diminution of temperature. The relative amount of moisture is 
 greatest at sunrise, least at midday, and is greater in winter than in sum- 
 mer ; the air in midsummer contains absolutely three times as much 
 watery vapour as in midwinter, nevertheless it is relatively drier in the 
 former than in the latter season. 
 
 In the country and at tlie seashore the air contains ozone, an allotropic 
 form of oxygen that is rapidly broken up by its tendency to part with 
 
 one atom of its oxygen to any oxidizable substance with 
 Ozone. 1 • , •. • . . T. • /• 11- 
 
 which it comes in contact. It is formed during thun- 
 derstorms, and is found in the atmosphere of pine woods. It has a pe- 
 culiar odour, and its power of liberating iodine from an iodide distin- 
 guishes it from the ordinary form of oxygen. When it is present it 
 indicates that there is an absence of oxidizable organic matter, and from 
 this standpoint is considered a criterion of the purity of' the air of a 
 locality. 
 
 Air may also contain carburetted hj'drogen, carbon monoxide, carbon 
 bisulphide, sulphurous acid, ammonia, organic matter and carbon in 
 
 towns, and sodium chloride and other salts at the sea 
 
 Vitiation of Air. , a ■ • •.• ^ i i .^i • ,• c i 
 
 shore. Air is vitiated by tlie respiration oi men and 
 
 animals, by the combustion of fuel and of lighting mediums, by the de- 
 composition of organic matter, and by processes of manufacture. 
 
 A healthy adult, at rest, breathes at the rate of from sixteen to 
 twenty-four times a minute ; and while the capacity of the lungs varies, 
 about five hundred cubic centimetres of air — something more than one 
 pint, or about 30*5 cubic inches of air — enter the lungs at each respi- 
 ration. In the course of an hour one hundred and twenty gallons, or 
 seventeen cubic feet, of air are breathed. Exercise or employment in- 
 creases the number and depth of the respirations, and consequently the 
 amount of air that is consumed. The expired air contains more aqueous 
 vapour, a larger amount of carbonic acid, and organic matters ; the quan- 
 tity of carbonic acid varies from 0*62 of a cubic foot to 1'5 cubic foot in 
 one hour, according as the individual is at rest or is at work. The 
 quantity of organic matter is also dependent upon these two conditions 
 as well as upon the general health, and it is the quantity of this matter, 
 with that which is exhaled by the skin, that so rapidly vitiates the air in 
 a tightly closed room and makes it dangerous to health. The organic 
 matter is of mixed composition, tliough its nature has not yet been pre- 
 cisely determined ; it has a fetid odour, and it is putrescible, oxidizable, 
 and nitrogenous ; it is by no means constant in its amount, but it is difii- 
 23 
 
3:22 HYGIENE. 
 
 cult to rid an apartiueiit of it. The quantity of aqueous vapour varies 
 with the amount of moisture in the atniospliere and the temperature of 
 the respired air ; it has been estimated to amount to from seven to 
 twentv-two ounces in twenty-four hours. 
 
 "While the standard of carbon dioxide has been placed at 0*() per 1,000 
 volumes of air, it may be present to the e.xtent of 2 per l,00l) without 
 producing any very injurious effect on health ; but al)ove that quantity 
 it causes headache and other symptoms of malaise. 
 
 Modern methods of heating and lighting have diminished the amount 
 of air vitiation due to combustion. The combustion of coal produces 
 carbon, carbon dioxide, disulphide and monoxide, sulphur, sulphur diox- 
 ide and sulphuric acid, ammonium compounds, and water ; that of wood 
 produces carbon monoxide and dioxide and water ; that of coal-gas pro- 
 duces carbon monoxide and dioxide, nitrogen, sulphur dioxide, ammonia, 
 and water; and that of oil produces carbonic dioxide. One pound of 
 coal re(piires 24-0 cubic feet of air for complete combustion ; an ordinary 
 gas-burner consumes from three to live feet of gas per hour, and each 
 cubic foot of gas requires from iive to eight cubic feet of air. An ordi- 
 nary lamp will consume about 3'2 cubic feet of air in an hour. 
 
 The animal and vegetable matters contained in drains, cesspools, sew- 
 ers, and vaults are subject to fermentation and putrefaction, and produce 
 various gases, fetid principles, as well as animal alkaloids. The charac- 
 teristics of sewer air will vary with the flushing and ventilation of the 
 sewer. 
 
 The gases or dust that are thrown off in some processes of manufac- 
 turinor contaminate the air to the detriment of the workmen or of the 
 residents of the immediate neighbourhood of the manufactory. Many 
 processes of manufacture, which need not be enumerated, generate poison- 
 ous or noxious gases or vapours, the bad effects of which are, as a rule, 
 manifested by a general deterioration of the health of the workmen. The 
 inhalation of dust in manufactures in which metallic or non-metallic, 
 vegetable, animal, or poisonous chemical substances are employed, often 
 causes a thickening of the tissues of the lungs, or the condition of chronic 
 poisoning characteristic of the chemical agent. 
 
 A variety of substances are suspended in the air ; mineral substances, 
 
 decomposing animal and vegetable matter, and bacteria and their spores, 
 
 are present in greater or less amounts. In cities the 
 
 1 n are of inpun- cQj^^f^jj-jjj^f^^JQj^ jg o-reater than in the countrv, and it is 
 
 ties %n the Air. ^ , , . . . Vi • i 
 
 greater in large crowded cities and especially in those 
 
 in which the streets are narrow than in those in which the streets are wide 
 and there is abundant opportunity for the action of sunlight and wind. 
 
 The amount of each gas contained in the air is determined by elaborate 
 chemical analysis. 
 
MICRO-ORGANISMS IN THE AIR. 
 
 32/ 
 
 The organic matter is either pulverulent or gaseous. The former 
 may be filtered off by means of glass or asbestos wool, and the latter 
 absorbed by chemical solutions which undergo certain changes in the 
 presence of certain quantities of such gases. 
 
 The quantity of dust is determined by aspirating a large quantity of 
 air through thick, dry filters which will retain all suspended matter, and 
 the difference between the weight of the filter before and after the aspira- 
 tion indicates the amount of solid matter ili a certain quantity of air. 
 
 The varieties of micro-organisms in the air are determined by expos- 
 ing plates or dishes containing a nutrient gelatin to the air, or by drawing 
 the air through a tube coated with such gelatin. The microbes grow in 
 the gelatin and form colonies. By making examinations of the separate 
 colonies the varieties and characteristics of the germs are determined. 
 In a quiet room, as in a sewer, the micro-organisms settle down and leave 
 the air comparatively free ; and in dwelling-rooms it has been found that 
 their number decreases as the cubic space of, and exposure of the room 
 to, sunlight increases. 
 
 The following table, adapted from Sir Henry Eoscoe, indicates the 
 relation between the size of the room and the number of micro-organisms, 
 as well as the quantity of organic matter and of carbonic acid : 
 
 Cubic Space per Person. 
 
 100 to 180... 
 180 to 260. . . 
 260 to 340... 
 340 to 500. . . 
 500 to 1,000 . 
 1,000 to 2.500 
 2.500 to 4,000 
 
 Carbonic acid. 
 
 Orga 
 
 Qic matter. 
 
 Total germs. 
 
 11-5 
 
 
 2-7 
 
 80-0 
 
 10-7 
 
 
 2-7 
 
 49-0 
 
 10-3 
 
 
 21 
 
 32-0 
 
 9-2 
 
 
 1-5 
 
 42-0 
 
 8-6 
 
 
 1-0 
 
 6-0 
 
 6 7 
 
 
 0-7 
 
 9-1 
 
 7-9 
 
 
 9 
 
 13-1 
 
 It has also been found that the purer the air the more equal is the 
 number of colonies of bacteria and of moulds, while in impure air the 
 micro-organisms increase and the moulds remain stationary in number. 
 Unfortunately, science has not yet determined the micro-organisms of 
 measles, whooping-cough, small-pox, typhus fever, scarlet fever, and 
 chicken-pox, which seem to be particularly likely to be conveyed by aerial 
 means. It has been ascertained that in buildings in which cases of pul- 
 monary tuberculosis have been frequent the air is likely to contain the 
 tubercle bacilli which is coughed up in sputum, becomes dry, and is 
 blown into different corners or crevices by the wind, to be again 
 dislodged by air currents. 
 
324 
 
 HYGIENE. 
 
 CHAPTER III. 
 VENTILATION, HEATING, AND LIGHTING. 
 
 VENTILATION. 
 
 A^KNTH.ATioN is tliG procodure by wliit-h a sufficioiit qnaiitity of pure 
 
 air is supplied without perceptible draught ; it is an absolute necessity 
 
 that the air be supplied, and this is more frequently done 
 
 by ill-titting windows and doors and the porosity of 
 
 walls than by special appliances. 
 
 Di*. J. Lane Notter has prepared the following table of the number 
 
 of cubic feet of fresh air reijuired hourly : 
 
 Definition 
 Methods. 
 
 Adult males. . 
 Adult females 
 Children 
 
 In repose. 
 
 3.000 
 
 2.000 
 1,500 
 
 In Rentle 
 exertion. 
 
 4.500 
 
 ;iooo 
 
 2,250 
 
 In hard work. 
 
 9.000 
 6.000 
 4.500 
 
 For each gas-burner there should be an allowance of from 5,000 to 
 9,000 cubic feet of air per hour. 
 
 If a room has an open fireplace in which a lire burns, there is suffi- 
 cient change of air ; but in a steam-heated or furnace-heated apartment 
 there is too often inadequate ventilation and consequent accumulation of 
 noxious products. Good ventilation is more difficult in some countries 
 than in others ; in tropical and subtropical countries houses are built 
 with large windows, doors, halls, and rooms, and there is free admission 
 of air ; but in more rigorous climates such conditions are, of course, 
 impossible. 
 
 AVarm air may be admitted anywhere, cold air only in the upper 
 portion of a room. 
 
 The unobstructed passage of air through open doors and windows 
 (perflation) is the simplest method of ventilation, and may be applied 
 daily in any climate for a longer or shorter time, in ac- 
 erjia ion. cordance with the character of the weather. The cele- 
 brated Dr. Erasmus Darwin advised the workingmen of Nottingham to 
 preserve their health by opening the Avindows of their sleeping-rooms 
 whenever they left them to go to their workshops, and to keep the win- 
 dows of their workshops open whenever the weather was not insupport- 
 ably cold. Every room should be ventilated, if possible, with opposite 
 windows opened, in order that air currents may pass directly through the 
 apartment ; but if the rigour of the climate renders it impossible to keep 
 the windows open for any length of time, or if the cubic space proper- 
 
VENTILATING APPARATUS. 325 
 
 tionate to tlie number of occupants of tlic room is inufJcquatc to aflord 
 
 each individual a proper supply of fresh air, then it will be necessary to 
 
 have recourse to some special contrivance to maintain a constant renewal 
 
 of air. 
 
 There are a number of inventions of ventilating apparatus that may 
 
 be conveniently arranged in four classes, as formulated by JJr. Edward 
 
 F. Willoughby : 1. Direct communications with tlie 
 
 . , outer air by means of inlets through the walls, and 
 
 Apparatus. ^ •' _ _ » _ _ ' 
 
 outlets in the same position or communicating with the 
 chimney, or by a large funnel in the roof of the house. 
 
 2. Ventilation by tubes for the admission of air, with or witlir»ut sim- 
 ilar tubes for outlets. 
 
 3. Appliances which utilize the heat and products of combustion of 
 gaslights for purposes of ventilation. 
 
 4. Methods in which the heat of the stove is made available for 
 w'arming the air entering by channels behind the lire, thus combining the 
 heating and ventilating arrangements. 
 
 In the first class may be included Dr. Hinckes Bird's simple arrange- 
 ment of a piece of wood made to fit between the lower sash and the 
 frame ; the bottom of the sash rests upon this, and the top is raised above 
 the bottom of the upper sash, affording a space through which the air 
 enters in an upward direction without perceptible draught. Or the l6wer 
 piece of the upper sash may have holes bored in it to allow air to enter 
 without draught ; the objection to this form of ventilation is that it 
 weakens the sash. Or a louvre may be arranged by removing one of the 
 lowest panes in the upper sash and introducing a glass louvre by means of 
 a metal framework. The window may swing, or above the sash there 
 may be a transom attached at the bottom and swinging inward at the top, 
 so as to direct the air against the ceiling. A register may be placed near 
 the ceiling and connected with a flue that passes to a chimney topped by 
 a cowl. A perforated glass or metal disk attached to an upper pane 
 similarly perforated is a convenient ventilator. In cold climates, where 
 double windows are used, excellent room ventilation may be secured by 
 opening the outside sash at the bottom and the inside sash at the top. 
 
 In the second class are included bricks having rectangular or conical 
 openings that are placed behind the washboard ; or Tobin's tubes, which 
 are right-angled hollow tubes, the horizontal limb of which is exposed to 
 the outer air, and the vertical limb is in the room ; this latter system may 
 be associated with one in wdiicli a similar set of tubes passes from the 
 ceiling to an exhaust shaft to remove the foul air. 
 
 The third class is exemplified by MacKinners tubes, which consist of 
 one cylinder inside the other, the area of the inner tube and of the space 
 between the inner and outer being equal, both passing from the ceiling 
 
326 HYGIENE. 
 
 to the outer air ; tlie inner tube projects above and below the outer ; and 
 if a gas jet is ])hiced below the inner opening the hot and vitiated air 
 passes out through the inner tube, while fresh cold air is introduced 
 through the outer tube. This apparatus can nut well be used in conjunc- 
 tion with any other ventilation method. 
 
 The fourth class includes such methods as the hot-air furnace, in whieh 
 the fresh air is made the means of distributing the heat. 
 
 fresh air nuiy be introduced and foul air withdrawn fi-om an apart- 
 ment by mechanical means, the most familiar of which 
 
 y .:, .. are fans or turbine wheels rotated by steam, water, or 
 
 hot air. 
 
 In order to determine wliether the ventilation is adequate it is neces- 
 sary to know the cubic space of an apartment. In common lodging 
 houses 400 (in New York city), in a schoolroom 300, in military barracks 
 600, and in a hospital ward 1,200 cubic feet should be the minimum allow- 
 ance for each occupant. If the room is rectangular the space is easily calcu- 
 lated by nmltiplying together the length, breadth, and height ; from this 
 I product deductions must be made for the cubic space occupied by the dif- 
 ferent articles of furniture, and about three feet for each occupant. If the 
 room has recesses, their cubic capacity must be calculated and added to 
 that of the room ; if the recess is triangular, find the area of the triangle 
 by multiplying its base by half its height and this product by the depth 
 of the recess ; if conical, multiply the area of the base by one third the 
 height ; if cylindrical, multiply the area of the base by the height. 
 
 HEATING. 
 
 When the temperature of the air is so low that the rapidity of radia- 
 tion of heat from the body is greater than its production, it is necessary 
 
 to produce warmth artificially. The loss of body heat 
 Various 3Iefhods. ' ,. . i , i . i i . , i . .,, , 
 
 may be limited by heavier clothing, but this will only 
 
 prove a substitute when the individual is exercising. Heat may be dis- 
 seminated by radiation, in which it travels through the air without warm- 
 ing it ; by conduction, in which the heat passes from one molecule of 
 matter to an adjacent one ; and by convection, in which the heat is car- 
 ried by masses of warmed air. Heating may be accomplished by fire- 
 places, stoves, furnaces or h3aters, hot-water pipes, and steam pipes. 
 
 A fireplace is a familiar means of supplying radiant heat; but as the 
 intensity of the heat is inversely proportional to the square of the dis- 
 
 rrn. IT.- , tance of the person to be heated, while those imme- 
 
 The Fireplace. , ' ^ ' , _ 
 
 diately around the fireplace are warm, those in a distant 
 part of the room may be less comfortable. It is an extravagant method 
 of heating, consuming about eight pounds of coal per hour, five eighths 
 of the heat from which passes out of the chimney; it also involves 
 
METHODS OF HEATING. 327 
 
 considerable labour in carrying coal aiid I'ciiioving ashes, and tlic latter 
 increase the amount of dust in the room. The fireplace shoidd stand as 
 well forward in a room as possible, so as to secure the radiation from its 
 sides ; and it should be built in an inner and not, as is usually the case, 
 in an outer wall of the house, in order that the heated chimney may 
 benefit the temperature of the dwelling rather than dissipate its warmth 
 in the external air. 
 
 In a good open fireplace the back width of the grate is one third of 
 the front width. Having the sides at this angle increases the radiation 
 of heat into the room. The back of the grate should curve forward. 
 The chimney fine should be narrow, and there should l^e Imt little space 
 between the floor of the grate and the ash pan, so that the combustion of 
 fuel will be slow. 
 
 Where natural gas is plentiful and cheap, open fires of gas, or gas 
 
 logs, in which the gas from Bunsen burners heats imitation logs made 
 
 of iron and covered with asbestos, is a clean and easily 
 Gas as Fuel. , ,11^1,. i . ^ i 
 
 managed method of heatmg ; and if the products of 
 
 combustion are carried up a fine it is hygienic. But this commendation 
 does not extend to gas stoves that are imconnected with a flue ; these 
 quickly use up the oxygen in a room, and produce a quantity of carbonic 
 acid that is likely to prove disastrous to those breathing such a vitiated 
 atmosphere. 
 
 Stoves may be of iron, fire clay, or porcelain. They entail consid- 
 erable labour, are more likely to smoke and get out of repair than open 
 grates, render the air too dry and burn the organic 
 matter in it, producing disagreeable odours, and, when 
 made of iron and overheated, allow the escape of carbon monoxide and 
 dioxide into the apartment. There are many varieties of stoves, but 
 almost all, if not all, have the disadvantage of allowing the escape of 
 gases in the course of time, in consequence of too rapid combustion of 
 fuel with too great closure of the flue aperture. 
 
 Furnaces or heaters are in general use in American cities. They con- 
 sist of a large fire box surrounded by a hot-air chamber containing a 
 water reservoir, and connected by an ingress box, flue, 
 or shaft, with the external air. The heated air ascends 
 through flues and enters the rooms by registers placed some distance 
 above the floor. The use of furnaces is advantageous in that it does 
 away with the necessity of having but one fire for the house, the coal 
 and ashes are confined to the cellar, and the heat can be increased as may 
 be desirable. But in this last respect lies also the great disadvantage of 
 furnaces, for too often the furnace is too small for the house, and in very 
 cold weather it is so heated that the expansion separates the joints of the 
 several pieces of the fire box, and the noxious coal gases escape into the 
 
328 HYGIENE. 
 
 hot-air elianiber and are carried tliron^lunit the dwelliui]^. Another dis- 
 advantage is that the water reservoir in the hot-air eliambcr is too often 
 allowed to remain empty, and consecjuently there is no moisture in the 
 heated air entering the living-rooms. A most serious disadvantage is 
 that the air may be obtained in part from a cellar containing a servants' 
 water-closet that is badly flushed or not flushed at all, slop buckets, or 
 decaying vegetables. The air shaft is often loosely constructed of boards 
 unprovided with movable sides or bottoms, to permit cleaning at the com- 
 mencement of each cold season, or with a gauze or cheese-cloth Alter to 
 retain the particles of organic and inorganic dust wiiicli arc derived from 
 the outer air. 
 
 Steam coils or steam pipes are largely used in the United States for 
 heating purposes. The frequency with which elevators and dynamos are 
 
 used in public buildings, stores, and manufactories ren- 
 Sfcam Coils rind t , • ^ ^ x ^ £ i.^ t'i a- 
 
 iiteam Fi }e-< ders Steam serviceable lor each 01 them, i he creation 
 of steam-supply coni])anies in lai'ge cities furthers the 
 employment of steam for heating. Steam heating may be direct by 
 means of radiators placed in a room, or indirect by means of a radiator 
 placed in a box communicating with an air shaft, the hot air entering the 
 room by means of a register. Steam heating is an excellent method, 
 because by means of an electric thermostat the temperature can be regu- 
 lated mechanically, the necessary amount of moisture may be obtained 
 by means of vessels containing water placed upon the steam coils, and 
 there is no consumption of oxygen or production of noxious gases. The 
 objection to it is its first expense. 
 
 There are two kinds of hot-water heating — one in which the water is 
 heated in a boiler before it circulates through the pipes, the other in 
 
 which the pipes are directly heated in the furnace 
 Hot-water Heating. ^ .\ ^ - n j xi i xi i ^i. 
 
 lire ; the former is called the low-pressure, the latter 
 
 the high-pressure system. 
 
 There is a direct relation between the pressure and the temperature 
 in the high-pressure system, in which wrought-iron pipes having one-half- 
 inch diameter are used, a short piece of empty pipe being placed at the 
 highest point of the system to regulate the expansion of the water, which 
 is heated to 300° Fahr., but which rapidly cools with any decrease in the 
 fire ; there may be differences in the temperature of different parts of 
 the same coil. 
 
 In the low-pressure system the water is heated in a boiler and rises 
 by its specific gravity into the pipes and coils, forcing before it the water 
 which has cooled. The water in the pipes may attain a temperature of 
 200° Fahr. Mr. Anderson calculated the emission of heat by liot-water 
 pipes, and concluded that for ordinary dwelling-houses one square foot 
 of pipe surface was necessary for every sixty-five cubic feet of space. 
 
LIGHT, NATURAL AND ARTIFICIAL. 329 
 
 LIGHTING. 
 
 The illuminating power of daylight in an apartment is almost directly 
 proportionate to the square of the distance of the object from the win- 
 dow. Interference with the adtnission of davliifht by 
 Value of Dayliylit. , . „ , ■..,.,,. 
 
 trees, vines, flowers, or draperies is inadvisable. Jjac- 
 
 teriological investigations have proved that the micro-organisms of dis- 
 ease flourish best in the dark or in subdued light. Physiological research 
 has proved that daylight exercises an important influence on the health 
 of human beings. So God's mandate, " Let there be light," should be 
 reverently obeyed by all householders. 
 
 The window areas of all rooms, especially sitting and sleeping rooms, 
 should be generous. The glass should be kej^t well cleaned, and the 
 draperies only suflicient to prevent glare. In schoolrooms the windows 
 should extend from a few feet above the floor almost to the ceiling ; the 
 desks, which should slope at an angle of from thirty-five to forty-five de- 
 grees, should be placed so that the light strikes them from hehind and 
 from one side. Artificial illumination is obtained by means of gas, 
 petroleum, or other oils, electricity, and candles. 
 
 Reference has already been made to the disadvantages of gas as fuel 
 in consuming oxygen and producing undesirable combustion products — 
 disadvantages that are outweighed by its convenience and cheapness for 
 illuminating purposes and the lessened risk of fire. The 
 constituent of coal gas which afi:ords illumination is car- 
 buretted hydrogen. The burners in common use are the fish-tail, in which 
 there is a slight concavity in the top and two apertures convergent from 
 below upward, so as to cause the two gas streams to meet ; the bat's wing, 
 in which there is a vertical slit in a hemispherical top ; and the Argand, 
 in which there are numerous apertures in a circular ring. In all of these 
 there is imperfect combustion of gas, but an incandescent gas burner has 
 been invented in which a Bunsen burner is surrounded by a cylinder of 
 asbestos gauze treated with zirconium sulphate. This cylinder in the 
 presence of the heat of the burner becomes incandescent and produces a 
 brilliant white light. 
 
 For reading purposes there is no light superior to that of a German 
 
 student lamp, in which the flame from a kerosene or petroleum burner is 
 
 ^ ,„ , , ^ used. An opaque glass shade, green externally and 
 
 The student Lamp. i ., . n i ii t i -,..", 
 
 WMiite internally, should be used, to prevent dissipation 
 
 of the light rays. The inspection of coal oil in all States, and improved 
 
 processes of manufacture, have resulted in the production of an oil that 
 
 is less easily inflammable than that used some years ago. 
 
 Candles and colza oil are so expensive in comparison with their scanty 
 
 illuminating power that they are not likely to be generally used. 
 
330 HYGIENE. 
 
 The electric li^-lit may be produced by the incandescence of a loop of 
 carbon filament inclosed in a glass globe exhausted of air, or by the in- 
 candescence in the approximated tijts of two carbon rods 
 
 The Electric Liijht. j i. xi • ^\ xx >. • ii i *^i • i *. 
 
 exposed to the air; tlie first is called the incandescent 
 
 and the latter the arc light. The advantages of electric light are that it 
 is as easily managed as gas, it does not ])olluto the atmosphere, it may be 
 introduced into a dwelling Mithont danger from the strength of the cur- 
 rent, and its illuminating power is greater than that of gas ; the obstacle 
 to its use is its cost. The latter objection is now less serious than it was 
 a few years ago ; and with improved methods of producing electricity 
 seems likely to disappear before very long. 
 
 CHAPTER lY. 
 METEOROLOGY. 
 
 Meteobology is the science which treats of the atmosphere and its 
 conditions, particularly in reference to heat and moisture. In the scope 
 of this article it is impossible to enter into any consid- 
 e ni ion. eration of the laws governing the various phenomena 
 of thermometric and barometric variations, winds, humidity, and rain- 
 fall, all of which are intimately associated. 
 
 The temperature is due not only to the passage of the sun's rays 
 through the atmosphere, but also to conduction from the rays in impact 
 with the earth's surface. 
 
 For the determination of temperature thermometers are employed. 
 
 These instruments may be graduated fine glass tubes having an expanded 
 
 bulb containing mercury or alcohol ; or they may con- 
 
 e ermina ion oj ^.^^ ^^ ^^^^^ spiral strips of brass and steel arranged with 
 
 Temperature, . ., 
 
 the former as an inner and the latter as an outer coil, 
 
 the centre of the coil being fixed and the free end communicating with 
 an index that moves along a scale that has been accurately graduated by 
 means of a mercury thermometer ; the brass expands at a high tempera- 
 ture more strongly than steel, and at a low temperature the latter con- 
 tracts the coil. 
 
 The mercurial thermometer, graduated according to Fahrenheit's 
 
 method, is most commonly employed in the United States and Great 
 
 Britain. This scale was invented in 1714 ; the zero was 
 
 obtained by placing the thermometer for about one 
 
 2 hermometer. ./ r s^ ^ i . i r 
 
 quarter of an hour in a mixture of equal weights of 
 
 snow and sal ammoniac, because it was the lowest temperature then known 
 
DETERMINATION OP^ TEMPERATURE. 331 
 
 and was supposed to represent absolute cold ; the point was recorded on 
 the glass. The bulb of the thermometer was plunged amid pieces of ice 
 about the size of peas and then placed under the arm of a healthy man, 
 and that temperature was recorded as blood heat ; the space between this 
 and the zero was at first divided into twenty-four degrees, which made 
 the point at which water freezes eight degrees above zero. Subsequently 
 each of these long degrees was divided into four short degrees ; that 
 made the freezing point of water thirty-two degrees and tlie normal tem- 
 perature ninety-six degrees. The boiling point is obtained by placing 
 almost the entire length of the thermometer in a curi-ent of steam pro- 
 duced by boiling water in a flask or other inclosed vessel. In from ten 
 to fifteen minutes after boiling has commenced the thermometer will 
 register the maximum point, which is also marked on the glass, correc- 
 tion being made for barometric pressure. 
 
 By Fahrenheit's scale the space between the freezing (32°) and the 
 boiling (212°) points of water is divided into one hundred and eighty de- 
 grees. In the Celsius, or centigrade, and the Reaumur 
 Fahrenheit, Celsius, ";■, . . i • , • ^ ^ • ^ ^ -t • 
 
 and Reaumur. thermometers the zero point is obtained by plunging 
 
 the bulb into small pieces of ice and the boiling point 
 by immersion in steam, as above described ; but Celsius divided the inter- 
 vening space into one hundred and Reaumur into eighty degrees. Con- 
 sequently 212° Fahr. equal 100° Celsius or 80° Reaumur. To convert 
 Fahrenheit into centigrade temperature is effected by the following for- 
 mula (C = Centigrade, R = Reaumur, and F = Fahrenheit) : 
 
 ^o (F° - 32) X 5 ^, T70 C° X 9 , _ 
 
 C = ~ — — ; or the reverse, 1 = - — \- 32. 
 
 y o 
 
 ^o (F°-32)X4 ^, ^, R° X 9 , _ 
 
 R = ^ 7-^ — - : or the reverse, F = — — -, \- 32. 
 
 9 4 
 
 I)0 O X 4: , ^Q R X o 
 t == ■ — or the reverse, C = : . 
 
 5 4 
 
 Thermometers are placed in the shade in order to determine the tem- 
 perature of the air and exclude the action of the sun's radiant heat upon 
 
 the thermometer ; and in order to obtain accurate tem- 
 The 3Iban 
 Temperature perature of rooms it is necessary to exclude the radia- 
 tion from heaters, grate fires, stoves, gas, lamps, etc., by 
 means of screens ; if an accurate record is essential the temperature of 
 the room must be taken at the floor, the ceiling, and the middle of the 
 apartment, at an outer and an inner wall, in the centre of the room, and 
 near the heating apparatus ; add together the various temperatures ob- 
 tained and divide the sum by the number of observations made, and the 
 quotient will be the mean temperature. 
 
 Maximum and minimum thermometers are used for accurate record 
 of temperature. Usually that of Rutherford is employed, in which the 
 
332 HYGIENE. 
 
 instruments are attached horizontally to a glass plate or board, the bulb 
 of one pointing to the left and that of the other to the right. One is 
 a mercur}' thermometer with the bulb directed downward, in Mhich the 
 column propels a minute steel rod to the maximum or farthest point it 
 reaches, and the other is an alcohol thermometer having its bulb directed 
 horizontally; against the cohiinn of tlie lluiil rests a small porcelain rod, 
 past which the alcohol Hows when the tem[)erature rises, but as the tem- 
 perature falls the rod is carried back to the lowest ])oint by the surface 
 cohesion of the fluid. The mean temperature is obtained by adding 
 the maximum and the minimum and divitling the sum by two. 
 
 Metallic thermometers are made as recording thermometers or tluT- 
 mographs. A Hue point holding a few drops of ink is attached to the 
 extremity of the index, and a chart moved by clockwork passes contimi- 
 onsly beneath the index. The curve of the temperature is thus recorded 
 during a day, a week, or a month. 
 
 At meteorological stations an ordinary and a maximum and minimum 
 
 thermometer, a psychrometer, a hair hygrometer, and a barometer are 
 
 employed in making observations. The psychrometer. 
 Determination of -, . . • .^ • r •-. • .^ 
 
 rr -I-, used to ascertain the amount oi moisture in the air, 
 
 Huimdity. ... 
 
 consists of two ordinary mercurial thermometers, the 
 
 bulb of one instrument being covered with a piece of muslin that is kept 
 
 covered with water ; this is called the wet bulb ; the evaporation of the 
 
 water cools the bulb, and the bulb is cooled more and the evaporation is 
 
 greater the dryer the air is. From the difference between the dry and 
 
 the wet bulbs the relative humidity is calculated. 
 
 A hair hygrometer consists of a hair, about twelve inches long, freed 
 from oil by soaking in ether for twenty-four hours; it is mounted in a 
 brass frame, its lower end wound once around a pulley and stretched by 
 a weight of about 15'4 grains troy. At ordinary tem]ieratures the hair 
 changes about one thirtieth part of its length, according to the moistness 
 or dryness of the atmosphere, and by means of this change in the length 
 moves an index over a graduated arc that indicates the relative humidity. 
 
 Torrieelli found that if a tube about thirty-six inches long and a cpiar- 
 
 ter of an inch in diameter were closed at one end, filled with mercury, 
 
 and placed open and downward in a cup or vessel con- 
 
 Determinahon of twining mercury, there always remained in the tube a 
 
 AtmoHjmeric ■, c i . • i -i mi • 
 
 Pressure column ot mercury al)out thirty inches long, luis col- 
 
 umn is maintained in place by the pressure of the air — 
 that is, on an average, about 14'67 pounds to the square inch. The 
 amount of pressure varies continually within small limits. A barometer 
 constructed in the foregoing manner is called a cistern barometer, the 
 variations in atmospheric pressure being determined by means of a scale. 
 This instrument is usually inaccurate, one cause being the capillary de- 
 
ATMOSPHERIC PRESSURE. 333 
 
 pression of tlie inerciiry in the glas.s tube. The defect may be correct(;(] 
 by using a wider tube, or employing a tube that has a shghtly increased 
 diameter as its closed end is reached. In the siplion barometer the tube 
 is shaped like the letter J, and the mercury column in the long tube is 
 counterbalanced by the atmospheric pressure plus the weight of the col- 
 umn in the short tube ; the atmospheric pressure is measured by the dif- 
 ference of the lengths of both columns, a scale being attached to the 
 instrument or the glass being graduated. 
 
 Another variety of barometer is the aneroid, an instrument of which 
 the essential principle is that an elastic metal case exliausted of air is 
 compressed in proportion to the amount of atmospheric pressure. The 
 case may be an almost circular metal tube that has been exhausted of air, 
 and is fastened to a box by its middle portion, its extremities being at- 
 tached by rods to an arc of a toothed wheel that moves an index. As the 
 pressure rises, the ends of the tube approach each other. Or, instead of 
 a ring, a strong metal box, one side of which is of thin metal that is made 
 concave by air pressure, may be exhausted of air. A rod, soldered to the 
 centre of this thin metal side which forms the lid, supports a horizontal 
 arm holding a small metal block. A spring holds a second small block, 
 and the relative position of these blocks is changed by an increase of 
 pressure which forces in the lid, or a decrease of pressure that allows it 
 to rise, and by means of a screw this change is recorded. The scales of 
 both these instruments are graduated by a mercurial barometer. 
 
 In order to read the record of a barometer, the position of the summit 
 of the meniscus of the mercury column is determined, usually by means 
 of a rod or vernier that may be moved by a screw or by the hand; tlie 
 inches and tenths of inches are read directly on the scale, and the 
 hundredths and thousandths on the vernier. 
 
 The instrument should be placed in a room that has a uniform tem- 
 perature, and near a window in such a manner that it is lighted with- 
 out exposure to the direct rays of the sun or to air currents. It must 
 hang perpendicularly in such a fashion that the top of the column will be 
 at about the level of the eyes of the observer. Some instruments are 
 made so that they establish their own equilibrium ; all that is necessary is 
 to hang them on a hook. 
 
 All barometer readings must be corrected for instrumental error, for 
 capillarity, for temperature, and for altitude above the sea level. In the 
 monograph, Instructions for Yolnntary Ohservers, published by the 
 Chief of the United States Weather Bureau, full instructions for the use 
 of these instruments are given. 
 
 The direction, the strength, and the duration of aerial currents are 
 of interest from a hygienic standpoint. The first is determined bv 
 weathercocks ; the second by an instrument called an anemometer, which 
 
334 HYGIENE. 
 
 consists of four hollow hcmisplicrcs attached to the extremities of four 
 
 rods fastened, at right angles to each other, to an axis connected with 
 
 a series of cog-wheels. The rotation of the earth and 
 Movement of , /. ., rj.ii ' i i. ^.i 
 
 . ... consequent exposure oi its surtace to tlie sun s neat, the 
 
 saturation of air with evaporated water, the radiation 
 
 from the earth's surface, and the iiitluenee of elevatioTis, are factors that 
 
 are concerned in the causation of winds. 
 
 Climate is the combined effect of temjieraturo, density, humidity, rain- 
 fall, winds, and some other factors which ai-e modified by soil, elevation, 
 ]>roximity to the equator or to seas, lakes, or mountains, 
 and other local features of the environment. For ex- 
 ample, forests diminish terrestrial radiation, increase rainfall, and mod- 
 erate the heat of hot climates and the cold of cold regions. 
 
 Climate is divided into warm, extending from the equator to 35° lat- 
 itude ; temperate, extending from 35° to 55° latitude ; and cold, extending 
 from 55° to the poles ; these are subdivided into equatorial, tropical, sub- 
 tropical, sul)polar, and polar. 
 
 The adaptability of the human organism to climate is evidenced by 
 the population of various regions of the earth. In climates in which the 
 temperature of the air equals or exceeds that of the body less food is re- 
 quired, because there is less demand for the production of body heat ; the 
 skin acts more vigorously, and there may be a deposit of pigment in its 
 deeper layers ; and there is indisposition to physical or mental effort. In 
 very cold climates clothing and carbonaceous food enable the individual 
 to resist the rigour of the regions, and there is an increase in mental and 
 physical vigour ; in such climates more carbonic acid is given off ; there 
 is more waste of tissue in order to maintain the animal heat ; growth does 
 not increase, although it is maintained at a normal standard, and muscular 
 power is increased. In a temperate climate man attains the best physical 
 and mental development. 
 
 The degree of absolute humidity is an important factor ; the drier or 
 colder the atmosphere the greater the excretion of water by the lungs. 
 Furthermore, in a dry, hot air perspiration is imperceptible, because it is 
 at once taken up by the air. A marked increase in humidity in a warm 
 temperature diminishes the excretion of moisture by the lungs and the 
 skin and increases its excretion through the kidneys and intestines, and 
 renal irritability or diarrhoeal diseases may follow. 
 
 Ocean climate, while varying in different latitudes, is distinguished by 
 its equability. The evaporation of the water decreases the sun's heat by 
 day and impedes the radiation of heat from the earth at night, and thus 
 modifies the difference between the day and night temperature ; and the 
 air contains a greater percentage of ozone, as well as small proportions of 
 iodine and bromine vapours. The barometric pressure and great humidity 
 
EFFECT OF CLIMATE ON HEALTH. 335 
 
 diminish the pulse and respiration rates, tliere is an increase in tissue 
 change, with consequent improvement in appetite and sleep. The sea- 
 shore is therefore of benefit in convalescence from disease, in conditions 
 in which there is bad nutrition, especially in children, in scrofulous dis- 
 eases, in some forms of disease of the heart and arteries, in neurasthenia 
 and states of nervous irritabilit_y, and in some forms of kidney disease. 
 
 Island climates are necessarily influenced by the size and configuration 
 of the island, its latitude, and the character of the ocean surrounding it. 
 In summer much benefit may be derived from the bracing climates of the 
 islands on the coast of Maine, while in winter the benefit of a residence in 
 some of the Bahamas, Bermudas, or other of the West Indies is decided 
 for those having weak lungs or suffering with nervous prostration. 
 
 An inland climate may be moist and warm or moist and cool, 
 dry and warm or dry and cool. Moist and warm climates are found 
 where there is little elevation above the sea level, much vegetation, 
 and moisture from sluggish streams ; they are unsuitable as hygienic 
 residences, as malarial fevers usually abound. Similarly, moist and 
 cool climates are hygienically undesirable because they produce rheu- 
 matic and catarrhal affections. Dry and warm climates are hygi- 
 enically suitable and are especially advantageous for invalids ; in 
 winter in the United States, southwestern Texas, southern California, 
 Arizona, Xew Mexico, and southern Utah, and abroad Egypt and 
 Nubia, have climates of such a type. T)ry and cold climates are of 
 therapeutic advantage in winter, as has been proved by the experience 
 of invalids in the Adirondack Mountains and in eastern Colorado. The 
 advantages of these latter localities are partly due to the elevation ; both 
 the absolute and relative humidity are low, the air is aseptic in conse- 
 quence of the absence of inorganic and organic impurities, the atmos- 
 phere is not vitiated by gases from manufactories, and the sunshine is 
 hotter and the air cooler. 
 
 A mountain climate is useful in anaemia and chlorosis, in malarial 
 poisoning, in loss of appetite and gastric disturbances, in chronic 
 catarrh of the throat and bronchial tubes, in weak lungs, and in nerv- 
 ous conditions. 
 
 In diseases of a chronic character, in convalescence from disease, 
 and in conditions in which there is a predisposition to disease, a change 
 of climate is often of the greatest importance. The sudden changes of 
 temperature during the winter in the Xorthern States are very trying for 
 people advanced in years, and it would be prudeiit for them to have a 
 winter residence in southern Alabama, western Texas, Xew Mexico. 
 Arizona, or southern California, where they could go on the approach 
 of winter and whence they could return when spring was well estabhshed. 
 
33G HYGIENE. 
 
 CHAPTER Y. 
 THE SOIL. 
 
 The problems rc£rni'(]iiiir tlic soil in irs relation to public lioalth are 
 A'orv c'oiii})lo.\'. Fruiii a liyi^iciiic standpoint it is (le>iral)le to know 
 
 whether it is adapted for luil)itation, irriuation fields or 
 Composition. . r,^. ,. ., , ' . . ,, 
 
 eenietenes. ilie suriace soil niay be principally com- 
 posed of gravel, clay, or sand, but the subsoil is often of a different na- 
 ture, as one may ascertain by sinking a well or a shaft, a succession of 
 different materials being encountered. The surface soil consists of altered 
 and decomposed rock and hunnis, aii<l in tlie interstices between the j)ar- 
 ticles there are air (ground air) and water (ground water). The long-con- 
 tinued action of the sun, frost, rain, and minute vegetable growths break 
 up the rock into brash, which is further disintegrated into nmd, clay, or 
 sand, and is mi.xed with the products of decomposition of animal and 
 vegetable matter. The rock lichens, which grow upon the decomposing 
 surface of the rock, absorb moisture and carbonic acid from the atmos- 
 phere and disintegrate the surface of the rock ; the lichens die and are 
 further broken up by the bacteria of decay, and upon this mixture of dis- 
 integrated rock, organic matter, and bacteria other lichens grow and die ; 
 in course of time they are succeeded by mosses, and the rock is more and 
 more broken up and the layer of organic matter constantly increased, 
 until finally it is possible for more highly organized plants to grow. 
 
 The acid rocks, in decomposing, yield clay, silica, and the alkaline 
 carbonates. Granite decomposes into a loam and the schists into a loamy 
 soil. The basic rocks decompose into a marl or coloured clay and the 
 carbonates of calcium, magnesium, and iron. 
 
 Prof. Darwin showed the important influence earthworms exercise in 
 forming the soil, lie said : " When we behold a turf-covered expanse 
 
 Ave should remember that its smoothness, on which so 
 
 „' ,, ■ much of its beauty depends, is mainly due to all the 
 
 l^arthicorms. _ _ _ . 
 
 inerpialities having been slowly levelled by worms. It 
 is a marvellous reflection that the whole of the superficial mould over 
 any such expanse has passed and Avill again pass every few years through 
 the bodies of worms." 
 
 In the first portion of this article reference was made to the fact that 
 without micro-organisms it was impossible for fermentation, decompo- 
 sition, putrefaction, and like processes to take place. 
 uro orf/a is .. ]yj;jq^^(j| estimated that something less than sixteen grains 
 of soil from the Rue do Rennes in Paris contained about 1,300,000 germs ; 
 Eberbach found in Dorpat soils 500,000 germs ; Beumer found in the 
 soil at Griefswald 1,250,000 germs if it was examined at once, but if the 
 
GERMS IN THE EARTH AND IN SUBSOIL WATER. 337 
 
 examination was delayed lie obtained 45,000,000 ^erms ; while Maggiora, 
 at Turin, calculated that he found 7lS,000,000 germs in about one fourth 
 of an ounce of soil. Fraenkel found that in the upper layers of culti- 
 vated as well as uncultivated soils there were from 100,000 to 350,000 
 micro-organisms in something more than fifteen grains of soil ; but if the 
 latter was obtained below the surface of the ground, at depths varying 
 from three to six and a half feet, the proportion of microbes decreased 
 markedly and proportionately to the depth, varying from 2,000 to 200 
 germs at the lower depth, while between nine and twelve feet below the 
 surface few if any organisms were found. 
 
 The vast majority of the micro-organisms found in the soil do not 
 produce disease ; some of them favour and some retard the disease-pro- 
 ducing organisms. Of the latter, there are found in the soil the bacilli 
 of tetanus, of malignant oedema, of splenic fever, and the coccus which 
 causes pus formation. 
 
 The rain Avater that falls upon the earth either wholly or partly sinks 
 beneath or wholly or partly runs off the surface, in accordance with the 
 character of the upper layer of the earth, whether sand 
 or clay, fiat or hilly. The subsoil water is that which 
 sinks beneath the surface until it reaches an impermeable stratum, along 
 the surface of which it percolates until it finds an outlet, usually in a 
 spring, or sinks deeper into the earth, permeating the deepest layers of 
 rock and constituting the ground water. The upper level of the subsoil 
 water varies with the nature of the superficial and deep layers of the 
 soil, their inclination, and the quantity of rainfall ; and it is in constant 
 movement, usually toward the nearest water course. Pettenkofer found 
 that it moved toward the Isar at Munich at the rate of fifteen feet daily, 
 and that there was a difference of ten feet between its highest and lowest 
 levels during the year. 
 
 Pettenkofer held that the greatest number of deaths from typhoid 
 fever occurred when the ground water was at its lowest level ; and while 
 there was a coincidence in these facts at Munich, the relationship has not 
 always existed in other localities. In the United States and England it 
 is generally held that typhoid fever is a water-borne disease, which is 
 often produced by ground water carrying the germs from a privy^ or cess- 
 pool to a well. But the able investigations of Dr. Henry B. Baker, Sec- 
 retary of the. State Board of Health of Michigan, showed that for several 
 years there was a direct relation between the sickness and deaths from 
 typhoid fever and the depth of water in wells in that State ; in the month 
 of October, when the water in the wells reached its lowest level, there 
 were the most deaths and sickness from typhoid fever, and in the month 
 of April, when the level of the well water was highest, there were the 
 least deaths and sickness therefrom. 
 24 
 
338 HYGIENE. 
 
 The invcstig-ations of Prof. Bowditch in Massachusetts and of Dr. 
 Buchanan in England proved that there was a direct rehition between 
 the dampness of the soil and the prevalence of tuberculosis. This is the 
 result of the bad inlluence such soils exert on the residents thereon 
 rather than upon any nuilti})]ication of the bacillus tuberculosis in the 
 subsoil water. The inti-oduction of subsoil drainage has greatly reduced 
 the nutrtality from phthisis in a number of localities. 
 
 Dr. J]allard found that in England there was a curious relationship 
 between infantile diarrhoea and the temperature of the soil ; this variety 
 of children's disease always increases in the summer months, and he found 
 that when a thermometer placed four feet beneath the earth's surface 
 reached a temperature of 56° Fahr. there was increased mortality from 
 infantile diarrha?a, no matter what the temperature of the air might be. 
 This is simply a coincidence, aside from the depressing effects of hot 
 weather on the infants, because infantile diarrhoea is a fermentation pro- 
 cess that follows the introduction of certain micro-organisms into an 
 infant's gastro-intestinal tract by means of its food. 
 
 So malaria, diphtheria, rheumatism, and pneumonia have been ascribed 
 to subsoil water, though the only part subsoil water could have in devel- 
 oping those diseases would be its bad influence on the general condition 
 of persons living in a territory where that water remains at a high 
 level. 
 
 There is a certain amount of air in all soils, the quantity depending 
 upon the loose or compact character of the soil; in fact, only the hardest 
 rocks are free from ground air. Pettenkofer found 
 that ground air contains more carbon dioxide than is in 
 the atmosphere, the amount of the gas increasing with the depth from 
 which the air is obtained, being greater in autumn than in spring, and 
 increasing with the temperature and the moisture of the soil ; these re- 
 sults were corroborated by Fodor at Budapest ajid Flecli at Dresden, who 
 found that the oxygen of the air on passing into tlie soil enters into a 
 chemical combination with carbon derived from various animal and vege- 
 table sources. The amount of nitrogen in the ground air is almost con- 
 stant ; ammonia, ammonium sulphide, hydrogen sulphide, and marsh gas 
 are also found in variable quantities in ground air, according to the degree 
 of decomposition and putrefaction going on. No soil absorbs gases in 
 exactly the same proportion in which they exist in the atmosphere ; some 
 al)Sorb more oxygen, some more nitrogen. 
 
 The ground air, like the ground water, is in constant motion, the wind 
 in its passage over the soil withdrawing air from it ; a low barometric 
 pressure increases the amount of carbonic acid in the upper layers of the 
 soil ; changes of temperature influence the diffusion of the ground air ; 
 in autumn and winter, when the soil is warmer than the atmosj^here, the 
 
SOILS SUITED TO SPECIAL PURPOSES. 339 
 
 ground air oscapcs and is replaced by tJio coldc;)- atmosplieric aii', wliilo in 
 s^^ring and sunnner it is colder and denser tluui the atmosphere, and sub- 
 sides into the lower layers of the soil. Kain will foi'ce tlie ground air to 
 a deeper level, althongh it is likely to escape at some distant locality 
 where the soil was not wet ; and elevation of the level of the ground 
 water necessarily elevates the superjacent level of the ground air. 
 
 From a sanitary stand j^oint the ground air is impoj'tant because in 
 buildings in which there is a heating apparatus in the cellai- the increased 
 warmth of that apartment serves to aspii'ate the ground air from the 
 colder earth beneath the cellar floor and about the walls of a house. Pet- 
 tenkofer found that escaped coal gas found its way through twenty feet 
 of soil and affected the inmates of a dwelling. When the gaseous odour 
 of the upturned earth of a city street is recalled, it will be understood how 
 easily the gas in such earth can pass into a cellar and how insidiously it 
 will affect the health of householders. The necessity of laying gas mains 
 in cemented, ventilated trenches so as to avoid infecting the ground air 
 with the constant leakage from the mains is apparent. 
 
 In selecting a site for a house an elevation should be chosen, such as 
 
 the ridge of a hill or a gentle slope, rather than a valley or a steep de- 
 
 ^ . ,. clivity. The greater exposure of the elevation to the 
 
 Bmldmg Sties. i ,i ■ i i • ,i •! i • t . i 
 
 sun and the wind results m the soil being drier, the air 
 
 more thoroughly exchanged, and the noxious gases more rapidly and com- 
 pletely removed. The washing from heights always brings a cjuantity of 
 decomposable organic matter into a valley, and there is a higher level of 
 ground water. The question of exposure is largely a matter of latitude ; 
 in some localities an easterly or southerly, in others a westerly or north- 
 erly frontage is preferable, according to the desirability of avoiding winds 
 or of securing or avoiding sunshine. Localities in which the soil is 
 moist in consequence of bad natural drainage, too great height of the 
 ground water, or overflow of a river, should be avoided. Solid rock, sandy 
 or pebbly soils, in which there is a minimum amount of organic matter, 
 are the best grounds for building. 
 
 For an irrigation field a large territoiw of permeable sandy soil is 
 most suitable on account of its capacity for moisture ; gravel soils do not 
 retain enough water, and clay soils are impermeable. In selecting land 
 for a cemetery in which the dead may be disposed of by inhumation the 
 soil should be of such a character that the bodies will rapidly decay. The 
 ground water should not at its highest level approach within from eight 
 to nine feet of the surface, so gentle slopes or elevated plateaus are the 
 best sites ; if there is a high level of ground water it may become in- 
 fected with pathogenic microbes from dead bodies and carry these disease- 
 producing germs to a source of water supply. 
 
 Made soils — that is, ground formed by filling in low-lying or marshy 
 
340 HYGIENE. 
 
 ground, water conrtscs, gullies, and excavations with ashes, garbage, and 
 other refuse — should be avoided, for such foundations are not only damp, 
 but are easily penetrated by ground air. 
 
 CHAPTER YI. 
 WATER. 
 
 "Water is a compouTid of oxygen and hydrogen in the proportions of 
 eight parts by weight of oxygen to one of hydrogen. At a temperature 
 
 of less than 32° Fahr. it forms a solid ice, and above 
 
 Composition and 0100 t? i i. 1 i. • i? i.i • j. • 1 
 
 r,, . ■ ,■ 212 I'alir., at a barometric pressure 01 tliirty inches. 
 Characteristics. ' ' .1 •> 
 
 it becomes a gas (steam) ; during the process of freez- 
 ing water expands 8"5 per cent, in volume and gives off a large amount 
 of heat, which is again absorbed when the ice is li(]uefied. So, when 
 boiled, water expands. Ileference has been made to the disintegrating 
 effect the solidification of water has upon rocks and soils ; and the influ- 
 ence of the expansion of the water in breaking supply pipes in a house 
 in a cold climate is a familiar experience to most persons. 
 
 "Water is an almost universal solvent, taking up a greater or less quan- 
 tity of all the gases and of most of the metals and their salts. The rain 
 in falling becomes charged with the o-aseons and solid constituents of the 
 atmosphere, and water in flowing over or through the soil dissolves va- 
 rious organic, inorganic, and gaseous substances contained therein. 
 
 The atmosphere is an immense sponge into which watery vapour is 
 absorbed by means of the heating influences of the sun's rays, and from 
 which it is in course of time precipitated as rain, hail, or snow. 
 
 "While water is one of the greatest necessities of man, with air and 
 food constituting the tripod upon which life rests, it is, in consequence 
 of man's carelessness, one of his most active enemies, because several of 
 the communicable diseases which are most prevalent and which largely 
 increase the mortality rates are water-borne diseases. In most civilized 
 countries the spectacle is presented of a water supply that is contaminated 
 by the excreta of the inhabitants of the locality or by their neighbours, 
 and there is nothing that gives a community more concern than the ques- 
 tion as to where it may obtain a supply of pure water. 
 
 The sources of water supply are rivers, lakes, wells, or rain ; by the term 
 river may be implied all running water, no matter what 
 Rivers the size of the stream. The amount of water in a run- 
 
 ning stream depends upon springs, ground water, and 
 surface water. Rain or snow, which are the products of the evaporation 
 
SOURCES OF WATER SUPPLY. 341 
 
 of water, fall upon the grouiul and a portion flows oil", accord in;_^ to the 
 inclination of the surface, while another portion percolates through the 
 interstices of the soil and forms the ground water, which eventually 
 finds its way to some spring or other running stream. In flat countries, 
 in which the soil is dense or clayey, the surface water may he evapo- 
 rated largely, although everywhere a portion of the surface water is 
 evaporated while a portion is absorbed by the roots of grasses, trees, and 
 other vegetation. Dr. Gilbert calculated that of an annual rainfall of 
 thirty inches, nineteen or twenty inches are thus evaporated ; the amount 
 of evaporation depends upon the amount of vegetation, as on l)are earth 
 only seventeen out of thirty inches of rainfall are evaporated, and on 
 sandy soil only four inches out of twenty -five are thus disposed of. The 
 evaporation is greater at a high than at a low temperature. 
 
 River water varies in quality and purity, some streams, like the Mis- 
 sissippi and Missouri, containing large amounts of inorganic matter in 
 suspension and solution, others containing both inorganic and organic 
 matters in solution, these qualities varying wdth the territory through 
 which the streams fiow. The water of a river is likely to be further pol- 
 luted by the sewage of cities and the refuse or water from mines and 
 manufactories, and by the surface drainage from lands fertilized by 
 manure. 
 
 The addition of a moderate quantity of sewage to a flowing stream 
 may not exercise any specific deleterious influence on the stream, because 
 tliere is a certain amount of self -purification in running water in conse- 
 quence of the action of sunlight, the oxygen of the air, water plants and 
 bacteria, and fish. But the oxidation of sewage is a slow process, and it 
 is not possible to say how far a stream must fiow beyond the point of 
 entrance of sewage before the latter is completely oxidized. 
 
 In a last analysis all fresh water passes through the phases above re- 
 ferred to from its origin as rain until its re-evaporation. Dr. George 
 Vivian Poore tells us that an inch of rain is equal to 22,624 gallons per 
 acre, and with the remarkable variations in rainfall in the United States 
 of from less than five to over seventy inches per year, it is seen that 
 there are precipitated from 113,120 to 1,583,680 gallons of water per acre. 
 
 Wells are either surface or shallow, deep, or artesian ; surface wells 
 are those which are sunk into the superficial layers of the soil, receiving 
 their supply from the ground water ; deep wells pene- 
 trate through a stratum impermeable to water, and re- 
 ceive their supply from a deep spring or the deeper water courses ; while 
 artesian wells or tube wells pass through a number of strata and reach 
 water some hundreds of feet beneath the earth's surface. The depth of 
 a surface well varies with the distance of the first impermeable stratum 
 from the earth's surface ; the water is subsoil water, its height in the 
 
342 HYGIENE. 
 
 ^vell depending upon the hciglit of the snbsoil water, which varies at 
 different seasons of the year, as has been mentioned ; this water is rarely 
 pure, because it is often polhited \)\ pcreolativtii thi'dugh manure heaps 
 and leakage from cesspools. If the latter are bituated in ground at a 
 lower level than the well there is no chance of such contamination, but 
 if situated in irround on a level with or hiirher than the well such con- 
 tamination is unavoidable. A surface well drains M'ater from a region 
 that may be re]U'esented by an inverted cone with the bottom of the well 
 as the apex, and the radius of the base of the cone is twice the depth of 
 the well, so that a well fifty feet deep would drain all the surface of the 
 ffround for one hundred feet in all directions from its mouth. As, how- 
 ever, the drainage of a surface well will vary with the character of the 
 soil and the season of the year, and nuiy be affected by territory more 
 remote than twice its depth, it is best to locate such a well much farther 
 from a possible source of contamination than that above mentioned. 
 
 A draw well, open at the top, is much more exposed to pollution 
 and infection than a pump well, and this is also more true of a well which 
 has brick or cement sides than of one which has iron pipe as its lining. 
 The mouth of the well should be protected by coping and closed over, 
 and the water should be examined chemically and bacteriologically from 
 time to time to determine its potability ; such examinations are neces- 
 sarily the work of an expert. It must not he imagined because the water 
 of a ivell is clear, cool, sparTding, and palatahle, that therefore it is a 
 good drhiking loater^for the agreeahle taste may depend upon the pres- 
 ence of organic salts associated with carhonic-acid gas. 
 
 As a rule, the water of a deep well, obtained by digging or blasting 
 through an impervious stratum, is better and purer than that of a surface 
 well, though the well may not be as deep as many surface wells. The 
 walls of such a well should be of metal, in order to prevent the gradual 
 filtration of ground water which occurs through a brick wall. 
 
 An artesian or tul)e well is made by attaching a perforated steel nozzle 
 to an iron tube and driving this into the ground, adding new portions of 
 tube and thus boring through several thousand feet of strata. Sometimes 
 pure water is obtained, and sometimes the supply is brackish, or so im- 
 pregnated with gases and mineral salts that it can not be used for domes- 
 tic purposes. 
 
 Fresh-water lakes when sufficiently large are an excellent source of 
 water supply provided they do not serve as receptacles for sewage, and 
 provided due care is taken by those living in their drainage areas to avoid 
 building cesspools and forming compost heaps that will continually men- 
 ace the purity of the water. The yearly evaporation from a surface of 
 water in a temperate climate has been estimated at twenty inches (C. 
 Greaves), and this, with the daily consumption of water, demands for the 
 
TO INSUEE THE PURITY OF RAIN WATER. 343 
 
 replenishment of tlie ,snj)plj the greatest care of tlie sanitary condition 
 of the drainage area. 
 
 Reference has been made to the great absorptive power of water, and 
 this quality is manifested in a striking degree by the rain, wliich in pass- 
 ing through the atmospliere absorbs not only some of 
 the air Itself, but also the sulphurous-acid gas, the am- 
 moniacal salts, nitric and nitrous acids, the solid amorphous and crystal- 
 line particles, such as soot, dust, etc., and micro-organisms that foul the 
 atmosphere. Eain may therefore be truly said to wash and purify the 
 air; and each gallon of rain collected inland, remote from towns, con- 
 tains 2"1 grains of saline constituents and O'OY grain of combined nitro- 
 gen in a gallon. The quantity of ammonia and sulphurous acid varies 
 with the locality where the rain falls, but these substances are principally 
 contained in the first rain that falls. "At an ordinary temperature each 
 gallon of rain water dissolves 5 "5 cubic inches of atmospheric gases ; of 
 this, nearly 2 cubic inches are oxygen, 3'5 cubic inches are nitrogen, and 
 0"14 cubic inch is carbon dioxide. A part of the oxygen is used by 
 the organic matters in the water " (Dr. Thomas Stevenson). The greatest 
 proportion of bacteria is found in the first rain that falls ; Dr. Miquel 
 counted two hundred thousand germs in something more than a quart 
 of rain water. The number of bacteria in the rain in the warm months 
 of the year is greatly in excess of that found in winter and spring rain. 
 Besides bacteria, the spores of fungi, microscopic plants, and the pollen 
 of grasses and flowers are contained in the first portion of the rainfall. 
 
 Special precautions should be taken to insure the cleanliness and 
 purity of rain water collected from buildings for drinking purposes ; and 
 on account of the impurities it acquires from the air, as well as on ac- 
 count of the presence of dust, vegetable matter, excrement of birds, etc., 
 the first portion of rain that falls should not be preserved. 
 
 There are several ingenious devices that have been invented which 
 may be attached to the pipe from the roof to the cistern, and which au- 
 tomatically separate the first from the later portion of a rain. By exer- 
 cising care in this respect it will be possible to avoid introducing into a 
 cistern organic matter which will decompose and render the water unfit 
 for use. 
 
 As good an authority as Dr. Stevenson recommends that if rain water 
 is to be used for drinking purposes it should always be filtered through 
 sand and charcoal, or some similar material, so as to remove suspended 
 matters before storing it. In Louisiana, where large wooden, vatlike cis- 
 terns are built on supports above ground, it is customary to interpose a 
 layer of charcoal and sand between the water and the supply pipe. But 
 in other localities the cisterns consist of cement or brick-lined jug-shaped 
 excavations, and the rain water passes into it direct from the roof with- 
 
3J4 HYGIENE. 
 
 out proliiuinarv iiltration. In some places iron tanks arc used for storage 
 and distribution of rain, but the metal quickly corrodes, and has no advan- 
 tao-e over the above-ground wooden cistern or the thoroughly cement- 
 lined underiTi'ound cistern. Under any circumstances the water should 
 be tiltered through sand, charcoal, or some other efficient substance before 
 it is stored. 
 
 From the reports of the AVeather Bureau it is possible to learn the 
 averaije vcarly rainfall in a locality, and with a knowledge of this and of 
 the area of the horizontal surface of roof used to collect the rain it is 
 possible to determine the size of cisterns necessary to store the rain as 
 well as the amount of the supply. The roof area is obtained by multi- 
 plying the length by the breadth without reference to the slope of the 
 roof fthus, if the building is 00 feet long by 25 feet broad, the roof area 
 will be GO X 25 = 1,500 square feet. In an annual rainfall of 30 inches 
 one fifth must be deducted for evaporation. Eeduce the 1,500 square 
 feet to square inches by multiplying by 144, and there are 216,000 scpiare 
 inches, which, multiplied by the total unevaporated rainfall of 24 inches, 
 equals 9,984,000 cubic inches of rain ; divide this by 1,728 cubic inches, 
 and there are 5G,004 cubic feet, equal to 43,220 gallons, or a daily aver- 
 age of 118 gallons, which is sufficient for a family of three persons. Ob- 
 servation has shown that the rainfall in the driest year is one third less, 
 while in the wettest year it is one third greater than in the average year. 
 
 Rain water is particularly useful for washing and cooking on account 
 of its freedom from the salts of lime or magnesia, and is known as a 
 soft water. A hard water is one which contains these minerals, and the 
 degree of hardness is designated as so many grains of calcium carbonate 
 per gallon ; on boiling, the carbonic acid is driven off and the calcium is 
 deposited as a grayish-white substance on the interior of the cooking 
 vessel. Hard water is not desirable for cooking, because some of the 
 mineral substance is deposited on the surfaces of meat or vegetables, and 
 it is undesirable for washing, because the salts combine with the oleic or 
 stearic acid of soap and form a curdy precipitate. One grain of chalk 
 is estimated to waste about eight grains of soap. 
 
 The Rivers Pollution Commissioners of England stated that prefer- 
 ence should always be given to spring and deep-well water for purely 
 domestic purposes, not only on account of the much greater intrinsic 
 chemical purity and palatability of these . waters, but also because their 
 physical qualities render them peculiarly valuable for domestic supply. 
 They are almost invariably clear, colourless, transparent, and brilliant — 
 qualities which add greatly to their acceptability as beverages — while 
 their uniformity of temperature throughout the year renders them cool 
 and refreshing in summer and prevents them from freezing readily in 
 winter. Such waters are of inestimable value to communities, and their 
 
QUANTITY OF WATER CONSUMED. 345 
 
 conservation and utilization arc wortliy of tlio greatest efforts of those 
 who have the public health under their chai-ge. The commission consid- 
 ered that stored rain water and surface water from cidtivated land, wliile 
 moderately palatable, was suspicions ; and that river water to which sew- 
 age gained access and shallow well water, while palatable, was dangerous. 
 
 In the United States tiie prevalent custom of disposing of all sewage 
 by emptying it into the nearest water course is gradually polluting the 
 smaller streams and lakes, and is likely in time to seriously interfere with 
 the usefulness of large rivers and lakes as sources of water supply. Such 
 pollution should be stopped by the national Government. 
 
 It is necessary for a community to have a liberal supply of water 
 of good quality for drinking, cooking, bathing, washing, scrubbing of 
 all sorts, flushing water-closets and sewers, lifting ele- 
 LiUral Supply. ^^"^^^'^^ ^"^ cleaning streets. Dr. Louis C. Parkes esti- 
 mated that the following quantities were consumed 
 daily for each person : 
 
 Gallons per head. 
 
 f Fluids as drink 0-33 
 
 I Cooking 0-75 
 
 Personal ablution 5-00 
 
 Utensil and house washing 3-00 
 
 Washing clothes 8-00 
 
 Water-closets 5-00 
 
 Trade and manufacturing 5-00 
 
 f Cleansing streets ^ 
 
 I Public baths and fountains. . . I 
 
 Municipal, j pi^ghi^g and cleansing sewers \ ^ • 00 
 
 I Extinguishing fires i 
 
 Total 2708 
 
 The foregoing estimate does not include water required by animals 
 for drinking and washing, nor the leakage from mains, taps, and closets. 
 
 The consumption per head of the population varies in different cities, 
 as may be seen from the following table modified from Mr. A. Wynter 
 Blyth's excellent Manual of Puhlic Health : 
 
 Household. \ 
 
 Gallons 
 per head. 
 
 Alexandria, Egypt 18-20 
 
 Amsterdam, Holland. 11-15 
 
 Adelaide, Australia 50 
 
 Athens, Greece 21-56 
 
 Baltimore, Md 54 
 
 Barcelona, Spain 7-14 
 
 Berlin, Germany 13-3 
 
 Bombay, India 20 
 
 Boston, Mass 73-3 
 
 Buenos Ayres, Argentine Republic 20 
 
 Buffalo, N. Y 60 
 
 Gallons 
 per head. 
 
 Cairo, Egypt 11 
 
 Calcutta, India 2-2 
 
 Chicago, 111 102-5 
 
 Christiania, Norway 39-7 
 
 Cologne 53 
 
 Copenhagen, Denmark 13-9 
 
 Cleveland, 45 
 
 Cincinnati, 45 
 
 Detroit, Mich 87 
 
 Dresden, Saxony 60 
 
 Fraukfort-on-the-Main 59 
 
346 
 
 HYGIENE. 
 
 Ilainburg, (Jormany. 
 llurniver, Geniiauy. 
 Loiulon, Fiiiirlaml.. . 
 Lcipsio. Gmnaiiy.. . 
 
 Louisvillo, Ky 
 
 Madrid. Spain 
 
 Marsoilles, France. . 
 Mont real. Canaila.. . 
 Munich, Bavaria.. . . 
 
 Gallons 
 piT lu'tnl. 
 
 GO 
 31 
 
 ^■5 
 24 
 
 158-4 
 0« 
 33 
 
 Naples. Italy 1.t4 
 
 New York, X. Y 
 
 Ottawa, Canada 
 
 Paris, France 
 
 Pesth. Hungary 
 
 Philadelpliia, Pa 
 
 Rio Janeiro. Brazil 
 
 100 
 102 
 3G 
 33 
 58 
 30 
 
 Gallons 
 per head. 
 
 Rome, It;\ly 100-38 
 
 Rotterdam, Holland 22-45 
 
 Rouen, France 30-8 
 
 San Francisco, ("al 045 
 
 St. Pctershurir, Russia 21-3 
 
 Seville. Spain 7-2G 
 
 Sheffield, England 35 
 
 Salem, Mass 55 
 
 Stockholm. Sweden 13-5 
 
 Stuttgart, Germany 2G-4 
 
 Sydney, New South Wales 25 
 
 Toronto, Canada 82 
 
 Trieste, Austria 44 
 
 Valparaiso, Chili 20 
 
 Vienna, Austria 13.2-19-8 
 
 Washington, D. C 143 
 
 An examination of the table affords no good evidence of the reasons 
 for the consumption. Ottawa, Canada, with a cold climate, consumes six 
 times as much water as Bombay or Naples, with their warmer climates 
 and presumal)ly greater demands for water for bathing and street clean- 
 ing. Undoubtedly nmch water is wasted, especially in larger and newer 
 cities, in which an average of from thirty-five to forty gallons per head per 
 day should be ample. I^^ot only does this unnecessary waste of water entail 
 heavy expenditure to provide a supply, but it also necessitates provision of 
 large and expensive sewers to remove it. The trouble about an insufficient 
 water supply is that there is want of personal cleanliness. hal)itations are 
 insufficiently cleansed, streets are not sprinkled or washed, and sewers are 
 not properly flushed out. Dr. Pole states that the storage capacity of 
 reservoirs should equal from 150 to 250 days' supply, according to the 
 community and the average quantity of rainfall. Mr. Hawksley has 
 found tliat a formula for calculating the required number of days' supply 
 which should be stored is to divide 1,000 by the square root of the aver- 
 age annual rainfall in inches. For example, M-here the average is 25 inches 
 
 the storage capacity should be 
 
 1000 
 
 4/25 
 
 irioo ^ ^ 
 
 — .,— = 200 days' storage. Such 
 
 capacity is, however, rarely if ever attained. 
 
 In some localities it is necessary to have a system of settling reservoirs, 
 in which a proportion of the suspended matter is deposited before the 
 water is pumped to the distributing reservoirs. All 
 reservoirs should be carefully supervised, in order that 
 they may not be contaminated by thoughtless or malicious persons or by 
 animals ; they should be so situated that they are not likely to be polluted 
 by dust from drives or roads ; they should be exposed to the air, and if 
 it is possible to arrange for a system of falls for the water when changed 
 
MUNICIPAL WATER SYSTEMS. 347 
 
 from one reservoir to another, aeration will Lc improved ; and they should 
 be kept free from water weeds. 
 
 An engineer, in calculating the arrangement of the water supply for 
 a town, bases his estimate upon the population, with a reasonable allow- 
 ance for increase. The supply must be so placed that gravity will force 
 the water above the roof of the highest building. The erection of the 
 unattractive high buildings in a number of American cities has made it 
 impossible to arrange a water supply that can be carried by gravity above 
 their roofs. In such places the water must be pumped to a tank on the 
 roof. In cities in which there is great disparity in the size of the build- 
 ings care must be exercised to lessen the pressure of the water in its 
 transit from the large distributing mains to the houses by interposing 
 smaller pipes so as to increase the resistance. 
 
 Water mains are either cement-lined brick tunnels or, more fre- 
 quently, cast-iron pipe, the capacity of the latter being adapted to the 
 greatest demand for water at any hour of the day, and 
 , p. the pipes being coated with pitch, coal tar, or glaze to 
 
 prevent corrosion. 
 
 The mains are usually connected with the house by means of lead pipe. 
 Hard waters soon coat the interior of lead pipe with the sulphate or car- 
 bonate of lead, which prevents solution of the lead by the water, while 
 soft waters may dissolve the lead, producing a soluble oxide which is 
 poisonous. Where the water is very soft, block- tin pipes may be used in 
 the house ; or the water may be passed through a filter of sand, broken 
 flint, and pieces of limestone, in order that it may absorb silica, which 
 prevents any action on lead by the soft water. 
 
 Most public water supplies in the United States are constant ; that is, 
 
 water may be obtained at all times from the public mains. 
 Systems : Intermit- -r -, -, ,-, -. . . , • . , , .^ 
 
 tent and Constant. ^^ «^"^^ P^^^^^^' ^^o^^ever, the supply is mtermittent, the 
 water only flowing for a few hours during the day. 
 The objections to the intermittent system are that the water must be 
 stored in some receptacle in the house, and whether it be an iron- or a 
 metal-lined tank, or wooden tub, it becomes flat, absorbs impurities from 
 the air, and is likely to be otherwise polluted by organic matter falling 
 into it. The best materials for a cistern are slate, stoneware or tiling, 
 or galvanized iron ; it should be placed in a light and well-ventilated 
 situation, and should be protected by a cover ; the overflow pipe should 
 be properly trapped, and the supply pipe should have an automatic cut- 
 off ; and, finally, it should be regularly inspected and cleaned out if it 
 contains any deposit. With the constant service there is no necessity for 
 house storage of water, the supply is plentiful, and not subject to the 
 deterioration as well as to the multiplication of micro-organisms which 
 occurs in water stored in a tank. 
 
us HYGIENE. 
 
 In all systems of public water supply there is a lari2:e amount of waste. 
 Dr. Parkes states that in Loudon it was estimated that lifteen out of thirty- 
 live o;allons per liead i-an to waste in the soil in conse- 
 TTrts/c of n iiti'i: ' i- 1 I 1 • • L- ■ 11 
 
 (juenee or leaks at the junetu)n ot mams and other pipes. 
 
 Another source of waste is carelessness oi individuals about tirmly closing 
 faucets, or inattention to a faucet from which there is constant dripping. 
 While a generous supj)ly of water is desirable, unnecessary waste is 
 blameworthy, and it would perhaps be well for each house to have a water 
 metre, as tlien the occupant of the house would be as careful to prevent 
 water waste as he is to prevent gas or electricity waste when he knows 
 that he must pay for the quantity that is consumed. 
 
 The pollution of water by solid particles of inorganic matter in sus- 
 pension or partial solution, and by solid and liquid organic matter, makes 
 its purification a matter of great importance. Refer- 
 ;,. , • ence has been made to the value of settling reservoirs 
 
 U (iter. ^ 
 
 for ridding water of a part of the suspended matter, and 
 it has been ascertained by recent investigations that such reservoirs do 
 more, in that they free the water from a certain proportion of micro- 
 orijanisms. Tils found in examining the water of the reservoir at Frei- 
 burg, Germany, that the number of micro-organisms is invariably smaller 
 in the water from the reservoir than in that taken from the stream sup- 
 plying the reservoir ; and while he attributed the difference to the limited 
 amount of food material available, it is more probable that, as Frankland 
 says, who cites this case, the decrease is due to the process of sedimenta- 
 tion. Frankland found that water taken from the river Thames, at a 
 point where one of the water companies had an intake pipe, contains 
 more bacteria than either of two small storage reservoirs, and four times 
 as many bacteria as a large storage reservoir in which the water is kept. 
 This observer and his wife found that the water of the Loch of Lin- 
 trathen, which furnishes Dundee its water supply, contains more bacteria 
 than the streams that supply the loch, a fact thej' deemed due to sedi- 
 mentation. 
 
 Filtration has been found the best means of eliminating the greater 
 portion of the foreign matter in water. The best media for that pur- 
 pose are sand and gravel, the sand acting not only as a 
 
 Filtration and mechanical strainer, but its fine edges break up and 
 Chemical Exami- . ' ® ^ . 
 
 nation. i^oXo. organic matter and facilitate its oxygenation. 
 
 Formerly great stress was ]ilaced upon the value of 
 a chemical examination of drinking water, and to-day it is a custom with 
 certain boards of health to pul)lish from time to time chemical analyses 
 of the water supply. In L*^.S8 the then National Board of flealth pub- 
 lished a report by Prof. J. "W. Mollet, who, in association with other dis- 
 tinguished chemists, devoted several years to a chemical examination of 
 
THE POTABILITY OF WATER. 349 
 
 potable water with especial reference to the determinatioii of tlie amount 
 of organic matter contained in it. After several years' labour lie con- 
 cluded that it was impossiljle to decide absolutely upon the wholesonne- 
 ness or unwholesomeness of a drinking water by the mere use of any 
 of the processes employed by chemists for the estimation of organic mat- 
 ter or its constituents ; and he even expressed the opinion that the 
 results of analyses for organic matter should be deemed of secondary 
 importance in weighing the reasons for accepting or rejecting a water 
 which is not manifestly unfit for drinking on other grounds. 
 
 Prof. Mollet referred at that time to the conclusions reached by 
 Miiller, Schloesing and Muntz, Storer, Warington, and others as to the 
 process of nitrification being due to the presence of a living ferment, and 
 he suggested that the presence of nitrates and nitrites, which were held 
 to be indicative of the noxious character of water, is really due to the 
 presence of a special nitrifying micro-organism, which is to be classed 
 among the organisms capable of propagating disease. It had been known 
 for years that water contains bacteria, but it was not until 1883 that 
 methods were introduced which rendered the bacteriological examination 
 of water trustworthy. Different investigators have studied the subject, 
 and it has been found that water in its several forms, except boiled, and 
 wherever obtained, contains microbes. Frankland quotes Janowski, who 
 found, in Russia, in fifteen grains of freshly fallen snow, from 34 to 300 
 living bacteria ; and Schmelk found in a similar quantity of snow ob- 
 tained from a Norwegian glacier, at a point about six thousand feet above 
 the sea level, 2 living bacteria and 2 moulds, C. Fraenkel found in ice 
 from a lake near Berlin from 21 to 8,800 living bacteria in a piece weigh- 
 ing a little more than fifteen grains ; and Uffreduzzi found in ice manu- 
 factured from water from the river Dora, at Turin, 580 microbes in 
 fifteen grains, a greatly smaller number than was contained in the Earns 
 quantity of river water, which shows that freezing does kill a number of 
 germs. Foutin found Y29 microbes in fifteen grains of hail, Proskauer 
 found in an extended series of observations that in fifteen drops of water 
 from the river Spree, at the intake of the Berlin waterworks, there was a 
 minimum of 750 and a maximum of 17,000 micro-organisms. Miquel 
 found that in fifteen drops of water from the Seine at Choisy, above 
 Paris, there were 300, at Bercy, in the immediate vicinity of the city, 
 1,200, while at St. Denis, below the city, there were 200,000 bacteria. 
 Percy Frankland found that Thames water, collected above the intakes 
 of the water companies, contained in an average of three years (1886 to 
 1888) 2,190 bacteria in July and 55,900 bacteria in January, the sun's 
 heat and the increased light serving to decrease the number in the sum- 
 mer months and the washings from the land increased the number in the 
 winter months. Dr. C. Gil man Currier found in the same quantity of 
 
350 HYGIENE. 
 
 water from the Delaware River, at tlie waterworks intake, 28,000 bac- 
 teria; in M-ater from the Schuylkill Kiver, 43,750 bacteria; in water from 
 a Newark liydrant, 4,000 bacteria; in Mississippi water collected above 
 Minnea}>olis, i\'2() bacteria; in Spokane River water, 09 bacteria; in AVil- 
 lamette water, 44 bacteria; and in Saratoga Lake water, 50 bacteria in 
 the surface water and 103 bacteria in that thirty-two feet below the sur- 
 face and one foot above the bottom. 
 
 A chemical analysis of water which had been subjected to sand filtra- 
 tion showed a slight diminution in the amount of solid matter and but 
 few other chani>:es ; but bacterioloiricid examination conducted tlirough- 
 out the year showed that there was a decrease of from 05 to 98 per cent, 
 in the number of bactei-ia. Dr. Frankland states that the factors which 
 influence the number of micro-organisms in the water are: Storage ca- 
 pacity for untiltered water, so as to have the advantage of sedimentation ; 
 the thickness of tlie fine sand through which filtration is carried on, as 
 the sand loses its filtering power in the course of time, and of course this 
 loss would occur more rapidly in a thin than in a thick layer ; filtration 
 if rapid, removes bacteria less perfectly than if the rate is slow ; and fre- 
 quent renewal of the filter bed is essential. 
 
 A filter bed is generally constructed as a J-shaped tube in which the 
 longer limb is some ten feet in depth and represents the layers of sand 
 and gravel and the layer of unfiltered water ; the pressure of the main 
 volume of water gradually forces the layers just above the sand into and 
 through a two-foot stratum of fine sand, a foot and a half of screened 
 gravel, which is fine at the top and coarse at the bottom, and two feet 
 and a half of broken stone, and the filtered water emerges at the shorter 
 limb. The employment of sand filtration, which has proved of such 
 great value in the experience of a number of European cities, is in slight 
 favour in the United States. 
 
 Alum in a proportion of six grains to the gallon of water will pre- 
 cipitate suspended and dissolved matters in a tur])id water ; the precipi- 
 tate carries with it a certain amount of micro-organisms, and in the clear 
 water which remains there are fewer bacteria than in the water before 
 the alum was added. Limewater is added to a hard water, so tliat it 
 will combine with the carbonic acid which holds lime and magnesia salts 
 in solution and forms new compounds, which are precipitated ; on a large 
 scale quicklime is slaked in a tank of water, and the water to be softened 
 is allowed to flow gradually into the tank, the water being mixed by me- 
 chanical means, such as wheels, paddles, etc. ; it becomes milky and is 
 allowed to settle for twelve hours. 
 
 For various reasons it maj' be necessary or desirable for a householder 
 to filter his drinking water. The most recent investigations on the sub- 
 ject of domestic filters showed that the Pasteur-Chamberland filter, in 
 
FILTERING, BOILING, AND DISTILLATION. 351 
 
 which water is forced through a cylinder of biscuit porcelain, would 
 filter, at a pressure of about thirty-five feet, about ten gallons of water 
 in twenty-four hours ; and that the water, v)}ten the filter' 
 was new, was free from bacteria, but after it had been 
 in use for a short time bacteria appeared in the filtered water. Freuden- 
 reich's experiments showed that bacteria multiply and grow in the pores 
 of the iilter, and that every five days the cylinder should be removed, 
 carefully scrubbed, and sterilized in boiling water. The ]3erkefeld filter 
 has a cylinder of baked infusorial earth, in the pores of which micro- 
 organisms will grow as in the Pasteur-Chamberland iilter ; this cylinder 
 should be cleaned by rubbing it with a loofah (a vegetable sponge pro- 
 duced by a variety of gourd) under running water and then yjlacirig it in 
 cold water which has been boiled for three quarters of an hour. Es- 
 march's investigations have shown that filters of porous stone will not 
 interfere with the passage of bacteria, although they may intercept inor- 
 ganic matter. Asbestos is a good filtering medium, retaining bacteria for 
 a short time, but soon requiring sterilization by heat. Maignen's rapid 
 filter consists of a layer of animal charcoal and asbestos cloth ; but this 
 will not intercept bacteria for very many days and is not easily sterilized. 
 Most of the other filters in vogue for domestic use are merely mechanical 
 and temporary strainers, and can not be recommended. There is no such 
 thing as a perfect filter made, and in the nature of the multiplication of 
 bacteria it is unlikely that a perfect filter can be made — tliat is, an ap- 
 paratus that wnll deliver water free from germs for an indefinite period. 
 With proper care the first three filters referred to may be relied upon, 
 but the water they furnish is not likely to be much superior to that 
 sterilized by boiling. 
 
 Distillation is an excellent method of purifying water, and in a num- 
 ber of cities mineral water and artificial-ice companies supply distilled 
 
 water. If the first portion of the distillation, in which 
 Distillation. i .-i i , , • n • n n , 
 
 volatile substances are contained, is allowed to escape, 
 
 the rest of the distillate is free from foreign ingredients. The distilla- 
 tion of sea water furnishes steamships with their water supply. Small 
 distilling apparatuses have been invented for domestic use, and in marshy 
 countries, or localities in which malaria is prevalent, their use prevents 
 much sickness. 
 
 Too often filters are undesirably placed in a dark, damp situation, 
 near sinks, or even closets. They should be in well-lighted places, and 
 
 the receptacle and the filtered water should be thor- 
 Care of Filters mid , , . -t j i i -t v i • j n j .. 
 
 F'lt d W t • ^^W^^J sterilized by boiJing or baking and allowed to 
 
 cool with a cover on, so as to prevent the introduction 
 
 of kitchen air. Not infrequently sterilized water is received in an un- 
 
 sterilized receptacle. While filtration is in process see that the receiver 
 
3o2 HYGIENE. 
 
 is properly covered. Do not allow liltorod and sterile water to stand ex- 
 posed to air, and do not keep it indeiiuitely ; use it as it is filtered. 
 
 When there is a prevalence of any water-borne disease, such as chol- 
 era, typhoid fever, diarrluv'a, dysentery, malaria, or yellow fever, sterilize 
 all drinking water by boiling it. The important experi- 
 ments of Dr. Currier showed that if water be boiled 
 for fifteen minutes all disease-producing bacteria and their spores are 
 killed. The boiled water should be placed in closed vessels and set aside 
 to cool. If cooled while uncovered it will absorb gases and vapours 
 which impart an unpleasant taste. It is also likely to be contaminated 
 by microbes in the air. Boiling drives off volatile gases in the watei-, 
 precipitates lime salts, and makes the water softer. Boiled water should 
 not he cooled hy adding ice to it. Reference has been made to the fact 
 that ice contains living hacteria, and Prof. T. M. Prudden's experiments 
 showed that the bacillus which produced typhoid fever was alive in ice 
 after almost three and a half months, so it may be appreciated that it 
 would be possible to infect sterilized water by adding ice to it. 
 
 The methods of water analysis, whether chemical or bacteriological, 
 are too elaborate to be described here, and they should be undertaken 
 only by one who is thoroughly conversant with the subject. In general, 
 it may be said that if an analysis shows that chlorides are present in large 
 an^ounts in association with ammonia, nitrates and nitrites, and phosphoric 
 acid, the water is probably contaminated by sewage. Ammonia unassoci- 
 ated with nitrates and nitrites or chlorine indicates animal or vegetable 
 contamination, while changes in the relative proportion of nitrates and 
 nitrites suggest the presence of bacteria. 
 
 CHAPTER YII. 
 BATHS AND BATHING. 
 
 One of the most im])ortant uses of water from a hygienic standpoint 
 
 is its employment for bathing, and a fit index of the intelligence and 
 
 culture of a connnnnity is the number of bath tubs it 
 
 ■"^^ yy^^^^^'^ contains. As a measure in the treatment of disease, 
 and Therapeutic , , . . • ^ • ^ ^ ^ i • • 
 
 Measure bathing IS mentioned in the oldest sacred writings or 
 
 India, and as a measure of purification it is often re- 
 ferred to in the Old Testament. In the writings of the ancient Greek 
 and Roman physicians bathing is mentioned as a hygienic and a thera- 
 peutic measure, and the religious code of the Mohammedans directs that 
 
VARIOUS KINDS OF BATHS. 353 
 
 it be employed. Tlio necessity of tlio frequcTit use of tlu' Imtli may b(} 
 recognised when the functions of tlie skin are remembered ; tlje quantity 
 of perspiration varies with tlie temperature, humidity, occu])ation, and 
 quality and quantity of food and drink. 
 
 A bath may be local, in which only one portion of the body is im- 
 mersed, or general, in which there is immersion of the entire body ; or 
 tiie water may be applied as a douche, a sliower, a spray, or in fine needle- 
 like streams. There are baths in which water is not used, as in hot-air 
 baths, or the bath may be of vapour impregnated with some medicinal 
 substance. Baths are distinguished according to temperature, as cold, 
 varying from 52° to 60" Fahr. ; cool, from 60° to 80° Fahr., according 
 to the season of the year ; tepid, from 80° to 90° Fahr. ; warm, from 90° 
 to 95° Fahr. ; hot, from 95° to 105° Fahr. ; and very hot, from 105° to 
 to 120° Fahr. 
 
 As water is a better conductor of heat than air, a cold bath abstracts 
 more heat from the body than would a still atmosphere of the same tem- 
 perature. The contact of the cold water with the skin 
 The Cold Bath. . • i . -i ^ i xi n 
 
 at once stimulates the nervous system, and the small 
 
 blood-vessels of the skin are contracted, there is less blood in them, and 
 there is an increased consumption of oxygen and elimination of carbonic 
 acid. But if the bath is continued very long the contraction is succeeded 
 by a paralj'tic dilatation of the capillary blood-vessels, and the skin has 
 a bluish-red hue. A cold bath of short duration taken on arising in the 
 morning is an admirable tonic, because the contraction of the blood-ves- 
 sels of the skin increases the amount of blood in the internal organs, 
 especially the central nervous system ; there is a more rapid removal of 
 waste products and consequent increase in functional activity. Upon 
 leaving the bath there is a reaction in consequence of the dilatation of 
 the vessels of the skin, there is an increased radiation of heat, and an 
 agreeable sense of exhilaration. Individual susceptibility to cold water 
 varies, and some persons react to a cold bath at a temperature that would 
 cause such a shock to others that the vessels of the skin would be para- 
 lyzed by the cold and fail to react and dilate on leaving the bath, and 
 there would be mental and physical exhaustion instead of a sense of ca- 
 pacity for such exertion. For such individuals a cold sponge or shower 
 bath, taken while standing in warm w^ater, will produce the same desira- 
 ble reaction and sense of well-being as does the cold bath in others. 
 
 Warm baths dilate the cutaneous vessels, and .by this means lessen the 
 amount of blood in the internal organs ; they impart health to the body, 
 lessen the excretion of animal heat, and increase per- 
 spiration. The hot water is a better solvent of the 
 fatty excretions of the skin than cold water. On account of the dilata- 
 tion of the blood-vessels, which lasts after leaving a warm bath, it is best 
 25 
 
354 HYGIENE. 
 
 tliat tlie biitlicr should go to bed at once, in order to prevent sudden cool- 
 ing of the skin's surface with consequent chill. If these baths are taken 
 on arising they should be at once followed by a cold si)onge or shower 
 bath, in order to contract the capillaries. A hot bath before going to 
 bed is an excellent measure to ])roinote sleep, lessen nervousness, and in- 
 crease the action of the sweat glands in couditioiis in which it is desirable 
 to lessen the work ])erfornied by tlie kiiliieys. 
 
 Sea bathing is an excellent mode of administering the cool bath, for, 
 in addition to the ordinary advantiigcs of the latter, the slight increase in 
 
 respiration not onlv increases the consmnption of oxy- 
 
 Sea Bathing. i ^ i x- •' i- i i • *. - \ 
 
 gen, but also of lodnie and bronnne vapour contanied 
 
 in the sea air, the increased density of the salt M-ater has a more stinni- 
 
 lating ellect upon the skin, and the constant motion of the water acts as 
 
 a mild form of massage. Sea baths are best taken during the early part 
 
 of the day, either before or at least two hours after breakfast, and the 
 
 bather should not remain in the water too long. One bath a day should 
 
 suttice, and on leaving the water the skin may be douched with fresh 
 
 water and should be rubbed vigorously. 
 
 The shower, needle, or rain bath, supplying cold, hot, or warm water, 
 
 are admirable measures for quick bathing. They combine the stinnilating 
 
 effect of the forcible impact of the water on the skin's 
 The Shoiver, Needle, j. -^i ,i i ^ n ^i /• n ^ 
 
 D • T> ti, surface with tlie advantao^es of the form of water em- 
 or Ram Bath. ^ 
 
 ployed. These baths are particularly useful in large 
 
 pul)lic institutions, because no time is lost in tilling and emptying a tub; 
 
 it is impossible that the same water will be used to bathe more than one 
 
 person, and less water is used to accomplish the same results. 
 
 If everybody could afford it of course the ideal arrangement would 
 
 be to liave a bathroom connected with each bedroom in a house, in order 
 
 that the occupant of the sleepino- apartment mio;ht step 
 The Bathroom. • , i • , ,, .,i , ^^ ^ ■ 
 
 into bis bath witiiout unnecessary dela}- on awakening 
 
 in the morning or leave the bath for his bed at night. While a water- 
 closet in the bathroom may be a convenience, and the daily flushing of 
 the soil pipe by the waste pipe from the bath tub is likely to prevent 
 entrance of sewer gas, still the use of such a closet is limited to the occu- 
 pant of the room, and the presence of the closet eidiances the possibility 
 of contamination of the air by sewer gas. The bathroom should always 
 be provided witii a window for ventilation with the outer air; the floor 
 and walls are preferal^ly tiled, and, if this is inipractical)le, the floor may 
 be of hard wood with cork mats by the tub, or it may be covered with 
 linoleum. If the walls are not tiled they should be covered with hard 
 plaster and painted. 
 
 The tub may be made of iron, zinc, copper, porcelain, slate, marble, 
 or tiles set in cement ; iron and zinc tubs are cheapest, but are kept 
 
SANITARY REQUIREMENTS OF THE HOME. 355 
 
 clean with difficulty, the first-montioncd metal being subject to oxidatif)n 
 
 and rust; copper tubs are expcnBivc and also troublesome to keep clean ; 
 
 slate or marble tubs are also expensive and cold in 
 The Bath Tub. . , i • , i ■ i i i. i 11 
 
 winter; porceJam tubs are easily kept clean, and nave 
 
 the advantage over zinc and copper tubs in that they can ha put in 
 
 place witliout being inclosed by a lot of woodwork, which is necessary 
 
 to liide the unsightly frames of these latter. At the present day it is the 
 
 custom to place all bath tubs so that there is t)o wooden casing to make 
 
 inclosed space about them, free access being possible to di-y the floor and 
 
 to repair the pipes if need be. 
 
 The tub should be supplied with hot and cold water, and the pipes 
 should have a diameter which will permit a flow of w^ater that will rapidly 
 fill the tub. Each tub should have an overflow pipe of sufficient calibre 
 to carry away the surplus water in case of inattention, and this pipe 
 should communicate with the w^aste pipe between the tub outlet and the 
 trap. The w^aste pipe should have a large calibre, in order to rapidly 
 empty the water, and it should be provided with a suitable trap before it 
 empties into the drain pipe. 
 
 Excellent rain or needle baths are now made and sold at such reason- 
 able figures that, without extravagant outlay, they may be placed in bath- 
 rooms, and materially enhance their range of usefulness. 
 
 CHAPTER VIII. 
 THE DWELLING: ITS SANITARY NECESSITIES. 
 
 The essential sanitary necessities of a dwelling are good light and ven- 
 tilation, the first for its intrinsic influence on the health of the individual 
 as well as its germicidal action on microbes, the second 
 in order to prevent the various disorders consequent 
 upon bad air. It would seem that these conditions could easily be at- 
 tained, but experience constantly show^s the difficulty of obtaining and 
 maintaining them. Besides good light and air, the house should be situ- 
 ated on dry soil where there is no malaria; it should be built in such a 
 manner that the foundation walls will not admit ground water or ground 
 air, that the walls will not admit the cold in winter or the heat in sum- 
 mer, and that the roof will prevent leakage ; it should have, in cold cli- 
 mates, a well-arranged heating apparatus ; there should be a sufficient 
 supply of pure w^ater ; and there should be a satisfactory arrangement 
 for the removal of sewage. 
 
356 HYGIENE. 
 
 One of the most objectionable features of cities is the crowding of 
 houses, one being erected beside another, so that there is virtually no cur- 
 tilage. The city landowner is too often desirous of 
 
 Mr f age am makinir the most out of his property, and on a lot 
 Meiglit. ^ . , . . 
 
 which has a frontage of fifty feet he will build three, 
 
 and even four houses ; as a consequence, the rooms are long and deep, 
 and their interior parts are never properly lighted. If the property is a 
 lot having a small frontage in a business part of the city, a twelve- or fif- 
 teen-story ofiice building may be erected on it; this method of building 
 exists not only in those cities of the United States in which the land 
 available for business purj^oses is limited, but also in many of the smaller 
 AVestern and Southern cities whose development is for the future to de- 
 termine. The curtilage should be at least four times the superficial area 
 of the house — that is, a house having a front of twenty-five feet by a 
 depth of sixty feet should be built in a lot having an area of six thousand 
 square feet, so as to afford air and light space on the three sides which 
 are not exposed to the street. By law the height of no house should be 
 allowed to exceed the width of the street between the gutters, and if the 
 streets are wide and the air space on the sides of the house sufticient there 
 will be free circulation of the air about the house and a purer supply 
 introduced within the liouse for purposes of ventilation. 
 
 In various cities in the United States as well as in England the narrow 
 streets have so interfered with trafiic, and so furthered the development 
 
 of disease, that the first-mentioned reason has been em- 
 Width of Streets. i j r i • i. j t. j 
 
 ployed as an excuse for condemning property and broad- 
 ening the streets. Wide streets, with cross streets at frequent intervals, 
 and parks and gardens, are sanitary necessities for all cities. AVitli wide 
 streets and sufficient curtilage it is not likely that the residents of a city 
 will want for light and air. 
 
 The dwelling should be built on natural ground, because made ground 
 is likely to be damp or to contain organic matter, and consequently to 
 
 produce exhalations which may infect the interior of 
 
 .t^ „. *^ the dwelling. A purchaser of a house should carefully 
 
 Dwelling. . . , , ^ , ., ^ • ^ ^ 
 
 examine into the character of the soil upon which the 
 
 building is situated, and ascertain whether any spring or water course for- 
 merlv occupied the land. As a measure of precaution to insure the dis- 
 posal of ground air and ground water it is well to have a course of subsoil 
 drain pipes running through the ground beneath the building and con- 
 necting with ventilating pipes in the walls or beside the house. 
 
 All foundation walls should be laid not less than four feet below the 
 surface of the earth, on solid ground, and, in case the nature of the soil 
 requires it, piles should be driven, or iron rails filled in with concrete laid 
 to prevent the walls from settling. The footing under all foundation 
 
FOUNDATION, EXTERNAL AND INTERNAL WALLS. 1357 
 
 walls should be of concrete, not less than eighteen inches thick and ex- 
 tending on each side to half the thickness of the wall ; oi- the footing 
 
 may be of stones, not less than two feet by three quar- 
 Foundaiion Walls. ^ r r , n i i i i • j. t/ i.i x i 
 
 ters of a foot, well bedded m cement, if the founda- 
 tions of the building are laid above the ground the walls should be jjro- 
 vided with what is called a damp course, which is a sheet of lead, or a 
 layer of asphalt, vitrified stoneware or slate, laid horizontally in the 
 wall, in cement, not less than six inches above the ground level. In some 
 soils it is necessary, if the house has a cellar, to excavate an ambit or 
 blind area around the external wall. 
 
 The area included within the walls of the cellar should be covered 
 with a good layer of concrete and cement, so as to limit as much as possi- 
 ble the aspiration of ground air, which is always likely 
 The Cellar Floor. ^ \ ^, n • i . i . /; i • i 
 
 to occur when the cellar is heated by a furnace, or whicii 
 
 may be forced in by elevation of the ground-water level. This cement 
 
 suffices for the floor, but sometimes it is covered with a wooden flooring. 
 
 The latter should be laid at least nine inches above the cement in order 
 
 that there may be an air space between the cement and the wood so as to 
 
 lessen dry rot in the latter. 
 
 The external walls should be of suitable material, preferably good 
 
 bricks, stones, or similar material, of adequate thickness and construction, 
 
 in order to keep the interior of the edifice at an equable 
 
 r, n- temperature. In the northern United States the walls 
 
 Dwelling. "^ _ 
 
 of dwelling houses should be at least twelve inches thick, 
 thouffh in southern climates and in England a minimum thickness of nine 
 inches may be allowed ; but if the dwelling house is more than fifty feet 
 in height the walls of the first story should be sixteen inches in thickness ; 
 the rest of the wall should be twelve inches thick. Interior walls should 
 not be less than eight inches thick, though party walls should be at least 
 twelve inches. Party walls should be continued above the roof for at 
 least two feet, so as to form a parapet, which will assist in preventing the 
 spread of fire. For the latter reason a beam inserted in party walls should 
 have at least four inches of masonry between it and a beam on the oppo- 
 site side of the wall. 
 
 Bricks are porous, and not only admit air, but absorb water, which 
 may cause dampness in the interior of the house. The inside four inches 
 of walls way be formed of hard-burned hollow tiles, which prevent the 
 entrance of external air, the loss of heat in winter and entrance of heat 
 in summer, and tend to carry the ground air, if it gains access, above the 
 house ; these tiles are tied and bonded into the walls between the outer 
 and the inner portions of the walls. 
 
 The roofs should be made of tin, tiles, slate, or some other incombus- 
 tible material, so as to lessen the risk of fire, and suitable gutters should be 
 
358 HYGIENE. 
 
 built along the eaves to collect the rain water from the roof. The rain 
 
 water is carried from the gutters by conductor pipes or leaders, the size 
 
 of which can not be absolutely calculated by any niathe- 
 Tlie Roof. .• 1 1 1 j: 1 • ^ 11 
 
 matical rule ; a rough lurmula is to allow one S(]uare 
 
 inch of the area of a transverse section of the ])ipe for each sixty to sev- 
 enty square feet" of roof, the area of the latter being calculate^l by multi- 
 plying the length by the l)readth of the house. In cities rain water may 
 be collected in cisterns, or the conductor pipes may con\ey it more or less 
 directly to a sewer or beneath the sidewalk to the gutter, hut in the coun- 
 try it must l>e collected or conducted clear of the house by means of 
 superficial drains or gutters and distril)uted over the surface of the soil. 
 If the conductor pipes are connected with underground drain pij)es the 
 latter become leaky and choked \\\) by dirt and vegetation. 
 
 Every room should be provided with at least one window in order to 
 furnish sufficient light and ventilation ; the window should open directly 
 
 into the external air, and its area should equal at least 
 
 one tenth of the floor space. Each window should be 
 constructed so that at least one half of it may be easily opened to its full 
 extent, and the top of the window should be not less than seven feet six 
 inches above the floor. A habitable room should be at least eight feet 
 six inches in height from the floor to the ceiling, and there should be at 
 least six hundred cubic feet of air space for each occupant, whether a 
 child or an adult, although it is customary to count two children under 
 ten years of age as one person. In each room where there is no fireplace 
 or chimney, adequate and proper change of air must be secured by means 
 of an aperture, transom, or air shaft, which should have a sectional area of 
 at least one hundred square inches. 
 
 In the arrangement of the interior of a house care must be exercised 
 that halls and staircases have independent light and ventilation, for a hall 
 
 that ends in a dark passage can not be properly cleansed 
 riangempn oj ^^^^-j .^ cJeyoi(3 of the disinfecting influence of lio-ht, 
 the Jnteviot: ... ;-' ■> 
 
 while a lack of ventilation will make these parts of a 
 
 house a means of facilitating the exchange of foul air. In many city houses 
 the staircase well is surmounted by a skylight in the roof; this should 
 be connected with ventilators, which will facilitate the removal of foul 
 gases and impure air, and it is a better an-angement to have the kitchen 
 and sanitary offices on one side of the staircase, while the living rooms 
 are on the other side. It Avas the custom in the St)Uthern States to place 
 the kitchen and privies in buildings discoimected frou) the house. A suit- 
 able hood placed over a stove or range, connected with a flue running 
 alongside the chimney and provided with a venrilating cowl, will materi- 
 ally aid in removing the odours of cooking. 
 
 The question of the water supply of a dwelling has been discussed, but 
 
HINTS ABOUT PLUMBING. 359 
 
 mention may be made liere of tlic; dcsii-uLility of liavinf^ tlic supply pipe 
 as it enters the liouse furnished with a cut-off and drip pipe, so that in 
 case of accident or in cold weather the main supply of 
 '^^ ^" water can be cut off and the liouse pipes may be emptied 
 of their contained water by means of the drip, one or more faucets at the 
 top of the house being opened so that the pressure of air will force out 
 the water. All supply pipes in the house should be exposed or placed in 
 a cavity in the wall which is covered by easily removed w^oodwork tliat 
 will permit of access to the pipes. There should be but one main supply 
 pipe, the pijies for each floor connecting with it as branches, and it is 
 often a matter of convenience to have a cut-off cock at each floor, so 
 that in case repairs are necessary the water supply for tlie floor may 
 be discontinued without interfering wnth that for the house. All traps 
 should be of drawn rather than cast lead or of brass, their inside sur- 
 faces should be perfectly smooth so as to avoid retaining organic mat- 
 ter, and they should be so made that they can be easily removed. The 
 brass traps should be carefully examined for any sand holes in their 
 partitions. 
 
 All sinks should be spacious, and those that are porcelain-lined or of 
 stone or slate are more easily kept clean than those of iron, copper, or 
 zinc. The sink should not be inclosed by woodwork, and there should 
 be a piece of stone or metal, the same length as the sink, placed against 
 the wall at the top of the sink in order to prevent wall-wetting. The 
 waste pipe of the sink should be two inches in diameter, to facilitate self- 
 cleansing ; it should have its aperture protected by a perforated cap, in 
 order to keep coarse particles from entering and clogging the pipe, and 
 there should be in the latter, beneath the sink, a suitable trap which can 
 be removed and cleansed of grease. Sometimes the grease is collected in 
 a grease trap, which is a tank made of stoneware or metal, having inlet 
 and outlet pipes which have their apertures beneath the level of the water 
 in the tank ; the grease collects on the surface of the water and is re- 
 moved from time to time. 
 
 While the removal of liquid and solid refuse will be considered in a 
 
 subsequent section, it is appropriate to mention here the arrangements 
 
 which are in ordinary use for receiving the excretions 
 
 The Removal of _^^ ^j^^ human body, such as the ordinary water-closet 
 
 Excreta : Water- / ' i • • c • i • i 
 
 closets apparatus, dry-earth closets, and privies of various kinds. 
 
 Every closet of this description should be so arranged 
 that it is effectively ventilated. In cities the water-closets are most com- 
 mon ; these consist of the pan closet, composed of a conical basin in 
 which a pan at the lower aperture is tilted by raising a handle and the 
 contents are thrown into a receiver, whence they fall into a trap that 
 passes on to the soil pipe. Yalve closets consist of a basin from which 
 
MO HYGIENE. 
 
 the watLT it tMn[)tied bv raising a valve by means of a handle in the scat; 
 this variety is now rarely employed in the United States. The Hushing- 
 rim, long-hopper closet consists of a long conical l)()\vl into which the water 
 is discharged by a flushing-rim placed at the upper v^lgi} ; the excreta hang 
 about the sides and a large (piantity of water is reipiired to cleanse the 
 basin. The wa.-b-oiit elti>er has a ba>in that eiiijities into a trap, one arm 
 of which is eonstaiiTly oi)en and exposed to the air; the water enters this 
 basin in a direct downward stream, which drives everything before it, but 
 the exposed arm of the trap may be smeared with faecal matter, or faeces 
 may not be flushed out of the water in the trap, and there is not infre- 
 quently some odour about such a closet. The wash-down closet has a 
 hopper-shaped bowl, the small extremity of wiiich forms, with the soil 
 pipe, a U-shaped trap ; this is a satisfactory model and does not reipiire a 
 large quantity of water. 
 
 A good water-closet should l)e free from odour, easily flushed, simple 
 in construction, so that it is not likely to get out of re])air, and the soil 
 pipe should be properly ventilated. AVhite glazed earthenware is better 
 than enamelled iron for the basin, which should contain a sufficient quan- 
 tity of water to prevent smearing and should be so shaped that the excreta 
 will fall directly into the water. The water should enter the basin with 
 sufficient force to thoroughly cleanse it, a fan-shaped piece of metal being 
 sometimes placed opposite the inlet so as to spread the water over the en- 
 tire surface, and the water should flow from a flushing cistern placed four 
 or five feet above the closet basin. Various plans have been proposed for 
 the purpose of automatically disinfecting water-closets, but if the closet is 
 properly constructed disinfectants are not required. Mr. W. P. Gerhard 
 calls attention to the facts that where porcelain water-closets are used the 
 floor-joint, which is on the soil-pipe side of the trap, must be tight, and 
 the connection between the earthenware arm of the bowl and the soil 
 pipe must not be made of too rigid material, or the slightest settlement of 
 the floor will break the earthenware. 
 
 In the country there are better means of disposing of excreta than the 
 water-closet, as has been al)ly and forcibly portrayed by Dr. George 
 Vivian Poore in his very interesting Essays on Rural Hygiene. Dr. 
 Poore says : " Since the introduction of the water-closet, and prol)ably as 
 a direct consequence of it, we (the Englisli) have had four severe epidem- 
 ics of cholera, a disease not previously known, and enteric or typhoid 
 fever, previously almost or quite unrecognized, has risen to the place of 
 first importance among fevers in this country." lie urges that the rule 
 of Xature which most affects health is that all refuse matter shall be re- 
 stored without delay to mother-earth ; and he quotes Mr. Charles Eich- 
 ardson, a civil engineer, who speaks of the great progress in scientific 
 discovery and invention made during this century ; but in the midst of 
 
THE DISPOSAL OF EXCRETA. 301 
 
 all the beneficial inventions (luring the period was one wliolly evil — 
 the water-closet. 
 
 Dr. Poore's fundamental maxim is that excrement should never be 
 allowed to come into contact with water; closed sewers should only be 
 resorted to in cases of the direst necessity and with a full sense of their 
 danger, while a cesspool is the most immoral of all insanitary subterfuges, 
 the pressure of the contained water being sure to foi'ce an outlet and con- 
 taminate the underground water. So Dr. Pooi'c advocates tlio more gen- 
 eral employment of the earth closet, and his long experience has proved 
 the correctness of his judgment. 
 
 Dr. Poore advises that an earth closet should be in a building either 
 distinct from the house or approached by a short passage or corridor that 
 
 has cross ventilation, and the apartment should be lierhted 
 HJarth Closets. . 
 
 from the top, in order that any impurity might be no- 
 ticed at once, while a concrete or tile floor furthers cleanliness. Beneath 
 the seat there is a galvanized-iron receptacle, which is placed in the same 
 spot by means of guides fastened to the floor, and which may be removed 
 from the front, back, or sides. The earth should be stored in a bin along- 
 side the seat, and should be thrown upon the dejecta by means of a flour 
 scoop, rather than by a mechanical contrivance which always throws the 
 earth on exactly the same spot-; and under no circumstance should the 
 earth be artificially dried by heat, as sifting and storing it in a shed a few 
 weeks before it is needed will make it dry enough. The receptacle should 
 be emptied daily, the contents placed in a shallow trench in a field and 
 lightly covered with earth, so that microbial action will soon reduce the 
 whole mass to the condition of garden earth or humus, which may be 
 used again and again in the closet, and when ripe it is earth, not manure, 
 that is unsurpassed for horticultural purposes. Garden earth or humus is 
 the best kind of earth to use in such a closet, because it contains large 
 numbers of microbes which quickly change the organic matter ; earth 
 taken from a considerable depth and ashes are sterile. The interchange 
 between the earth and the oi'ganic refuse is quickest in ordinary summer 
 weather, when it is accomplished in about three weeks, and it is delayed 
 or checked by cold or drought ; during the process the earth should be 
 stirred over occasionally. 
 
 Where the earth closet is not used a dry privy may be constructed ; 
 there is no pit, the privy being built above the ground and entered by 
 
 means of one or two steps. A box of dry earth may be 
 The Dry Privy. . j j 
 
 kept in the closet and a scoopful be thrown upon the 
 
 excreta ; if the mixture of earth and excreta is turned over from time to 
 
 time, and there is a suflicient quantity of dry earth used, there will be 
 
 very little odour. From a hygienic standpoint it is absolutely essential 
 
 that the dry earth should cover the excreta sufficiently to prevent flies 
 
302 HYGIENE. 
 
 crawling over it, and tlicnce carrvlng away niicro-oi'ganisnis with wliich 
 food stutts may be infected. 
 
 Where water-closets are used ilu' pipe which i-iMiiu'cts the closet with 
 the sewer is called the soil pipe, and all the waste-water jnj)es of the house 
 are likely to empty into it. These })ipes are made of 
 ' drawn or cast lead, of zinc, of earthenware, of east and 
 
 of wrought iron. Jxnid, zinc, and earthenware pi[)es are undesirable, and 
 not often used for the purpose. Cast-iron pipe is likely to have sand 
 holes or imperfect seams, therefore each piece should be tested at the 
 foundry by hydrostatic pressure ; and in order to prevent oxidation of 
 the interior of the pipe, with consequent retention of frecal matter on the 
 rough surfaces, the pipes should be protected by a thorough coating of 
 coal tar, or by dipping the pipes while heated into a bath of asphalt, or 
 they might be galvanized, or made impervious to rust bj some method, 
 such as the Bower-Barff process. Sanitary engineers favour wrought-iron 
 pipe of about four inches diameter for an ordinary dwelling, with screw 
 joints, so that the risk of lead-caulked joints may be dispensed with. In 
 England and in some parts of the United States it is customary to place 
 the soil pipes outside of the house, bnt in most parts of the United States 
 the climate is too severe in winter to permit of such an arrangement. If 
 a soil pipe is properly constrncted, and this may be determined by testing 
 it, if it is carried well above the toj) of the house and its open extremity 
 is provided with a ventilating cowl, so as to increase the outward tlow of 
 air, if the soil pipe is connected with the sewer pipe by means of a curved 
 bend, so that the flow of sewage from one pipe into another is not im- 
 peded, and if all waste-water pipes which empty into the soil pipe are 
 properly trapped, there is no objection to the presence of the soil pipe 
 within the house. Sewer air does not behave in a manner different from 
 other air, it does not have special laws of diffusion, and it is likely to es- 
 cape in the direction of least resistance when dammed back, and so will 
 escape through the pipe in the roof. 
 
 While it is held by sanitarians that no drain which receives sewage 
 should travei'se the basement of a house, this pipe, like the soil pipe, must 
 usually be included in the interior of a dwelling. For- 
 merly a drain pipe was buried beneath the cemented 
 floor of a cellar, where it was practically inaccessible. Now it is sus- 
 pended from the ceiling or carried along the side of the cellar wall, where 
 it may be easily inspected. Sometimes, in order to secure drainage, the 
 drain pipe is placed in a brick and concrete trench below the level of the 
 cellar floor ; but such trenches are likely to harbour vermin and accumulate 
 dirt and moisture, so it is preferable to embed such a drain in concrete 
 and have manholes or hand-holes for inspection purposes at either end of 
 the embedded section. Cast-iron or wrought-iron pipes are preferable to 
 
WASH BASINS, WASHTUBS, AND TRAPS. 363 
 
 glazed eartlienwarc pipes for sueli druins ; tlie lortrier pi|)(;.s .should lie 
 lead- jointed, coated iiiBide and out to prevent corrosion, and in part of 
 their course there should be cast-iron intercepting traps or hand-hoUis. 
 
 Drains should always be laid in straight lines, a bend being made by 
 means of a pipe that has the desired curve. If the gradient of a liouse 
 drain is low it is advisable to connect an automatic flush tank with the 
 head of the drain, so as to prevent any blo(;king of the pipe by a deposit. 
 
 The stationary wash basins in a house may be tip-up basins, in \\hich 
 
 the bowl is supported on pivots and the water is emptied into a receiver 
 
 by' tipping the basin, but the receiver is not easily 
 Slationary Wash \ i ' i • ti i , i c i rm i • 
 
 s'^J^.o cleansed, and IS likely to l)ecome loul. llie chain-and- 
 
 plug basin consists of a bowl from which tiie water is 
 emptied by a waste pipe, the aperture of which is closed by a plug 
 attached to a chain ; one of the objections to this basin is that it may 
 overflow if the overflow pipe at the top of the basin becomes plugged, the 
 chain collects dirt, and the waste pipe is too often fouled by pins, buttons, 
 threads, and other small articles dropping into it. The open stand-pipe 
 overflow and the secret waste-valve basins have objections that need not 
 be considered here. The waste pipe should be trapped below the basin, 
 and again by a U or S bend just before it enters the soil pipe. 
 
 Washtubs in the kitchen or laundry of houses should be made of 
 stone, slate, or enamelled iron, the tub standing away from the wall so 
 that it may be accessible on all sides. Wooden or zinc- 
 lined tubs should not be used. The tubs should stand 
 at such a height above the floor that their traps may be easily removed 
 and cleaned, and this should be done at regular times, because the traps 
 are sure to collect lint, thread, and buttons from clothes. 
 
 A trap is an appliance in some part of the course of a drain or sewer 
 pipe, and is used to exclude from a house the foul air produced in drains 
 or sewers. A trap may be useless in consequence of 
 being improperly laid, or because of leakage, or as the 
 result of the collection of sediment ; so all traps should be provided with 
 means for examining their interior^^. The retention of M^ater in the trap 
 prevents the passage of sewer air, and if the flow of waste water is in- 
 frequent the trap may become unsealed in consequence of evaporation, 
 which may be furthered by the heated air of the house ; or if the soil 
 pipe or drain is not ventilated by an aperture opening into the air, there 
 may be a backward pressure of sewer air, which will force it through the 
 Avater in the trap, or so impregnate the trap water with it that the foul 
 air is given off in the house. The experiments of Philbrick and Bow- 
 ditch showed that the momentum of falling water helped the air draft to 
 siphon most of the different kinds of traps, even when the top of the 
 soil pipe was open ; and the siphonage could be prevented by introducing 
 
304 HYGIENE. 
 
 air at a normal pressure at the crown of the trap by means of a venti- 
 lator j)ipe. AVliilo the plumbing regulations of several cities besides New 
 York require that all ti-aps must be back-aired or ventilated, yet, as Mr. 
 W. P. Gerhard has indicated, this necessitates a complicated dn]>lieate 
 system of pipes, M'liich is expensive, and has the risk of increasing the 
 number of pipe Joints. If non-sijthoiiiiig traps are used, and all the fix- 
 tures are located directly at or within a short distance of the lines carried 
 U|i to the roof, siphouage is unlikely to occur under any ordinary condi- 
 tion. It has been found that it is safer to connect the waste pipes of baths, 
 basins, sinks, etc., directly with the large soil pipe by Y-branches located 
 as near as practicable to the fixtures drained than to place long lines of 
 smaller-sized wastes separately. The larger the soil pipe the less the risk 
 of any abnormal air pressure occurring b}' its use, so long as it is not 
 likely to become encumbered by the accretion of solid matter. 
 
 Large drain pipes, however, are undesirable; a four-inch pipe will 
 suffice for a small dwelling, a five-inch pipe for an ordinary four-story 
 city house, and a six-inch drain for a large residence. 
 
 English sanitarians advise, in order to prevent the passage of sewer 
 air into a house, that the waste pipes be absolutely separated from the 
 drains, emptj'ing outside of the house over trapped gullies. While the 
 existence of an open space of at least eighteen inches between the end of 
 the waste pipe and the trap lessens the possibility of sewer air gaining 
 access to a house by means of the traps, such an arrangement is imprac- 
 ticable in the colder parts of the United States. 
 
 All plumbing work should be tested by a qualified sanitary engineer 
 
 before it is accepted. For all new work the water test and the aii- test 
 
 should be tried not only on the main vertical and hori- 
 Testing Plumbing. , ,. \ ^^ ^ ^ i mi 
 
 zontal hues, but also on all the branches, ihe water test 
 
 is applied by plugging the lower end of the pipe, and then filling the pipes 
 
 with water, and the pressure will force the water through any imperfectly 
 
 closed ]uncti<)ns. The air test is applied by forcing compressed air into 
 
 a plugged pipe. Imperfections in the joints or traps may be discovered 
 
 by the smoke test, in which smoke is pumped into tlie pipes, or a rocket 
 
 which burns and produces a large quantity of smoke is placed in the 
 
 lovv^est portion of the soil pipe. Oil of peppermint may be poured into 
 
 the top of the soil pipe, and its pungent odour will be perceived at any 
 
 trap or joint which is imperfect. In moving into a house it is well to 
 
 apply the pe])permint test to the pluml)ing ; the general line of water 
 
 supply and drainage should be observed, and all joints should be inspected 
 
 to learn whether there is any moisture indicative of leakage about them. 
 
 An examination of the waste pipes from bath tubs, stationary washstands, 
 
 sinks, and washtubs should be made, and all the traps opened, examined, 
 
 and cleaned, if necessary. The overflow pipes should be examined, tested 
 
SEWAGE AND GARBAGE. 305 
 
 by pouring water into tlicrn to prove wliet]i(;r tliey are open or occluded, 
 and it should be noted whether they enter the waste pipe between its out- 
 flow aperture and the trap. The flushing tanks of water-closets should be 
 exannined to see whether they are clean and work freely. Avoid having 
 woodwork about plumbing, and see that all fixtures are easily accessible. 
 Old lead pipes may be ]:)ainted or bronzed, and are much more easily 
 kept clean and bright than the nickel-plated plumbing. Mr. Gebhai'd 
 recommends in preference to the latter that the pi])ing be electro-copper 
 bronzed or finished in oxidized silver, so as to du away with the need 
 of constant polishing. 
 
 CHAPTER IX. 
 
 THE DISPOSAL OF REFUSE. 
 
 The refuse of a community includes the fseces and urine of men and 
 animals, which, with the waste water from washing and- cooking, consti- 
 tute sewage, and the ashes, dust, refuse food, fi-agments 
 Definition of p j- ^ • , i i i , n i 
 
 P f or fabrics, paper, metal, wood, glass, stone, and crock- 
 
 ery, and the sweepings of the streets, which constitute 
 garbage. No question is of greater importance to a community from 
 either a sanitary or an economic standpoint than the best methods of dis- 
 posal of sewage and garbage ; and as Alexander solved the problem of 
 untying the Gordian knot by cutting it with his sword, so civic commu- 
 nities have, as a rule, solved the problem of sewage and garbage disposal 
 by emptying these waste products into the nearest water course. This 
 method has entailed great expense in the construction of sewers, the ne- 
 cessity of supplying large quantities of water, and of the employment of 
 labourers and vehicles to remove garbage ; it has polluted water courses, 
 filled up the beds of streams, and strewn the banks or shores with decay- 
 ing organic matter and debris of various kinds. Only allow a commu- 
 nity to get rid of its own sewage and garbage, and no thought is given 
 to the effects of these substances on other neighbouring communities ; 
 in this matter our acts show that we do not think we should be our 
 brother's keeper. 
 
 An adult male, living on a mixed animal and vegetable diet, is esti- 
 mated by Lawes to pass four ounces of solid faeces and forty -five ounces 
 of urine pe?' diem. When fresh, about one fourth of 
 the faeces and one thirtieth of the urine are dry solids. 
 Of an equal weight of urine and fieces, the latter is more valuable as a 
 manure, although the urine passed in twenty-four hours is ten times as 
 
366 HYGIENE. 
 
 valuable for fertilizinir as the feces passed in the same time. Dr. G. V. 
 Poore estimared that in London about two hundred tons of most valuable 
 manure ran to waste in the urine passed daily by the. inhabitants of that 
 citv, while Messrs. Lawes and Gilbert calculated that the money value of 
 the chemical constituents of the annual excretion of each individual of 
 a mixed population was two dolhirs and five cents {8s. 5f'/.). As it is 
 impossible to collect fjvces and urine without includinu- other sub- 
 stances, the money value of the excreta of an urban p()[ndation can not 
 be realized. 
 
 Besides the substaiices just referred to, sewao^e contains kitchen slops, 
 or water containing soap, grease, and the washings, or a solution of ani- 
 mal and vegetable matters ; bedroom slops, consisting of water, soap, and 
 dirt from the body and clothing ; the waste water from manufactories ; 
 and often the rain-water washings of the roofs of houses and the streets. 
 Sewage may be removed by the water-carriage system, by Liernur's, War- 
 ing' s, or other systems, or by conservancy methods. 
 
 By the water-carriage system all sewage is removed from the house 
 by drains connected with sewers constructed on the separate or the com- 
 bined systems ; in the former the surface and the sub- 
 
 a er-cnniaye ^^.^ water are removed by one set of pipes and the 
 bystem. . . -^ ^ ^ 
 
 sewage by another, while in the latter system the sewers 
 
 are constructed of such capacity that they will carry off the rain and 
 
 subsoil water. 
 
 The pipes for sewage in the separate system are of glazed stoneware 
 or concrete, circular, and have diameters varying from six to eighteen 
 inches, according to the popnlation of the districts in 
 V* • ^iiich they are located. These pipes mnst be carefully 
 tested for flaws, cemented at the joints, and laid on a firm bed of con- 
 crete at a gradient sufficient to afford a velocity of about three feet per 
 second. There should be a properly curved junction between smaller and 
 larger pipes, so that there will be no deposit on the wall of the pipe, and 
 the interior of the pipes must, when they are laid, be kept free from all 
 cement or (Uhris that mio-lit obstruct the flow of sewao-e. A manhole 
 should be built where a tributary joins a main sewer, so as to permit the 
 examination of the pipes in case of obstruction or defect. These pipes 
 have been laid with tile drains upon them or upon Q -shaped subsoil drain 
 and pipe rests, which serve to drain the subsoil water. The main outlet 
 of this system is a brickwork sewer. All rain water is allowed to filter 
 into the soil, or is conveyed into underground drains, which discharge 
 into the nearest body of water. 
 
 In this system the volume of sewage is much less than in the com- 
 bined system, the quantity can be estimated with fair accuracy, and tlie 
 composition is uniform, it is easily inspected and flushed, and its cost is 
 
CONSTEUCTION AND VENTILATION OP SEWERS. 307 
 
 less tlian that of the C()iri1)incd system. It is especially econoinical if tlie 
 sewage lias to be purn])ed to an irrigation field. 
 
 Sewers intended to convey house and manufacturing sewage as well 
 as rain water must be of moderately large diinensions. While twelve- or 
 
 eighteen-inch pipes may be used to carry the sewaere 
 The Combined ^' ^ , • -i i ^^ ,• \ . 
 
 a , ii'om cross streets in residence localities, the main sew- 
 
 ers must be Imilt of a circular or ovoid shape, the small 
 end of the ovoid downward, in order that there may be less friction, and 
 that the liquid may have a greater depth when the volume of sewage is 
 small. The circular' form is used for outfall sewers, where the volume 
 of sewage is large, because of its greater strength and cheapness. These 
 sewers should be constructed of curved glazed bricks or blocks laid in 
 cement, and the lower segment of the sewer embedded in concrete ; the 
 brickwork of a sewer under three feet in diameter maybe 4-5 inches 
 thick, for larger sewers it should be nine inches thick, and in bad ground 
 two courses of brickwork are required. 
 
 The gradient of a combined sewer should be sufficient to produce a 
 velocity of not less than two and a half nor more than four and a half 
 feet per second, a less gradient being required to produce the same ve- 
 locity in a large than in a small sewer. Drains and small sewers should 
 always join large sewers at an angle which follows the direction of the 
 flow of sewage. The radius of a curve should not be less than ten times 
 the sectional area of the sewer. Manholes should be built over the 
 sewers at regular intervals and at all junctions and changes of direction, 
 so as to allow of inspection and cleaning. 
 
 The arrangement of the outfall of a sewer will depend upon the dis- 
 posal of the sewage by direct discharge into some body of water, or by 
 chemical treatment, or by irrigation, or b}^ pumping. If sewage is to be 
 treated chemically, a duplicate series of settling tanks, varying in num- 
 ber and size according to the volume of the sewage, must be constructed. 
 When it is to be purified by irrigation the sewage may flow to the irri- 
 gation farm by gravitation, or it may have to be pumped from a storage 
 tank or reservoir at the outfall. Where sewage is discharged into a water 
 course the sewer should be carried far enough out to be covered by the 
 water at all stages of height. 
 
 Free ventilation of sewers is necessary in order to prevent the con- 
 centration or stagnation of sewer air, which sometimes contains fetid 
 gases, such as sulphuretted hydrogen, carbon disulphide, 
 Sewers ^ compound ammonias, organic vapours containing 
 
 ptomaines and leucomaines, and microbes. The aper- 
 tures at the manholes are used for ordinary sewer ventilation, the velocity 
 of the flow of the sewage tending to create a current of air in the same 
 direction. Any increase in the volume of sewage naturally diminishes 
 
368 HYGIENE. 
 
 the quantity of air, a sudtleii licavy rain prodm-ing manifest expulsion of 
 sewer air. If steani from manufactories or hot ii(piids are discharged into 
 sewers there is an expansion of sewer aii\ which may be discharged 
 througli the nearest opening or may be forced into the (h-ain pipes of 
 houses. A sewer without ventiUitors, or one in whicli these apertures ai-e 
 choked uj), is dangi'rous because its air may be forced into tlie drain and 
 soil pipes of houses and tind its way through defective joints or traps. 
 
 If a sewer is well tiuslied and free frc»m obstruction the direct ventila- 
 tion just referred to suffices; but if the air from a manhole ventilator has 
 any odour it is likely that there is a deposit in the sewer which should be 
 removed by Hushing. Filtration of sewer air, the use of deodorants and 
 of elaborate systems of ventilation, are valueless. 
 
 Ventilation is much more easily secured in the combined than in the 
 separate system of sewers ; in the latter the sudden entrance of a volume 
 of water causes greater displacement of air than in a large sewer, and the 
 air has no chance to escape. Ventilating pipes carried above ground may 
 be placed at inspection maidioles at convenient distances. 
 
 In badly constructed sewers, as well as in sewers in which there is a 
 small quantity of fluid in proportion to solids, there are likely to be de- 
 posits of semisolid organic matter from Mdiich there 
 Flushing Sewers. ,v • ^■ • t i x ^ 
 
 are oiiensive gaseous and organic uiscliarges. In order 
 
 to obviate this the sewers should be flushed systematically. This flushing 
 is accomplished by means of flushing gates, attached at the sites of man- 
 holes and covering the whole or a sectional area of the sewer. When 
 these gates are closed the sewage is dammed back, and when they are 
 opened the volume of sewage flushes the sewer below with a velocity 
 which is proportional to its head. 
 
 Sometimes automatic gates, hinged below the centre, are used, the 
 gate remaining closed until the sewage rises to a point on the upper sur- 
 face where the pressure is so great that the gate tilts forward in a hori- 
 zontal position, thus liberating a vohune of sewage, the flushing gate re- 
 turning to its position as the sewage falls to a normal level. 
 
 Small sewers may be flushed by pumping water into them by a fire 
 engine. The flushing is required most during the summer months and 
 periods of drought. 
 
 C. T. Liernur devised a system in which each house is provided with 
 
 one set of drains for i*emoving faecal matters from air closets, and another 
 
 set for disposing of rain and household waste water. 
 
 c, , The former set is connected with pipe drains in the 
 
 System. _ ^ _ ^ ^ 
 
 streets, which discharge into the nearest water coui-se. 
 The closets consist of hoppers with siphon traps which are connected by 
 means of soil pipes with street sewer pipes emptying into small air-tight 
 tanks; the latter communicate with larger tanks, wliich are connected 
 
VAKIOUS SYSTEMS OF SEWERS. 369 
 
 with a central tank at the sewage works. ]>y means of powerful air 
 pumps, and on opening valves in the street sewers, the sewage is sucked 
 along the pipes, and, as it contains iMit a small amount of water, it is con- 
 centrated by heat, dried in revolving cylinders, and used for fertiHzing 
 purposes. 
 
 The Berlier system is similar to the Liernur system in its use of sepa- 
 rate drains and of an air vacuum, except that it dispenses with valves 
 which must be worked by hand, each house drain em- 
 
 The Berher, ptying into an air-tight receptacle which, when full, is . 
 Systems opened automatically by a floating valve, and allows the 
 
 sewage to be sucked awaj-. 
 
 The Shone system is intended for use in level countries, where sewers 
 can not be laid with any, or very slight, gradient. The street sewers 
 empty into fairly large air-tight receptacles, out of which the sewage is 
 emptied by compressed air. The method has been found very satisfac- 
 tory in the towns in which it has been employed. 
 
 The Waring system is a system of separate sewage removal, in which 
 an automatic siphon flush tank is located at the dead end of each branch 
 sewer. The tank is built of brick and concrete, and is situated below the 
 level of the street ; it is filled from the water mains, and the water is dis- 
 charged by an annular siphon into a box beneath the tardv, which is con- 
 nected with the sewer. A manhole is located over the mains at each 
 interval of five hundred feet ; and _L-pieces in which the upright stems 
 reach the street level and are covered with lids should be inserted at 
 intervals in order to allow for cleaning. 
 
 The use of privies or middens is so general throughout the world that 
 
 its disadvantages are familiar to all. Leaky and fetid privies and midden 
 
 heaps composed of accumulated excrement are a con- 
 
 ^ c, , stant menace to health. A privy should be at least ten 
 
 System. . 
 
 feet away from a dwelling, and from fifty to one hun- 
 dred feet away from a well ; it must be roofed over to exclude the rain 
 and provided with ventilating apertures beneath the roof. The floor of 
 the privy should slope toward the door, and at its lowest part it should 
 be at least six inches above the ground. The receptacle under the seat 
 should be constructed of nine-inch brickwork set in cement or asphalted, 
 its floor should be three inches above the ground level, and its capacity 
 should not exceed eight cubic feet. The contents of the receptacle should 
 be kept dry by throwing dry earth upon them ; no slop waters should be 
 thrown into it. 
 
 Such privies as have been described are more conveniently cleaned if 
 
 pails are substituted for the impermeable trough receptacle. The pails 
 
 should be of galvanized iron, provided with a heavy lid to prevent 
 
 leakage, round in shape, so as to be easily cleaned, and have a capacity of 
 
 26 
 
370 HYGIENE. 
 
 ten o^alloiis. These pails may he removed two or three times a week, and 
 in communities where a numher of people use the system a scavenger 
 may be employed to collect the tilled ])ails and return 
 ' ■^'^ " ■ the em])ty ones. Ko kitchen sloi)s or gai-bage should be 
 thrown into the pails, and the contents are less oli'ensive if dr}- earth is 
 thrown in ; ashes or charcoal are less satisfactory, as they interfere with 
 the fertilizing value of the excreta, although these substances are good 
 deodorizers, and must be used in large communities where it would be 
 impracticable to sujiply enough earth. 
 
 A cesspool, properly speaking, is an excavation in the soil which is 
 intended to receive fiscal matter, kitchen slops, and other liquid waste 
 from a house. The use of water-closets in houses in 
 ^''-^po • suburban or rural localities, where there are no sewer 
 connections, has popularized the construction of cesspools. In the course 
 of time the cesspool is likely to become an intolerable nuisance ; its con- 
 tents, both liquid and gaseous, percolate into the soil and contaminate 
 the subsoil water and the products of their putrefaction pollute the air. 
 When the cesspool is full its contents must be pumped out and the mat- 
 ter conveyed somewhere, the difficulty of disposal increasing with the 
 volume of contained sewage. 
 
 In some American cities — for example, New Orleans — and in many 
 European cities, cement-lined cesspools are built in the yards of houses, 
 sometimes two being built side by side, so that the solids are retained in 
 one and the liquids flow over into the other. Each cesspool has a venti- 
 lating pipe that reaches above the roof of the house. They are emptied 
 by pumping their contents through an air-tight hose into a cart holding 
 a tub like a street sprinkler. In Europe a somewhat similar cart is used, 
 which is connected with a small engine that extracts the fetid gases from 
 the cesspool and burns them in its furnace, and at the same time creates 
 a vacuum in a metallic tank on the cart. The contents of the tanks may 
 be discharged on land, or carried to a crematory, or otherwise disposed of. 
 
 In country districts in which each house has sufficient yard territory 
 excrement can be safely and advantageously disposed of in the garden, as 
 
 has been urged by Dr. Poore. But where a country 
 The Earth System, r ^ • ^ • j;^ i ii ^ , ^ n ^ £ 
 
 district IS lairly well populated the removal oi excre- 
 ment by the pail system is quite an expense, for the greater the distance 
 that such manure must be carried, the greater becomes the expense of 
 supplying it. There is the sanction of antiquity to the earth system. 
 Deuteronomy, chapter xxiii, verse 18, directs: "And thou shalt have a 
 paddle upon thy weapon ; and it shall be, when thou wilt ease thyself 
 abroad, thou shalt dig therewith and shalt turn back and cover that which 
 cometh from thee." Such undoubtedly is the true application of the idea 
 earth to earth. 
 
PURIFICATION OF SEWAGE. 371 
 
 Only an enactment by the General Government of the United States, 
 
 under the puljlic-welfare clause of the Constitution, could secnre such 
 
 legislation as has existed in England since 187^5, in vir- 
 
 1*/"^ ''/^ tue of which it is illegal to discharge crude sewatcc into 
 
 Water Courses. . ^ ■ . 
 
 any river, water course, or lake. J>ut in the nineteen 
 years that have elapsed since the enactment of the law it has Ix^on im- 
 possible to enforce generally its provisions in (^reat Britain, and tlie dif- 
 ficulty of doing so in the United States may be imagined. 
 
 Where the volume of seM^age is small in comparison witb the volume 
 of M'ater of the running stream, the oxidizing effect of air and sun- 
 light aid in destroying organic matter; there is a partial deposit of tlie 
 coarser matter in sewage, and animalculse and bacteria aid in converting 
 the organic matter. As a result of these factors, streams receiving sewage 
 have been found free from chemical or bacterial taint some distance beyond 
 the sewer outfall. But if the stream is small, or if its volume is materi- 
 ally decreased in warm weather, or if there are fresh accessions of sewage 
 from towns situated within a few miles of each other, but little self-puri- 
 fication can take place, and the pollution increases from the source to the 
 mouth of the stream. The bed and banks of the stream are covered with 
 a deposit of decaying sediment, and fermentative processes exist in the 
 water saturated with organic matter. In warm weather this is a great 
 nuisance, the M-ater is unfit for use, and public health is menaced. 
 
 The discharge of crude sewage into any water should be prohil)ited, 
 as the sewage may be purified by precipitation, filtration, or irrigation. 
 
 If sewage is allowed to settle in tanks the suspended matter gradually 
 
 subsides to the bottom, leaving a more or less clear liquid at the top ; but 
 
 this is a slow process, and in order to expedite precipi- 
 
 rcpiat tation, chemical agents have been added to the sewage 
 
 Process. . , 
 
 before it enters the settling tanks. A large number 
 
 of chemical substances were employed for this purpose, and fictitious 
 
 values were assigned to the fertilizing value of the precipitate ; but most 
 
 of the processes proved to be signal failures, experiment showing that 
 
 chemical precipitation of insoluble and soluble oi'ganic matter did not 
 
 produce a material that was of sufficient value to justify the increased 
 
 cost. 
 
 In order that precipitation may afford the best results, it is requisite 
 
 that the sewage should be delivered fresh, and at once mixed with the 
 
 cliemical before it is discharged into the tanks. The latter should be at 
 
 least four feet in depth, and arranged in duplicate series, so that the 
 
 effluent may pass over weirs half an inch beneath the surface. The 
 
 tanks must be emptied and cleaned at regular intervals, and the sludge 
 
 may be conveyed to fields, where it is buried for fertilizing purposes, or it 
 
 may be compressed into solid cakes in a hydraulic press, the shidge often 
 
372 HYGIENE. 
 
 being mixed with road sweepings ; the value of these cakes as manure is 
 
 a fraction of the cost of their production. 
 
 The best precipitating agents are Hme, ahnnina sulphate, and iron 
 
 protosulpliate. Lime combines with tlie carbonic acid in water, forming 
 
 aiL insohible calcium carbonate, which is precipitated 
 
 cipi a tng ^^^^ carries down with it much of the suspended or<ranic 
 Agents. . . . 
 
 matters in sewage, but the organic matter and annnonia 
 
 in solution are unalTected. If too much lime is used the sewage becomes 
 
 alkaline, and fermentation is increased. 
 
 xVhimina sulphate combines with calcium carbonate in sewage, form- 
 ing calcium sulphate and aluminum hydrate, which is precipitated, carry- 
 ing with it most of the soluble and some of the suspended organic nuitters. 
 Sometimes lime and alumina sul})hate are combined. 
 
 Iron protosulphate acts best in an alkaline sewage, and it is often used 
 in conjunction with lime ; it oxidizes organic matter, and retards putre- 
 factive processes in the sewage. 
 
 The clarified effluent contains a large quantity of organic matter, and 
 it should nut be allowed to enter a stream until it is further purilied by 
 land nitration or irrigation. 
 
 There is no precipitation process that utilizes sewage to any advan- 
 tage, and as it incompletely purifies sewage, it is not to be recommended. 
 
 Investigation has shown that sewage is purified if it is passed through 
 porous soil, the best results being obtained by filtration from above down- 
 ward, as upward filtration does not remove all the solu- 
 n ble organic matters. The soil acts as a mechanical filter, 
 
 Processes. ^ ^ t ^ t 
 
 retaining the suspended and precipitating the soluble 
 orofanic matters, which are oxidized and converted into carbonates, nitrites, 
 
 *5 T 7 7 
 
 and nitrates. The soil should be porous, so as to permit of free aeration, 
 without which there can be no oxidation ; it must not retain too mucli 
 water, it must l)e level, and the area must be sufficient for the quantity of 
 sewaire. At least an acre of land must be allowed for each thousand of 
 population, for a large volume of raw sewage applied to a small area of 
 land clogs the surface and water-logs the subsoil. The difficulties of 
 this method of filtration are met by irrigation. 
 
 Mr. George W. Fuller, in his report ujion the purification of sewage 
 by filtration published in T/ie Tiuenty-fifth Annual lieport of the State 
 Board of Health of Ma^mchuKetts., says that sewage filters resemble com- 
 plex living organisms in that ventilation and respiration must be main- 
 tained, otherwise their functions are interrupted and their lives as filters 
 come to an end. A portion of the insoluble matter or sludge is deposited 
 upon or near the surface of a filter through which sewage passes, clog- 
 ging up tlie surface, interrupting ventilation, and deteriorating the purity 
 of the effluent. "With filters of suitable material more than one hundred 
 
FILTRATION xVND IRRIGATION. 373 
 
 thousand gallons per acre may Ijo purified daily, with a removal of over 
 ninety per cent, of the organic matter, the permanency of the filter being 
 independent of the size of material, but directly dependent upon the 
 treatment of thp filter bed. Filters in operation for six years showed 
 that there was practically no more nitrogen stored in them at the end 
 than at the beginning of the year. 
 
 Mr. Fuller's investigations showed that systematic raking, with occa- 
 sional harrowing or ploughing of the bed, was very satisfactory, especially 
 for coarse materials ; that systematic scraping, followed by raking, gave 
 good results for fine materials, though the scraping was inadvisable un- 
 less associated with raking or harrowing ; that the efficiency of very fine 
 material was increased by trenching with coarse material, the size of 
 which should be carefully graded to prevent clogging^, that allowing a 
 filter bed to rest for a limited time facilitated the removal of stored or- 
 ganic matter ; and that the capacity of filters should not be taxed during 
 the winter months to such an extent that more organic matter is stored 
 throughout the sand than can be removed during the high nitrification 
 which goes on during the spring and summer. 
 
 Filtration of sewage through coarse gravel at a rapid i-ate, and with 
 the aid of a current of air drawn through the gravel, consumed sludge to 
 a large extent, and gave the greatest purification of the elfluent water. 
 And if the sludge is first removed by sedimentation, filters of finer mate- 
 rial may be operated at a more rapid rate than if ordinary unprecipitated 
 sewage is used. 
 
 Sewage may be disposed of by irrigation over or beneath the soil's 
 surface. Where plenty of land is available and sewage can be conducted 
 to it by gravity, surface irrigation is the simplest and 
 cheapest mode of disposal. The acreage must be sutii- 
 cient, that the sewage may be applied to the fields intermittently in order 
 to insure sufficient aeration of the soil and to prevent the land from be- 
 coming water-logged. The soil should be loose and porous, and if it is 
 clayey it must be broken up and mixed with ashes, sand, or lime ; it must 
 be well drained, and the quality of the soil will indicate the area avail- 
 able for the number of inhabitants. 
 
 The outfall sewer should be conducted to the highest point on the 
 land, the sewage should be passed through a screen so that all large, solid 
 particles may be removed, and it should then be allowed to flow by grav- 
 ity through open masonry or concrete gutters placed along the tops of 
 ridges, whence it may be distributed through sluices to the surface of the 
 ground. 
 
 The irregularity in the volume and the degree of dilution of the sew- 
 age is a disadvantage in the use of the irrigation system, and interferes 
 with the value of the crops that are produced. The experience of Eng- 
 
374 HYGIENE. 
 
 Jish sewage farms is that there are i)r;u'tieally but tlirec crops — Itahari 
 rye grass, cabbages, and niangolds — which are not injuriously affected by 
 sewage; and of these, Italian rye grass has been found to be the best 
 because it llourishes in a quantity of sewage that would kill most other 
 plants, from five to seven cuttings being obtained in a year, and it puri- 
 fies the sewage day and night, in wet weather and in sunshine. AVhen 
 cut, however, this grass does not keep well or bear long transportation, 
 and it is only converted into hay in dry, warm sunshine. As sewage 
 contains all the fertilizing ingredients the soil requires, land to which 
 sewage has been applied is far more productive than other land in the 
 same neighbourhood. In France, Germany, and England sewage irriga- 
 tion has transformed barren wastes into fertile fields ; and the more thoi-- 
 ough the percolation of sewage through the soil, with intermission to 
 prevent too large a quantity in each irrigation field, the better are the 
 crops and the purer is the efiluent water. 
 
 An irrigation farm may become a nuisance if the sewage is decom- 
 posed when it arrives, or if the conduits are used permanently so as to 
 allow of the deposit of sewage on their bottom and side, or if the sewage 
 is improperly distributed, or if there is inadequate subsoil drainage and 
 consequent stagnation of water on the surface of the field. There is no 
 evidence from any locality where sewage farms exist that these establish- 
 ments are likely to affect injuriously the health of man or animals. 
 
 The subsurface irrigation system consists in carrying the sewage in 
 an air-tight conduit from the house to a sewage or flush tank. The latter 
 should contain two chambers, the first being used to 
 retain the solids and kitchen grease, while the second 
 and larger tank receives the liquid sewage from the first tank by means 
 of a deeply trapped overflow. By means of an automatic siphon the 
 licjuid sewage is discharged once or twice a day into an outlet pipe that 
 leads to the irrigation field. The main conduit to the field should be a 
 water-tight drain pipe which connects with a two-inch porous drain pipe 
 that has a system of lateral absorption di'ain tiles, laid with open joints, in 
 trenches twelve inches deep, at a gradient of from six to eight inches in 
 one hundred feet. 
 
 Subsoil is less preferable than surface irrigation for the disposal of 
 town sewage, but for rural houses, or even small groups of houses, where 
 the sewage purification would have to be effected on land adjoining the 
 residences, subsoil irrigation may be more suitable. 
 
 If there are not enough absorption tiles the field is likely to become 
 water-logged, or if the gradient is too steep the bulk of the sewage runs to 
 the lower end of the field, or the tiles may be laid too deep and the sew- 
 age does not gain access to the upper layers of the soil, or the tank may 
 liave but one cham])er and the tiles soon become choked. 
 
MUNICIPAL SCAVENGING DEPARTMENTS. .*]T5 
 
 111 many manufactiirinf^ districts in tLf; llnitof] States water courses 
 are polluted by the waste from factories. Tliis may l;e liquid or solid, 
 
 and may contain poisonous siil>stances, dyestuflis, oils 
 
 Manufadurinq r . ' ^• ^ ., i • i • ti i j. i 
 
 „•' , "^ or lats, or soJid matter winch is likely to clog up a 
 
 stream. The liquid refuse could Ije precipitated, or it 
 
 might be disposed of by intermittent downward filtration in a suitable 
 
 soil. The latter would probably be unfit for agricultural purposes. Solid 
 
 refuse should be cremated. 
 
 The solid refuse of a city consists of garbage, ashes, general ruljbish, 
 market and manufactory refuse, and street sweepings. Most of tliis 
 refuse being in a more or less solid condition, it is re- 
 „ 7v K> f ', moved by a municipal scavenging department; but the 
 
 proper disposal of the collected material is a problem 
 which is receiving attention throughout the world, as it involves impor- 
 tant sanitary and economical features. The main question to be decided 
 is the best sanitary disposition of refuse ; and if the expense of such dis- 
 posal can be reduced by utilizing a part or all of the refuse, the com- 
 munity is correspondingly benefited. 
 
 Refuse may be divided into two important classes — waste organic and 
 inorganic material. The first consists of scraps of food, offal, and decay- 
 ing animal and vegetable substances ; the second of ashes and cinders, 
 household dust and rubbish, etc. The dust and ashes are unlikely to 
 give rise to nuisances, although their retention on premises may be in- 
 convenient ; but the organic matter will ferment, putrefy, and cause 
 decided nuisances. 
 
 In some cities in the United States there is a municipal system for 
 collecting all refuse, in others only the organic garbage is collected, while 
 in others each individual must arrange for the disposal of his waste and 
 refuse. There is a great difference in the character of refuse, and this 
 necessitates different plans for its removal. 
 
 If it was possible to have each household cremate its kitclien garbage 
 the problem of disposal would be easier. Dr. S. H. Durgin, of Boston, 
 has invented a very simple apparatus for this purpose. It consists of a 
 perforated sheet-iron cylindrical basket which has a tight bottom and a 
 capacity of three or fonr quarts ; this is inserted into an expanded box in 
 the stovepipe, and allows the hot air and smoke to pass on all sides of 
 the basket, drying the contents and carrying the odours out of the chim- 
 ney. The basket is easily withdrawn and will receive garbage from time 
 to time as it is made in the routine of kitchen work ; without extra fuel 
 the garbage is dried to charcoal, and Dr. Durgin states that the latter 
 may be used to start a fire in the morning. In some houses it is the cus- 
 tom to throw all organic matter into the ash box of the kitchen range or 
 the furnace ; this sometimes results in the odours penetrating the house. 
 
376 HYGIENE. 
 
 and the upper surface of the refuse may be incinerated, while the surface 
 restins: on the tioor of the ash box remains moist. 
 
 AVliore natural gas or coal oil are used as fuel, a small tightly covered 
 iron box, which has a pipe connecting with a Hue to carry oH" the odour, 
 may be used to cremate kitchen garbage. 
 
 It is ffenerallv recoijnised by sanirarians that dry and moist refuse 
 should not be mixed, as is the case in New York city, the ash can be- 
 ing the receptacle for kitchen refuse, ashes, and rubbish of all kinds. 
 It is true that there is an ordinance prohibiting such a mixture, but its 
 provisions are not enforced. Kitchen refuse should be separated from 
 ashes and other dry rubbish ; this is easily accomplished by having !>epa- 
 rate pails or galvanized-iron ash cans for the receptacle of each kind of 
 garbage. These should l)e removed in separate garbage and ash carts ; 
 the former should be galvanized-iron carts, which are covered in order to 
 prevent the etHuvia which arises from the decomposing mass from becom- 
 ing a nuisance ; the ash carts are better and more easily disinfected if made 
 of iron, and they should also be provided with covers so as to ])revent the 
 wind blowing the fine ashes and dust into the street, to the detriment of 
 the respiratory passages as well as the clothing of pedestrians. In winter, 
 when large quantities of coal are used, the ash carts should collect the 
 ashes at least every third day ; in summer once a week will suffice, though 
 daily collections are necessary in tenement-house districts, where the in- 
 habitants have no means for storage. 
 
 In order to prevent the accumulation of kitchen refuse in the house it 
 is necessary that it should be removed daily, especially in summer time. 
 Instead of being removed in carts, it may be collected in cox'ered buckets 
 or pails; the disadvantage of this method is that these i-eceptacles will be 
 less than half full at one house and overfilled at another. It also entails 
 more trouble and expense to disinfect a number of pails than one cart. 
 
 Garbage may be disposed of by dumping on land or into a water course 
 or the ocean, or it may be cremated. It is a common practice in Ameri- 
 can cities to dispose of all garbage by creating a midden heap at some 
 dumping place; the organic matter, owing to the lai-ge rpiantity of ashes 
 and the absence of what Dr. Poore has appropriately termed the " living 
 earth," decomposes and there is that disgusting pollution of the atmos- 
 phere with which most inhabitants of large communities are familiar. If 
 low ground is used for such dumping and is afterward employed as a site 
 for building, it is almost impossible to prevent poisoning of the atmos- 
 phere of the ])uilding by the polluted soil. In villages or small commu- 
 nities where there are wells a public dumping ground is not unlikely to be- 
 come a source of contamination to the well water, although this will not 
 be the case if the garbage is composed only of ashes and is free from all 
 organic matter. 
 
THE DISPOSAL OF SOLID REFUSE. 377 
 
 Duni])inii^ gar])age into a water course or carrying it by scows into the 
 ocean lias the disadvantage of polhiting the water course with oi-ganic 
 matter which will not be disposed of by iish, and filling up the bed of the 
 stream, or of the tide conveying it back again to the shore. Here, again, 
 the dumping of ashes alone would uot be prejudicial to health, but regard 
 must be had for the impracticability of getting all the inhabitants of a 
 city to burn their kitchen refuse and general rubbish. 
 
 The practice of separating kitchen garbage and using it to feed cattle 
 or pigs is feasible in the country, but in a large city the expense of its 
 transportation to points where it will be consumed is heavy, and too often 
 this garbage is unlit for food. 
 
 Another method of disposal of the kitchen garbage of a city is by one 
 of the patented processes, in which the garbage is heated and dried by 
 superheated steam for about six hours, losing over half its weight, and is 
 then mixed with benzine or some similar liquid which will sepai-ate the 
 fatty matter ; by distillation the fat is separated from the benzine, which 
 is used over again, and sold. 
 
 Cremation of refuse has been in use for a number of years, and is one 
 of the best, if not the best, of the methods mentioned for the disposal 
 of garbage. The garbage is burned in a number of furnaces, the moist- 
 ure first being driven off by heating it in chambers near the furnaces; 
 the heat from these destructors is used for boilers which may utilize 
 the steam in various ways, such as the production of electric light. 
 With the products of combustion, partly burned vapours and fine dust 
 are likely to be carried off by the chimney, producing a nuisance ; this 
 may be prevented by passing all smoke, etc., from the furnaces through 
 a second furnace at the foot of the chimney. The clinkers from the fur- 
 nace are used for the foundation of roadways and the manufacture of ar- 
 tificial stone, while the fine ashes are used for making mortar. A careful 
 estimate has shown that the cremation of garbage is more economical 
 than any other method of disposal, excepting dumping. 
 
 In country places where animals are not kept that will dispose of the 
 kitchen garbage Dr. G. Y. Poore recommends that a piece of galvanized- 
 wire netting three or four feet wide be used to inclose a circular space 
 some three or four feet in diameter, the netting being .fastened upright 
 by means of a few wooden stakes. All kitchen an.d garden refuse which 
 will decompose is thrown into this netting and a little earth is thrown 
 upon the heap from time to time ; there is no offensive odour from such 
 a heap, because it is exposed to the air on all sides, and it slowly settles 
 down. When one such heap is filled a second may be started, and after 
 a full refuse heap has fermented for some time it should be sifted ; the 
 sif tings are used for fertilization, and any residue is burned. The rule 
 should be that refuse susceptible of decomposition should be covered 
 
378 HYGIENE. 
 
 witli earth, while all other refuse should be burned, as the ash con- 
 tains large quantities of mineral substances which are useful for ma- 
 nure. Cinders are useless as manure, and these with broken glass and 
 crockery can be used for drainage trenches or as the foundation of gar- 
 den paths. Dr. Poore says that there is scarcely any form of domestic 
 refuse that is not serviceable in the garden ; bones and the shells of fish 
 should be burned until converted to an ash that may be used for fertiliz- 
 ing purposes, while tin cans which held food products are hammered into 
 a Hat bulk and buried where they can not interfere with tillage ; he con- 
 siders that a scavenger's cart robs men of that which not enriches it 
 but makes them poor indeed, and that it is a strain upon his conscience 
 to pay taxes to support an institution wliich is not only useless, but which 
 literally preaches thriftlessncss to the unthinking ])Oor. 
 
 Street cleaning and the disposal of garbage exercise an important in- 
 fluence on public health, and ought in all cases to be performed b}' the 
 
 local authorities and not bv the individual householder. 
 
 Sired Cleaning. .^ <• ^^ £ ^^ ' n <• -^ ■ ^ c 
 
 Over one lourtii oi tlie retuse oi a city is composed ot 
 
 the sweepings of the streets. 
 
 Streets should be swept at night or in the early morning, after or 
 before the traffic of the day, and before sweeping in dry weather they 
 should be sprinkled so as to settle the dust and prevent its being blown 
 about by the wind. In fact, during dry weather streets should be 
 sprinkled morning and afternoon, independently of sweeping, in order 
 to prevent the dust being blown into the respiratory passages and into 
 houses. There are a number of excellent patterns of sprinkling carts, 
 and their use should be more general. 
 
 In Xorthern cities the removal of ice and snow is an expensive fea- 
 ture of street cleaning; if allowed to remain, traffic is interfered with, 
 
 walking is an abomination, and the snow becomes mixed 
 Removal of Ice and ., ^^. ^ j- ^.i^, mi i • n 
 
 e With all kinds oi nltli. Ihe snow and ice are usuallv 
 
 ijUOW. " 
 
 cleared from the pavement by the householder ; in the 
 streets it is best shovelled into long, high ridges, which leave a space be- 
 tween the snow and the gutter to convey the melted snow to the sewers, 
 and the space between the ridges is free for the passage of vehicles. The 
 ridges are shovelled into carts, and the snow thus removed as fast as pos- 
 sible, the work being begun in those parts of the city where -traffic is 
 heaviest and population densest. 
 
NUTRITIVE INGREDIENTS OF FOODS. 379 
 
 .. CriAPTETl X. 
 FOOD. 
 
 Food is a general term used to designate the substances wliicli, wlien 
 taken into the body, yield the energy that maintains the functional- ac- 
 tivity of the organism or build the tissues requisite for 
 ejim ion. growth. During adolescence growth is promoted by 
 
 means of food wiiich, in adult life, also maintains the weight of the body 
 at a normal standard or increases the weight under certain conditions, 
 while in all stages of life it is the function of food to supply the mate- 
 rial necessary to produce animal heat and to yield the muscular and nerv- 
 ous power essential for the body's work. 
 
 The nutritive ingredients or '"nutrients" of foods are classified as in- 
 organic, such as mineral salts and water, and organic ; the latter are sub- 
 divided into nitrogenous, proteid or albuminous, and 
 Classification. ., ^ . • j. ^ x x v i 
 
 non- nitrogenous nutrients, such as lats, carbony- 
 
 drates, and vegetable acids. The following scheme will show Kichet's 
 classification of foods : 
 
 A. Without carbon, inorganic. 
 
 XT -i- ( Carbohydrates. 
 
 Non-nitro":enous. ■{ ^ ■' 
 
 I ° I Pats 
 
 B. With carbon, organic ■{ ,.,,'. ■ -, 
 
 I XT -J- S Albummoids. 
 
 I Nitrogenous . . ■ ■ ] ^^ ,, . . , 
 [ ( ison-albummoids. 
 
 All animal bodies contain among their chemical elements carbon, hy- 
 drogen, oxygen, nitrogen, sulphur, phosphorus, chlorine, fluorine, silica, 
 potassium, sodium, calcium, magnesium, iron, and manganese ; these occur 
 in various combinations. Water forms about two thirds of the body 
 weight. Albuminous or proteid substances constitute the greater portion 
 of the solid and a part of the fluid tissues of the body, and by their oxida- 
 tion certain nitrogenous substances are formed and excreted ; the pro- 
 teids are composed of carbon, hydrogen, nitrogen, oxygen, and sulphur, 
 and some contain phosphorus. Fats, which constitute a portion of all 
 animal bodies, are composed of carbon, hydrogen, and oxygen. As the 
 elements which forni the constituents of the body are derived from food, 
 it is essential that the latter should contain all the elements that are found 
 
 in the body, for there is no living matter without proteid. 
 Average Amount i i t ' , ^ , i , • ' • ^ j.*j. x 
 
 consumed Daily, carhohydrate, fat, and certain mineral constituent.. 
 
 Charles Richet made an estimate, based on the popu- 
 lation of Paris in 1890 and the amount of food stuffs consumed in that 
 city in that year, that an average man weighing 145'5 pounds or an 
 average woman weighing 125'25 pounds consumed daily : 
 
380 HYGIENE. 
 
 Bread 8,024 Pastry and cakes 30!) 
 
 Beef 3,54!) I Rico ami starches 154 
 
 Pork 617 
 
 Poultry and game G17 
 
 Fish. .!..... ^. 617 
 
 Eggs '. 541 
 
 Frtiits 12,345 
 
 Fresh vegetables 6,944 
 
 Dried vegetables 463 
 
 Potatoes 1,388 
 
 Sugar 603 
 
 Butter 462 
 
 Li (J II ids. 
 
 Milk 1,928 
 
 Wine 10,801 
 
 Olive oil 185 
 
 Cider and beer 772 
 
 Alcoholics 386 
 
 The pastry and cakes should be induded with the bread and rice, 
 making a total of 8,478 grains. Tlic meat, poultry, game, and fish 
 amount to 5,400 grains of gross weight, and if allowance is made for 
 bone, fat, feathers, and skin or shells, the quantity is reduced to 4,021 
 grains. So the weight of the fresh vegetables and fruits makes no 
 allowance for the peelings, etc., which probably amount to half the 
 weight. Oil and butter might be included as fats amounting to 648 
 grains. 
 
 Of the non-nitrogenous nutrients, the carhohydrates are derived chiefly 
 from vegetable foods. These occur in potatoes, wheat, corn, and other 
 starchy foods. Sugar, glucose, sorghum, etc., and cellu- 
 lose are carbohydrates ; they are composed of carbon, 
 hydrogen, and oxygen. The natural ferments of the saliva and the pan- 
 creatic juice convert starch into a sugar called maltose, which is converted 
 into a sugar known as dextrose ; a substance called invertin changes or- 
 dinary cane sugar into invert sugar, which is a mixture of two sugars — 
 levulose and dextrose. The portal system conveys the sugar to the liver, 
 and under the influence of the cells of the liver and other organs this 
 sugar (dextrose) is converted into glycogen ; the investigations of Pavy 
 and others indicate that the latter substance when associated with nitrog- 
 enous matter is converted into proteid matter. Dr. Pavy holds that so 
 closely is the nitrogenous portion of the food concerned in the assimi- 
 lation of carbohydrate matter, when the former is deficient in quantity 
 the carbohydrates do not become applied to the nourishment of the sys- 
 tem in the same beneficial manner as when nitrogenous substances are 
 present in proper proportion. That carbohydrates are important fat pro- 
 ducers is shown l)y numerous exact experiments with animals ; the in- 
 testine constitutes the main seat of preparation of carbohydrate matter 
 for absorption and subsequent use in the system, and fatty matters are 
 found flowing through the lacteals into the system, wliile according to 
 some authorities their presence can be accounted for only on the hypothe- 
 sis that the fat originated in the carbohydrate matter of the food. 
 
 Fat is a constituent in the dietary of most nations, either in the form 
 
NUTRITIVE FUNCTIONS OF FOODS. ' 381 
 
 of meat, tallow, lard, iiulk or cream, butter, and vegetable oils. It dif- 
 fers from the carbohydrates — which also contain carbon, 
 hydrogen, and oxygen — because there is not enough 
 
 oxygen to combine with the hydrogen and form water in a molecule 
 
 of fat. 
 
 Proteids, or nitrogenous compounds, or alhuminoids constitute a most 
 
 important class of foods. They include the albumen or white of eggs, 
 
 the casein or curd of milk, the myosin or basis of mus- 
 Proteids , . ^ u 
 
 cle, the fibrin of the blood, the gluten of wheat, the con- 
 
 glutin of peas and beans, and the globulins contained in the seeds of 
 
 cereals and other classes of the vegetable kingdom. 
 
 The proteids include the group called gelatinoids, such as the ossein 
 and gelatin of bones, the chondrin of cartilage, and the keratin of the 
 hair, nails, horns, etc. The nitrogenous ingredients of foods and of the 
 body are commonly grouped together under the designation " protein." 
 
 The vegetable acids — oxalic, tartaric, citric, acetic, malic, etc. — form 
 salts in the body which are converted into carbonates that preserve the 
 alkalinity of the fluids and tissues of the body. 
 
 Organic nitrogenous matter is an essential ingredient of food, and in 
 the digestive tract the pepsin and hydrochloric acid of the gastric juice 
 
 convert it into peptones, albumoses, and syntonin ; and 
 Nutritive Functions ,, , • c ,i ,. . . . . 
 
 of Food trypsm of the pancreatic juice converts it into pep- 
 
 tones, a part of which are converted into leucin and 
 tyrosin. Therefore by gastric and intestinal digestion nitrogenous mat- 
 ters are converted into albumoses and peptones, which are transformed 
 into the proteids of the blood ; these are taken up by the cell ele- 
 ments to nourish the tissues of the body and form the essential basis of 
 those structures which possess active or living properties. AVhile the de- 
 composition of these substances varies with the quantity taken in the food, 
 it may be said, in general, that the amount of nitrogenous matter ingested 
 must equal the quantity that is excreted if health is to be preserved. 
 
 Some of the gelatinoids are useful as food stuffs ; gelatin is easily 
 digested and has a certain nutritive value that is best manifested when it 
 is mixed with some other proteid, or nitrogenous substance, such as 
 meat. Chondrin and keratin are vastly inferior to gelatin for food pur- 
 poses. 
 
 The fats and carbohydrates are sources of energy and heat ; they may 
 be of animal or vegetable origin, the former being more digestible. The 
 digestion of fats takes place in the small intestine by the action of the 
 pancreatic and intestinal juices which separate it into very minute globules, 
 such as exist in milk, and these are absorbed by the intestinal villi. 
 
 Carbohydrates have the advantage of being cheaper than nitrogenous 
 foods, and reference has been made to the fact that they produce fatty 
 
382 HYGIENE. 
 
 substances, but tbat the production is limited unless some nitrogenous 
 substance is associated with them. 
 
 "Water is an essential element of food not because it undergoes any 
 change like other foods, but because its solvent properties are essential 
 for the solution and absorption of aliment as well as the excretion of 
 eiiete substances produced in the ltL>dv. 
 
 Like water, saline substances are essential, not fttr the production of 
 energy, but because they constitute important elements in certain fluids, 
 tissues, and secretions of the body. riK)S[)hate of lime is present in all 
 the structural elements of the body, and, with the jihosphates of calcium 
 and magnesium, constitutes the greater jiortion of the solid parts of bone. 
 Sodium chloride is important to keej) the globulins of the blood in solu- 
 tion, and as a source of the hydrochloric acid in the gastric juice. Iron 
 salts are essential for their inliuence in forming the luemoglobin of the 
 red blood-corpuscles. 
 
 All vital processes are associated with two forms of force or energy — 
 
 heat and motion. The first is manifested by the almost constant tejupera- 
 
 ture of the normal human body, and the second by the 
 
 '^ "/,' 'j^o."J'^ beatino; of the heart, the respiratory and other muscular 
 Food c>tuffs. ^ . . 
 
 movements, and the activity of the cells of all the tissues 
 
 of the body. These forms of energy are developed as food undergoes 
 the processes of change, or metabolism, in the body, and in a healthy 
 adult at labour have been estimated at one fifth cellular labour and four 
 fifths heat. The unit of force, or kilogrammetre, is considered to be 
 the amount of energy which is essential to raise one kilogramme (2'204 
 pounds avoirdupois) to the height of one metre (3*28 feet) ; and the unit 
 of heat, called a calorie, or gramme-degree, is the amount of heat which 
 is necessary to raise one gramme (15"43 grains) of water one degree centi- 
 grade (1"S° Fahr.) ; one thousand gramme-degrees are equivalent to four 
 hundred and twenty-five kilogramraetres. 
 
 The amount of potential energy in food stuffs may be expressed by 
 measurements of heat or of mechanical labour ; these latter are deter- 
 mined by an apparatus called a calorimeter. Prof. Tlubner calculated that 
 
 In one pound of protein there are 1,800 calories. 
 
 " " '' " carbohydrates " " 1,800 " 
 
 Ilubner calculated that 100 parts of animal albumin etjuals 52 parts of fat, 
 or 114 parts of starch, or 129 parts of dextrose ; and that to produce the 
 same amount of energy it would be necessary to take 1()0 parts of fat, 232 
 parts of starch, 234 parts of cane sugar, or 250 parts of dry dextrose. 
 Prof. Frankland calculated that 0-55 pound of fatty matter w^ould furnish 
 the same amount of power as could be obtained from 1'3 pound of fiour, 
 
COMPOSITION OF FOOD MATERIALS. 383 
 
 1'5 pound of sugar, 8'r> pounds of lean Ijoof, and 5 i)ounds of potatoes; 
 now these figures show tliat the potential energy of a food stuff simply 
 indicates its nutritive vulue in a certain direction, but not tliat it is un- 
 important whether the energy is obtained from a proteid, a liydrocarbon, 
 or a carbohydrate, for the oo pounds of lean beef might be digested witli 
 more difficulty than the U"55 pound of fatty matter, and with less difficulty 
 than the 5 pounds of potatoes. 
 
 The graphic chart of the composition of food materials as they are 
 bought in the market, including the edible and non-ediljle portions, given 
 on the following page, is from Dr. W. O. At water's valuable monograph 
 on Foods and Diet.''' 
 
 Tliis table shows that animal foods contain the most water, and vesre- 
 table foods, excepting potatoes and turnips, the most nutrients. The 
 fatter the meat the less the amount of water ; very lean meat may be 
 almost four fifths water, fat sirloin almost two fifths, and fat pork almost 
 one tenth water. The flesh of fish contains more water than that of 
 warm-blooded animals. It may also be noticed that while the veg- 
 etable foods are rich in carbohydrates, meats contain none, though the 
 latter contain large quantities of protein and fats which are present in 
 very small proportions in most vegetables, except beans and oat-meal. 
 
 Weight for weight, fats have almost 2*25 times the potential energy 
 of either proteids or carbohydrates; and as water has no potential energv, 
 food stuffs that have the most fat and the least water, such as butter and 
 fat pork, have the highest fuel value. Lard, suet, and especially olive oil 
 exceed butter in fuel value, while oleomargarine about equals it. The 
 ribs and flanks are the fattest cuts of beef, the loin is the fattest cut of 
 mutton or lamb, while lean cuts of pork contain as much fat as the fattest 
 cuts of other meats. Prof. Atwater calls attention to the high fuel value of 
 canned corned beef, which is cooked before canning, and, being free from 
 bone and other refuse, contains a larger amount of protein and fats than 
 an equal quantity of fresh beef. The table does not show the nutritive in- 
 gredients of chicken and turkey, which have less fat than some meats, con- 
 tain a large amount of refuse, bone, etc., and furnish large quantities of 
 protein. Fish that have dark meat are rich, those that have light meat are 
 generally though not always poor, in fats. Attention is directed to the 
 similarity in the proportions of the nutrients in oysters and in milk. 
 
 Cheese contains more proteids and fats and less water than milk, the 
 first-mentioned constituents exceeding in quantity the proportions con- 
 tained in most meats ; a pound of cheese contains abont twice as mucli 
 
 * The Yearbook of the U. S. Department of Agriculture for 1894. See also Bulletin 21 
 of the Office of Experiment Stations of the U. S. Department of Agriculture on Methods 
 and Results of Investigations on the Chemistry and Economy of Foods. 
 
384 
 
 HYGIENE. 
 
 COMPOSITION OF FOOD MATERIALS. 
 Nutritive ingredients, refuse, and fuel value. 
 Nutrients. Non-nutrients. 
 
 
 Protein. Fats. Carbo- Mincrftl 
 hydrates, matters. 
 
 Water. Refuse. 
 
 Protein compounds— e. <7., lean of meat, white of egg, casein (curd) of milk, and gluten of wheat — 
 make muscle, blood, bone, etc. 
 
 ^^^^J^^%i:^^^^, \ -«•- - f-l to yield heat and muscular power. 
 
 Nutrieut.s, etc., p. ct. 
 Fuel value or 1 lli. 
 
 10 
 
 20 
 
 30 
 
 40 
 
 r-io 
 
 (30 
 
 ro 
 
 ^0 
 
 90 
 
 3*0 
 
 400 600 1200 RiOO 2000 24- 00 2S00 3200 3000 40i OO 
 
 * Without bone. 
 
DIGESTIBILITY OF FOOD. 385 
 
 of nutrients as a pound of good meat, Lrit if eaten eooked, as in Welsh 
 rarebit, the cheese is not easily digested and assimilated. 
 
 Vegetable foods differ principally in the quantity of water and pro- 
 tein, tlie former constituent being always greater in fresh vegetables, as 
 in beets and turnips, in which it amounts to almost ninety per cent. Dry 
 vegetable food stuffs, such as the different kinds of flour and meal, contain 
 about seven eightlis nutrients and one eighth water ; the amount of pro- 
 tein is greater in oatmeal than in wheat flour. 
 
 A calculation of the amount of carbon and niti'ogen will not deter- 
 mine the nutritive value of a food, because the latter quantity depends 
 
 not only upon the amount of nutrients it contains, but 
 Nutritive, Value -. ,, ,. /^ , , j. • ^ ^i i. t 
 
 J 7^- 1-, -i-, also upon the proportion of tliese nutrients that are di- 
 and Dtgestibiliiy. ^ ^ '- 
 
 gested and absorbed. The digestibility of food includes 
 such different factors as the facility with which a particular food stuff is 
 changed into substances utilized in the body, the time that is required for 
 such processes, and the influence of different substances and conditions 
 on digestion. As Prof. Atwater says, the effects upon health and comfort 
 are so dependent upon the peculiarities of different individuals and are so 
 difliicult to measure that it is impossible to make hard-and-fast rules re- 
 garding the digestibility of food. 
 
 The quantity of food digested is obtained by M^eighing and analyzing- 
 the quantity of food consumed and the amount of excrement passed, and 
 as the latter represents the amount of food undigested and unassimilated, 
 the difference between the latter and the food consumed is the amount 
 digested. 
 
 The proteids of meat, fish, eggs, milk, and cheese are more digestible 
 than those of potatoes, peas, rice, and white and rye bread. As re- 
 gards the relative digestibility of meat and fish, or white meat and 
 dark, there is a difference of opinion. Raw beef is more digestible than 
 smoked beef. 
 
 The investigations of physiologists have shown .that the flesh of ani- 
 mals and fish remains in the stomacli from two and a half to five hours ; 
 in order of digestibility, lamb is first, then beefsteak, lean meat, mutton, 
 fish, veal, and pork. Much of the fat of animal food may fail of digestion, 
 and Prof. Atwater considers that, as ordinarily eaten, five per cent, of the 
 fat of meats, eggs, milk, butter, oleomargarine, and lard will be undi- 
 gested. If cooking makes the meat tough it becomes more indigestible. 
 
 Such starchy foods as rice, barley, and tapioca remain in the stomach 
 about two hours ; beans, peas, and potatoes remain about two and a half 
 hours; white bread remains three, and brown bread four hours. Vege- 
 table food, consisting as it does of large quantities of carbohydrates, is 
 digested more or less completely, even the cellulose being of use in the 
 processes of digestion. 
 27 
 
3S6 
 
 HYGIENE. 
 
 Dii't and Di- 
 etaries. 
 
 To jireserve lioalth it is necessary to arrange a diet suited to the de- 
 mands of the body ; it must contain enough proteids, salts, and water to 
 aid in forming and repairing tissue, and enough carbo- 
 livdrates and fats to keep tlie body warm, for if the 
 food is insutHoient in (]uantity or cpiality tlie body will 
 be iin]u-iiperlv TKiurisliod ami the health impaired in consequence. 
 
 Individuals diller in their ability to digest food, and modifications in 
 health may make a difference in the ability of the same individual to di- 
 gest food. Some persons can not eat certain fruits, others avoid certain 
 meats, others milk or eggs, etc. 
 
 If too much food is taken at a meal the stomach is distended by the 
 bulk and there is imperfect digestion. Part of the meat is not converted 
 into peptones, the carbohydrates and fats are split up by the action of 
 bacteria into butyric and other fatty acids, and the foods are not absorbed 
 from the digestive tract. The amount of food required for different peo- 
 ple varies with the occupation, age, sex, and idiosyncrasies of the individ- 
 ual as well as with the climate. 
 
 During the fii'st six months of life the rapid growth of the infant ne- 
 cessitates food which will furnish the material necessary for that growth 
 as well as for the maintenance of the nitrogen equilibrium of the body. 
 The following tal)le, prepared by Konig, shows the minimum amount of 
 nutrients recpiired daily at different ages : 
 
 Period of Life. 
 
 WEIGHT IN OUNCES. 
 
 Proteid. 
 
 Fat. 
 
 Carbohydrates. 
 
 Child up to one year and a half 
 
 Child from six to fifteen vears 
 
 0-64 to 1-15 
 2-15 to 2-57 
 
 3-70 
 
 2 95 
 
 3-21 
 
 2-57 
 
 0-96 to 1-44 
 1-19 to 1-60 
 
 1-80 
 
 1-41 
 
 2-18 
 1-60 
 
 1-92 to 2-88 
 8-03 to 12-86 
 
 Man at moderate work 
 
 16-5 
 
 Woman at moderate work 
 
 12-86 
 
 Old man. . . 
 
 11-24 
 
 Old woman 
 
 8-35 
 
 
 
 The diet of children* varies with the rapidity of growth, the carbohydrates 
 and fats being proportional to the carbonic acid excreted. 
 
 Physiological experiments and investigations have furnished data that 
 permit the calcidation of diet for an individual at work or at rest. 
 
 
 MODERATE WORK. 
 
 ACTIVE WORK. 
 
 SEVERE WORK. 
 
 
 
 S Si 
 
 09 
 
 
 c 
 
 < 
 
 
 
 o 
 
 < 
 
 ■a . 
 Oh 
 
 < 
 
 Proteids 
 
 Fats 
 
 Oz. 
 
 3-52 
 
 1-76 
 
 14-08 
 
 3,140 
 
 Oz. 
 
 4-59 
 
 2-96 
 
 14-26 
 
 3,160 
 
 Oz. 
 
 4-83 
 
 4-12 
 
 12-40 
 
 3,055 
 
 Oz. 
 
 4-48 
 4-48 
 15-84 
 3,520 
 
 Oz. 
 
 5-64 
 
 2-56 
 
 20-00 
 
 3,630 
 
 Oz. 
 
 4-94 
 
 3-17 
 
 15-31 
 
 Oz. 
 
 5-12 
 
 3-52 
 
 15-84 
 
 3.370 
 
 Oz. 
 5-28 
 
 5-28 
 17-60 
 4,000 
 
 Oz. 
 
 6-50 
 
 2-85 
 
 20-10 
 
 Oz. 
 6-24 
 
 8-80 
 
 Carbohydrates 
 
 Fuel value, calories 
 
 22-88 
 5.700 
 
 
 
 
RELATION OF FOOD TO WORK. 
 
 587 
 
 The forcgoiiii^ table sliows tlie difTercnce of diet necessary for differ- 
 ent characters of work, and as people who do not do muscular exercise 
 require less food than those who work, the diet for an individual at rest 
 should be less than that of one doing moderate work. The greater the 
 work done the larger the amount of food necessary. 
 
 Prof. Atwater has compiled a valuable taijle, published in his mono- 
 graph on Foods: Nutritive Value and Cost (Farmer's Bulletin IS'o. ii3, 
 U. S. Department of Agriculture), which shows liow the actual dietaries 
 of people of different classes in different parts of the world compare with 
 the standard dietaries above referred to. 
 
 American and European Dietaries and Dietary Standards. 
 
 [Quantities per man per day.] 
 
 American {Massachusetts and Connecticut). 
 
 Family of carpenter in Middletown, Conn. . . 
 
 Family of glass blowers in East Cambridge, Mass. . . . 
 
 Boarding house, Lowell, Mass. ; boarders, operatives 
 in cotton mills 
 
 Boarding house, Middletown, Conn. ; i Food purchased 
 well-paid machinists, etc., at mod--< 
 erate work ( Food eaten .... 
 
 Blacksmiths, Lowell, at hard work 
 
 Brickmakers, Massachusetts ; 237 persons at very 
 severe work 
 
 Mechanics, etc., in Massachusetts and Connecticut ; 
 average of four dietaries of mechanics at severe work 
 
 Average of twenty dietaries of wage workers in Massa- 
 chusetts and Connecticut 
 
 Average of five dietaries of profes- ( Food purchased 
 sional men and college students \ 
 in Middletown, Conn ( Food eaten 
 
 NUTRIENTS. 
 
 Fuel 
 value. 
 
 Pro- 
 tein. 
 
 Fats. 
 
 Carbo- 
 hy- 
 drates. 
 
 Pounds. 
 
 0-25 
 0-23 
 
 0-29 
 
 0-28 
 
 0-23 
 0-44 
 
 0-40 
 
 0-48 
 
 0-34 
 0-30 
 
 0-27 
 
 Pounds. 
 
 0-28 
 0-29 
 
 0-44 
 0-41 
 
 0-34 
 0-67 
 
 0-81 
 
 0-65 
 
 0-50 
 0-36 
 
 0-34 
 
 Pounds. 
 
 0-70 
 1-06 
 
 1-21 
 0-94 
 
 0-84 
 1-75 
 
 2-54 
 
 1-G5 
 
 1-38 
 1-12 
 
 1-08 
 
 Calorics. 
 
 3,055 
 3,590 
 
 4,650 
 4,010 
 
 3.490 
 6,905 
 
 8,850 
 
 6,705 
 
 5,275 
 
 4,140 
 
 3,925 
 
 Nutri- 
 tive 
 ratio.* 
 
 5-5 
 
 8-2 
 
 7-6 
 
 6-8 
 
 7-3 
 
 7-4 
 
 11-0 
 
 6-6 
 
 7-5 
 6-6 
 
 6-6 
 
 * The nutritive ratio is the ratio of the protein to the sum of all the other nutritive 
 ingredients. The fuel value of the fat is two and a quarter times that of the protein and 
 carbohydrates. In calculating the nutritive ratio the quantity of fats is multiplied by 
 two and one fourth. This product is added to the weight of the carbohydrates. The 
 sum divided by the weight of the protein gives the nutritive ratio. Materials with large 
 amounts of fats or carbohydrates and little protein, like fat meats or potatoes, have a 
 "wide" nutritive ratio. Those with a large amount of protein as compared with the 
 carbohydrates and fats, like lean meat, codfish, and beans, have a "narrow" nutritive 
 ratio. In othar words, the materials rich in tissue-forming substances have a narrow, 
 and those with a large preponderance of fuel materials have a wide, nutritive ratio. This 
 is an important matter in the adjusting of food to the demands of the body. 
 
 A well-balanced diet is one which has the right ratio of protein to the fats and carbo- 
 hydrates. A relative excess of the tissue formers makes the ratio narrow, while an excess 
 of the fuel ingredients makes an overwide ratio in the diet. Either of these errors is dis- 
 advantageous. Our food materials and our diet are apt to have too wide a nutritive 
 ratio. In other words, we consume on the whole relatively too little protein and too 
 much of the carbohydrates and fats. 
 
388 
 
 HYGIENE. 
 
 Dietaries. 
 
 European {Englixh, German. Daiiiah, and ^Swedish). 
 
 Well-fed tailors, EnglMml. Playfair 
 
 Ilanl-worked weavers. Kii>;:laii(l. I'layfair 
 
 Biaeksmiths at aetive labour, Eiiglaiul, Playfair 
 
 Mei-lianio, Munieh, sixty years old, in comfortable 
 
 eireumstaiu'es. Ii,i:;ht work. Forster 
 
 Well-paid nieelianies, ^lunieh, Voil 
 
 Carpenters, coopers, locksmiths, Jiavaria : avera^^e of 
 
 eleven dietaries, Voit 
 
 Miners at severe work, Prussia, Stoinheil 
 
 Brickmakers (Italians), Munich: diet mainly m.iize 
 
 meal and cheese, severe work, Ranki' 
 
 German army ration, peace footinij 
 
 (Jormaii army ordinary ration, war footing,' 
 
 (ierman army extraordinary ration, in war 
 
 rniversity professor, Munich; very little exercise, 
 
 Kanke 
 
 Lawyer, Munich. Forster 
 
 Physician, Munich, Forster 
 
 Physician, Copenhagen, Jurgensen 
 
 Average of seven dietaries of professional men atid 
 
 students, Germany, Denmark, and Sweden.. . . 
 
 Dietary Sta^idards. 
 
 Adult in full health, Playfair 
 
 Active labourers, Playfair 
 
 I\Ian at moderate work, Moleschott , 
 
 ]\Ian at moderate work, Voit 
 
 Man at hard work, Voit 
 
 JIan with little physical exercise, Atwater 
 
 ^Man with light muscular work, Atwater 
 
 Man with moderate muscular work, Atwater.. . . , 
 
 Man with active muscular work, Atwater 
 
 i\lan with hard muscular work, Atwater 
 
 NUTRIENTS. 
 
 
 
 
 
 Phiel 
 
 Pro- 
 
 Fats. 
 
 Cnrbo- 
 hv- 
 
 value. 
 
 tein. 
 
 
 drates. 
 
 
 Poundi. 
 
 Pound*. 
 
 Poundi. 
 
 Calorie*. 
 
 0-21) 
 
 0-09 
 
 l-U) 
 
 3,055 
 
 0-84 
 
 0-09 
 
 1-37 
 
 3.570 
 
 0-39 
 
 OIC 
 
 1-47 
 
 4,115 
 
 0-26 
 
 0-15 
 
 0-76 
 
 2,525 
 
 0-34 
 
 0-12 
 
 1-OC 
 
 3,085 
 
 0-27 
 
 0-08 
 
 1-28 
 
 3, 150 
 
 0-30 
 
 0-25 
 
 1-40 
 
 4,195 
 
 0-37 
 
 0-26 
 
 1-49 
 
 4,540 
 
 0-25 
 
 0-09 
 
 l-()6 
 
 2,800 
 
 0-30 
 
 O-Vi 
 
 1-08 
 
 3,095 
 
 0-43 
 
 0-10 
 
 1-49 
 
 3,985 
 
 0-23 
 
 0-22 
 
 0-58 
 
 2,325 
 
 0-18 
 
 0-28 
 
 0-49 
 
 2,400 
 
 0-28 
 
 0-20 
 
 0-80 
 
 2,830 
 
 0-30 
 
 0-31 
 
 0-53 
 
 2,835 
 
 0-25 
 
 0-22 
 
 0-63 
 
 2,670 
 
 C-26 
 
 0-11 
 
 1-17 
 
 3,140 
 
 0-34 
 
 0-16 
 
 1-25 
 
 3.G30 
 
 0-29 
 
 0-09 
 
 1-21 
 
 3, ICO 
 
 0-2(5 
 
 0-13 
 
 1-10 
 
 3.055 
 
 0-32 
 
 0-22 
 
 0-99 
 
 3,370 
 
 0-20 
 
 0-20 
 
 0-66 
 
 2,450 
 
 0-22 
 
 0-22 
 
 0-77 
 
 2,800 
 
 0-28 
 
 0-28 
 
 0-99 
 
 3,520 
 
 0-33 
 
 0-33 
 
 1-10 
 
 4.0G0 
 
 0-39 
 
 0-55 
 
 1-43 
 
 5,700 
 
 N iitri- 
 tive 
 ratio. 
 
 4-7 
 4-8 
 4-7 
 
 4-3 
 
 4-0 
 
 5-3 
 0-7 
 
 5G 
 
 5-0 
 4-() 
 4-1 
 
 4-7 
 G-3 
 4-4 
 4-1 
 
 4-7 
 
 5-5 
 
 4-7 
 4-9 
 5-3 
 4-7 
 
 5-8 
 5 G 
 G-9 
 
 On the l)a.si.s of the foregoing standard of dietaries a man doing mod- 
 erately hard muscular work should eat thirteen ounces of round steak, 
 which contains 0-14 pound of proteids, equal to 095 calories; three ounces 
 of butter, which equal 680 calories ; six ounces of potatoes, which con- 
 tain 0'02 pound of proteids, equal to 320 calories ; and twenty-two ounces 
 of wlieat bread, which contain 0-12 pound of proteids, equal to 1,760 
 calories ; thus making the total proteids 0-28 pound, equal to 3,455 calo- 
 ries. The proportion between the proteids and the non-nitrogenous or- 
 ganic food stuff in a diet should average from 1 to 3*5 or 4*5, while the 
 proportion of fat to carbohydrates should not be less than 1 to 9. 
 
 In arranging a dietary due attention must be paid to the daily quan- 
 tity of food, which must not be indigestible on account of bulk, propor- 
 tion of cellulose, acidity, or bad cooking. There must be a variety in tlie 
 food supply, and the llavotiriDg and seasoning should receive careful 
 attention. 
 
 A great deal of information may be obtained from the table of diet- 
 
TABLE OF DIETARIES. 
 
 JS9 
 
 aries arranged by Prof. Atwater, wliicli indicate the dilTerent combinations 
 and cost of foods for an average man doing moderat(!l_y hard mnscnlai- work : 
 
 Prices used in estimating Cost of Daily Dietaries. 
 
 Articles. Price per 
 
 J}(ipf ; pound, cents. 
 
 Neck 7 
 
 Chuck 10 
 
 Shoulder 12 
 
 Sirloin 20 
 
 Uump 10 
 
 Hound 14 
 
 Liver 10 
 
 Dried beef 25 
 
 Mutton : 
 
 Shoulder 12 
 
 Leg 18 
 
 Loin 20 
 
 Pork : 
 
 Loin 16 
 
 Ham 16 
 
 Salt pork 12 
 
 Sausage 12 
 
 Fish: 
 
 Mackerel 12 
 
 Wholecod 8 
 
 Articles. Price per 
 
 Pish (continued) : pound, cents. 
 
 Dry salt cod 7 
 
 Salt mackerel 13 
 
 Canned salmon 15 
 
 Lobster 12 
 
 Eggs, 24 cents per dozen 14 
 
 Milk, 7 cents per quart '>fi 
 
 Butter .'JO 
 
 Cheese 1 'i 
 
 Potatoes, white 1 i 
 
 Sweet potatoes 2 
 
 Turnips 2 
 
 Sugar 5 
 
 Beans 5 
 
 Corn meal 2^ 
 
 Oatmeal 5 
 
 Wheat flour 2i 
 
 Graham flour 3 
 
 Wheat bread 4 
 
 Rice 7 
 
 Canned corn 1 C 
 
 Daily Dietaries. Food Materials furnishing approximately the OSS Pound 
 of Protein and 3,500 Calories of Energy of the Standard for Daily Dietary 
 of a Man at Moderate Muscular Work. Cost estimated, fi^om Prices given 
 in Preceding Table. 
 
 
 Amount. 
 
 Cost. 
 
 NUTRIENTS. 
 
 Fuel 
 value. 
 
 Food Materiai,s. 
 
 Total. 
 
 Protein. 
 
 Fats. 
 
 Carbo- 
 hydrates. 
 
 I. 
 
 Beef, round steak 
 
 Butter 
 
 Ounces. 
 
 i;j 
 3 
 6 
 
 22 
 
 Cents. 
 
 11-40 
 0-65 
 1-25 
 5-50 
 
 Pounds. 
 
 0-26 
 0-16 
 0-17 
 0-89 
 
 Pounds. 
 
 0-14 
 
 6- 02 
 0-12 
 
 Pounds. 
 
 0-12 
 0-16 
 
 0-62 
 
 Pounds. 
 
 o-is 
 0-75 
 
 Calories. 
 
 695 
 680 
 
 Potatoes 
 
 330 
 
 Bread 
 
 1.7G0 
 
 
 
 11. 
 
 Pork, salt 
 
 Butter 
 
 44 
 
 4 
 
 2 
 
 16 
 
 8 
 
 23-80 
 
 3-7.') 
 5-00 
 2-00 
 
 13-75 
 
 5-65 
 5-65 
 1-75 
 
 1-85 
 3-00 
 
 1-48 
 
 0-21 
 0-11 
 0-84 
 0-33 
 
 0-28 
 
 6 -23 
 0-04 
 
 30 
 
 0-21 
 0-11 
 0-02 
 0-01 
 
 0-90 
 
 6 '59 
 
 0-28 
 
 3,455 
 
 880 
 450 
 
 Beans 
 
 1,615 
 
 Bread 
 
 640 
 
 
 
 III. 
 Beef, liver 
 
 30 
 
 9 
 3 
 
 8 
 12 
 12 
 
 1-49 
 
 0-17 
 0-16 
 0-06 
 0-63 
 0-50 
 
 0-27 
 
 0-13 
 
 6-62 
 0-07 
 0-07 
 
 0-35 
 
 0-03 
 0-16 
 0-02 
 0-03 
 0-01 
 
 0-87 
 
 0-03 
 
 6-63 
 0-53 
 0-42 
 
 3,585 
 875 
 
 Butter 
 
 Milk, it- pint 
 
 780 
 165 
 
 Corn meal 
 
 1,330 
 
 Bread 
 
 965 
 
 
 
 
 44 
 
 17-90 
 
 1-52 
 
 0-28 
 
 0-35 
 
 0-99 
 
 3,515 
 
390 
 
 HYGIENE. 
 
 NUTniENTS. 
 
 Food Materials. 
 
 IV. 
 Beef, sirloin steak 
 
 Butter 
 
 Milk, IJ pint 
 
 Potatoes 
 
 Flour 
 
 VI. 
 
 Beef, neck.. 
 
 Butter 
 
 Milk, 1 pint 
 Potatoes.. . . 
 Oatmeal.. . . 
 
 Bread 
 
 Sugar 
 
 VII. 
 Beef, shoulder . . 
 Salmon, canned. 
 
 Butter 
 
 Milk, 1^ pint. .. 
 
 Potatoes 
 
 Oatmeal 
 
 Flour 
 
 Sugar 
 
 VIII. 
 
 Beef, chuck 
 
 Ham 
 
 Two eggs 
 
 Butter 
 
 i\Iilk. 1 pint . . . . 
 
 Potatoes 
 
 Flour 
 
 Sugar 
 
 IX. 
 Beef, sirloin steak. 
 
 Mutton choi)s 
 
 Butter 
 
 Milk, U pint 
 
 Potatoes 
 
 Oatmeal 
 
 Bread 
 
 Sugar 
 
 Ouncas. 
 
 12 
 8 
 28 
 12 
 12 
 
 V. I 
 
 nam 12 
 
 Pork, salt ^ 
 
 Butter 1 
 
 Potatoes 8 
 
 Beans 5 
 
 Flour 12 
 
 Cost. 
 
 ■SSi 
 
 10 
 1 
 
 IG 
 
 16 
 4 
 
 Hi 
 ■6 
 
 66 
 
 24 
 
 8 
 
 2 
 10 
 
 6U 
 
 10 
 6 
 3 
 
 2 
 
 16 
 12 
 
 8 
 
 1 
 
 58 
 
 
 
 2 
 24 
 
 8 
 
 3 
 
 12 
 
 C4 
 
 CenU. 
 
 15-00 
 5 -65 
 6-15 
 0-95 
 1-85 
 
 29-60 
 
 12 
 
 00 
 
 
 
 35 
 
 1 
 
 90 
 
 
 
 65 
 
 1 
 
 55 
 
 1 
 
 85 
 
 18 
 
 30 
 
 Total. 
 
 4' 
 
 1 
 
 3 
 
 1 
 
 1 
 
 4' 
 
 0' 
 
 17' 
 
 6 
 3 
 4' 
 5 
 
 
 1 
 0' 
 
 23- 
 
 6 
 6 
 4' 
 3 
 3 
 
 1 
 
 
 '2Q- 
 
 10 
 6 
 3 
 5 
 
 
 3 
 
 
 "so"' 
 
 Pounda. 
 
 0-25 
 0-16 
 0-22 
 0-12 
 0-65 
 
 1-40 
 
 0-37 
 03 
 0-05 
 0-09 
 0-27 
 0-65 
 
 1-46 
 
 19 
 05 
 13 
 17 
 23 
 67 
 19 
 
 •63 
 
 16 
 10 
 13 
 18 
 09 
 11 
 55 
 19 
 
 •51 
 
 22 
 19 
 05 
 11 
 13 
 12 
 44 
 06 
 
 -32" 
 
 17 
 14 
 11 
 18 
 09 
 17 
 50 
 12 
 
 1-48 
 
 Protein. 
 
 Poundi. 
 
 0-12 
 
 o-oti 
 
 0-01 
 0-08 
 
 0- 
 
 O-ll 
 
 0-01 
 0-07 
 0-08 
 
 0-27 
 
 0-10 
 
 04 
 02 
 04 
 09 
 
 -29 
 
 09 
 06 
 0:{ 
 
 04 
 01 
 05 
 
 •28 
 
 08 
 04 
 
 05 
 01 
 08 
 07 
 
 0-28 
 
 Fats. 
 
 Pounda. 
 
 0-13 
 0-16 
 
 0-08 
 
 6*-6i 
 
 0-38 
 
 0-26 
 0-03 
 0-05 
 
 6-6i 
 
 0-01 
 0-36 
 
 07 
 05 
 13 
 06 
 
 oi 
 
 01 
 -33~ 
 
 13 
 
 13 
 02 
 11 
 04 
 
 •6i 
 
 -44 
 
 09 
 10 
 11 
 06 
 
 6i 
 
 01 
 
 0-38 
 
 Carbo- 
 hydrates. 
 
 0-08 
 0-11 
 0-56 
 
 0-75 
 
 0-08 
 0-19 
 0-66 
 
 0-83 
 
 0-05 
 0-15 
 17 
 0-56 
 0-19 
 
 M2 
 
 07 
 08 
 08 
 47 
 19 
 
 •89 
 
 0^05 
 0^11 
 0^38 
 0-06 
 
 0-60 
 
 0-07 
 0-08 
 0-13 
 0-42 
 0-12 
 
 0-82 
 
 Fuel 
 value. 
 
 Caloiiet. 
 
 725 
 680 
 570 
 240 
 1.235 
 
 3.450 
 
 1,300 
 110 
 225 
 160 
 505 
 
 1,235 
 
 3,535 
 
 550 
 225 
 325 
 320 
 460 
 1,280 
 345 
 
 3,505 
 
 450 
 245 
 565 
 485 
 160 
 230 
 1.030 
 345 
 
 3,510 
 
 800 
 650 
 135 
 450 
 325 
 240 
 825 
 115 
 
 3,540 
 
 485 
 465 
 450 
 485 
 160 
 345 
 965 
 230 
 
 3,585 
 
TABLE OF DIETARIES. 
 
 301 
 
 
 Amount. 
 OuiiceB. 
 
 12 
 
 « 
 
 3 
 16 
 
 8 
 
 2 
 12 
 
 4 
 
 Cost. 
 
 NUTRIENTS. 
 
 Fuel 
 value. 
 
 Food Materials. 
 
 Total. 
 
 Protein. 
 
 Fats. 
 
 Carbo- 
 hydrates. 
 
 X. 
 Beef, Tieck 
 
 Cents. 
 
 5-25 
 6-00 
 5-65 
 3-50 
 0-65 
 0-65 
 3-00 
 1-25 
 
 Poundn. 
 
 0-22 
 03 
 0-16 
 0-12 
 0-09 
 0-12 
 0-50 
 0-25 
 
 Pounda. 
 
 0-12 
 0-03 
 
 6-63 
 0-01 
 0-02 
 0-07 
 
 Pound*. 
 
 0-lU 
 
 6- 16 
 0-04 
 
 ()-6i 
 0-01 
 
 Pouodt. 
 
 6-65 
 
 0-08 
 0-09 
 0-42 
 0-25 
 
 ClorlCf. 
 
 0(;o 
 
 Lobster 
 
 65 
 
 Butter 
 
 Milk, 1 pint 
 
 cso 
 
 325 
 
 
 100 
 
 Oatmeal 
 
 230 
 
 Bread 
 
 960 
 
 Sugar , . 
 
 460 
 
 XL 
 Beef dried 
 
 65 
 
 3 
 
 10 
 
 H 
 
 3 
 
 12 
 
 8 
 
 3 
 10 
 
 4 
 
 25-95 
 
 4-70 
 11-25 
 2-00 
 5-65 
 2-65 
 0-65 
 0-95 
 2-50 
 1-25 
 
 1-49 
 
 0-06 
 0-19 
 002 
 016 
 0-09 
 0-09 
 0-17 
 0-42 
 0-25 
 
 0-28 
 
 0-05 
 0-09 
 0-01 
 
 6-62 
 0-01 
 0-03 
 0-06 
 
 0-32 
 
 o-oi 
 
 0-10 
 0-01 
 0-16 
 0-03 
 
 6-6i 
 0-01 
 
 0-89 
 
 6-64 
 0-08 
 13 
 0-35 
 0-25 
 
 3,540 
 140 
 
 Mutton leg 
 
 580 
 
 One ea'ff 
 
 70 
 
 Butter 
 
 680 
 
 Milk f pint 
 
 245 
 
 Potatoes 
 
 160 
 
 Oatmeal 
 
 345 
 
 Bread 
 
 800 
 
 Sugar 
 
 460 
 
 XII. 
 
 Beef, round steak 
 
 Cod, dried 
 
 5^ 
 
 8 
 
 2 
 
 H 
 
 3 
 20 
 
 8 
 
 2 
 10 
 
 4 
 
 31-60 
 
 7-00 
 0-90 
 2-00 
 5-65 
 4-40 
 0-65 
 0-65 
 1-55 
 1-25 
 
 1-45 . 
 
 0-16 
 0-03 
 0-02 
 0-16 
 0-15 
 0-09 
 0-12 
 0-55 
 0-25 
 
 0-27 
 
 0-09 
 0-03 
 0-01 
 
 6-64 
 0-01 
 0-02 
 0-07 
 
 0-33 
 
 0-07 
 
 6-6i 
 
 0-16 
 0-05 
 
 6-6i 
 
 0-01 
 
 0-85 
 
 6- 06 
 0-08 
 0-09 
 0-47 
 0-25 
 
 3,480 
 
 425 
 40 
 
 One effff 
 
 70 
 
 Butter 
 
 680 
 
 Milk, li pint 
 
 405 
 
 Potatoes 
 
 160 
 
 Oatmeal 
 
 230 
 
 Flour 
 
 1,030 
 
 Sugar 
 
 4G0 
 
 XIII. 
 Sausage 
 
 58^ 
 
 4 
 
 14 
 
 2 
 16 
 
 5 
 
 2 
 16 
 
 8 
 
 3 
 
 24-05 
 
 3-00 
 7-00 
 3-75 
 3-50 
 1-55 
 0-90 
 2-00 
 2 00 
 0-95 
 
 1-53 
 
 0-14 
 0-07 
 0-11 
 0-13 
 0-26 
 0-11 
 0-24 
 0-33 
 0-19 
 
 0-27 
 
 0-03 
 0-07 
 
 6-64 
 0-07 
 0-01 
 0-01 
 0-04 
 
 0-31 
 0-11 
 
 6-ii 
 
 0-04 
 
 0-01 
 6- 61 
 
 0-95 
 
 6-65 
 0-18 
 0-10 
 0-23 
 
 0-28 
 0-19 
 
 3,500 
 510 
 
 Cod, whole 
 
 • 140 
 
 Butter 
 
 450 
 
 Milk, 1 pint 
 
 325 
 
 Beans 
 
 505 
 
 Rice 
 
 205 
 
 Sweet potatoes 
 
 420 
 
 Bread 
 
 640 
 
 Sugar 
 
 345 
 
 
 
 XIV. 
 Beef, rump 
 
 70 
 
 6 
 
 12 
 2 
 
 1 
 16 
 
 8 
 1 
 8 
 4 
 3 
 
 24-65 
 
 6-00 
 9-00 
 3-75 
 1-00 
 3-50 
 0-65 
 0-30 
 1-25 
 0-75 
 0-65 
 
 1-58 
 
 0-17 
 0-10 
 0-11 
 0-04 
 0-13 
 009 
 0-05 
 0-44 
 0-21 
 0-12 
 
 0-27 
 
 0-05 
 0-07 
 
 6 -62 
 
 0-04 
 0-01 
 0-01 
 0-05 
 0-03 
 
 0-28 
 
 0-12 
 0-03 
 0-11 
 0-02 
 0-04 
 
 6"6i 
 
 1-03 
 
 i 6-65 
 0-08 
 0-04 
 0-38 
 0-18 
 0-13 
 
 3,540 
 590 
 
 Mackerel 
 
 Butter 
 
 280 
 450 
 
 Cheese 
 
 130 
 
 Milk, 1 pint 
 
 325 
 
 Potatoes 
 
 160 
 
 Oatmeal 
 
 Flour (wheat) 
 
 115 
 825 
 
 Flour (Graham) 
 
 405 
 
 Sugar 
 
 230 
 
 
 
 
 60 
 
 26-85 
 
 1-46 
 
 0-28 
 
 0-33 
 
 ' 0-85 
 
 3,510 
 
392 
 
 HYGIENE. 
 
 
 Amount. 
 
 Cost. 
 
 NUTRIENTS. 
 
 Fuel 
 value. 
 
 Food Matkuiai^s. 
 
 Total. 
 
 Protein. 
 
 I'UtS. 
 
 Carbo- 
 hydrates. 
 
 Poiinils. 
 
 XV. 
 Beef sho\iltlor 
 
 Ounce*. 
 
 9 
 (5 
 
 U 
 
 H 
 
 8 
 8 
 8 
 8 
 4 
 2 
 
 56 
 
 8 
 4 
 ;{ 
 ■2i 
 
 1 
 
 !(} 
 
 8 
 
 o 
 
 i) 
 
 H 
 
 Genu. 
 
 G-75 
 G-00 
 2-00 
 2-80 
 1-75 
 0-C5 
 1-00 
 l-2r) 
 100 
 0G5 
 
 Poundi. 
 
 0-18 
 0-19 
 0-02 
 008 
 0-OG 
 0-09 
 0-12 
 0-42 
 0-lG 
 0-12 
 
 Pounds. 
 
 0-10 
 OOG 
 0-01 
 
 6 •02 
 0-01 
 0-01 
 0-05 
 0-02 
 
 Pciindi 
 
 0-08 
 0-13 
 0-01 
 0-08 
 0-02 
 
 6" 02 
 
 Cnlorlps. 
 
 515 
 
 Mam 
 
 6 
 
 
 
 
 
 
 
 02 
 08 
 11 
 35 
 14 
 12 
 
 055 
 
 One e.ix;; '. . . 
 
 Huttor 
 
 70 
 340 
 
 Milk, ^ pint 
 
 1G5 
 
 Pi.)tatoes (white) 
 
 IGO 
 
 Sweet potatoes 
 
 210 
 
 Corn meal 
 
 Bread 
 
 825 
 320 
 
 SuEfar 
 
 230 
 
 
 
 XVI. 
 Beef, chuck 
 
 33-85 
 
 5-00 
 3 -00 
 4-00 
 4-70 
 100 
 3-50 
 0-G5 
 0-90 
 2 •20 
 0-45 
 
 1-44 
 
 0-18 
 0-08 
 0-05 
 0-13 
 0-04 
 0-13 
 0-09 
 0-11 
 0-38 
 0-09 
 
 1-28 
 
 0-24 
 0-02 
 0-07 
 0-08 
 0-04 
 0-13 
 0-07 
 0-12 
 0-42 
 0-lG 
 0-12 
 
 0-28 
 
 0-08 
 0-04 
 0-03 
 
 6-()2 
 004 
 001 
 0-01 
 0-05 
 
 0-34 
 
 0-10 
 0-04 
 0-02 
 0-13 
 0-02 
 0-04 
 
 o'-6i 
 
 
 
 6 
 
 
 
 
 
 
 82 
 
 05 
 08 
 10 
 32 
 09 
 
 3,490 
 5G0 
 
 Mackerel, salt 
 
 230 
 
 Two esTirs 
 
 135 
 
 Cheese 
 
 5G5 
 130 
 325 
 
 Potatoes 
 
 IGO 
 
 Bread 
 
 Suirar 
 
 205 
 720 
 175 
 
 
 
 XVII. 
 Ham 
 
 55 
 
 8 
 4 
 
 1 
 
 1(5 
 G 
 8 
 8 
 4 
 2 
 
 G3 
 
 8 
 8 
 U 
 
 r 
 
 12 
 4 
 4 
 1 
 1 
 4 
 2 
 3 
 
 25-45 
 
 8-00 
 1-75 
 G-00 
 2-80 
 1-00 
 3-50 
 0-50 
 1-00 
 2-50 
 100 
 0-G5 
 
 0-28 
 
 0-07 
 0-02 
 0-04 
 
 6-62 
 0-04 
 0-01 
 0-01 
 0-05 
 0-02 
 
 0-3G 
 0-17 
 
 
 
 64 
 
 3,205 
 870 
 
 Cod. dried 
 
 ()•();■) 
 O-OG 
 
 0-n 
 
 0-35 
 0-14 
 0-12 
 
 50 
 
 
 
 
 
 
 
 6 
 
 03 
 
 08 
 02 
 04 
 
 02 
 
 200 
 
 Butter 
 
 Cheese 
 
 Milk, 1 pint 
 
 Potatoes (wliitc) 
 
 Sweet potatoes 
 
 310 
 
 130 
 325 
 120 
 210 
 
 Corn- meal 
 
 825 
 
 Bread 
 
 Sugar K 
 
 S20 
 230 
 
 XVIII. 
 Pork chops, loin 
 
 28-70 
 
 8-00 
 5-00 
 2-00 
 5 -Go 
 1-75 
 0-95 
 0-50 
 4-00 
 0-30 
 0-45 
 0-Go 
 0-40 
 0-95 
 
 1-47 
 
 0-20 
 0-15 
 0-02 
 0-lG 
 0-00 
 0-12 
 0-02 
 0-07 
 0-06 
 05 
 0-22 
 Oil 
 0-19 
 
 0-28 
 
 0-07 
 0-10 
 0-01 
 
 (i-02 
 0-01 
 
 o'oi 
 
 0-01 
 
 6-03 
 0-02 
 
 
 
 
 30 
 
 in 
 
 0-83 
 
 ()'o2 
 
 0'(')2 
 0-11 
 0-02 
 O-OG 
 0-04 
 0-05 
 0-10 
 0-09 
 019 
 
 8,620 
 065 
 
 Liver 
 
 0-03 
 0-01 
 OIG 
 0-02 
 
 o'oi 
 
 330 
 
 One efg 
 
 70 
 
 Butter 
 
 Milk, i pint 
 
 Potatoes 
 
 675 
 
 1G5 
 240 
 
 
 35 
 
 ('orn, canned 
 
 Rice 
 
 130 
 115 
 100 
 
 Flour (wheat) 
 
 Flour (Graham) 
 
 410 
 205 
 
 Su car 
 
 345 
 
 
 
 
 59i 
 
 30-60 
 
 1-43 
 
 0-28 
 
 0-36 
 
 0-79 
 
 3,485 
 
PECUNIARY VALUE AND PREPARATION OF FOOD. 3();{ 
 
 Important as tlio question of diet may Ijo in tin; c/dHc. of a hcaltliy 
 population, it is of much greater import in regard to the population of 
 charitable, educational, and penal institutions, of hospitals, and of soldiers 
 and sailors. The consideration of the diet of the sick is omitted here, as 
 that matter is essentially a part of the treatment, while the diet of insti- 
 tutions does not come within the scope of this work. 
 
 As the cost of food is the heaviest item in the living expenses of 
 working people, who have to arrange their diet according to their wages, 
 it is a matter of great importance to indicate how the 
 fF d most nutritious food may be obtained at the lowest 
 
 price. In the United States, Great Britain, and Ger- 
 many more than fifty per cent, of the income of a family is spent for 
 food, which is often deficient in proteids and fats and excessive in carbo- 
 hydrates. In most of the towns of the United States the cost of foods is 
 greater than in the country, though the cost varies in different sections. 
 The cheapest food has been defined as that which supplies the most nutri- 
 ment for the least money, but the most economical food is that which is 
 the cheapest and at the same time best adapted to the wants of the eater ; 
 and Prof. Atwater goes on to say that those who economize in the pur- 
 chase and use of food, and who carefully consult the prices, have in gen- 
 eral very vague ideas about the relation between the value of food for 
 nourishment and its cost. He calls attention to the fact that from one 
 dollar to two dollars a pound may be paid for the protein of animal food 
 that could be obtained in other equally wholesome and nutritious forms 
 for from fifteen to fifty cents per ponnd ; and he refers to the fact that 
 the cheapness or dearness of different food stuffs is often judged by the 
 prices per pound, quart, or bushel, without regard to the amounts or 
 kinds of actual nutrients which they contain. The graphic chart given 
 on the following page is taken from Prof. Atwater's monograph on Food 
 and Diet and gives an estimate of the amount of nutrients thai could be 
 purchased for ten cents. 
 
 All articles of food should be prepared before eating, and most food 
 
 stuffs require cooking. Fruits and vegetables must be 
 The Preparation t -, ^ t n i ^ ^^ • c ^ 
 
 f -p ^ washed and peeled when eaten raw, the grain of wheat 
 
 separated from the husk and ground, and bone, gristle, 
 and superfluous fat I'emoved from meat. 
 
 Good cooking will increase the digestibility of food, enhance its pal- 
 atability, and destroy micro-organisms that are likely to be attached to it. 
 Animal food is digested raw as well as cooked, but it is more palatable 
 and more easily masticated when cooked. The essential object in cooking 
 meat is to firmly coagulate the superficial layer of albumin in order to 
 retain the flavouring and other constitnents which have so great a nutri- 
 tive value ; and after coagulating the external portion, to continue the 
 
394 
 
 HYGIENE. 
 
 PECUNIARY ECONOMY OF FOOD. 
 
 Amounts of actually nutritive ingredients obtained in different food ma/criats for JO cents. 
 
 Protein. Fats. Carbohydrates. Fm-l value. 
 
 Protein compounds— r. g.. lean of meat, white of egg, casein (curd> of milk, and t^hiU n of wlaat— 
 make muscle, blood, bone, etc. 
 
 Fats — e. </., fat of meat, butter, and oil, I „ r i * • iii * i i 
 
 C<nbohydnites-e. y., starch and sugar, ) ^«'^^*^ "^ ^^^^ ^° ^'^^'^ ^eat and nuiscular power. 
 
 Beef, round. 
 
 Price 
 
 per 
 
 pound. 
 
 Ten 
 
 cents Pounds of nutrients and calories of fuel value in lOcei.ts' 
 will I wuith. 
 
 buy — 
 
 Cents. 
 
 Lbs. 
 
 13 
 
 0-83 
 
 W 
 
 ILb. 
 
 :Lb.s. 
 
 :>, Lbs 
 
 4 Lbs. 
 
 •lOOUCaL mOO CaL GOOOCaL SOOOCal 
 
 Beef, sirloin 18 
 
 0-55 
 
 Beef, rib 16 
 
 0-63 
 
 Mutton, leg. 
 
 12 0-83 
 
 Pork, spare rib 12 
 
 0-83 
 
 Pork, salt, fat. 
 
 Ham, smoked . 
 
 14 I 0-71 
 
 IP) 0-G3 
 
 Codfish, fresh 
 
 8 1-25 
 
 Codfish, salt... 
 
 m^ 
 
 1-67 
 
 Oysters, 40 cents quart. 
 
 20 
 
 0-50 
 
 Milk, fi cents quart | 3 
 
 3-33 
 
 ^K 
 
 Butter. I 24 
 
 0-42 
 
 Cheese. 
 
 Eggs, 25 cents dozen. 
 
 Wheat bread. 
 
 Wheat flour. 
 
 Corn meal 
 
 16 
 
 0-63 
 
 16J I 0-60 
 
 2^ 
 
 Oatmeal. 
 
 2-50 
 
 v/,y^////////////.y//////y 
 
 4-00 
 
 5-00 
 
 Beans, white, dried 
 
 Rice. 
 
 Potatoes, 60 cents bushel. 
 Sugar 
 
 2-f)0 
 2-50 
 
 2-00 
 
 10-00 
 
 5 2-00 
 
 imi. 
 
 ^ 
 
INFLUENCE OF FOOD ON HEALTH. 395 
 
 process at a lower temperature in order tliat tlio meat may Ije cooked 
 throughout. In boiling, the meat should be put in Ijoiling water for from 
 live to ten minutes so that the piece will be enveloped by a coating of 
 firmly coagulated albumin ; the kettle is then placed on a pai-t of the 
 stove where the water will retain a temperature of 180° Fuhr., three 
 quarters of an hour being allowed for each pound of meat, and a small 
 quantity of salt added to the water in order to hasten the coaguhition of 
 the albumin and increase the density of the water so as to lessen the ooz- 
 ing out of the meat juices. 
 
 Stewing has for its object the partial extraction of the meat juices by 
 the water, the moderate coagulation of the albuujin, and the softening of 
 the gelatin and fibrin ; so meat should be stewed in water at a tempera- 
 ture between 1-35° and 100° Falir., which is best attained by the use of a 
 double boiler, the meat being left in the water for the same time as in 
 boiling. 
 
 In roasting, the meat should be exposed to a hot fire and turned on 
 the spit until its surface is brown, then moved away so as to avoid burn- 
 ing and turned constantly, twenty minutes being allowed for each pound 
 of beef. It is customary in the United States to bake instead of roast 
 meats ; the piece is put in a baking pan, placed in a hot oven, and basted 
 and turned every ten minutes or so lest it should burn. 
 
 Vegetables should be boiled in a small quantity of water to which a 
 little fat and salt are added to prevent the loss of the vegetable salts ; the 
 globulins and albumins are coagulated by cooking, as is the case with 
 meat, while the starch grain swells and bursts its covering of cellulose. 
 
 An excess of food is likely to result in indigestion ; an excess of pro- 
 teid food may cause disorders of the liver and the muscles ; an excess of 
 fats and starches is likely to produce dyspepsia and corpulence ; and an 
 excess of water increases the oxidation of the proteids. 
 
 An inadequate supply of food results in general weakness, lessened 
 resistance of the body, and increased risk of acquiring disease. An in- 
 sufficient supply of proteids causes increased oxidation 
 i^uaiy cm ijiian- ^^ ^^^ body proteids in order to maintain the equilib- 
 rium of nitrogenous matter, and there is loss of weio:ht ; 
 an insufficient supply of fats and carbohydrates necessitates an increased 
 supply of proteids, or otherwise there will be a consumption of the pro- 
 teids of the body. 
 
 As a rule, persons eat too much and the diet is one-sided, there being 
 too little proteid and too much fat and carbohydrate food in the shape of 
 sugar, starch, and fat meats. Too little regard is paid to the quantity and 
 quality of food demanded by different habits of life. The diet tables 
 that have been given show that the most nutritious and wholesome diet- 
 ary for a person doing a moderate amount of muscular work is one in 
 
396 HYGIENE. 
 
 wliieli there is a mixed diet consisting of a lar^e proportion of vegetables 
 and cereals and a smaller quantity of milk, tisli, eggs, and meat. But 
 f(-tr an indi\itlual leading a sedentary life and engaged in mental work, 
 the best ilietary will include a generous sup]>ly of vegetables and cereals 
 and a small (juantity of tisli or llesli. The tish is recommended not be- 
 cause it contains any nutriment especially adajited to replenish the waste 
 of the brain cells, but only because it is less likely than meat to overload 
 the digestive system. 
 
 Food may be noxious or unlit for use because, if meat, it is taken from 
 diseased or immature aninuils or has undergone putre- 
 
 ^^OXiOUS Foods. r ,• 1 •£ X 11 1 -i. 1 1 
 
 lactive changes; or, it vegetable, because it has decom- 
 posed or is unripe; or, if manufactured, because it is adulterated or 
 becanse the processes of mannfacture lessen its nutritive properties. 
 
 In most places there is a State or local law which authorizes sanitary 
 inspectors to seize and destroy meat which is diseased, unsound, or other- 
 wise unfit for food, when it is exposed for sale. Good meat is firm but 
 elastic to the touch, and does not pit or crackle when pressed ; its colour 
 is uniform, bright, and marbled with fat. The flesh of rantton and pigs 
 is paler than that of beef or calves. The inspection of all cattle that are 
 to be killed for food should be a duty of the State, because expert knowl- 
 edge is sometimes requisite to determine the existence of disease. Many 
 animals are infected with parasites, some of which apparently exercise no 
 deleterious effect on their host, and others, like the Tricliina sjnralis^ may 
 kill its host and infect any person who eats the flesh it infests. There is 
 no doubt that the great prevalence of tuberculosis is due in part to the 
 use of the meat products from tuberculous animals for food. The flesh 
 of animals that have died of foot-and-mouth disease, pleuro-pncumonia, 
 anthrax, swine fever, and the like, is apt to contain toxins that have 
 been produced by the disease, if not the micro-organisms originating the 
 malady. 
 
 Adulteration may produce food that is injurious or non-injurious to 
 health, and investigation has shown that it is generally practised. Prof. 
 Sharpless has included under the head of injurious or deleterious adul- 
 teration the use of copper in pickles, of red lead in Cayenne pepper, of 
 arsenical colours in candy, and of water and other substances in milk. 
 Non-injurious or fraudulent adulterations include the addition of chicory 
 and other substances to coffee, of cotton-seed to olive oil, of flour and 
 turmeric to ground mustard, of glucose to cane sirup, of oleomargarine 
 to butter, etc. Any extended remarks upon the characteristics of adul- 
 teration are beyond the scope of this article, as their detection requires 
 the use of special instruments and a knowledge of the details of micro- 
 scopical and chemical investigation. 
 
MATERIALS EMPLOYED FOR CLOTHING. 897 
 
 CHAPTER XL 
 CLOTHING. 
 
 The essential purpose of clotliing is to aid in maintaining the animal 
 heat of the body, to afford protection against cold and heat, wind and 
 rain, and, by varying the composition and quantity of clothing, to enable 
 man to live in any climate. Besides this, clothing serves for decency and 
 adornment. 
 
 The materials employed for clothing are derived from the animal and 
 vegetable kingdoms ; from the first are obtained furs, skins, leather, wool, 
 silk, and feathers ; from the second, linen, cotton, hemp, 
 Employed J"^^' ^"^ Other substances. Besides these substances, 
 metals, glass, and mineral dyes are used as accesso- 
 ries for clothing. 
 
 Furs have been used for clothing by the inhabitants of cold climates 
 from time immemorial, and not only afford excellent protection against 
 cold and wind, but also prevent the radiation of heat from the body. 
 Skins of animals from which the hair has been removed are also of ad- 
 vantage to prevent the loss of heat, and when made tough by tanning or 
 other process the skin, called leather, is used for shoes, leggings, caps, and 
 other articles of clothing. 
 
 Wool is the hair of the sheep, alpaca, camel, Cashmere goat, and other 
 animals ; it is manufactured into cloth, j^arn, flannel, etc. It is more por- 
 ous and has a greater capacity for absorbing water than vegetable fabrics ; 
 it may feel warm and dry when it contains an amount of water that would 
 make cotton or linen feel wet and cold, because, while it absorbs moisture 
 freely, it parts with it slowly, and thus prevents chilling of the surface 
 with lowering of the temperature due to evaporation. It is a non-con- 
 ductor, and prevents the dissipation of the bodily heat. In consequence 
 of its capacity for absorbing water it takes up perspiration. TToollen 
 under-garments should be frequently washed, but unless washed in tepid 
 water with a soap Avhicli contains no soda they become hard and the 
 fibres shrink. Improved processes of manufacture have produced the 
 so called natural wools, which cause less irritation when worn next to the 
 skin than does the ordinary woollen or flannel underclothing. 
 
 Silk is a fibre produced by the silkworm of the Bomhyx mori, or 
 silk moth, which feeds on the mulberry plant. It is a poor conductor of 
 heat, and will take up a large quantity of moisture without feeling damp, 
 though in this hygroscopic quality it does not equal wool. It does not 
 irritate the skin nor does it shrink like wool. 
 
 Linen is made from a fibre obtained from the flax plant, Linv.m iisita- 
 
398 HYGIENE. 
 
 iissiitiu))! y' the fibres are joiuted and cylindrical. Linen cloth is fine, 
 smooth, and of close texture ; it is a good conductor of heat and a poor 
 conductor of moisture. 
 
 Cotton is also a vegetable fibre, obtained from the Gossyj)imn hrrha- 
 ceuni y the fibres are spun into thread, and thus used to make cloth, which 
 has a smooth texture of varying degrees of fineness. Cotton is absorbent 
 and rapidly parts with heat in consequence of re-evaporation. 
 
 ILenip and jute are vegetable fibres that are spun into coarse fabrics, 
 which are sometimes used for clothing. 
 
 The choice of clothing is largely a matter of climate and of season, 
 
 with the added factor, as in the case of food, of temperament. One 
 
 individual will wear a suit of thin cotton gauze iinder- 
 
 Choice of Clothing. ,, , , , .,, , , 
 
 wear all tlie year round, anotlier will wear wool, and 
 
 another silk in the same latitude. 
 
 As' air is a bad conductor of heat, a fabric which is M'oven so that its 
 pores will contain a quantity of air is warmer than one that has a fine, 
 thin, close mesh. If there is wind the air in the mesh of a thick cloth 
 is renewed, evaporation is hastened, and in consequence there is increased 
 chilling of the surface of the body; on this account -it is necessary in 
 cold, windy weather to wear furs and thick woollen clothes, several laj'ers 
 of clothing being worn, the number varying with the need of the wearer. 
 A fabric containing India rubber or some preparation thereof, such as in 
 the Mackintosh, is warm on account of its impermeability, but, inasmuch 
 as it induces copious perspiration, the consequent danger of chilling ren- 
 ders a material of this kind less desirable than heavy woollen goods, 
 except for use in very stormy weather. 
 
 In a temperate climate, wdiere long periods of summer heat and hu- 
 midity are rare, woollen under-garments are best for wear the year round ; 
 
 but even the fine light-weight woollen garments are nn- 
 Under-qannents. , ii- ,< ^ -,^ ■ -, r^ t. 
 
 endurable in many parts of the United States during 
 
 summer weather, and only cotton or linen is tolerated, loose clothing best 
 serving to protect from the heat, because it favours a free circulation of 
 the air. AYinter underclothing should correspond to the shape of the 
 figure, covering the entire upper part of the chest and shoulders, fasten- 
 ing on the shoulder instead of in front, and having a double thickness of 
 cloth in that portion of the chest region which will lie beneath the outer 
 shirt where the vest is open. This clothing should not compress the 
 chest or arms, and the combination suits of undershirt and drawers in 
 one piece are very desirable, especially for w^omen, because there is no 
 drawer band to compress the aljdomen. Where wool irritates the skin 
 a thin gauze or silk garment may be worn next the skin and a medium- 
 weio;ht woollen garment over it. 
 
 The frequency with which underclothing must be changed will depend 
 
COMMON SENSE IN DRESS. 399 
 
 upon tlic luibits of the individual in rei^ard to Ijutliini^ and upon liis 
 tendency to perspire. 
 
 The linen shirt so popular to-day is nothing but a starched breast- 
 plate, but the fine cambric shirts worn by gentlemen a century ago, or 
 t'he plaited bosoms once so familiar in the southern part of the (Jnited 
 States and still used there, are clean, fresh, and cool. 
 
 The colour of the fabric of the outer garments is an important de- 
 tail. White absorbs one half the heat that black garments do ; so in 
 summer the various shades of light coloured clotlis 
 should be selected for cool clothes. While a coat may 
 fit snugly, it should not restrict the movements of the chest or arms by 
 being tight, nor be oppressive in weight in consequence of padding. The 
 vest is a desirable garment to protect the abdomen, and, when the 
 aperture from the neck downward may be long or short, the space may 
 in cold weather be filled in by a scarf, or a chamois or flannel chest-pro- 
 tector may be worn. 
 
 Hats should have a space between the top of the hat and the hair, and 
 they should be provided with ventilating apertures in the top or at the 
 sides to facilitate the escape of the heated air. Open- 
 work straw hats are quite cool for summer use — more so, 
 perhaps, than the helmets worn in tropical and subtropical climates. A 
 hat should have a broad brim to protect the eyes from the sun ; and the 
 large felt hat, worn in the Southern United States and by troops in the 
 field on the frontier is an excellent covering. 
 
 To attempt to discuss the hygiene of woman's apparel, or to fulminate 
 against the ills induced by corsets and the weight of several garments 
 , about the waist, is supererogatory. The increasing popu- 
 
 Jarity oi outdoor exercise among women is likely to do 
 more to secure sensible dress than all the criticism heretofore written 
 from a medical standpoint. Bicycling and horseback riding especially 
 have served to popularize the combination iinder-garment, skirts are in 
 the way, stiff corsets can not be worn, and tight lacing is impracticable. 
 So much is being written about the evolution and habiliments of the com- 
 ing woman that the writer feels incompetent to prophesy her choice of 
 garments or to make suggestions that would pass unheeded, because the 
 dictates of fashion must be followed. 
 
 Stockings and socks are made of almost all kinds of fabrics, and the 
 season of the year will govern, as a rule, the selection of the material. 
 
 Women and children, whose legs are not protected by 
 StocMngs and ,, . , ? i i i ' • ^ 
 
 ^ , their garments as are men s. sliould wear m winter 
 
 heavy woollen stockings over the legs of long woollen or 
 
 silk drawers ; this will prevent the chilling of the lower extremities, which 
 
 is so often associated with the use of lisle-thread or silk stockings, in 
 
400 HYGIENE. 
 
 women a prevalent cause of uterine disorder. Stockings sliuuld not be 
 supj)orted by circular garters worn above or below the knee, but by sus- 
 penders attached to the waist. 
 
 Boots and shoes should be matle of good plial)le tanned leather, with 
 strong soles of oak-tanned leather ; the light-coloured leathers are excel- 
 lent, being cool and comfortable. Impermeable glazed 
 
 Boots and Shoes. ^ . i ^i • i • i i i. • \ £ i 
 
 or jiatent leather is an undesirable material lor shoes, as 
 
 it retains the heat and moisture of the foot, keeping the skin bathed in 
 
 perspiration, which sometimes has a fetid odour, India rubber, while an 
 
 excellent article for overshoes in wet or snowy weather, or for boots 
 
 which are used in M-alking through wet grass or standing in water, is not 
 
 a suitable material for shoes for daily wear, as this material is iiu])erme- 
 
 able, like patent leather. 
 
 If shoes are not made to order so as to conform to the shape of the 
 foot, the purchaser should note that a ready-made pair has a straight edge 
 to the inner side of the sole, in order that the great toe shall not be dis- 
 placed. While broad-toed shoes are not attractive, perhaps, they are cer- 
 tainly as pleasing to the eye as the sharply pointed shoe, which endeav- 
 ours to make the external covering of the foot resemble one of the digits 
 of a bird. Unless the sharply pointed shoe is much longer than the foot 
 the toes will be so compressed and deformed that an operation may be 
 required. The greatest care should be exercised in selecting children's 
 shoes, for the delicate and tender structures are easily affected by a badly 
 fitting shoe. 
 
 In summer time, and in localities where there is but little dust, low 
 shoes are cool and convenient. For general wear the ordinary laced or 
 buttoned shoes, reaching a little above the ankles, are excellent. For peo- 
 ple with sluggish circulation, or those who suffer with cold extremities, 
 boots are advisable. The weight of the leather of which the boot or 
 shoe is made necessaril}^ varies with the uses the wearer makes of it ; the 
 same thing may be said of the sole, which should alwa^^s be wider than 
 the foot and sufficiently heavy to prevent moisture or cold penetrating 
 the leather in walking. Heels help to keep the foot off the ground, but 
 they should be broad and low and not cut in the fashion known as French 
 heels, which throw the weight of the l)ody forward on the toes. Chil- 
 dren's shoes should not have heels. Fortunately, there is a growing ap- 
 preciation of the intrinsic beauty of a normal foot, and the use of tight 
 shoes will be less popular. 
 
ESSENTIALS OF AN IDEAL NURSERY. 401 
 
 CHAPTER XII. 
 HYGIENE OF INFANCY AND CHILDHOOD. 
 
 ISToTiiiNG is more essential to tlie future welfare of an individual tlian 
 the hygienic surroundings during infancy. While sturdy, vigorous indi- 
 viduals have developed in unsanitary environments, such a result is lare. 
 A large proportion of infants so situated die before their fifth year, or 
 acquire systemic weakness that results in premature death during adoles- 
 cence or early manhood. The development of the individual may be 
 divided into three periods: infancy, from birth to the com])letion of the 
 first dentition ; childhood, from the first dentition to puberty ; and ado- 
 lescence, from puberty to full growth. 
 
 Whether parents are able or unable to afford the luxury of a nursery, 
 
 it is important, above all things, that the house should be in a healthy 
 
 locality and that its sanitary arrangements should be 
 The Nursery. . ... 
 
 satisfactory. The room in which children are to be 
 
 brought up should be the brightest, sunniest room in the dwelling, prefer- 
 ably having a southern exposure, with morning rather than afternoon sun ; 
 such an apartment should be well ventilated, for plenty of air is as essential 
 as plenty of light to a growing child. Furthermore, as the bedroom must 
 often serve as the hospital in which the diseases of childhood are treated, 
 means for securing an abundance of light and air are doubly essential. 
 
 The floor should be of fine-grained, closely joined, smooth boards, or 
 of parquetry flooring, which is particularly well adapted for the nursery, 
 its patterns being such that they will amuse the child. Where the ex- 
 pense of parquetry or of hard-wood flooring can not be incurred, a carpet 
 cut in the form of a rectangular rug may be used ; such a rug can easily 
 be removed from and replaced in the room in case of sickness of a con- 
 tagious nature, but it is likely to be soiled by the child's discharges or 
 food, and must be cleansed annually at least. 
 
 The woodwork of the room should either be of the natural wood, 
 filled and varnished, or painted with some light-coloured paint that will 
 easily show the dirt. The nervous system is sensibly affected by different 
 colours — yellow attracts the nerves of sight, red excites, green soothes, 
 blue renders them torpid — and judgment must be shown in the selection 
 of colours for the walls and ceiling. The walls should be so constructed 
 and prepared that they may be painted and varnished, though varnish 
 turns yellow with age, and such a wall loses its clearness and freshness in 
 the course of lime ; still it is more easily cleaned by being wiped down 
 with a moist sponge than is a wall covered with paper or tapestry. If 
 wall paper is used, an ordinary tinted paper with dado below and lighter 
 28 
 
402 HYGIENE. 
 
 colour above is cheap and durable, and very attractive desif]fns are pre- 
 pared for use in the nursery. In buyinj:; ]>apers care must be taken to 
 select a trustworthy dealer w ho will not furnish papers coloured by ar- 
 senical pijxnient. This careful selection of attractive tints for a nursery 
 will insensibly educate the child to appreciate good colours. 
 
 Furniture slu)uld be of liglit-coloured wood, so that by showing the 
 dirt it will indicate the necessity of beinpr cleaned, and it should be light 
 in structure, so that it may be easily moved. The A'ienna bent-wood fur- 
 niture, or oak or ash furniture, are excellent for a room used by children. 
 There should not be much carved work in order that dust shall not be 
 harboured. Thick, heavy upholstery and curtains are unadvisable ; the 
 light should be freely admitted, and nothing but curtains of white goods 
 that may be easily washed should be used. Shades may be of dark 
 material, to exclude the light when desired, or Venetian blinds, which, 
 while excludinsr liij-ht admit air, are useful. 
 
 An open fireplace with a gas fire is very desirable for its ventilating 
 eflfect, but a coal fire makes so large an amount of dust that the usual 
 method of heating by hot air, steam, or a stove is to be preferred. An 
 open fireplace must be protected by a strong wire screen or fender, but 
 the latter must not be used to dry diapers and thus vitiate the air. If the 
 heating is by hot air the registeis should be placed some distance above 
 the floor so as to avoid floor draughts and to increase the circulation. 
 There should be ventilating outlets at the ceiling, or the air may be 
 changed by some of the means referred to in a former portion of this 
 article. As there is great loss of heat through window glass, there is a 
 constant current of cold air descending in front of a window. This may 
 be lessened by the use of a double sash, which may be put in at a small 
 expense and which aifords excellent ventilation. 
 
 While it has been held by most authorities that a uniform tempera- 
 ture of (i5° Fahr. is good for a nursery, many think that a temperature 
 of from To° to 75° Fahr. is necessary during the day, though a lower tem- 
 perature is refpiisite at night. As artificial lights, except electricity, not 
 only give off heat but consume the oxygen of the air, it is inadvisable that 
 a light be kept burning at night in a nursery ; furthermore, if the light is 
 at all high it is likely to make the child's sleep restless. 
 
 However convenient stationary plumbing may be in a nursery, it is 
 objectionable because it is so likely to become fouled by the accumulation 
 of filth, pins, thread, etc., in consequence of washing diapers in the room. 
 
 Water for the baby's bath should be warmed to from 984° to 100° 
 
 Fahr., and ought always to be tested by a bath thermometer; when the 
 
 . child is a few months old and in summer this bath may 
 
 be followed l\y a cooler one, and the temperature of the 
 
 water. may be gradually reduced to 90° Fahr., while in the second year 
 
HOW TO BATHE AND CLOTHE AN INFANT. 403 
 
 from 75° to Y0° Falir. sliould not be iincouifortable. Tlie cliild should 
 be placed in the tub and briskly rubbed in order to stimulate the activity 
 of the skin as well as to bring fresh water in contact with the surface of 
 the body. Care must be taken to choose a bland, pure soap that will not 
 irritate the delicate skin of the child, and a sponge or soft wash rag should 
 be used. It is easier to soap a very young infant while it is lying on a 
 bath towel or folded sheet on tlie nurse's lap, subsequently transferring it 
 to the tub, where it should have its head supported so that it will not get 
 water in its eyes and mouth, and where it may be encouraged to exercise 
 its limbs. After the bath the child should be carefully dried with a soft 
 Turkish bath towel, the rubbing being gentle and effective, A bath should 
 not be given when the stomach is full, after a meal, or when it is empty. 
 
 The use of powder after a bath is a firmly rooted custom that need 
 not be observed if the child has a healthy skin that is thoroughly dried ; 
 but in some (especially fat) children there is a tendency to chapping in 
 the skin of the groins, buttocks, and other regions where there are cuta- 
 neous folds, and a little finely powdered talc combined with boric acid is 
 useful. If the skin is very sensitive a pint of wheat bran in a bag or a 
 teacupful of common salt may be dissolved in the bath. 
 
 The scalp should be ke})t scrupulously clean, and the hair may be 
 brushed with a soft brush that should from time to time be thoroughly 
 washed. 
 
 The mouth should be washed daily with a piece of soft cloth moistened 
 
 with a solution of salt water of a strength of one per cent. ; as soon as 
 
 several of the milk teeth appear a soft toothbrush 
 Care of the 3Iouth i ii i i <■ j <• ^ .- /> /-^ .m 
 
 ■ , rj, .J should be used, a tew drops of a solution of Castile soap 
 
 and oil of wintergreen in water making a good denti- 
 frice. The early teeth should be carefully inspected by a dentist from 
 time to time, and on the first appearance of a spot of decay the affected 
 tooth should be filled. If decayed, the first teeth are likely to interfere 
 with mastication and to influence the development of the permanent 
 teeth. The first teeth should not be removed unless they are interfering 
 with the eruption of the permanent teeth. 
 
 The clothing of infants should be light, soft, and warm, and easily put 
 on and taken off, the quantity and quality varying with the season. The 
 
 clothes must allow free expansion of the chest and 
 Infants' Clothinq. ^ , ,, „ , ji ^^ ^• \ \ i -ui 
 
 stomach, as well as freedom of the limbs. As a cnild s 
 
 animal heat is easily disturbed, a poor conducting material should be se- 
 lected for the clothes. Light wools in summer and heavier woollen goods 
 in winter should be the rule, so as to avoid chilling from sudden changes 
 of temperature. There is a tendency to overload the infant with a num- 
 ber of skirts or dresses, which are usually too long ; these are unnecessary 
 for either warmth or comfort. A fine, soft woollen shirt reaehino^ well 
 
404 PIYGIENE. 
 
 over tlie chest, covering the arms, and extending below the buttocks, is 
 the first covering ; often this is supplemented by the protection and sup- 
 port afforded by a binder, cut bias to secure easy expansion, of flannel 
 placed about the abdomen. Over this is placed a flannel skirt which ex- 
 tends some distance below the feet, and finally the outer dress, of such 
 material as may be fancied. The napkin should be made of medium- 
 weight cotton goods — linen is too cool — which must not be too bulky 
 when appHed, which should be changed as often as necessary, and which 
 should not be used a second time until washed. Knitted socks, without 
 shoes, are the best foot covering. All clothing must be thoroughly dry. 
 Heavy hats or bonnets must be avoided. 
 
 As soon as the child commences to use its limbs freely the dresses and 
 skirts should be shortened, and it should be given every facility to exer- 
 cise its limbs and learn to crawl. 
 
 As the child grows older, drawers may be substituted for napkins, the 
 clothing becomes shorter and should be supported from the shoulders, 
 there must be an absence of all tight bands that will compress parts or 
 restrict free motion, the stockings become longer and are supported by 
 suspenders attached to the waist of the shirt, and broad, easy, heelless 
 shoes of soft leather are worn. 
 
 If the use of flannels causes prickly heat, muslin or linen underwear 
 should be worn next the skin. 
 
 "When the child is a week old in summer, or a month old in winter, it 
 should be taken out so that it can get fresh air, except on very windy, 
 very cold, or rainy days. The child should be placed in a baby carriage, 
 it should be covered according to the character of the weather, and the 
 carriage should be propelled in a direction in which the wind will not 
 blow or the sun shine directly in the child's face. It is an advantage to 
 have delicate children sleep in the open air in the carriage on bright, dry 
 days. 
 
 TJr. L. Emmett Holt advises that a child should be fed four or five 
 
 times daily during the first three days of life, as it can only obtain a small 
 
 „ . , ^ quantity of milk from the breast at each feeding : no 
 
 Feeding an Infant. , <• i i i , . , . ,, • ^ -, ^ -, ■, 
 
 otlier lood but that which is naturally provided should 
 
 be given a very young infant, and it is very objectionable to give them 
 gruels or baby toddy. AVhen the milk begins to flow abundantly, about 
 the third day, the infant should be nursed every two hours during the 
 day and twice during the night, each breast being suckled for about ten 
 minutes and washed clean after nursing. "When six weeks old the in- 
 terval between the feeding may be made two and a half hours, and when 
 three months old the interval may be increased to six hours. In the fifth 
 month the bal)y need not be fed between nine o'clock at night and six 
 o'clock in the morning. If the mother's milk is insufficient in quantity 
 
HOW TO FEED AN INFANT. 405 
 
 or quality the child may he partly or wholly fed artificially ; hut as the 
 mother's milk is, as a rule, the hest food for the child, every effort should 
 he made to nurse it until it is weaned in the ninth or tenth month. Nurs- 
 ing prulonircd heyond a year in likely to injure hoth the mother and the 
 child. lu the second year the child may he fed four or fi\e times 
 a day. 
 
 Mother's milk contains thirteen parts of solid matter and eighty-seven 
 parts of Avater. The solids consist of a fat (ci-eam), a carbohydrate (sugar 
 of milk), a proteid (the curd), and salts. Cow's milk contains three times 
 as much curd and about half as much sugar as woman's milk, so certain 
 additions should be made to it in order to fit it for infant's food. Skim 
 off the top milk from a bowl that has stood for at least six hours, and to 
 eight ounces of this, or to four ounces of cream, add six heaping tea- 
 spoonfuls of milk sugar (four of cane sugar) and sixteen ounces of barley 
 water. The latter is made by boiling one tablespoonful of barley and 
 one pint of water for six or eight hours, adding water as it boils away, 
 and finally straining through a cloth and adding a little salt ; this will 
 keep for forty-eight hours, though it is better to make it fresh daily, and 
 in summer it must be kept on ice. Milk prepai'ed as above directed. Dr. 
 Holt says, may be given to a child until it is seven or eight months old ; 
 then the quantity of milk in the mixture should be doubled and the milk 
 sugar be increased one third. While condensed milk has had great popu- 
 larity as an infant food, it contains too much sugar and too little cream, 
 so it should be diluted with water and cream added in order to secure fat. 
 If a child's food does not contain enough fat the bones become soft and 
 the muscles flabby ; it is on this account that so many of the children's 
 foods are valueless. 
 
 Bottles used for infant feeding will be filled with bacteria likely to 
 give rise to gastro-intestinal disorders, unless they are thoroughly cleaned 
 by being washed in hot soapsuds, then transferred to boiling water for 
 fifteen minutes, and gradually allowed to cool in the water. Black-rubber 
 nipples should be used, and these may be kept in a fifteen-per-cent. solu- 
 tion of boric acid and washed just before feeding. 
 
 Dr. L. E. Holt gives this excellent dietary for a child eighteen months 
 old : First meal at, Y a. m., a tablespoonful of some cereal with salt and 
 one tablespoonful of cream, half a pint of milk. Second meal, at 10 a. m., 
 half a pint of milk. Third meal, at 1 p. m., one tablespoonful of scraped 
 meat, two small pieces of dried bread, half a pint of milk. Fourth meal, 
 at 4: p. M., eight to twelve ounces of milk. Fifth meal, at 7 p. m., milk 
 with farina or arrowroot. During the third and fourth years four meals 
 a day will suffice, eggs, meats, and vegetables being given. 
 
 A child should always have a bed for its sole use. The bed should 
 have no curtains, the hair mattress should be soft and firm and rest on 
 
406 HYGIENE. 
 
 springs, the pillows thin, and the covering moderate, ^[ost mothers cover 
 
 their children too heavily and keep them bathed in perspiration during 
 
 their sleep. In summer a child's bed should be pro- 
 
 Sleepinq Arrange- • j j .^i -^ i ^ ^ ^ -^ o ,^ n- -t 
 
 fiienls vided With a mosquito bar to protect it irom the ilies and 
 
 mosquitoes. Young infants will sleep about nine tenths 
 of a day, a one-year-old child about two thirds of a day ; older children 
 will take a nap during the day until their fourth or fifth 3'car. The 
 infant should be put to bed at seven o'clock, tiie young child at eight, 
 and either should be allowed to sleep undisturbed. Nothing is more in- 
 jurious to the nervous system of a child than to awake it at a certain 
 hour in the morning ; the child is excited, the heart's pulsations increased, 
 and there is a state of agitation. Sleep is a physiological necessity, and a 
 parent may rest assured that if a child sleeps a very long time it is be- 
 cause the nervous system needs the rest afforded by slumber. 
 
 After childhood is well established — that is, in the fourth year — the 
 child should be educated to use its mind ; because as the muscles of the 
 
 body become strono;er throuojh use, so is it necessary for 
 Early Education. ^, i . , , . . 1 \ . .. 
 
 the brain to l)e used, in a somewhat systematic manner, 
 
 to develop the mind. There is no better beginning than the admirable 
 
 plan elaborated by Froebel, known generally as the kindergarten system. 
 
 This occupies the child's time to some purpose, teaching it how to use its 
 
 faculties in the recognition of form, colour, action, etc. It is too much the 
 
 custom to keep children out of school because it is not deemed advisable 
 
 to force their mental powers ; but a few hours' schooling a day is not 
 
 likely to force their powers, and it does give the child a valuable training 
 
 as well as relieves it of the ennui incident to unoccupied time. 
 
 Time well occupied is as necessary for the happiness and welfare of a 
 child as for an adult. Sufficient sleep, good air and light, daily bathing 
 and exercise, and mental occupation will do much to prevent the ills that 
 infantile flesh is heir to. 
 
 If the child is likely to have any supposedly hereditary diseases, if 
 
 one or both of its parents are tuberculous, if it is very large or very thin, 
 
 if it is easily fatigued, if it has an unhealthy, anaemic 
 General Ilt/qienic ^ , i . 1 i.i i. •. - •^• 
 
 Consid 'til appearance, great care must be taken that its nutrition 
 
 is sufficient. It should he placed under medical care, 
 and by the judicious employment of hydrotherapy, gymnastics, dietetics, 
 fresh air, and sunlight, the bad condition may be cured. In such a child 
 intellectual work should not be prolonged, though it should not he 
 omitted. K child predisposed to constitutional diseases may be so built 
 up that its organism will resist thoin, and all traces of the inherited 
 diathesis will disappear. The child of nervous parents, living in the en- 
 vironment in which it was born, is likely to cultivate various functional 
 nervous diseases ; but ])laced in surroundings where its tendencies are 
 
CARE OF BOYS AND GIRLS AT PUBERTY. 407 
 
 recognised and intelligent methods are ad()];t(;d to repress tlieni, such a 
 child may reach adult life free from nervous disease. 
 
 During infancy and childhood the vital powers are engaged in tlie 
 nutrition and growth of the individual, but at the period when tlie repro- 
 ductive capacity becomes established there is an evolu- 
 tion of organs that are concerned in tlie perpetuation of 
 the species. There is no fixed time for the appearance of puberty. 
 Climate, race, heredity, temperament, occupation, and physical condition 
 influence the beginning of that epoch. The old custom of basing the 
 advent of puberty in a boy upon his sexual capacity is fallacious. The 
 advent of male puberty occurs when the various physiological changes of 
 alteration in tlie modulation of the voice and the growth of down on the 
 face and of hair on the pubes commences. In girls puberty dates from 
 the first appearance of the menstrual flow, which may commence before 
 the twelfth, and usually appears during the fifteenth year ; and the change 
 is accomplished more quickly than in the case of the opposite sex. The 
 girl reaches maturity more rapidly than the boy. 
 
 This is a period of life which should be regarded as full of risk and 
 demanding careful consideration in both sexes, for if the body has not 
 been Avell nourished during childhood, if there is any factor that has 
 caused excessive nervous development, there is the probability that the 
 late puberty will so tax the individual that subsequent ill health, eitlier 
 physical or mental, will follow. Too often is seen at this time what 
 Herbert Spencer has characterized as " that antagonism between body 
 and brain which we see in those who, pushing brain activity to an ex- 
 treme, enfeeble their bodies." 
 
 The education and habits of a boy at puberty should receive careful 
 
 supervision. He should be taught, if not by his father at least by the 
 
 family physician, what the significance of the change 
 Care of a Boy at . -^j, ,-, • x j a. • i r, • 
 
 p-^, ^ IS. it there is any tendency to organic weakness his 
 
 exercise and diet should be regulated, though this is 
 needless in the case of a healthy boy. His mind should be well occupied. 
 He should sleep alone, and on a hard bed. His room should be well ven- 
 tilated, and he should take a cold bath every morning. If there is evi- 
 dent nervous disturbance the physician may prescribe each night a dose 
 of potassium bromide, or such other drug as he may see fit, for a boy 
 may, like a girl, have at this time hysterical or other nervous disorders, 
 and even perverted mental or moral excitability, sometimes with delusions. 
 Girls are, unfortunately, particularly liable to nervous disturbances 
 connected with the establishment of menstruation, and 
 ^^^ P h ^^ " even moderate hysterical symptoms may indicate seri- 
 ous utero-ovarian irritation or disease that should be 
 treated by the physician. Insanity, epilepsy, trance, or paralysis may 
 
408 HYGIENE. 
 
 result from untreated hysteria associated with coininencing menstruation. 
 There may be a diminution in the quantity of the menstrual flow, or it 
 may be absent or too frequently repeated ; such cases demand medical 
 rather than home treatment. The custom of adniinisterlny alcoholic 
 drinl's at this time of life for revwdial purposes can not he too strongly 
 depi'ecated. Social station has little influence on freedom from such dis- 
 orders. In fact they are more likely to occur in the children of the rich 
 leading sedentary lives than in those of the poor whose fate it is to en- 
 gage in some healthful kinds of labour at an early age. Too much work 
 does harm, and under overstrain there result debility and incapacity for 
 ordinary functions, and perhaps premature exhaustion. 
 
 Dress is very influential in affecting the developing woman. The 
 appearance of menstruation is considered by many mothers as an index 
 for the use of corsets, so this compressing band encircles the waist, forcing 
 the weight of the intestine upon the newly developing sexual organs. Is 
 it then a matter of surprise that, in consequence, the uterus is displaced 
 from its normal position and the Fallopian tubes and ovaries are irri- 
 tated, while the upward displacement of viscera affects the action of the 
 diaphragm and limits free expansion of the lungs? Loose, easy dress, 
 supported by the shoulders, not the waist, is more essential to a girl at 
 puberty than immediately after her birth. IS^o girl can ride a horse or a 
 bicycle easily, or play lawn tennis, or engage in the other popular sports 
 of the day, unless she has plenty of chest capacity for increased action of 
 her heart and lungs when exercising. 
 
 At all periods of growth the culture of the mind should be subor- 
 dinated to the furtherance of moral culture and the development of 
 physical stamina. It is a matter of common observa- 
 
 Physical Trlining. *^^" *^^^^ ^^^^^^ posture at school, at home, or induced 
 by occupation, and over or under exercise, cause in- 
 sufficient chest and muscular development and bodily asymmetry. An 
 increased popularity of all outdoor sports and games, and a recogni- 
 tion of the advantages afforded by systematic gymnastic drill in a well- 
 lighted, well-ventilated gymnasium, whose instructors recognise that simi- 
 lar muscles have not equal power in all individuals of the same age, must 
 have a beneficial effect on the improvement of the individual. The 
 results afforded by the investigations of the physiologists indicate that 
 the exercise of the muscles directly exercises certain regions of the brain, 
 thus indirectly improving the circulation and nutrition of that organ of 
 the mind. But exercise must be calculated to l)ring most of the groujis 
 of muscles into play ; not limited, as is walking, to the growth of the 
 muscles of the lower extremities of the body, or, as in rowing, to the play 
 of the muscles of the upper extremities and back. The scope of e^xercise 
 is more fully considered in another article in this volume. 
 
OLD AGE COMES ON APACE. 409 
 
 One of the most disastrous occurrences during this period is preco- 
 cious indulgence or abuse of the sexual instincts or appetites, resulting in 
 
 a premature breakdown of the constitution or in the pro- 
 Abuse of the Sexual -, ,- r i -c i t x i ij. tj; -at 
 
 r ,. , duction 01 a number oi maladies oi adult liie. ivlen- 
 
 Instmcts. 
 
 tal and physical debility are the consequences of such 
 abuses, and their prevention is a matter for the consideration of the 
 moral teacher rather than the hygienist. As such excesses produce their 
 chief deleterious effects upon the nervous system, so does the use of alco- 
 hol or tobacco at this period result in most injurious consequences to the 
 nervous organization ; alcohol and tobacco are not only unnecessary, but 
 they are poisons that are only tolerated by their hahitues in consequence 
 of long usage. 
 
 CHAPTER XIII. 
 HYGIENE OF OLD AGE. 
 
 The hygiene of old age is a very extensive subject, which can be con- 
 sidered only in a general way in these pages. With increasing years 
 there is gradual and progressive impairment in the structure and func- 
 tions of the whole body, and it is requisite, in order to preserve health 
 and retard the natural decay, to impose no greater task upon any organ 
 or system of organs than its reduced power or capacity can discharge. 
 
 All undue mental excitement or depression must be avoided, and the 
 
 brain should not be overworked by prolonged mental labour, or operations 
 
 in business which involve great strain and anxiety. 
 Mental Activity. ~^^ . ^ ^ ^ • , • i , , i i i ^ 
 
 JVlental labour is an essential to those who have always 
 
 been brain workers, but such labour should not be carried beyond the 
 point when slight fatigue is experienced ; a moderate exercise of the 
 mental faculties is " conducive to a healthy discharge of the cerebral 
 functions," which, through the brain, has a salutary inilueuce on the entire 
 system. Idleness and listlessness are as likely to lead to degeneration and 
 atrophy of the brain as is overwork. If the mental faculties have been 
 mismanaged during adult life there is likely to be more or less aberration 
 from a normal standard, causing the peculiarities, or, to adopt the vernacu- 
 lar, the crankiness of old age. 
 
 The lessened capacity of the stomach and its decreased muscular power 
 and nervous energy indicate the necessity of moderation in eating and 
 
 drinking and the use of those foods that are both nu- 
 Diet. . . 
 
 tritious and easily digested. A mixed diet is most suit- 
 able in old age, those vegetables and meats beins; selected that are easilv 
 changed by the smaller quantities of gastric and intestinal fluids. More 
 
410 HYGIENE 
 
 li«]uids than solids are needed, althougli there is a diminution in the quan- 
 tity of perspiration, the hangs exhale less moisture, and the kidneys do 
 not excrete urine as in adult life. Too large a (piantity of fluids, how- 
 ever, unnecessarily dilutes the gastric juice and diminishes its solvent 
 power as well as delays the other processes of digestion. Those who have 
 a good appetite should eat oftener, rather than chance overloading the 
 stomach by a heavy meal, which is digested so slowly that ferments may 
 be produced which, when taken into the system, act as poisons. ]\leats 
 should be tender and neither overdone nur uiulerdone ; roast beef or mut- 
 ton free from fat and gristle, poultry, and game are digestible; ])ork, salt 
 meats, veal, and lamb are indigestible and should not be used. Spinach, 
 potatoes, cauliflower, Brussels sprouts, asparagus, and raw tomatoes are 
 preferable to cabbage, carrots, and turnips. The ability to digest white 
 or sweet potatoes varies Avitli indivitluuls, though these vegetables are 
 better digested when baked. AVhile must ti.sh are digestible, shellfish, 
 especially lobsters and crabs, salmon, mackerel, and eels are undesirable. 
 Soups should be free from fat and large quantities of vegetables. The 
 stimulant and sedative effects of tea and coffee are useful in the weakened 
 tone of the stomach in advanced years. Plain simple dishes are to be 
 preferred to a variety of entrees served with rich sauces. The quantity 
 of food should be commensurate with the expenditure of tissue in mental 
 and physical exercise. Milk and eggs are among the best food stuffs foi- 
 the aged, and if starchy foods are given, malt preparations may have to be 
 administered, because there is not sufficient saliva or pancreatic juice to 
 make the first change in the digestion of carbohydrates — their conversion 
 into sugar. Food should be made appetizing by good cooking and the 
 skilful use of condiments, though it is to be remembered that the will- 
 power in old age often assumes the vacillating character of youth, and if 
 food is particularly inviting the aged may give way to gluttony or over- 
 indulgence. The moderate use of fermented or malt liquors is often of 
 advantage, for they stimulate the healthy discharge of the gasti-ic func- 
 tions. Sherry, port, and Madeira are often found beneficial, though their 
 use is usually unnecessary in those who have been unaccustomed to the 
 use of alcoholic drinks. 
 
 Exercise is as essential to the welfare of the old as to the young. The 
 
 particular form selected must be determined by the physical needs of each 
 
 individual. It is important to take exercise as far as 
 
 Exercise. •■< ^ • ,^ • -trn 1 ,^ • i c 
 
 possible in tlie open air. When the weather mterieres 
 with outdoor exercise massage may be substituted. Light work in a garden 
 is very useful as a means for calling most muscles of the body into play. 
 
 As there is a diminished power of generating and preserving heat in 
 the aged, it is necessary for them to wear M'arm clothing in order to pre- 
 vent the possible evil effects of chilling the body. Woollen underclothing. 
 
FOR THE AGED AND BRAIN WORKERS. 411 
 
 of different wciglits according to tiie season of tlie year, should be worn ; 
 furthermore, it is desirable for the aged to use chest protectors, abdominal 
 bands, and knee protectors during cold weather, as tlje 
 vmg. ehest, abdomen, and knees are particularly apt to be 
 
 affected by the temperature. Those who suffer greatly from the cold 
 should use two suits of underwear — silk next the skin and wool over the 
 silk ; such an arrangement is necessary for those who^e skin is irritated 
 by wool. Cotton instead of linen sheets should be used. 
 
 The skin, like the other organs of the body, loses the activity of its 
 
 functions in old age ; it becomes dry, withered, and scaly, and does not 
 
 carry off effete matter from the pores, which are con- 
 
 nng an eep. ^^.^^^^^ . j^g action should therefore be furthered by 
 frequent bathing with the friction of a bath glove or flesh brush, the 
 body being dried by a Turkish towel. Tepid baths followed by a cold 
 or cool shower bath are most useful. 
 
 Sleep is variable in the aged, some sleeping several hours a day as 
 well as through the night, others, while retiring early, awakening at an 
 early hour in the morning. For the repair of tissue waste and for rest 
 for the nervous system sleep is as necessary in old age as in infancy. The 
 room should be quiet, the temperature and air supply carefully regulated, 
 and the bed covering sufficient for warmth without being heavy. An 
 afternoon nap, if it does not prevent sound sleep during the night, is both 
 pleasant and healthful. 
 
 With the diseases of old age this article has nothing to do, but 
 whether the labour and sorrow of old age referred to by the psalmist is 
 to predominate will depend entirely upon the early life of the individual. 
 Oliver Wendell Holmes said something about preferring to be sixty years 
 young rather than forty years old, and a well-regulated life will as assur- 
 edly lead to a mellow old age as will an ill-regulated life eventuate in a 
 decrepit maturity. 
 
 CHAPTEE XIY. 
 HYGIENE OF BRAIN WORKERS. 
 
 The nervous system of the brain worker is constantly exercised, while 
 in many cases the muscular system is used onlv at rare and irregular in- 
 tervals. There is more or less torpor in the performance of the functions 
 of the organs, and the individual is subject to various disturbances. The 
 brain-cells must be kept in good order for the healthy operation of the 
 mind ; their nutrition must be well maintained, as thev do not act well 
 
412 HYGIENE. 
 
 when the body is stuffed with an indigestible or overwhehning amount 
 of food or when it is starved. For the nutrition of these cells it is quite 
 necessary tliat the individual should have a good supply of oxygen ; in- 
 sufficient air soon becomes vitiated, and wlion respired interferes with the 
 best action of the mind. 
 
 One of the first" signs of mental overexertion is the intrusion of un- 
 welcome thoughts or unpleasant suggestions without relevancy to the 
 
 work or line of thought in which the individual is en- 
 
 Sigus of Mental , im • • -c n ' i i i • i • i i.i 
 
 r- ;. ^ao-ed. lliis is lullowed bv poor sleep, in which tliere 
 
 Fatigue. . . " . . . 
 
 are frightful dreams or there is insomnia. When such 
 
 conditions ensue, work should be stopped and a physician consulted. 
 
 As a result of the fatigue, exhaustion and temporary powerlessness of 
 the brain tissue ensue ; the sympathetic nerves normally contract uj)on the 
 blood-vessels which they accompany and diminish the supply of blood to 
 the brain, and thus produce sleep, but in morbid wakefulness the sym- 
 pathetic nerves lose their grasp upon the capillaries of the brain, to use 
 Dr. D. H. Tuke's expression, and the gray matter persists in keeping up 
 its molecular activity, which may at first produce brilliant results, but is 
 more often imperfect and intermittent, finally ending in vague, irregular, 
 and indefinite mental action. Instead of stopping work at the right time 
 in order to recruit itself the brain goes on acting, and when eventually its 
 action is suspended and the supply of blood is shut off, such an irritability 
 has been produced in the nerve tissue that the sympathetic nerves are 
 unable to control the vessels, and the brain's action recommences before 
 it has had sufficient rest following the preceding day's work. 
 
 Sleeplessness, dull headache, singing in the ears, a sense of fulness in 
 the head, inability to do an amount of mental work once easily per- 
 formed, powerlessness to read any book that demands the slightest con- 
 tinued attention, listlessness, and inaptitude for the duties of life are some 
 of the symptoms indicative of the exhaustion of the brain and of the 
 necessity of rest, if not of medical advice. 
 
 As the nature of the individual absolutely demands activity, so it re- 
 quires repose. Next to sleep, rest from work is a ne- 
 Activity and -i. i? ..i i • ^ mi • .. i i ^ 
 
 p cessity lor the brain worker, iiiis rest may be best 
 
 obtained by taking exercise ; or, if this be impossible, 
 by indulging in some amusement such as billiards, whist, chess, or some 
 similar game. 
 
 The diet of the brain worker should be digestible and easily assimila- 
 ble, the food should be properly cooked and seasoned, the meals taken at 
 regular hours not too long separated, alcoholic stimu- 
 lants should be eschewed, and the first symptom of in- 
 digestion should receive the attention of a physician. If food is taken 
 in too great excess and especially thus taken at long intervals, it will not 
 
SUBJECTS FOR MUNICIPAL LEGISLATION. 413 
 
 be digested and absorbed. Nitrogenous foods ai-o most rolisliod by brain 
 workers, who are likely to associate with their use large quantities of 
 coffee and tea. 
 
 Pure air, good light, regular hours of mental work, exercise, good 
 diet, bathing, and that exercise of the will requisite to maintain cheerful- 
 ness are the measures which will secure the best mental work. 
 
 CHAPTER XY. 
 OFFENSIVE TRADES OR OCCUPATIONS. 
 
 There are a number of trades or occupations that are offensive and 
 prejudicial to the health of a conmiunity, and they may be included in 
 one of the two classes : 1, Trades or business in which raw materials of 
 an animal or vegetable nature are employed ; 2, manufacturing processes 
 that evolve noxious gases or vapours. 
 
 In most cities there is a municipal ordinance which forbids within the 
 limits of the municipality bone boiling, bone burning, bone grinding, skin- 
 ning dead animals, or boiling offal, or the maintenance of any place of 
 business dangerous to life or detrimental to health, where unwholesome, 
 offensive, or deleterious odours, gas, smoke, deposit, or exhalations are 
 generated. 
 
 Slaughter houses should not be allowed within municipal limits, because 
 
 they pollute the atmosphere, there is likely to be an accumulation of filth 
 
 about the premises, which are kept clean with difficulty, 
 
 and they are infested with flies, which are likely to 
 
 carry the germs of tuberculosis, malignant pustule, or some other disease 
 
 to healthy persons, or to deposit these germs on cooked food stuffs. 
 
 The blood of animals is used for a number of purposes ; mixed with 
 fat and condiments, it is used for blood pudding ; or alone, it is used to 
 feed pigs ; or the serum may be separated from the clot so as to get the 
 albumin, and the clot is used for manure, the manufacture of Turkey red, 
 and other purposes. The fat of pigs is used to manufacture lard, while 
 that of cattle and sheep is used for manufacturing fat and oleomargarine. 
 Of the viscera, the first stomach of cattle and sheep is cleaned to make 
 tripe ; the second stomach and small intestine may be used to feed pigs 
 or dogs ; the small intestine may be used to make sausage skins or for 
 the manufacture of scraped guts ; the large intestine may be used for 
 human food ; the heart and lungs are used by sOme people for food, while 
 the liver and kidneys are frequently thus utilized. The utilization of the 
 
41i HYGIENE. 
 
 materials constituting the carcass of an animal becomes a nuisance in 
 consequence of the bad condition of the premises where the work is con- 
 ducted ; or because of the accumulation of material which is to be con- 
 verted into mercantile products ; or on account of the odour from the 
 boiling or other treatment of the articles. 
 
 The manufacture of glue from the bones, hoofs, horns, scraps of skin 
 
 and leather, etc., may be attended with great nuisance in consequence of 
 
 the foul odours from the boiling material or from the 
 
 Manufacture of ^,^,^-^^^^^ |gf^ ^f^gj. boiling. Soap manufacture may be a 
 
 Crlue and boap. /• i <v • 
 
 nuisance in consequence of the onensive odours from 
 
 some of the fats used ; this may be prevented by suital)le a])paratus. 
 Bone boiling is likely to produce very unpleasant odours, and the efHu- 
 vium shoidd be carried through a furnace to very high chimneys. 
 
 The conversion of a raw hide covered with hair and putrescible mate- 
 rial into leather may be carried on without nuisance. The latter is 
 caused by the bits of Hcsh, fat, hair, and skin which are 
 
 omerswn o allowed to accumulate on the premises and putrefy and 
 Hides into Leather. ^ r ./ 
 
 foul the air. The water in the tan ])its may be emptied 
 
 into and pollute a stream. The first-mentioned objection may be cor- 
 rected by cremating the refuse, and the second by filtration and precii)ita- 
 tion of the water. 
 
 The manufacture of artificial manures is very offensive on account of 
 the odours given off by the works. The vapours produced in the manu- 
 facturing processes should be burned in a furnace or 
 Artificial Manure. i i i ^ t , ^ i ,i mi _e 
 
 condensed by a cold-water shower bath, ihe use oi 
 
 air-tight receivers will further limit the effluvium so that no serious 
 nuisance will result. 
 
 In a number of manufactures unpleasant odours or I'efuse are pro- 
 duced ; the former may be obviated by propelling all vapours by a fan 
 through water, to a furnace, where they are consumed in part and dis- 
 charged by a high chimney. The manufacture of bricks, Portland 
 cement, lime, gas, and of substances containing arsenic, mercury, chro- 
 mium, lead, zinc, and phosphorus are often associated with nuisances which 
 are more likely to demand the attention of the health officer than of the 
 amateur sanitarian. 
 
ORIGIN AND NATURE OF COMMUNICABLE DISEASES. 415 
 
 CHAPTER XVI. 
 COMMUNICABLE DISEASES. 
 
 While it has long been known that certain diseases are communi- 
 cable, under certain conditions, from one individual to another, it was 
 not until the investigations of bacteriologists showed the 
 , ,, . true character of contagia that the question of the com- 
 
 municability of disease was removed from the domain 
 of speculation. The germ theory of disease rests upon the definite basis 
 referred to in the first portion of this article, and while it does not satis- 
 factorily explain every feature in the dissemination of disease, or finally 
 settle many very profound and complicated questions, it does afford a bet- 
 ter reason for the occurrence of disease than anything previously known. 
 The fact that the introduction of a certain germ, always found in the 
 body of a person affected with a particular disease, produced the phe- 
 nomena of that disease in an animal of another species, afforded logical 
 proof of the relation between that micro-organism and the disease in 
 question. Reference has been made to the fact that the microbial origin 
 of many of the most important of the communicable diseases is a matter 
 of deduction rather than demonstration. Investigation has shown that it 
 is not always the micro-organism itself, but the poisonous principles it 
 produces that originate man}" of the phenomena of disease processes. 
 
 Certain micro-organisms must be introduced into the system by means 
 of food and drink, others are introduced by respiration. They may be 
 dormant in food or drink, in clothes or furniture, retaining their conta- 
 gious properties and infecting, long after leaving their original host, 
 another person into whose body they are introduced, '^qq, Diseases in 
 General. 
 
 Communicable diseases include those that may be communicated to 
 
 another individual by any mediun. Formerly they were divided into 
 
 contagious diseases or those acquired by direct contact ; 
 GlassiUcations, Old . » , . , , • j_ i i • 
 
 J -XT infectious, or those communicated by air, water, or some 
 
 other fomites; or zymotic, in which the disease was 
 
 communicated by a living organism that had the nature of a ferment ; or 
 
 specific, in which the disease originated from some pre-existing case of 
 
 the disease by means of a specific virus. Such diseases are said to be 
 
 endemic when they are more or less restricted to some particular locality, 
 
 in which they reappear from time to time, like yellow fever in Havana. 
 
 An epidemic disease is one that appears suddenly, spreads rapidly, and 
 
 affects a large percentage of the inhabitants of the places where it appears. 
 
 A sporadic disease is one that appears as an isolated case that, apparently, 
 
 has no connection with a previously existing case. 
 
416 
 
 HYGIENE. 
 
 Louis C Piirkes has arriiiiii:ed a very comprehensive table of com- 
 municable diseases. They are arranged in Class A, in which the conta- 
 gion is disseminated by the air, as in the eruptive fevers; Class B, in 
 which the contagion is air- or water-borne, and is constantly present in 
 certain localities, where the disease may become epidemic and the conta- 
 gion exhibit special virulence; Class C, in which the disease is transmitted 
 from the sick to the healthy by inoculation ; Class D, in which a surface 
 lesion is necessary for the introduction of the air-borne contagion, or it 
 may be directly inoculated therein ; and Class F, in which the contagion 
 may be introduced by the air or by inoculation. Some of these diseases 
 afiEect man alone, others man and the lower animals. 
 
 COMMUNICABLE DISEASES. 
 
 Class A. 
 Contagion, usually air borne. 
 
 Class B. 
 
 Contagion, usually air- or water-borne. 
 
 Class C. 
 Contagion, usually by inoculation 
 
 Smallpox. 
 Scarlet fever. 
 Measles. 
 
 German measles. 
 Mumps. 
 Chicken pox. 
 Yellow fever. 
 Cholera. 
 Enteric fever. 
 Dysentery. 
 Diarrhoea. 
 ' Anthrax or malignant pustule. 
 Foot-and-mouth disease. 
 
 Whooping cough. 
 Influenza. 
 Typhus. 
 Erysi{)i'las. 
 Epidemic pneumonia. 
 
 Dengue. 
 Diphtheria. 
 Relapsing fever. 
 Oriental plague. 
 
 Leprosy. 
 
 Glanders. 
 
 Rabies. 
 I Vaccinia, 
 r Erysipelas. 
 
 Class D. 
 Surface lesion necessary for contagion, J Py,-p 
 
 air-borne or directly by inoculation. [_ Hospital gangrene. 
 
 Ophthalmia. 
 
 Syphilis. 
 
 Gonorrhoea. 
 
 Tetanus. 
 
 Septicaemia. 
 
 Puerperal fever. 
 
 Class E. 
 Contagion air-borne or by inoculation 
 
 \ Scrofula. 
 / Lupus. 
 
 r Tubercle. 
 
 [ Cerebro-si)inal meningitis. 
 
 The essential features of the principal communicable diseases are out- 
 lined in the table on the following page. 
 
 Smallpox is an acute infectious disease that was once the scourge of 
 mankind, causing about ten per cent, of the total number of deaths. But 
 the introduction of vaccination in ITDG in consequence 
 ' of Jenner's discovery has materially decreased the 
 
 prevalence of the disease. The prevalence of smallpox is directly related 
 to the thoroughness with Avliich vaccination is practised ; in 1890 the 
 death-rate from smallpox was ten times higher in towns of Switzerland 
 than in Germany ; it was thirteen times higher in towns of Hungary, 
 
TABLE OF COMMUNICABLE DISEASES. 
 
 417 
 
 Disease. 
 
 Period of incubation. 
 
 Appearance of eruption. 
 
 Period of infection. 
 
 Smallpox. 
 
 12 to 14, usually 12 
 
 Second or third day. 
 
 Three to seven weeks. 
 
 
 days. 
 
 on face and fore- 
 head. 
 
 
 Chicken pox. 
 
 7 to 14, usually 12 
 
 First to fourth day of 
 
 Fowr weeks; until every 
 
 
 days. 
 
 fever, on trunk and 
 shoulders. 
 
 scab has fallen. 
 
 Measles. 
 
 10 to 14, usually 10 
 
 Fourth day of fever, 
 
 During initial symptoms 
 
 
 days. 
 
 on forehead. 
 
 and until end of de.s- 
 quamation. 
 
 German measles. 
 
 7 to 15, usually 14 
 
 First to fourth day of 
 
 Same as measles. 
 
 
 days. 
 
 fever, on face. 
 
 
 Scarlet fever. 
 
 1 to 7, usually 3 to 4 
 
 Second day of fever. 
 
 End of desquamation and 
 
 
 days. 
 
 on trunk. 
 
 com pletc disappearance 
 of throat .symptom.s. 
 
 Diphtheria. 
 
 2 to 10, usually 2 to 
 
 No eruption ; rash 
 
 Until all discharges have 
 
 
 3 days. 
 
 sometimes on sec- 
 
 ceased and throat synif)- 
 
 
 
 ond or third day of 
 
 toms have disappeared. 
 
 
 
 fever. 
 
 
 Whooping cough. 
 
 4 to 14, usually 7 
 
 No eruption. 
 
 During catarrhal stage 
 
 
 days. 
 
 
 and as long as whoop 
 lasts. 
 While fever lasts. 
 
 Typhus fever. 
 
 1 to 14, usually 12 
 
 Fifth to eighth day of 
 
 
 days. 
 
 fever, on back and 
 sides. 
 
 
 Typhoid fever. 
 
 1 to 28, usually 12 
 
 Sometimes spots on 
 
 Until diarrhoea ceases. 
 
 
 days. 
 
 abdomen between 
 sixth and fourteenth 
 days. 
 
 
 Yellow fever. 
 
 1 to 7, usually 3 to 4 
 
 Jaundice sometimes 
 
 Until fever ceases. 
 
 
 days. 
 
 on second day of 
 fever. 
 
 
 Relapsing fever. 
 
 4 to 10, usually 6 
 days. 
 
 No eruption. 
 
 Until relapse ceases. 
 
 Mumps. 
 
 14 to 21 days. 
 
 No eruption. 
 
 Until swelling has disap- 
 peared. 
 
 Dengue. 
 
 3 to 5 days. 
 
 Often an eruption on 
 fifth to eighth day. 
 
 Until fever ceases. 
 
 Cholera. 
 
 2 to 5 days. 
 
 No eruption. 
 
 After diarrhoea ceases. 
 
 forty-two times higher in towns of Belgium, fifty-six times higher in 
 French towns, sixty times higher in Austrian towns, and ninety-seven 
 times higher in Italian towns, than in those of Germany. In Great Britain 
 the mortality was lower than in Germany, but the suspension of compul- 
 sory vaccination in certain districts is likely to increase the mortality- 
 rate. 
 
 While smallpox usually spreads from person to person by immediate 
 contact with the affected individual or with some article he has used, 
 experience has proved that the contagion may be conveyed by the 
 air to a distance. A person may be within a few feet of a smallpox 
 patient and neither touch him nor his clothing, yet acquire the disease ; 
 but that the infection is carried for from three to four thousand feet 
 without the agency of inefficient quarantine or of flies seems question- 
 able. 
 
 Dr. Barry traced, in England (Sheffield), the influence of a smallpox 
 29 
 
418 
 
 HYGIENE. 
 
 hospital for a circle of four thousand feet. The percentages of house- 
 holds attacked at successive distances were : 
 
 0—1,000 feet. 1—2,000 feet. 2—3,000 feet. 3—4,000 feet. Elsewhere. 
 1-75 ('•:>•> 0-U 0-05 0-02 
 
 ^[r. Powers, in investigating the infection of households in the neigh- 
 bourhood of the Fulhani smallpox hospital, found that the disease 
 decreased in frequency in circles at radii of a quarter of a mile from the 
 hospital, though the direction of the prevailing wind furthered the preva- 
 lence of the disea'^e in a seirment of the circle : 
 
 i mile. 
 11-40 
 
 J mile. 
 
 20;] 
 
 S mile. 
 1-33 
 
 1 mile, 
 0-90 
 
 The efficacy of vaccination de})en(ls upon its repetition every few 
 years, calf lymph being employed. If the person vaccinated is protected 
 by a former vaccination the new vaccination will not 
 amount to more than a local scab ; but if the individual 
 is unprotected there will be a typical case of vaccinia. The protective 
 influence is lost in the course of time, and it is generally found that re- 
 vaccination at puberty and adult life will be successful. It must not be 
 supposed tliat a large scar indicates a successful vaccination, for often 
 scj^tic matter is introduced with vaccine and the scar is the result of septic 
 infection. Dr. L. C. Parkes quotes Dr. Collie's statistics that under and 
 over fifteen years of age the mortality percentage of smallpox in the un- 
 vaccinated is nearly identical, while the influence of the number and char- 
 acter of scars in the vaccinated is not as important in those under, as in 
 persons over, fifteen years of age. These facts are well shown in the fol- 
 lowing diagram : 
 
 LONDON SMALLPOX EPIDEMIC, 1871, 1881. 
 Mortality Per Cent. 
 
 UNDER 15 YEARS 
 
 40r 
 
 A BCDE ABCDE 
 
 A, unvaccinated ; B, those havinsr onn or morR bad marks; 0, tliose havinij one good mark; D, 
 those having two good niark.s ; E, tliose having three good marks. 
 
HISTORY OF ASIATIC CHOLERA. 41!) 
 
 The diagram sliows the ephemeral character of llie primary vaccina- 
 tion, for while with one or more bad marks the mortality is reduced to 
 four per cent, in those under fifteen, it is ten per cent, in those over fif- 
 teen ; and the mortality from smallpox is lessened by the number of 
 good vaccination scars. While occasionally syphilis, leprosy, and septic 
 infection have followed vaccination, it was only in persons who were vac- 
 cinated with human instead of bovine lymph ; such cases are very in- 
 frequent, and vaccination is one of the greatest boons conferred on 
 mankind. 
 
 Cholera is a specific infectious disease caused by the cholera spirillum, 
 a micro-organism discovered by Prof. Koch. It is endemic in India, 
 
 where it has been known for centuries ; from that coun- 
 
 Gholera. , ■. • i • i • i • an 
 
 try it was carried as an epidemic, or pandemic, iiie 
 
 disease appeared in almost every country during the years 181T to 1823, 
 A second pandemic commenced in Bengal in 1826, extended over India, 
 thence to Persia, reaching Russia in 1829 ; from that country it spread 
 over Europe and was brought to North America. A third pandemic 
 commenced in 1846, extended over Persia, and attained its maximum in 
 Europe and the United States in 1848 to 1850 ; it prevailed more or less 
 extensively in the Western continents from 1852 to 1863, there being ap- 
 parently a continuous reproduction of the poison in extra-Indian countries. 
 The fourth pandemic commenced in India in 1863, extended to the sea- 
 coast of Arabia, and in a few weeks overran a large part of southern 
 Europe. The fifth pandemic commenced on the shores of the Black Sea 
 in 1871, spread over Europe, and reached America. The sixth pandemic 
 started in Egypt in 1883, ravaged southern Europe, and was carried 
 thence to South America. The seventh pandemic commenced in Persia 
 in 1891, extended to Russia in 1892, and thence reached several localities 
 in Europe. 
 
 There are three routes by which cholera reaches the Western nations : 
 1. By traversing India to the ISTortliwest Provinces, then crossing the 
 Khyber Pass on the north or the Bolan Pass on the west into Afghanis- 
 tan, then travelling onward to Cabul and to Herat, whence it follows 
 the caravan route through Balkh, Bokhara, Khiva, and the country of 
 the Kirghis into Russia. 2. It has spread from southern India up the 
 Gulf of Persia^ travelling northward to Syria and Egypt, and northwest- 
 ward across Persia to the Caspian Sea, thence along the western shore to 
 the Yolga, and up that river into Russia. 3. It has been transported to 
 the Red Sea, and thence to the countries bordering on the Mediterranean. 
 By means of vessels it has been carried eastward into China and Japan, 
 and one epidemic in America was introduced from Jamaica, whence the 
 disease was carried directly from India. 
 
 The large fairs that are held annually in several places in India are 
 
420 HYGIENE. 
 
 attended by mereliants and traders from all parts of that country, as well 
 as from neiglibonring states, and it may be easily understood how it is 
 possible for the healthy to be infected by those eomins; from localities 
 where the disease is prevailing, and for those infected traders crossing the 
 Himalayas to sow the seed of the pestilence as they travel. 
 
 The piliicrimage of the Indian ^lohammcdans to l\[ecca is another 
 medium by which cholera is distributed throughout Mohammedan coun- 
 tries. There is a prospect that international sanitary agreement will 
 secure the efficient sanitation of Mecca, and thus do away with this 
 plague spot. 
 
 In the Wanderiiuj Jew there is a picturesque description of the 
 progress of a cholera epidemic at the rate of the distance a man can jour- 
 ney in a day. Wherever pedestrianism, or horse or camel riding, afford 
 the sole means of travel the advance of a pestilence will be at such a rate 
 as is made daily. But these modes have been largely supplanted, and by 
 way of the Suez Canal there is frequent and rapid connininication between 
 India and Europe ; and the Caspian Sea steamers, connecting with the 
 Trans-Caucasian Railroad, place Russia in quick communication with 
 India. From the reports of the sanitary connnissioners with the Govern- 
 ment of India it may be seen that in live years, from 1886 to 1890, moi'e 
 than a million and a half of people died of cholera. The Government 
 of that country admits that what has been done in the direction of sanitary 
 reform may appear small in comparison with what remains to be done, but 
 it pleads the ignorance of the masses, their dislike of any change of custom, 
 the lack of sutlicient executive agencies, and the want of necessary funds 
 as mitigating circumstances that serve to condone its delinquency. The 
 latter seems the more flagrant in view of the number of capable and dis- 
 tinguished professional advisers it has had during the past thirty years. 
 
 As the writer has said elsewhere, while India's responsibility for past 
 cholera pandemics is possibly diminished by the then-existing ignorance 
 of the causation of cholera and the means by which the causative prin- 
 ciple was transmitted, our present knowledge shows that tliat country is 
 as responsible for cholera as are Central America, Cuba, and Brazil for 
 yellow-fever epidemics. However indifferent we may be to the annual 
 sacrifice of several hundreds of thousands of natives of India, however 
 much we may satisfy ourselves that it is but an application of the theory 
 of the extermination of the unfit and the survival of the fit, we can not 
 remain indifferent or satisfied when we contemplate the fact that evasion 
 of the responsibility of being our brother's keeper reacts upon ourselves 
 by perpetuating a disease that may at an}^ time invade the Western 
 World. 
 
 The experience of the United States has proved beyond question that 
 a properly administered quarantine will exclude cholera. The existing 
 
ON Vv^ARDING OFF THE CHOLERA. 421 
 
 system of notification of the appearance in a locality of one of tlie great 
 epidemic diseases enables our foreign consuls to notify our health officers 
 of the existence of tlie danger, and enables them to exercise additional 
 care in scrutinizing immigrants from infected countries. The detail of 
 medical officers of the United States to foreign ports of embarkation of 
 emigrants and the careful inspection of these people by competent medi- 
 cal men is another detail that has proved of great benefit in keeping 
 cholera out of the United States. 
 
 Dr. Ernest Hart, the able editor of the BriitHh Medieal Journal and 
 an able sanitarian, considers that the disease in question has proved of 
 such value in stimulating sanitary effort that it might appropriately be 
 called " the blessed cholera." 
 
 As he has aptly said, we may eat cholera, we may dririJc cholera, but 
 we can not catch it. In other words, if the purity of the water supply of 
 a community is assured, if its food supply is under the supervision of 
 competent officials, it is unlikely that an epidemic of cholera will enter its 
 boundary. As may be imagined, this entails the isolation of all affected 
 persons who may enter the confines of the community, the disinfection of 
 all discharges, the inspection of all railroad trains, and the preservation of 
 a general state of cleanliness. 
 
 An individual in a cholera-infected region must avoid excesses in eat- 
 ing or drinking, or late hours with insufficient sleep and dissipation, or 
 other forms of fatigue. Only boiled water should be used for drinking, 
 vegetables sliould be well cooked, fruit must be peeled, and care must be 
 used to prevent flies from having access to the food. The infectious 
 principle is contained in the discharges of a cholera-infected person, and 
 if the sick are avoided by all except their proper attendants, and if these 
 attendants are careful to disinfect the discharges and their hands and 
 clothing, it is unlikely that the disease will spread. 
 
 Yellow fever is an acute infectious fever occurring in tropical and 
 subtropical countries, characterized by jaundice and hsemorrhages. It 
 may be preceded by a feeling of lassitude and discom- 
 fort for several days before the attack, with headache, 
 pain in the back and loins, and lack of appetite. The period of incuba- 
 tion does not usually exceed four or five days, though it may be less than 
 twenty -four hours. The disease begins Avith a more or less pronounced 
 chill, more or less severe headache, persistent and distressing pain in the 
 loins, which are followed by, and continue during, the fever. AVith the 
 fever the face becomes flushed, or bright red and swollen, the eyeballs 
 shining and more or less decidedly injected ; there are more or less rest- 
 lessness and vomiting. The pulse, as a rule, is full, strong, and hard, but 
 as the disease progresses it loses its force and rapidity and becomes unusu- 
 ally slow and soft. The tongue is often narrow and pointed, slightlv coated, 
 
422 HYGIENE. 
 
 the niarii-iiis red, and the entire or^an iiu)i>r, hut later in the disease it be- 
 comes (Ivy and the coating is brownish. Thi^ skin is hot and dry during 
 the comnieucenient of the disease, and then it becomes moist, soft, and 
 cool, though occasionally it remains dry until death occurs; about the 
 end of the second day the skin becomes yellow, tlu' eoKmr varying in in- 
 tensity from that of an orange to a light yellow, the colour being due to 
 the deposit of blood or bile pigments, or both, beneath the superficial 
 layers of the skin. A notable feature of this disease is the decrease in the 
 quantity of urine excreted and the presence of albumin in the urine 
 passed. While in mild cases there may be but a moderate amount of 
 pain in the head and back, in mo.st cases these latter symptoms are severe 
 and distressing ; sleep is fitful and disturbed; there is often excitement, 
 which may end in delirium, or there may be apathy. 
 
 A common symptom in the early stages of the disease is vomiting; 
 the matter at first has a yellow colour, but later it has a brown or black 
 appearance, like coffee grounds. This l)lack vomit is due to the breaking 
 np of blood which enters the stomach in consequence of passive lu^mor- 
 rhage from the gastric nnicous meml)rane. This lui'morrhage may occur 
 in severe cases from the intestine, the bladder, the uterus, and the month 
 or nose. 
 
 There is a tenderness on pressure over the pit of the stomach, the ap- 
 petite is poor, and there is a constant feeling of discomfort and pain in 
 that organ. "When the fever ceases, especially if the vomiting has been 
 mild, there is likely to be a great desire for food, which, if gratified, will 
 result disastrously to the patient. 
 
 The prognosis of yellow fever is nnccrtain, because a case that apj^ears 
 mild at the beginning may change into a severe type of the fever. The 
 mortality has ranged in different epidemics from fifteen to eighty-five per 
 cent., the natives of a locality where the disease occurs suffering less than 
 iinacclimated residents. In those exposed to liard ships, in heavy drinkers, 
 and in individuals who lead dissipated lives, the disease is most severe. 
 The negro is less susceptible than the white race to the fever ; males are 
 more frequently attacked than females. 
 
 Surgeon-General George M. Sternberg, U. S. A., who studied the 
 subject of the bacteriology of yellow fever more exhaustively than any 
 other investigator, concluded that while the specific infectious agent in 
 yellow fever had not been demonstrated, it is ]irobable that it will be 
 found in the alimentary canal, as in the case of cholera. lie found that 
 there are many facts relating to the origin and extension of yellow-fever 
 epidemics which give support to the inference that the sj)ecific infectious 
 agent is present in the dejecta of those suffering from the disease, and 
 that accumulations of faecal matter and of other organic material of animal 
 origin furnish a suitable nidus f<^r the development of the "germ," when 
 
YELLOW-FEVER EPIDEMICS. 423 
 
 climatic conditions are favourable for its growth. Based on this reason- 
 ing, Dr. Sternberg suggested a method of treatment by one sixth of a 
 grain of bichloride of mercury and seven and one half grains of sodium 
 bicarbonate in three tablesi:)Oonf nls of ice-cold water every hour. 
 
 As has been said by an able committee of experts, the most frequent 
 agency in the dissemination of yellow fever from place to place is found 
 in yellow- fever patients ; and more epidemics of yellow fever have re- 
 sulted from the introduction into previously exempt places of persons 
 sick of the disease, or falling sick after arrival, than from all other causes. 
 But it is impossible to say to what extent the body, or the clotliing and 
 baggage, of the patient is responsible for an epidemic. 
 
 Yellow fever is unknown in Europe, except in Spain and Portugal, 
 where it was carried from Brazil and the Spanish West Indies ; it is also 
 unknown in Asia and Australasia. It has affected a few localities on the 
 west coast of Africa, while it seems to be endemic in Cuba, the Spanish 
 West Indies, and the eastern coast of South America. It is particularly 
 a disease of seaport cities, and it has been introduced into every seaport 
 of the Atlantic coast of the United States as far north as Boston, and 
 has even extended into the interior of the country along the Mississippi 
 River as far as St. Louis, and along the railroad routes. While the dis- 
 ease appeared occasionally in Cuba previous to 1761, since that date it 
 has existed there as an endemic, as was demonstrated by the Yellow Fever 
 Commission sent there by the United States in 1878, cases occurring not 
 only every year, but every month in the year. Yera Cruz and Rio Ja- 
 neiro have for years been endemic sites for yellow fever. 
 
 In 1793 there was a severe epidemic of yellow fever in Philadelphia 
 that Dr. Benjamin Rush attributed to putrid coffee ; the mortality was 
 ten per cent, of the gross population, although so many people (twelve 
 thousand estimated) left the city that it is likely that the actual mortality 
 was higher. In 1797 there was a second epidemic in Philadelphia, though 
 the mortality was not much greater than in 1669, 17-11, 1747, and 1793, 
 which are not always classed as epidemic years notwithstanding the fact 
 that a number of persons died of the fever. 
 
 In 1798 this fever was epidemic in New York, Philadelphia, Boston, 
 Charleston, S. C, Wilmington, l^ew London, and Portsmouth, the most 
 northern point in the United States where this fever has occurred. In 
 1802 there was another epidemic affecting the cities above mentioned, 
 except ISTew York and New London as well as Baltimore. There were 
 a number of local outbreaks of the disease subsequent to 1802, but no 
 general prevalence occurred until 1853, when the fever was general 
 throughout the States of Louisiana, Mississippi, Alabama, Florida, Ar- 
 kansas, and Texas. In 1867 the fever prevailed extensively in Louisiana 
 and Texas. Florida, Alabama, Mississippi, Louisiana, and Texas suffered 
 
424 HYGIENE. 
 
 airaiu in 1S73. The last extensive epitleinie was in 1S7S, when the fever 
 existed in Ahihama, Mississippi, Louisiana, and Tennessee, while there 
 were a few eases in Kentuekv, Ohio, Illinois, and Missouri. 
 
 The experience of the quarantine s^-steni in vogue at the stations eon- 
 ducted by the United States and the States shows that if there is proper 
 sanitarv supervision- of vessels at their points of departure, and, if there 
 is any evidence of sickness, if they are thoroughly disinfected by the 
 sanitary authorities at the point of arrival, the germ of the disease can 
 be excluded. It must be always remembered that yellow fever, like chol- 
 era and typhus fever, is not indigenous in the United States, and that 
 proper quarantine precautions will exclude it. Those infected or ill Mdth 
 yellow fever must be isolated as far as practicable; and if the infection 
 gains access to a town, the healthy inhabitants should be removed to 
 camps of observation, those who subsequently become affected being at 
 once removed to a sick camp. The excreta, clothing, and other articles 
 that come in contact with the sick must be carefully and rigorously disin- 
 fected. 
 
 A susceptible individual should avoid infected localities, and, if this 
 is not possible, he should not go near wharves and shipping, or dirty or 
 infected parts of the city. He should keep regular hours, observe mod- 
 eration in diet and drink, keep out of the sun during the hot portions 
 of the day, keep the bowels regular, use baths daily, and sleep some dis- 
 tance above the ground. The sanitary improvement of cities may be so 
 tlioroughly carried out that yellow fever, if introduced, would be no 
 more dangerous to the community than typhoid fever, and it would 
 necessitate no greater or no less care. 
 
 Typhus fever is an acute infectious disease that is characterized by a 
 sudden onset, a spotted eruption, and marked nervous symptoms; it gen- 
 erally terminates by crisis about the end of the second 
 
 UP u eta. ^^.gg],_ j|. jg j-jQ^ indigenous in the United States, and it 
 was formerly more prevalent than it is to day, being known as hospital 
 fever, ship fever, camp fever, or jail fever, on account of its tendency to 
 affect people congregated in limited and unsanitary quarters. It is essen- 
 tially a disease that is propagated by overcrowding, lack of cleanliness, 
 bad food, and intemperance. 
 
 While the specific germ of this disease, which must not be confounded 
 with typhoid fever, has not been discovered, its highly contagious char- 
 acter suggests that it is a germ disease. The period of incubation usually 
 lasts a week, tliough it may be twelve days, during Avhich there is a feel- 
 ing of discomfort. The invasion is marked by one or more chills, fol- 
 lowed by fever, headache, pain in the back and legs, a flushed face and 
 congested eyes, a dry, white-furred tongue, and a dull, stupid condition. 
 The eruption appears between the third and fifth days upon the abdomen. 
 
ISOLATION AND GENERAL SANITATION. 425 
 
 upper part of tlio chest, extremities, and face; tlie raslj consists of dusky, 
 red or rose-colonred spots. There may be voiniting and retention of 
 urine. Tlie prosti-ation becomes more ]n'onounced, there may be delirium, 
 or the patient lies in a dull, apathetic condition. Sometimes the patient 
 lies with the eyes open but unconscious regarding his environment. 
 When the crisis occurs at tlie end of the second week the patient may 
 awake from a sleep, feeling better and clear in mind ; convalescence is 
 moderately rapid and a relapse is rare. 
 
 The mortality of the disease varies in different epidemics from ten to 
 twenty per cent. After middle age the mortality sometimes exceeds fifty 
 per cent., while children rarely die. The female sex seems most suscep- 
 tible. The disease increases in intensity in cold weather, in consequence 
 of the overcrowding and ill ventilation of apartments. 
 
 The affected should be isolated in barrack wards or in tents, and the 
 apartments from which they were removed should be thoroughly disin- 
 fected. 
 
 CHAPTER XVII. 
 THE PREVENTION OF COMMUNICABLE DISEASES. 
 
 MEANS EMPLOYED. 
 
 Prevention of communicable diseases includes the collection and dis- 
 posal of all filth and the abatement of nuisances which are likely to con- 
 taminate the air, drinking water, or food supplies. 
 General Smiitatio7i. -r-, ^ ,, ■, , , . . , . .,, 
 
 _Dut tliorougli as the general sanitation may be, it will 
 
 not suffice to restrict all these diseases if there is careless dissemination 
 of contagion. By means of vaccination immunity maj- be conferred on 
 a community against the prevalence of smallpox, and medical science is 
 assiduously investigating the question of the prevention of those com- 
 municable diseases, but one attack of which, as a rule, occurs during life. 
 Until this question is decided recourse must be had to isolation and dis- 
 infection. 
 
 Isolation may be secured by sending the patient to a hospital for 
 communicable diseases, which is too often called a pesthouse. As a mat- 
 ter of course, such disease can not be treated in the 
 Isolation, ic ii -i t r •, . . . 
 
 wards of a general hospital, and few sucfi institutions 
 
 have detached pavilions for the reception of patients suffering with these 
 diseases. Home isolation is often impracticable, and it is desirable that 
 all communities should contribute to their own welfare by establishing 
 hospitals for patients suffering with diphtheria, scarlet fever, measles, 
 
426 HYGIENE. 
 
 chicken pox, variola, varioloid, ami other such diseases as may happen 
 to be prevalent. 
 
 AVherever the comnumity is large enough to have a board of health 
 it should be the duty of every ]>liysician to report in writing the name, 
 age, and residence of every inili\ idual under his care suffering with one 
 of the more importilnt communicable diseases. 
 
 The diseases so included are, as a rule, cholera, yellow fever, small- 
 pox, diphtheria, including membranous eroiip, typhus fever, typhoid 
 fever, relapsing fever, scarlet fever, measles, and in some localities tuber- 
 culosis. Besides the foregoing, in Frauce choleriform diseases, plague, 
 dysentery, puerperal infections, and ophthalmia neonatorum must be re- 
 ported ; Mhile in Englan.l and AYales erysipelas and continued fever are 
 reported and several of the above-mentioned diseases are not reported. 
 If the relatives of the affected person are unal)le to enforce jiroper iso- 
 lation, then the sanitary authorities should be vested with power to re- 
 move the piatient to a jiroperly equipped hospital, where sutheient care 
 and attention will be given to promote his recovery as well as to prevent 
 any extension of the disease. By thus isolating the first case it is almost 
 impossible for the disease to make any headway, because the infection 
 may be destroyed by proper methods, and those in association with the 
 patient can be kept under supervision until the period of incubation has 
 passed. 
 
 When hospital isolation is undesirable or impossible the patient should 
 be placed in a room in the top of the house, and other inmates of the dwell- 
 ing slionld have no commnnication with it. The carpet, curtains, and 
 other hangings, pictures, ornaments, and superfluous furniture should be 
 removed, as they may retain the contagious principle for months. Proper 
 ventilation should be secured by means of some of the measures sug- 
 gested in the chapter of this article on that subject. There should be an 
 abundance of light, because sunlight is an excellent disinfectant, the in- 
 fectious agent retaining its virulence longest in a dark room. Aerial 
 connection between the sick-room and the rest of the house should be 
 prevented by locking all doors of exit from the room save one, and tack- 
 ing outside of this one a sheet which is completely moistened with a two- 
 and-one-half-per-cent. solution of carbolic acid in glycerin, or some other 
 disinfectant liquid. 
 
 Nothing must be permitted to leave the room until it has l)een disin- 
 fected, and all dressings and rags should be burned. Soiled bedding and 
 clothing .should be placed immediately in a disinfectant solution. 
 
 If the disease is one of the contagious diseases of childhood and there 
 are other children in the house, it is advisable, if possible, to remove the 
 healthy children to some other house. Parents should not believe that it 
 is necessary for a child to have any of the communicable diseases, or that 
 
MANAGEMP3NT OF COMMUNICABLE DISEASES. 427 
 
 the sooner it lias such a disctise and "gets over it" the better. Disease 
 
 is not a normal, but an abnormal state, and consequently no disease need 
 
 be acquired in order to further a child's welfare ; and, furthermore, it is 
 
 impossible to say whether a child will get over a disease, for any of these 
 
 affections of childhood may be followed by sequelae that will affect the 
 
 child's health for the balance of its life. For this latter reason it is quite 
 
 essential that healthy children in a family in which one child is suffering 
 
 with a communicable disease should not be allowed to go to school. 
 
 Those in attendance on the sick should wear dresses made of some 
 
 material that may be easily washed. They should f re- 
 Other Preventive ^i ^ .^ ' ^ ^ •.^ i . -l 
 
 j^ , quently wash their hands with soap and water, subse- 
 
 quently rinsing them in some disinfectant solution. 
 
 All discharges from the patient should be received into a covered 
 vessel containing a disinfectant solution, in which they are allowed to re- 
 main for ten or fifteen minutes. The discharges should not be thrown 
 into a privy vault or cesspool, but buried at some distance from the 
 well. 
 
 In scarlatina, diphtheria, measles, and smallpox it is better to wipe 
 the discharges from the mouth and nostrils by Japanese paper napkins or 
 soft tissue paper, which can be placed in a paper bag (such as grocers use) 
 and burned. This arrangement is preferable to using rags or towels, as 
 the paper napkins cost but a small sum per gross and their destruction is 
 easily assured. 
 
 There should be no beating or brushing of clothing or bedding, or 
 dusting, in the sick-room, the dust being removed daily by wiping the 
 furniture, floor, and window sills with a cloth wet with a solution of cor- 
 rosive sublimate of a strength of 1 to 1,000, or with a five-per-cent. car- 
 bolic solution. Both on account of preventing annoyance to the patient 
 and of limiting the extension of the disease, the windows should be, in 
 warm weather, protected by screens or mosquito netting to exclude flies. 
 
 During convalescence from smallpox, scarlatina, and measles the body 
 should be disinfected daily by the use of warm baths, in accordance with 
 the directions of the attending physician. 
 
 Clothing, bedding, towels, etc., should be placed in a covered vessel 
 
 containing a five-per-cent. carbolic-acid solution, and then the articles 
 
 should, after prolonged immersion, be boiled or steril- 
 
 -D ,']■ . ized by steam. Where there is a public disinfecting 
 
 Bedding, etc. ■■ _ ^ o 
 
 plant all clothing may be sent to it. 
 
 An iron bedstead that has a woven-wire mattress is best for use in the 
 
 sick-room, because one or two blankets may be folded and laid over the 
 
 wire mattress instead of using a hair, cotton, or other mattress. A bed 
 
 so made is very comfortable, the frame can be thoroughly disinfected, 
 
 and the blankets can be sterilized more convenientlv than a bulkv mat- 
 
42S HYGIENE. 
 
 tress. If the latter is used it should be protected by a piece of rubber 
 sheeting that can be destroyed when the illness has terminated. 
 
 The bed linen must be kept clean, being changed as often as necessary. 
 The person of the patient should be kept scru})ulously clean ; the nates 
 must be carefully wiped with paper moistened with bichloride or carbolic 
 solution after each 6vacnation ; oil of sweet almonds, or some similar 
 substance, may be applied to prevent diffusion of the scales of epi- 
 dermis in some of the eruptive diseases; and in smallpox powdered 
 lycopodium and talc may l)e dusted on the body. The use of baths is an 
 essential. 
 
 All instruments, such as thermometers, tongue depressors, throat and 
 
 nose tubes for syringes, etc., should be kept immersed 
 
 Care of Instru- .^^ ^ carbolic solution, a piece of cotton on the bottom 
 
 7nentS, etc. ' ^ . tt ^^^ r ^ 1 
 
 of the receptacle preventing likelihood of breakage 
 of glass articles. 
 
 Dishes, spoons, forks, etc., should be boiled in a solution of bicarbon- 
 ate of soda and then rinsed in pure water. 
 
 Food and liquids should not be allowed to stand in the sick-room, as 
 they may become contaminated. Only sufficient food and drink for im- 
 mediate use should be taken in at one time, and the portion unused should 
 be thrown into a disinfecting solution. 
 
 Books, toys, papers, etc., which were used by the patient should be 
 destroyed by burning. Toys have been known to retain contagion for 
 months, and even years. When the patient leaves the room at the end of 
 convalescence he should be thoroughly bathed in a carbolic solution, the 
 liair being washed with a bichloride-of-mercury soap, or saturated with a 
 solution of that salt, the nails cleaned, and the nose and throat irrigated, 
 and he should put on clean clothing. 
 
 In the event of death from a dangerous infectious disease, the body 
 should be enveloped in a sheet wet with some strong disinfectant solu- 
 tion, such as a l-to-1,000 bichloride-of-mercury solu- 
 " n fh' tion, or a solution of six ounces of chloride of lime 
 
 in a gallon of water, and then placed in a hermetically 
 sealed coffin, or (preferably) cremated. The funeral services should be 
 private. 
 
 When the illness has terminated and the patient left the room, the 
 latter and its contents should be disinfected. If possible, all bedding, 
 clothing, rugs, and other fal)rics should be sent to a dis- 
 mnjec ion. infecting establishment. If this is not possible, the 
 furniture should be covered, after taking all articles that could be boiled 
 to the laundi-y of the house, and the ceiling and walls should be wiped 
 over with a cloth wet frequently in a l-to-1,000 corrosive-sublimate or a 
 five-per-cent. carbolic-acid solution. If the ceiling and walls are painted 
 
METHODS OF DISINFECTION. 420 
 
 they can be well cleaned in tliis way; if tlic ceilin^^ i.s kalsomined it 
 should be subsequently scraped and rekalsomined, and if llie walls are 
 papered they should be repapered. After cleaning the ceiling and walls, 
 the window frames, windows, and floors should be carefully sponged with 
 the same solutions. The covers may then be carefully removed from the 
 furniture, placed in disinfecting solutions, and subsequently boiled. The 
 furniture nmst be carefully and thoroughly washed with hot water and 
 soap, all drawers being taken out and all bed slats or springs removed, 
 and then it may be sponged over with a disinfecting solution. 
 
 When the word disinfectant is used it is intended to signify a substance 
 
 which destroys infectious material ; it is therefore synonymous with the 
 
 terms bactericide or germicide. An antisejAic is an 
 
 Disinfectants, ^gent that arrests fermentation or putrefaction, imped- 
 
 Deodorants ^"& *^® growth but not destroying the vitality of micro- 
 
 organisms. A deodorant is a substance that destroys 
 or masks offensive odours, but it is not necessarily a disinfectant or even 
 an antiseptic. 
 
 Clinical evidence has shown that the activity of most, if not of all, 
 communicable diseases is materially impaired when the patients are freely 
 exposed to a plentiful supply of air. Hot weather inhibits the propa- 
 gation of some diseases, cold weather limits the spread of others ; but the 
 agencies of air and temperature do not always suffice, and disinfection 
 by other means is essential. 
 
 The most efficacious means of destroying infectious material is to 
 burn it, though necessarily the application of this measure is limited by 
 
 the value of the article exposed to infection. Dry heat 
 
 Dry and Moist -n i j. • £ i.- i. • i i i. -i. j. x 
 
 „ -^ „ . will destroy infectious material, but it penetrates verv 
 
 Meat : Burning. •' ^ . . 
 
 slowly into bedding and clothing, and it also affects the 
 articles exposed to it. Moist heat in the form of steam or boiling water 
 is a most valuable disinfectant that is susceptible of general application 
 and does not injure fabrics. Steam penetrates far more rapidly than dry 
 heat, and if it is applied under pressure it will disinfect fabrics in a short 
 time. Portable disinfecting chambers are now made at a small cost which 
 should be owned by every small city and town ; in large cities more capa^ 
 cious disinfectors should be built, disinfection being obtained in such 
 apparatus in from five to thirty minutes if the steam is superheated and 
 under pressure. Mattresses, pillows, carpets, curtains, blankets, towels, 
 clothing, etc., may be disinfected by steam, though it is not applica- 
 ble to leather, rubber, etc. When the steam is not obtainable small 
 fabrics should be disinfected by boiling, while carpets and mattresses 
 may be scrubbed with a bichloride solution and then exposed to the sun 
 for some time, though the sunlight is likely to affect the colours of the 
 carpets. 
 
430 HYGIENE. 
 
 The use of certain eliemicals that, in detinire quantities, destroy a mi- 
 
 ero-or^-auisni and its spores is termed cliemical disinfec- 
 
 „. . - ', . tion. Koch, Steruberir, and other investiirators have 
 
 Disinfection. _ ' . _" . ^- 
 
 studied the etlects of different chemicals, and the use 
 of such agents is to-day based upon their conclusions. 
 
 Mercuric chloride or corrosive sublinuite is one of the most efficacious 
 and powerful germicides in use, although it is precipitated by albuminous 
 substances and is exceedingly poisonous. By using an acidulated solution 
 the coagulation of albumin may be prevented, and by colouring the liquid 
 and using rough glass bottles its poisonons character is likely to be re- 
 called. A solution may be made by dissolving one ounce of corrosive 
 sublimate and two ounces of hydrochloric acid in six gallons of water, 
 which are coloured by ten grains of aniline blue. But if fabrics are to 
 be disinfected the aniline should be omitted. Instead of hydrochloric 
 acid, potassium and sodium chloride in the proportion of two and a half 
 parts of each to one of sul)limate may be used to prevent coagulation of 
 albumin. 
 
 Carbolic acid is not so readily decomposed as corrosive sublimate, and 
 it may be used in solutions of a strength of from three to five per cent. 
 Crude carbolic acid mixed with an equal volume of concentrated sul- 
 phuric acid and filtered is a good disinfectant for excreta. 
 
 Chloride of lime is a useful disinfectant for excreta, but not for cloth- 
 ing; it may be used in a solution of six ounces to a gallon of water. 
 
 A freshly prepared solution of quicklime is a valuable disinfectant for 
 typhoid and cholera evacuations, and whitewashing rooms or buildings is 
 an excellent measure after the presence of contagious diseases of cattle. 
 
 Permanganate of potash is a feeble disinfectant. 
 
 Sulphurous-acid gas is a useful disinfectant where there is no colour 
 that can be injured and when there is sufficient moisture to insure pene- 
 tration. 
 
 Commercial disinfectants which are advertised and sold as such are 
 expensive, and possess no advantages over those above enumerated. Clean- 
 liness, the free use of hot water and soap, and light and air are the most 
 efficient and general means of disinfection. 
 
VI. 
 SUKGICAL INJUEIES AND SURGICAL DISEASES. 
 
 By ALEXANDER B. JOENSON, M. D. 
 
 INTRODUCTION. 
 
 SuKGERY is that part of medical science which deals especially with 
 
 the cure and relief of diseases and injuries by manual and mechanical 
 
 means. Although surgery and internal medicine go 
 
 The Relatio7i of \xq,i\^ in hand, and are mutually dependent one upon 
 
 Surgery to Inter- , , , ,,-.^111 1 
 
 nal Medicine. ^^^^ ^ther, a good surgeon must hrst of all be a good 
 
 physician. 
 "Within the past twenty -five years many important advances have 
 been made in our knowledge of the causes, and consequently of the 
 treatment, of surgical diseases. At the present time there is scarcel}' an 
 organ in the human body which has not been subjected to successful sur- 
 gical treatment. 
 
 In the following pages the attempt will be made to instruct the 
 reader in regard to such facts as will enable him to render prompt assist- 
 ance to those who may be injured in various ways, 
 First Aid to the i . t ^ ^ "c • ^ ' i • ^ ^ • ^ . 
 
 r ■ n and to know how to retrain from domo' what is hurt- 
 
 ful. 
 Still more than this will be attempted. There are many surgical 
 
 diseases, the prompt and fitting treatment of which may save the indi- 
 vidual from speedy death, from protracted pain and 
 
 Surgical Diseases. ..... n T p- • t ■ 1 
 
 invahdism, or from permanent deformity, it is the 
 
 special purpose of this article to describe some of these conditions, in 
 
 simple language, so that they may be recognised in time to admit of 
 
 early and successful treatment. 
 
 Only such diseases will be described as are of common occurrence, 
 
 and the recognition of which does not necessarily require professional 
 
 training, or, if others are mentioned, they will not be dwelt upon at 
 
 length. 
 
 ^ 431 
 
432 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 The writer would prctix his statements by the assertion that there is 
 nothing occult or mysterious in the recognition and tJ-eatment of surgical 
 injuries or diseases, and that all the measures used are 
 Common Souse ^j„^piy g^^jji .^g ^re derived from the dictates of com- 
 mon sense aided by the facts known to us by obser- 
 vation and experien6e. 
 
 CHAPTER L 
 WOUNDS. 
 
 When the livini,^ elements of which the body is comjiosed are sud- 
 denly torn asunder by mechanical violence, the condition thus produced 
 is called a wound ; if the overlying skin is broken, we 
 Open Wounds; ^ -^ ^^ ^^^ ^ wound : if not, of a subcutaneous 
 
 Contusions. ' , ^ . . t j- n ^ 
 
 wound or contusion. An example oi tlic former con- 
 dition is the cut made by a knife ; of the latter, a black eye or a black 
 and blue spot. 
 
 Under favourable circumstances the separated tissues are reunited by 
 the production from the parts adjacent of sufficient new tissue to close 
 the gap. Tlie steps of the process may be described briefly as follows : 
 The divided vessels contract and retract, the little round or white cells of 
 the blood crowd about their cut ends, and, partly bj' mechanical and 
 partly by chemical action, help to stop the bleeding, a most important 
 function on their part in wounds of large size. In a few hours a soft, 
 sticky substance, Avhicli glues the edges together, is poured out from the 
 sides of the wound. In this sticky substance many more of the little 
 white blood cells congregate. Soon the cells of the tissue near the wound 
 begin to divide, each one into two, and to arrange themselves like bricks 
 in the space to be tilled. The little blood-vessels also begin to sprout and 
 to form new hollow tubes which project in loops, and these are joined by 
 other loops from the opposite side of the gap ; then the little loops open 
 into each other, and a bridge carrying nutriment for the growing tissue 
 is formed. The little white cells which first entered the breach perish 
 for the most part, and become food for the new tissue cells which come 
 after them. Thus the deeper parts of the wound are united. Many of 
 the new blood-vessels afterward disappear because they are not needed, 
 and many of the new tissue cells change their shape and come to resemble 
 the cells from which they originated. 
 
 The surface of the wound, which should l)e covered by new skin, is 
 healed by the growth and multiplication of the uj)per layers of skin cells 
 
ON THE HEALING OF WOUNDS. 
 
 433 
 
 at the sides of tlie wound. They spread from tlie edges to unite in the 
 middle of the wound, like the ice which forms upon a pond in winter. 
 
 
 When all the surface of the wound is covered in we speak of the re- 
 sulting new tissue as a scar. 
 
 Where the edges of a wound are closely in contact, healing is often 
 complete in a week. 
 30 
 
434 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 If tlie ixap to be tilled is not too great, niany wounds of muscles, 
 bones, ""lands, and some other tissues are united by new nmscle, bone, 
 flaud. etc. : but if the mip is too i^reat, or other circumstances are unfa- 
 vourable. the union takes place by coniiccri\c ti>.-uc merely — i.e., by an 
 ordinary scar. 
 
 When a considerable gap \\\\\>{ be lillcd Itcforc a wound can heal com- 
 pletely, the process is carried on in precisely the same way as when the 
 edges are in contact, but a longer time is recpiired. The new tissue grows 
 up from the bottom of the wound. AVhen the cavity is tilled, the skin 
 grows over the raw surface from the old skin at the edges of the wound 
 as before. 
 
 The closer the contact of the edges of a wound dur'nuj Jwaling, the 
 
 sooner the process is completed and the smaller the scar — a very im])or- 
 
 tant thing, sometimes, because scars contract with age 
 
 and pull on the adjoining structures, thus producing 
 
 deformities, especially near joints and openings, like the mouth and eye. 
 
 We have considered hitherto the healing of a wound under the most 
 favourable circumstances. The process has gone on rapidly and continu- 
 ously. There has been no pain, no redness of the 
 
 ea.in(] ]/ irs g]^iii j^q fever, and only a very small amount of watery 
 Intention. . ' ' '' -^ mi i t i 
 
 discharge from the wounded surface. The blood-ves- 
 sels and tissues near the wound have produced just enough new tissue to 
 fill the gap, and nothing has interfered with this function. Clean wounds 
 in healthy tissues ahoays heal in this way. But all wounds do not, and 
 the reason is that often something interferes and delays and prevents the 
 healing. When a wound becomes inflamed and painful, and does not 
 heal rapidly, it is because bacteria are growing in it. They have been in- 
 troduced usually from without, either at the time the wound was made 
 or afterward, and this leads us to the consideration of inflammation in 
 wounds. 
 
 THE RELATION OF BACTERIA TO THE INFLAMMATION OCCURRING 
 
 IN WOUNDS. 
 
 The reader will be told in another part of this volume of the relation 
 
 of bacteria to certain diseases, but in no way do bacteria make their 
 
 presence more distinctly manifest than in the changes 
 The Omnipresence i • i xi j i j.i • ^ ^ 
 
 , o _^ . winch they produce when they gam access to a wound. 
 
 ]^ot all kinds of bacteria interfere with the healing of 
 wounds, but the few kinds that do are so very abundant that practically 
 they may be said to exist in every spot on earth which human beings 
 are likely to visit, except on the tops of high mountains and in regions of 
 extreme cold, and even there they are not to be got rid of, for they in- 
 habit the surface of our bodies and all the little pockets which the skin 
 
OMNIPRESENCE AND AGGRESSIVENESS OF BACTERIxV. 435 
 
 contains. It is safe to say that one can not touch the tip of a linger to 
 any, article of household furniture or to one's clothing witiiout bringing 
 away several and perhaps many of these bacteria which cause woiinds to 
 inflame. 
 
 On entering a wound the bacteria find a soil upon which they thrive, 
 and heat and moisture, the conditions which they need for their growth 
 and multiplication. 
 
 They attack tlie living cells, especially the white blood-cells and tissue- 
 cells, and are in turn attacked by them. The tissues of the body make a 
 violent effort to get rid of the invaders ; the blood- 
 Warfare between vessels of the part dilate and inucli nioi-c blood is 
 Bacteria and ^ ,^ ^ ,^ • i • i i • 1 1 • 
 
 Livina Cells poured througli them, carrying little wliitc cells m 
 
 abundance. They leave the vessels and do battle with 
 the bacteria, which they inclose within themselves. Sometimes they de- 
 stroy and sometimes they are destroyed. The increased amount of blood 
 in the vessels is the cause of the redness and heat of the skin about an 
 inflamed wound. The tissue-cells multiply and together with the white 
 cells of the blood form a barrier to stay the advance of the bacteria. 
 The tissue-cells kill and are killed by the bacteria. Much fluid also 
 escapes from the blood-vessels into the tissues. In connection with the 
 many cells crowded in the inflamed part, it causes the swelling of inflam- 
 mation. The consequent pressure upon the nerves causes the pain. 
 
 Many white blood-cells and young tissue-cells appear upon the sur- 
 face of the wound and escape carrying bacteria within them. They, 
 with "a watery fluid, constitute the discharge from an inflamed wound, the 
 matter or pus. Other changes are produced by the bacteria. If their 
 attack upon the tissue-cells succeeds and many tissue-cells are killed, a 
 considerable area of dead tissue may be produced. This result is some- 
 times favoured by the overcrowding of the blood-vessels with blood-cells, 
 resulting in a stoppage of the blood stream. When this takes place the 
 tissue-cells are deprived of their nutriment and fall an easy prey to the 
 bacteria. Death of the tissue results. 
 
 The bacteria are harmful in another way. They produce violent 
 poisons which injure the tissues locally, and are absorbed into the sys- 
 tem, causing fever, great weakness, headache, loss of 
 
 Poisons produced j-i. ^^ .-i j. i • i ^• 
 
 , r, , ■ appetite and other symptoms which are sometimes 
 
 by Bacteria, ^^ . . . . , 
 
 severe enough to kill the individual. 
 
 When the bacteria which cause putrefaction in dead animal matter 
 gain access to a part of the body already dead, like a mortified limb, 
 they produce poisonous substances which act on the body like the poi- 
 sonous alkaloids (atropine, strychnine, or morphine). This condition is 
 called Septic Intoxication. 
 
 When the bacteria of wound inflammation multiply in a wound or an 
 
436 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 abscess, they also produce substances which poison the system, and the 
 liviuij: bacteria may enter the bk^od current and multiply, furnishing an 
 additional source of }>uis(_in. This cunditiun is called /Sejitic Infection 
 or Sij't'tCiDJtia. 
 
 The sHi:;ht fever accom[iaiiyinu: a boil is due to this cause as well as 
 the most rapidly fatal form of inllammation of the bowels or ])erito- 
 nitis whieh often causes death in a few hours or days. 
 
 AVhen the bacteria growing in a wound cause coagulation of the blood 
 in a vein, ami the bacteria-laden clot softens and portions of it are car- 
 ried to distant i)arts by the blood stream, abscesses nuiy 
 ^ ' |)Q produced in remote organs. This condition is 
 
 called Pycemia. 
 
 Usually, if the wound be not too large and the poisoning of the sys- 
 tem not too intense, the living tissues finally triumph, the bacteria are all 
 killed, the pain, heat, redness, swelling, and fever sub- 
 Healinghij Second ^^. ^j^^ ^^.^^^^^^^ ^^^ ^^ discharges pus, the dead 
 
 Intention. ' it-i im- 
 
 parts are separated from the living and are cast oil or 
 
 absorbed, and the wound heals as did the clean wound already described. 
 The process has taken much longer, and has been attended hy much 
 suffering and often bv severe illness from which the individual has but 
 slowly recovered. 
 
 The amount of interference which bacteria cause in the healing of 
 
 wounds varies much according to the number and special kind of bacteria 
 
 introduced, the size and situation of the wound, and 
 
 The Interference ^y^^ health of the individual. A few bacteria are often 
 
 with Healina killed speedily by the tissues and do no harm, but if 
 
 many are present, and of a virulent character, if the 
 
 tissues have been greatly bruised, if much blood lies in the wound cavity, 
 
 if the wound discharge can not escape, if the health of the individual is 
 
 feeble and his tissues are poorly nourished, if they be already diseased in 
 
 certain ways, then the bacteria find a favourable field, and inflammation 
 
 more or less severe occurs. Besides the bacteria which cause ordinary 
 
 wound inflammation there are others which, when introduced into a 
 
 wound, cause inflammatory diseases of special kinds. They will be 
 
 alluded to in connection with these diseases. 
 
 THE SYMPTOMS OF WOUNDS. 
 
 "Wounds made with a sharp cutting instrument, or where the tissues 
 are separated without much bruising, are called incited wounds. Such 
 
 wounds cause pain when inflicted. The sharper the in- 
 
 Incised Wou7ids. ^ ^ i .i • n i.i i • i i.i 
 
 strument, and tlie more rapidly the wound is made, tlie 
 
 less the pain. AYounds of sensitive regions, like the fingers and face, cause 
 
 more pain than those of less sensitive regions, like the skin of the back. 
 
BLEEDING FROM ARTERIES, VEINS, AND CAPILLARIES. 4:^7 
 
 The divided tissues arc clastic, and hence contract, cansiiii^' tlie wound 
 
 to gape. If a wound is made across the lcn<^tli of u litub it usually 
 
 gapes more than when made parallel thei'cto. JJivided 
 
 apmg. muscles, especially, contract and cause the wound to gape. 
 
 A more important symptom of wounds is bleeding, which may take 
 place from arteries, veins, or capillaries. In hleeding from an a/rtery 
 the hlood is of a hright-red colour and fov)S out in jets 
 mg. qj}Jii(iJi corresjjond to the heating of the heart. The 
 
 hleeding from veins takes place in a steady stream which vnells up from 
 the divided vein, especially from the end^ farthest from the Jteart, and. 
 the hlood is of a darker colour. Bleeding from cajjillaries, the smallest 
 hlood-vessels, takes place hy an oozing from the vjhole wounded surface. 
 The bleeding from small arteries, veins, and capillaries usually soon stops 
 of itself by contraction and retraction of the cut ends of the little vessels 
 and coagulation of the blood in their interior. This is Nature's method 
 of stopping bleeding, and it is fortunate that these changes do take place, 
 else a wound, however slight, would be fatal — a fact well shown in those 
 persons called " bleeders," in whom, because Nature does not stop the 
 bleeding in the way described, trifling wounds may be followed by severe 
 or fatal haemorrhage. When very large arteries or veins ai-e cut — like 
 the large vessels of the neck or the principal arteries of the limbs — death 
 may take place from loss of blood in a few minutes. 
 
 The general symptoms of severe bleeding are paleness and coldness of 
 
 the face and surface of the body, especially of the extremities, rapid and 
 
 feeble pulse, great and increasing weakness, spots be- 
 
 bymp omsoj ^^^^ ^^^^ eyes, noises in the ears, nausea, vomiting, gid- 
 
 bevere -Bleeding. ./ ' ^ ^^ ^ o 
 
 diness, great anxiety of expression and feehng, thirst 
 
 and dryness of the throat, sometimes fainting, which aids in checking the 
 
 bleeding, because, in fainting, the heart pumps the blood through the 
 
 vessels feebly and coagulation is favoured thereby. 
 
 The signs of a fatal termination are air-hunger, gasping for breath, 
 convulsions, dilatation of the pupils of the eyes, unconsciousness, and the 
 involuntary escape of the contents of the bladder and lower bowel. 
 
 The struo-fflins: for breath and convulsions are due to the same cause 
 which produces these symptoms in strangling — i. e., want of oxygen, 
 which the blood supplies, in the brain. 
 
 The entire quantity of blood in the body is about ten per cent of the 
 body-weight, and hence an individual weighing one hundred and fifty 
 pounds would possess about fifteen pounds of blood. In such an indi- 
 vidual a loss of seven pounds of blood would be surely fatal, and a loss of 
 four pounds would be very dangerous. Very young and very old people 
 bear loss of blood badly. 
 
438 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 GENERAL TREATMENT AFTER GREAT LOSS OP BLOOD. 
 
 The bleeiliiii; liaviiiii^ t^toppcd of itself, or havinjo; been stopped accord- 
 ing to the directions given under The Tiratmoit of Wounds, certain 
 measiires are used to restore the patient's strength. 
 
 AVhen bleeding- lias been slight and the ])atient has fainted from fright 
 
 rather than from loss of l)lood, a horizontal position (no jiillow under the 
 
 lu'ad). x\\v smelling of salts (,)f aniiiumia or weak am- 
 Slight Bleed i>i(/. . ^ j. \.\ -..1^.1 i • • *. i.- £ 
 
 ^ monia water, together witli the acnnmistration 01 a 
 
 tablespoonful of any strong liijuor not much diluted, will usually be 
 
 eliicient. 
 
 AVhen the bleeding has been large in amount more active measures are 
 used. Put the patient in bed with no pillow under the head, raise the 
 foot of the bed on a chair or on books or bricks so 
 iny. ^^^^^ ^1^^ head is lower than the feet to enable the 
 vital organs, especially the brain, to get as much blood as possible. Cover 
 the body with warm blankets and lay hot bricks, bottles, or cans full 
 of hot water along the limbs and trunk, protecting the skin from bui-n- 
 ing by covei-ing the hot materials with flannel or towels. Give hot milk, 
 coffee, or water by the mouth liberally, together with brandy or whiskey 
 in doses of a tablespoonful, repeated every fifteen minutes, or until the 
 pulse becomes slower and fuller and the patient's colour improves. In- 
 ject into the lower bowel, with a syringe of any kind at hand, half a pint 
 of hot water containing two tablespoonfuls of whiskey or brandy. Lai-ge 
 amounts of strong liquor do not produce intoxication under such cir- 
 cumstances. 
 
 In extreme cases the limbs may be tightly bandaged from the toes and 
 fingers to the trunk, to drive the blood to the vital organs. Other meas- 
 ures are used by medical men, especially the introduction of warm water 
 containing a small amount of common salt and carl)onate of sodium into 
 the arteries or veins, or merely beneath the skin. This treatment is of at 
 least temporary benefit. The direct transfusion of human or other blood 
 is dangerous and has been generally abandoned. 
 
 SHOCK. 
 
 This is a condition of more or less profound depression of the nervous 
 system and vital forces produced by injuries. It may be present after 
 only slight injuries in feeble persons, or absent in injuries of the gravest 
 character in the robust. It usually follows extensive crushing injuries, 
 such as are produced by heavy vehicles or railroad cars when they pass 
 over the limbs, or when vital organs are seriously injured, or when niul- 
 tiple injuries exist. 
 
 The symptoms of shock are cold, pale and clammy skin, rapid and 
 
SYMPTOMS AND TREATMENT OF SHOCK. 4'.'/,) 
 
 feeble pulse, shallow or irref^iilar respiration, mental apathy. Usually 
 patients do not coni[)lain of pain and arc quite insensitive to external 
 impressions. This condition may ])ass into unconscious- 
 y^P^^'^^^j jie^^g and death, or improvement may take place grad- 
 ually after the lapse of minutes or hours. Occasionally, 
 instead of apathy, excitement may exist, but this is more common after 
 severe bleeding. 
 
 The treatment of shock is similar to that of severe bleeding, except 
 that there is no need of large doses of fluid unless the two conditions co- 
 exist. Friction of the limbs toward the trunk may 
 ^^'^sZck '^^ ^® practised with benefit. Where possible, hyprjdcrinic 
 injections of the one thirtieth of a grain of sulphate of 
 strychnine, fifteen or twenty drops of tincture of digitalis, and an amount 
 of whiskey suited to the reaction produced by the treatment, should be 
 given. A patient should neither be disturbed nor moved more than is 
 absolutely necessary for his safety, and no good surgeon performs any 
 serious surgical operation until the patient has rallied, unless it be neces- 
 sary in order to stop bleeding or to fulfil some other vital indication. 
 
 LOSS OP FUNCTION. 
 After any severe crushing injury to a limb it is commonly paralyzed. 
 When muscles or tendons are cut, the parts which they should move are 
 paralyzed as far as motion is concerned. This is especially noticeable in 
 cuts which sever the muscles and tendons about the forearm, wrist, and 
 hand. When nerves are cut the muscles which they supply are no longer 
 under the control of the will and, if the cut ends are not reunited, the 
 paralysis is permanent. Division of a nerve of sensation is followed by 
 loss of feeling in the part supplied by that nerve. 
 
 PUNCTURED WOUNDS. 
 
 Punctured wounds are such as are produced when sharp-pointed bodies, 
 like daggers, long splinters of wood, needles, sharp splinters of glass, or 
 other similar substances penetrate the tissues. The depth of such a wound 
 usually greatly exceeds its diameter. Such wounds usually heal readily 
 unless many hacteria are introduced with the svhstance which nuikes the 
 wound, or unless some important organ is penetrated or some hody cavity 
 is opened and its contents wounded. In wounds of the chest, for exam- 
 ple, the lung may be wounded ; of the head, the brain ; and in wounds 
 of the belly the intestines may be punctured. It is usually in wounds of 
 this character that we find portions of the instrument 
 
 ,. , '. which caused the wound left behind in the tissues. 
 mane Aneurism. , , 
 
 When an artery of large size is punctured, tue wound 
 of the skin may heal, but the hole in the wall of the artery may remain 
 
440 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 open, and a cavitv, iilled \vitli fluid blood eonmiunieating with the artery, 
 may be formed in the Hnib. This condirinn is often very serious, and 
 usually requires a sur^y;ic'al operation and the ligation of the wounded 
 blood-vessel for its relief. 
 
 CONTUSED AND LACERATED WOUNDS. 
 Contused and lacerated wounds are those in which the tissues are torn, 
 bruised, and crushed. The edges of the wound are ragged, often blue 
 or black in colour, and quite insensitive. The deeper parts are frequently 
 much more extensively injured than the appearance of the skin would 
 indicate, and often some of the wounded tissues are so bruised that they 
 die and must come away before the wound can heal. Of course the re- 
 sulting loss of substance delays the cure. Such wounds frequently do not 
 hieed. The largest blood-vessel may be torn and yet, by the crushing and 
 twisting of its elastic walls, a complete obliteration of the tube takes place 
 and no blood escapes. This is not always the case, and free bleeding may 
 occur, especially if an artery has not been torn com- 
 Bleeding. pletely across so that it is unable to contract and re- 
 
 tract. It is especially in wounds of this character that what we call 
 secondary bleeding may take place after one or many days. Where 
 such bleeding occurs early it may be due to the renewed force of the 
 heart, which was depressed at the time of the injury. When the bleed- 
 ing occurs later it is usually due to the separation of 
 Amputations. ^^^^ ^^^^ ^..^Ij ^^^ ^1^^ ^^,^^^,^^ ^^.j^.^,|^ j^.^^ ^^^.^^ ^^^^ ^^, 
 
 to ulceration of the artery caused by bacteria in the wound. In crushed 
 wounds of this kind amputations are often necessary. 
 
 GUNSHOT WOUNDS. 
 
 Gunshot wounds are such as are made by hard bodies, usually bullets 
 or shot, when projected from firearms at high velocities. Similar wounds 
 may be caused by stones, gravel, or other materials when driven by the 
 force of exploding gunpowder or dynamite in a blast. The injuries 
 caused by such missiles are most varied in character, 
 w^// / Only a few of their peculiarities can be mentioned here. 
 
 They are contused and lacerated, wounds. The wound- 
 ed tissues are more or less disintegrated or destroyed by the extremely 
 violent impact of the bullet. A bullet when spent may produce a bruise 
 of greater or less severity and not break the skin. When moving more 
 swiftly it may merely cut a groove in the skin, but 
 Wounds of En- usually produces a tubular wound in the tissues. The 
 trance and Exit. , ,, • ^ ^ ^ ^ ^ ^ 
 
 bullet may pass entirely through tlie body or remain 
 
 imbedded in the soft parts or bone. The wound of entrance is small — 
 about the size of the bullet. The wound of exit may be a mere slit in 
 
THE NATURE AND EFFECT OF GUNSHOT WOUNDS. 441 
 
 tlie skin, or, in tlie case of a Inillet fired from a i-iflc, much larger than 
 
 the wound of entrance, and, if the bullet strikes a hone, it may separate 
 
 into several pieces and produce several distinct wounds of the skin. 
 
 When fired at short or moderate range a large rifle bullet of soft lead 
 
 produces great destruction of tissue. The wound is often of conical shape, 
 
 the apex of the cone at the wound of entrance, its base 
 
 Effect of Bullets ^t the wound of exit. The soft parts are widely de- 
 
 fired at Short gti-oyed and the bones mashed to a pulp, with many 
 Moderate, and •' r ^ ^ i i ' J 
 
 Long Range. splinters and tissures 01 the bone extendmg to a great 
 
 distance. The hard, long bullet of small calibre, such 
 
 as is used by modern armies and fired with very great velocity, produces 
 
 similar injuries, but its destructive effects are thought to be less than 
 
 those produced by soft bullets of larger size. 
 
 The ajpiKtrent path of a hullet through the hody is often misleading, 
 since, when the velocity is low, a bone or even softer tissues may turn the 
 bullet from its course, so that a M^ound which appears to pass directly 
 through the chest or skull may have encircled the thorax or head just 
 beneath the skin. 
 
 A tubular bullet wound which injures no important structure often 
 heals rapidly without inflammation, unless infected with bacteria carried 
 in by portions of clothing or by a dirty finger or probe. 
 
 THE TREATMENT OF WOUNDS. 
 
 It is with considerable hesitation that the writer aj^proaches this topic. 
 To learn how to treat wounds properly is not easy, nor can it be taught in 
 any school other than that of experience extending over a period of years. 
 
 The rules which guide a surgeon in the treatment of wounds are sim- 
 plicity itself, but the application of these rules is fraught with difliculties 
 of a practical nature which are hard for an untrained 
 
 eory anc individual to overcome, and which, under certain cir- 
 
 Practice. . ' ' 
 
 cumstances, may be insurmountable. The writer would 
 
 therefore earnestly advise his readers to leave a wound alone as far as 
 possible and — except when a wound is of the most trivial character — to 
 seek at once the aid of a competent surgeon. 
 
 Unless a large artery is divided, a recumbent position with elevation 
 of the wounded limb is usually followed by cessation of the bleeding in a 
 few minutes. The loss of a few tahlesjyoonfuls of hlood is of no conse- 
 quence to a healthy adult. 
 
 There are, however, circumstances under which im- 
 Emtrqencies. ,. ^ . . 
 
 mediate action is called tor and where no surgeon can 
 
 be had. The following instructions are intended to enable individuals 
 
 to meet such emero^encies in the most intelliofent manner. 
 
442 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 RULES. 
 
 Several objects to be attained in the treatment of wounds may, for 
 convenience, be grouped under the following heads : 
 
 L Kot to introduce into a wound substances whirh will intL'rferc with 
 its speedy healing. " Among such substances may be mentioned bacteria, 
 cobwebs, tobacco, oakum, glue, styptic cotton, sulphate-of-iron solution, 
 or other destructive chemical. They often fail to stop the bleeding and 
 prevent at once any chance of n\\)\d hialing. 
 
 ir. To stop the bleeding. 
 
 III. In accidental wounds, to kill the bacteria which may have gained 
 access to the wound at the time it was received, or subsequently, and to 
 remove jjross dirt and foreio-n bodies. 
 
 IV. To remove such tissues as may liave been killed and separated 
 from their vital attachments, such as loose splinters of bone and por- 
 tions of soft tissue which are irrevocably crushed beyond the chance of 
 living. 
 
 Y. To bring the divided tissues into accurate contact and to keep 
 them so. 
 
 VI. To provide in certain instances for the escape of the wound dis- 
 charges. 
 
 VII. So to dress the wound that the wounded parts may be kept at 
 rest, and that no bacteria can gain access to the wound while the dressing 
 is worn. 
 
 VIII. In wounds which are already inhabited by bacteria, to get 
 rid of the bacteria as soon as possible so that the wound may heal. In 
 wounds where other poisons have been introduced, such as snake bites, 
 the stings of insects, wounds from poisoned arrows, and the like, to 
 prevent the absorption of the poison and to neutralize its effects upon 
 the system. 
 
 IX. Certain special objects, such as the replacement of organs which 
 have escaped from a body cavity through the wound, or occasionally the 
 retention of the displaced organ in its unnatural position when to put it 
 back might cost the patient his life. To this category also belongs the 
 reduction of deformity in broken bones where a wound communicates 
 with the fractured ends. 
 
 X. General treatment of the patient. 
 
 These comparatively simple indications^ as they are called, have taxed, 
 and do tax to the utmost, the skill and judgment of surgeons. And many 
 eminent men have devoted their lives to the solution of these problems, 
 most of them, happily, now solved. 
 
 To avoid introducing into a wound a styptic like sulphate of iron, or 
 a substance like line-cut tobacco, does not need special instructions, but to 
 
CAUSE AND PREVENTION OF WOUND INFECTION. 443 
 
 avoid introduciri*^ bacteria is anotlier matter. As the writer has ]>r(i- 
 
 viously stated, bacteria are widely distributed, and hence everything 
 
 wliicii is to come in contact witli a wounded surface 
 
 urgtca should be surqicaUy clean — i. e., free from the i^errns 
 
 CleanUness, ... 
 
 of infiammation. 
 
 There was an idea, formerly very prevalent among surgeons, that 
 bacteria usually entered a wound from the air. It is now known that 
 bacteria entering a wound from the air are comparatively few in number, 
 and that generally they may be disregarded as a source of wound infection. 
 
 The sources of infection wdiicli especially claim our attention are : 
 
 The hands of the jyei'son who dresses the wound,^ the materials used to 
 
 clean the wounded surface and the dressings v)Jiich are 
 
 omces o_ ^^ ^^ applied, the instrume^its to he employed, the vmter 
 
 Infection. -^f \ i n i i • _o i 
 
 With which the wound ts washed^ the skin oj the 'pa- 
 tient., and the wound itself., if the last he accidental. 
 
 To accomplish the removal and destruction of bacteria several means 
 
 may be adopted. They are partly mechanical, like washing the skin and 
 
 instruments with soap and water and scrubbing with a 
 
 The Removal brush ; partly chemical, as the use of substances, called 
 
 mid Destruction . . , . , . , ^ ^ • t ^ •^^ iA 
 
 f jD f ■ antiseptics, which are poisons to bacteria and kill them 
 
 or prevent their growth. Bacteria are also destroyed 
 hy exposing them to a high temperature. The ordinary bacteria of wound 
 inflammation are killed in a few minutes by immersion in water at a tem- 
 perature a good deal lower than boiling. Boiling water (212° Fahr.) 
 kills them almost instantly. When exposed to dry heat a higher tem- 
 perature is required and a longer time, and this method has but few prac- 
 tical applications in surgery. Steam at a boiling temperature acts less 
 promptly than boiling water, but is efficient. Cotton, bandages, towels, 
 and the dressings which are to be placed in or upon the wound are usually 
 freed from living bacteria in this way by surgeons at the present time, 
 but a special apparatus is required for the purpose, so that in this article 
 we shall be obliged to confine ourselves to other methods. 
 
 So to treat a wound that all, or nearly all, the bacteria may be ex- 
 cluded therefrom may be possible in a well-ordered hospital, and even in 
 a private house or in a surgeon's office, where all the 
 The Total Exclu- necessary appliances are at hand and the surgeon is pos- 
 sion of Bacteria ^^^^^^ ^^ ^^^ requisite skill. But in emergencies this 
 Emergencies. ^^" "^^ ^^ accomplished, and we must be content with 
 
 very imperfect measures in treating wounds under such 
 circumstances ; still, Nature is very kind, and a good many bacteria may 
 exist in a wound without seriously interfering with the healing, because, 
 as we have said, the healthy tissues can dispose of the germs of inflam- 
 mation when they are not too numerous. 
 
U4: SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 C)f all tlio ways in Mliich bacteria gain access to a wound, ])erliaps 
 none is more frequent than through the medium of a dirty finger, and 
 many a patient has lost his hfe at the hands of an ignorant or a careless 
 practitioner who has explored a clean wound with a bactei-ia-laden digit. 
 Therefore, do ?wt touch a wound until you, have leashed your Jtnitds. 
 The hands may be rendered moderately clean in the following way : 
 
 now TO WASH 'rilH HANDS. 
 
 Roll up your sleeves to the e]l»ow; wet tlie hands and forearms in hot 
 water ; rub soap in thoroughly (])refei'ably soft or potash soap), especially 
 into the creases beneath the nails. Get u]) a good lather, and then scrub 
 the liands and arms thoroughly with a still' lu'ush, particularly the ends 
 and sides of the lingers and beneath the nails, and keep it uj) foi' at least 
 three minutes. AVash off the soaj) in clean water, clean the nails witli a 
 bone iiail-ck'aner or a small piece of woo*], thi'ii send) the lingers again 
 with a brush and soap, and, lastly, wash the hands and arms thoroughly 
 in water which has been boiled. 
 
 If time presses, or you have no other means at hand, you may then 
 proceed to handle the wound ; but if any of the following substances are 
 obtainable and the case is not urgent, you had better f uither clean the 
 hands by immersing them for several minutes in one of these solutions : 
 
 Corrosive sublinuite — one part to one thousand parts of water. Tablets 
 of this substance can be obtained at any drug store, of such size that one 
 tablet dissolved in a pint of water makes a solution of the above strength. 
 This solution is very poisonous when taken internally, but harmless when 
 used in this way. 
 
 Oxalic acid — a double handftd to a rpiart of water. After using 
 this, rinse the hands in boiled water, -which stops the smarting of the 
 skin that oxalic acid sometimes causes. 
 
 Strong alcohol. 
 
 Permanganate of potash — a handful to a quart of water. The stain 
 can be removed at once with oxalic acid. 
 
 Carbolic acid — in the strength of one part to twenty or thirty of 
 water; but carbolic acid in solutions of this strength is but a feeble germi- 
 cide, is painful to the hands and very irritating to a fresh wound, and is 
 scarcely of more advantage than plain l^oiled water. 
 
 Of all these substances, corrosive sublimate is the easiest to obtain and 
 
 is by far the most ])owerful germicide. In unboiled water the germs of 
 
 ordinary wound inliammation are all killed in from lif- 
 
 ,, ,,. , teen to twenty minutes when the solution is of the 
 
 strength of 1 to 1,000 — i. e., seven grains and a half to 
 
 the pint. "Where boiled water is not to be had this substance is of great 
 
 value for cleansing the hands and the skin of the patient and the wound 
 
PRESSURE FOR THE ARREST OF BLEEDING. 445 
 
 itself. Altlioiig-li corrosive sublimate does liave a certain destructive in- 
 fluence upon freslily wounded surfaces, yet as a rule this is not great 
 enough to intei-fere vi^ith healing. 
 
 By the time the hands have been cleaned in one of these ways, tlje 
 bleeding, if the wound be slight, will probably have ceased, unless the 
 patient has been runuing about excited by fear, or has held the wounded 
 part under a running water-tap so that the clot has been washed away as 
 fast as it formed. 
 
 We will suppose that the patient has lain down and kept quiet and 
 has elevated the wounded limb, if it be a limb that is wounded, and that 
 the bleeding still goes on. 
 
 What is the quickest and surest way to stop it? 
 
 now TO STOP BLEEDING. 
 
 Here the carefully cleaned finger is of use, and the writer wishes to 
 
 emphasize one fact which, if the reader will only remember and put into 
 
 practice when called upon to stop bleeding, may save a 
 
 The Pressure of a life which must Otherwise be lost. Better than tourni- 
 
 mger le es quiets, bandages, pads, or any other device to stop bleed- 
 lemporary Device ^ "^ \ \ -t • ^ £ n 
 
 toSiopBleedi7ig. i"g at once and absolutely, is the pressure of a tnger 
 
 directly upon the point that bleeds. This is true no 
 matter how large the cut vessel may be. If there be more than one 
 bleeding vessel, two or more fingers may be used, or the finger may l)e 
 changed if tired. The pressure should be made against a bone, if pos- 
 sible, and need not be very forcible. Moderate jpresHure is enough. This 
 method is applicable to any region of the body which may be reached 
 with a finger or the hand. It is true that the pressure can not be kept 
 up indefinitely, but if it be constant, this alone may be sufiicient per- 
 manently to stop the bleeding from a vessel of considerable size in ten 
 or fifteen minutes. Under most circumstances pressure can be kept up 
 at least long enough, by changing the finger from time to time, for 
 skilled help to arrive. 
 
 There are other means of applying pressure for the arrest of bleed- 
 ing ; one of the best is called a tampon. To apply a tampon to a wound 
 it is necessary to have some clean cheese cloth, or cotton 
 
 How to Apply. cloth (muslin), or gauze, or any thin fabric wliich can 
 a Tampon to , . .„ t^tict -tiii.- 
 
 a Woimd ^^ *^^'^ "^*^*^ strips a foot and a half long. 11 obtain- 
 
 able, the antisejptic corrosive-stiblimate gauze on sale at 
 every drug store should he used. Hereafter it will be understood that, 
 unless otherwise stated, where "gauze" is mentioned this antiseptic gauze 
 is meant. If antiseptic gauze is not to be had, tear any cotton fabric into 
 strips an inch wide and eighteen inches long (gauze should be cut with a 
 scissors). Gauze may be used without further preparation. 
 
440. SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 Other materials should, if possible, be disinfected by soaking iu cor- 
 rosive-sublimate solution, Avhieh is subsequently to be squeezed out in a 
 clean hand, or the strips may be dropped into a teakettle of boiling 
 water and boiled for two minutes. AVlien boiled, the sti-ips should be re- 
 moved from the kettle Mith a clean stick or a pair of shears. When 
 cool enough, they should be squeezed as dry as possible. If no corrosive 
 sublimate and no teakettle is at hand, use a clean dry handkerchief torn 
 into strips. 
 
 Lay the strips down on a clean towel. 
 
 Be sure again that your fingers are clean. 
 
 DiiT out the clots from the wounds with your forefinger and try to 
 see where the blood comes from. Take one of the strips, an end in either 
 hand, push one end down on to the bleeding point and pack in the rest 
 of the strip on top of it, feeding it into the wound with one hand while 
 you pack with the other. Pack it in hard. After it is all in, keep up 
 the pressure with one finger and pack in another strip over the first. 
 Continue this until the wound is filled to the level of the skin and above 
 it. Then make a pad of gauze or cloth, cleaned in the way described 
 for the strips, and a little larger than the wound. It may have the 
 thickness of a folded handkerchief. Lay it over the packing in the 
 wound. Over this put a larger pad and then another still larger. 
 Now bind the pads firndy in place with any sort of a bandage — or a 
 pair of suspenders, if need be. This procedure will stop bleeding, 
 permanently as a rule, from any but a very large artery in loose 
 tissues, and is not infrequently used by surgeons in situations where 
 it is difficult or impossible to apply a catgut ligature directly to the 
 vessel. 
 
 It is of the utmost importance that the ivound and the padding shoidd 
 
 he clean and free from hacteria^ and the patient should he seen hy a su?'- 
 
 geon as soon as possihle. If no such aid is to be had, 
 
 Cleanliness and the packing should be removed very gently (without 
 
 Freedom from ^^etting), at the end of forty-eight hours and replaced 
 
 Bacteria the , 4: i i- --P n n r • l-l ^ 
 
 Chief Requisites ^y fresh packmg, if the bleeding recurs, m which event 
 
 it may be left in place for forty-eight hours more, when 
 the vessels usually will have closed. If the bleeding does not recur and 
 there is no pain, swelling, or redness about the wound, apply a dressing 
 of gauze over the wound, leaving out the packing. Keep it in place 
 with a bandage. Then leave it alone for a week, as long as there is no 
 pain, or bleeding, or soiling of the dressing with wound discharge. This 
 method of stopping bleeding has its disadvantages. Unless very care- 
 fully ap])lied, bacteria will be introduced, the wound will inflame, and 
 healing will be delayed. Therefore do not use it unless the hleeding is 
 severe. 
 
A GAUZE PAD OR A TOURNIQUET. 
 
 447 
 
 The Value of a 
 Firm Pad of 
 Gauze. 
 
 When bleedin<^ is only uiodei-Jitc in amount and occurs from small 
 arteries or large veins just beneath the skin, like those one sees beneath 
 tlie skin of a man's forearm, or fi'om any vessel not 
 very deeply situated, it can almost always be stopped 
 permanently by a firm pad of gauze bound over the 
 wound with a bandage. The wound should be cleaned 
 })roperly according to directions to be given later, and a pad applied 
 directly over it. This first pad should be larger than the wound. Over 
 it a number of layers of gauze 
 should be bound. The gauze 
 should cover a large area of skin 
 around the wound and enough 
 should be used so that no blood 
 appears on the outside. If not 
 applied very tightly, such a dress- 
 ing may be left in place for a 
 week — unless there is pain or the 
 discharge soaks through and ap- 
 pears as a stain on the outside. 
 
 If the bleeding has ceased only 
 after a very tight dressing of this 
 kind has been applied, so tight as 
 to cause pain or swelling and blue- 
 ness of the skin below the dress- 
 ing, then the outside or constrict- 
 ino; bandage alone should be re- 
 moved after four or five hours 
 and replaced by one less tight, 
 
 because this swelling and blueness may indicate that the circulation of 
 blood in the limb is being interfered with by the constriction. It is, 
 however, quite impossible to lay down hard-and-fast rules in such mat- 
 ters. Skill and judgment, bred of experience, are, in 
 practice, the only guides. 
 
 Bleeding from a limb may be arrested temporarily 
 by compressing the main artery against the bone at a point above the 
 wound — i. (g., between the wound and the heart. This may be done with 
 the fingers or with an improvised tourniquet. 
 
 A tourniquet is a bandage, handkerchief, or strap of webbing, into 
 
 the middle of which a stone, a potato, a small block of wood or any hard, 
 
 smooth body is tied. The band is tied loosely abjout 
 
 ourniqiie . ^^^^ limb, the hard body is held over the artery to be 
 
 constricted, and a stick is inserted beneath the band on the opposite side 
 
 of the limb and used to twist the band in such a wav that the limb is 
 
 Fig 2. — Application of an ijiprovised toukni- 
 quet to the femokal akteky. 
 
 Bleeding from 
 a Limb. 
 
44S 
 
 SUEGICAL INJURIES AND SURGICAL DISEASES. 
 
 The Elastic 
 Constrictor. 
 
 tii};litlj constricted thereby, and the hard body thus made to compress the 
 artery. (See Fig. 2.) 
 
 The directions for applying pressure to sjiecial vessels will be given 
 under Wuunds of Sj>i'ciiil Jieyions. 
 
 The entire t'ircuniference of a lind» may be constricted by any sort of 
 elastic band or rubber tube. 
 
 The band or tube is passeil around tlu^ limb several times on the 
 stretch, drawn tight and tied in a knot. In this way bleeding may be 
 stopped at once from the largest arteries. Such a band 
 may be improvised from the ordinary rubber tubes used 
 to convey illuminating gas to a gas-stove, or any other 
 strong elastic material may be used. The larger and softer the tube the 
 better. The smaller the tube the more it will bruise the tissues and hurt. 
 It may be put around the middle of the leg for wounds of the foot, 
 around the middle of the thigh for wounds below that point. Twice 
 around the u}>per part of the thigh close to the body, crossed in front 
 
 and then around the waist, for 
 wounds of the upper part of the 
 thigh. It may be put on the 
 arm anywhere except just at the 
 elbow, and to stop bleeding from 
 the upper arm, under the arm- 
 pit and over the shoulder. It is 
 very dangerous to leave such a 
 band in place for more than two 
 ri ] V' 1 hours, since the limb may subse- 
 
 i ■ ' ' quently die in consequence ; but 
 
 Fio. 3.— ScHAPi-'s ToiKNuuET. to Icavc It On a half hour or an 
 
 hour is not dangerous. Draw 
 the tube tight enough to stop the bleeding, and no tighter. The elastic 
 tube or band has the advantage that it requires no skill and but little 
 knowledge of anatomy to apply it efficiently. (See Fig. 3.) 
 
 General oozing of blood from small vessels may be stopped by the 
 application of cold or heat. Cold may be applied by pouring ice-water 
 into a wound, or by putting ice directly on the bleed- 
 ing surface. Cold acts by contracting the walls of the 
 blood-vessels. Hot water, at a temperature of 120° to 
 125° Fahr. (as hot as the tip of the elbow will bear without great dis- 
 comfort), acts by contracting the walls of the vessels and hastening the 
 coagulation of the lilood. Heat and cold are inferior to direct pressure 
 where it can he applied. In inaccessible regions, like the nasal cavity, 
 the vagina, the rectum, the bladder, cold, especially, is of use; in oozing 
 from large superficial surfaces, heat. 
 
 Bleeding from 
 Small Vessels. 
 
COLD, HEAT, LIGATURE, STYPTIC, AND CAUTERY. 449 
 
 It remains to speak of the niotliod of tlie ]iij::ati]re, of styptics, and of 
 
 the cauterization of bleeding surfaces with a piece of metal heated to a 
 
 dull red heat. 
 
 To stop the bleeding from arteries and veins surgeons depend chiefly 
 
 upon applying ligatures of catgiut to the ends of the divided vessel. The 
 
 catgut is rendered sterile — i. <?., free from bacteria, by 
 
 Ligatures, boiling it in alcohol, or by soaking it in antiseptics, or 
 
 yp ics, 7 , \)o\h of these procedures. This is the best way to 
 
 Cauterization. . . . 
 
 stop bleeding. Unfortunately, to apply it requires , 
 
 special instruments and special training, hence it can hardly be of use 
 
 in emergencies when no medical man is by. It is practically the only 
 
 method which will surely and permanently stop bleeding from a large 
 
 artery. The end of the divided vessel is caught with a forceps and 
 
 pinched, a strand of catgut is tied rather tightly around the vessel 
 
 beyond the forceps, the forceps is then removed and the ends of the 
 
 catffut cut off close to the knot, which remains in the wound and is 
 
 absorbed. 
 
 StyjJtics are substances which, when applied to a wound, cause coagu- 
 lation and destruction of the tissues, and sometimes arrest of bleeding. 
 They often fail to stop hsemorrhage, and the last condition of that wound 
 is worse, much worse, than the first. Any one who has seen a large 
 wound treated in this way is not likely to try it on himself or his friends. 
 The healing is delayed, and inflammation, blood-poisoning, and tedious 
 convalescence are. among the usual results of this form of treatment. 
 The use of styptics is to be condemned. 
 
 The cauterization of wounds with a hot iron is an old and effective 
 way of stopping bleeding. It is used under certain circumstances by 
 surgeons, and may be applicable to the early treatment of the bites of 
 rabid animals. It causes death of the tissues and delays healing, and is 
 not to be advised in the treatment of accidental wounds. 
 
 THE CLEANING OP FRESH WOUNDS. 
 
 In all accidental wounds some bacteria are pretty sure to be present, 
 
 and in many cases foreign bodies of various kinds are either lying in the 
 
 wound or embedded in the tissues. For example. 
 
 Bacteria and gravel, coal-dust, splinters of wood or iron, grease, and 
 
 oreign o les ordinary soil may be around into the raw surface, or 
 in Accidental •' V i -i i n n 
 
 Woutids. very likely some one has wrapped a soiled handker- 
 
 chief or towel about the wounded limb, or applied 
 chewing tobacco, a piece of salt pork, the skin of an eel, or glue to the 
 wound. It wall now be necessary to consider what measures may be 
 used to free the wound from these impurities. 
 
 We have hitherto been occupied with wounds where the bleeding has 
 31 
 
450 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 been so severe tliat other considerations have been subordinated to this 
 
 one ; but let us sujipose that the Avound does not bleed much, or that an 
 
 elastic band or a rubber tube has been a]>|)lied and that the bleeding has 
 
 ceased. Before examining the wound it is well to have 
 
 Preparations for everything ready and near at hand that is likelv to be 
 
 //if Treat inent , . , "" n-M • • i i i " i 
 
 ^ .y , used in its treatment. I his includes at least soap and 
 
 water and, if possible, boiled water so hot that you can 
 just keep the hand in it. It should be in several clean vessels, preferably 
 the vessels in which it was boiled. To one of these vessels may be added 
 some corrosive sublimate tablets — as many as will produce a solution of 1 
 to 1,000. Do not make it stronger. 
 
 Alcohol or ether is useful, and also oil of turpentine, the last for 
 cleaning very dirty skins, like the grimy hands of a machinist. Any or 
 all of these things are cleansing. 
 
 A scissors of any kind made fast to a string and dropped into the 
 boiling teakettle for two or three minutes is usually the only instrument 
 necessary. 
 
 Several towels, which have been in boiling water for a minute or two 
 or have been wrung out after being thoroughly wet in corrosive-sublimate 
 solution, are useful, especially for spreading out on the table so that other 
 clean things may be laid down upon them. 
 
 If gauze is obtainable, use this for the dressing; and if you have no 
 absorbent cotton, pieces of gauze may be used to wipe the skin and the 
 wound. If you have neither, use clean handkerchiefs boiled in water 
 or wet with corrosive sublimate, or, if these conditions are not to be 
 obtained, use clean handkerchiefs dry or any other clean cotton cloth. 
 It is better to use no dressing at all than a visibly soiled cloth of 
 any Tiind. 
 
 Bandages may l)e torn from a clean sheet. The method of applying 
 them will be spoken of hereafter. 
 
 If you have absorbent cotton, tear or cut it into masses the size of a 
 small orange, and immerse a dozen of these masses in the corrosive sub- 
 limate, or, if not in that, in the boiled water. If in neither, use it dry, 
 unless it is visibly soiled or has been long exposed to dust. In that case 
 you had better get along without it. 
 
 Arrange everything on a table, and put the bandages, gauze, cotton, 
 or whatever is to come into contact with the wound, on one of the clean 
 towels. Wash your hands as before described. 
 
 The neighbourhood of the wound should be bare of clothing for some 
 distance. 
 
 If the wound is clean-cut and not visibly soiled, cover it with a pad 
 of cotton or gauze, and while the pad is held in place, wash the surround- 
 ing skin over a wide area with hot water and soaj). "Wash oU the 
 
ON THE DRESSING OF WOUNDS. 451 
 
 soapsuds witli boiled water, llemove the jjad and douche the wound 
 
 thorouglily with boiled water or corrosive-sublimate solution, holding the 
 
 edges widely apart so that the fluid can reach every 
 
 '„ „ '" ■ portion of the wounded surface. If l^leedinj' has been 
 
 Clean yVoimd. ^ ^ _ '^ 
 
 started as a result of your manipulations, press a pad 
 of cotton or gauze firmly and steadily upon the surface from wliich the 
 blood comes. Keep up the pressure for two or three minutes, or longer 
 if necessary. As soon as the bleeding has ceased, wipe away the blood 
 and wet from the surrounding skin with a clean towel and apply a dress- 
 ing at once. 
 
 Suppose that instead of a clean-cut wound the injury is ragged and 
 bruised and full of grease and coal-dust, that a filthy handkerchief has 
 
 been placed upon it, and that the patient's skin is 
 
 How to Dress a ■ r\ >. i.i • i \. s: c< i j.i, 
 
 „.,,,„ , grimy, (jret everytlimg ready as before, bcrub the 
 
 skin and the wound itself with soap and water, and do 
 it thoroughly. Rub the skin around the wound with cotton wet with 
 oil of turpentine, if you have it. Many bacteria and much dirt will be 
 removed by this means. Then clean out the wound itself with cotton 
 wet with ether and then with alcohol, if you have them ; if not, with 
 corrosive sublimate, or, failing that, with boiled water. Wipe it out to 
 the bottom and search for every pocket, and diligently apply the wet 
 pads of cotton until every portion of the wound is as clean as persever- 
 ance can make it. Cut away loose fragments of tissue which are evi- 
 dently dead, with the scissors, and pick out foreign bodies with your 
 fingers. Finally, wash out the whole wound with corrosive sublimate or 
 with boiled water. Dry it with clean gauze or cotton, fill the cavity 
 with gauze or other clean material, leave the wound wide open, so that 
 all discharges can escape, and put on a dressing. 
 
 If the wound is on the hairy scalp, first cut ofi the hair with the 
 scissors, or, if you have a razor, shave it two inches away from the wound 
 all around, and then proceed as in the case of other wounds. 
 
 It will occur to most people that the above treatment might be a little 
 painful, and that it would be the part of wisdom to select rather a feeble- 
 bodied patient for measures of this character — preferably an enemy. It 
 certainly does require self-control on the part of the patient, and the cour- 
 age of his convictions on the part of the would-be surgeon; but it is the 
 best means of getting a dirty wound clean, and though it hurts at the 
 time, it will save much suffering in the future. 
 
 TREATMENT OF GUNSHOT WOUNDS. 
 
 Do not ])rohe a hullet wound. Do not put your finger in it, unless it 
 be necessary to stop bleeding. Clean the orifice of the wound and the 
 
452 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 skin iu the neighbourhood. Stoj) the hUedinij l>y pressure^ and send for 
 a surgeon as soon as possible. 
 
 TREATMENT OF PUNCTURED WOUNDS. 
 
 The safest treatment for a punctured wound at unskilled hands is to 
 wash thoroughly and disinfect the skin of the part, to withdraw with 
 the lingers, if within easy reach, any poi'tion of the instrument which 
 may be left in the wound, enlarging the wound with a scissors, if neces- 
 sary, in order to make its extraction more easy. Apply a dressing of 
 gauze or other clean material. (Some exceptions will be mentioned under 
 Punctured Wounds of Special Megions.) 
 
 Of wound treatment in general it may be said : Depend cJitefly upon 
 
 soap and water to ?nake things clean. It is a mistake to suppose that even 
 
 the strongest antiseptics can take the place of cleanli- 
 
 Antisepficscannot ^^^^_ p^ ^^^ ^j^jj^j, ^j^^^^ ^ dipping your hands in a 
 
 take the Place . ... 
 
 of Cleanliness Solution of corrosive sublimate you can disinfect them 
 
 and handle a fresh wound without risk. They must 
 be waslicd and scrubbed in soap and water first. There is much oil upon 
 the human skin which protects the bacteria from the action of most anti- 
 septics. Soap and water removes the oil and gives the antiseptic a chance 
 to act. 
 
 Before applying a dressing to a wound, wipe away all the blood from 
 the part and dry it with a clean towel. When called upon to treat a 
 wound remember that a little Mood makes a gt'eat showing., and that the 
 accidental division of a large artery is a comparatively rare accident, and 
 that a healthy adult can lose a pint of blood without serious danger. 
 
 Do not lose your head. 
 
 "Wash your hands, if you possibly can, before touching a wound. It 
 may be necessary to disregard this advice, but the instances will l)e rare. 
 After having got your hands clean, do not touch your own or the pa- 
 tient's clothing, or any article of furniture and then put your fingers 
 into the wound. First wash your hands again. Try to have everything 
 ready at hand, so that after you have begun to clean the wound your 
 measures may not be interrupted and your hands contaminated by hand- 
 ling any unclean thing. 
 
 You can not make a fresh clean wound heal any more rapidly by ap- 
 plying to its surface any substance whatsoever. Nature takes care of the 
 healing ; all that we can do is to try and get rid of such bacteria as may 
 have gained entrance into the wound, and to keep them from entering 
 while healing is going on. Therefore do not apply to a fresh wound any 
 substance because you are told that it is good for the wound, that it will 
 make it heal. Those who make such assertions are misinformed. 
 
TREATMENT OF THE EDGES OF A CLEAN WOUND. 45-'^ 
 
 Do not put sticking plaster or court plaster upon a fresh wound, how- 
 ever small. Such materials almost always contain bacteria and will be 
 likely tr» infect the wound. 
 iccmg as er. Above all things, do not jxndtice a v)ound to drav) 
 
 out the ivflavimation. The materials from which poultices are made 
 always contain bacteria, and the heat and moisture supply the conditions 
 best suited to their growth and development. And the 
 poultice itself furnishes an ideal soil for the germs of 
 inflammation to grow in. If the wound is clean, there will be no in- 
 flammation, and if it is inflamed, a poultice is the very w'orst application 
 possible, for reasons to be given hereafter. 
 
 Having once dressed a wound, its edges having been left in contact, 
 do not be in a hurry to dress it again. As long as there is no pain, no 
 staining of the dressings with wound discharge, no bad odour, and the out- 
 side of the dressing has not been contaminated by wet or tilth of any 
 kind, you may feel sure that the wound is doing well. If you take off 
 the dressing you may infect the wound with bacteria. 
 
 Do not cover the dressing of a clean wound with oiled silk or other 
 impervious material. It is better that the dressing should be as dry as 
 
 possible, and the oiled silk favours the accumulation of 
 Oiled Silfc. ^ 
 
 moisture. 
 
 Do not be afraid of " catching cold " in a wound. Such a condition 
 u/w ; • /-» 7^" ^^ ^^^ recognised by medical men. It is not cold, but 
 bacteria, which causes wounds to inflame. 
 
 To bring the edges of a clean wound into accurate contact is a great 
 advantage. It helps to stop the bleeding ; it puts the surfaces into the 
 most favourable position for union and assists the tissues to get rid of the 
 bacteria. Wounds are ordinarily closed hy sevmig the edges together 
 with a needle and thready and there is no efficient substitute for this 
 means. The necessary manipulations are not difficult. But to decide in 
 a given case wdiether a wound should be closed or left open requires 
 special knowledge and trained judgment, and the question is one which 
 often calls for the widest experience in order to answer it correctly. 
 The writer would therefore advise that no attempt be made to close any 
 wound beyond what may be done by arranging the edges with the fingers 
 or by compresses of gauze applied over it. 
 
 MATERIALS USED FOR DRESSING FRESH WOUNDS AND HOW TO 
 
 APPLY THExM. 
 
 Use corrosive-sublimate gauze such as is sold at the apothecaries', if 
 you can get it. Put on plenty of it. Shake out a large piece, crumple 
 it up into a loose mass and lay it on the wound. Then cover the skin 
 all around the wound with more ffauze. Cover the whole circumference 
 
454 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 of the limb with thick pads of this material, extending for a long dis- 
 tunce above and below the wound — for instance, in a wound of the fore- 
 arm near its middle, cover the limb with gau7,e thickly from the elbow 
 to the wrist. Fasten it on with a bandage tirmly. The dressing should 
 not slip. It should be comfortable. It should be put on in the position 
 which the limb is to" retain after the dressing is com})lete. 
 
 If you can not procure antiseptic gauze, use plain white cheese cloth, 
 or any other loosely woven cotton material tinished without sizing, or 
 from which the sizing has been removed by boiling in a solution of wash- 
 ing-soda. Whatever material is used, it must be of such a nature that 
 the discharges from the wound are readily soaked up into the dressing. 
 Fabrics containing sizing are not tit for this purpose. The soda must 
 be removed by washing in clean water. Soak the material in corrosive 
 sublimate and wring it out, or boil the material for live or ten minutes in 
 water ; wring it out when cool enough and apply. 
 
 Freshly laundered handkerchiefs and towels, especially if boiled and 
 not exposed to dust, maybe quite free from bacteria, and would then fur- 
 nish a good material for dressing wounds. They should be used in the 
 same way as gauze. A towel and a handkerchief taken at random from 
 the writer's bureau, and carefully examined at the laboratory of the Col- 
 lege of Physicians and Surgeons of Columbia University by Dr. R. G. 
 Freeman, were found to be practically free from bacteria. Both articles 
 had been boiled in soapsuds and had been rinsed in cold Croton water 
 
 and ironed. 
 
 BANDAGES AND BANDAGING. 
 
 Bandages are pieces of cloth, usually cotton, of various sizes and 
 shapes which are used for the following purposes : To exercise firm and 
 even pressure upon a part and thereby to hold wound 
 Bandaaes dressings in place ; to stop bleeding ; to keep the part 
 
 immovable and at rest ; to prevent swelling and ac- 
 cumulation of blood in the veins of a limb ; to hold splints of various 
 kinds in place. 
 
 A well-apjilied bandage should fulfil these requirements more or less 
 perfectly. It should not slip or become loose. It should not be put on 
 
 „ „ „ , so tightly as to interfere with the circulation of a limb. 
 
 Roller Bandages. miiiinii •/• 
 
 ilie so-called roller bandages — long narrow stnps oi 
 
 cloth made into a roll — are the best, and are commonly used by surgeons. 
 Pieces of cloth of triangular or oblong shape are usually easier to ob- 
 tain in emergencies, and are sometimes used as a substi- 
 Oblona Ba7idaaes ^"^^ ' ^^"* ^^^ many instances they fail to fulfil the re- 
 quirements and are hardly to be recommended in the 
 treatment of wounds wdiere a roller bandage may be made or ol)tained. 
 The triangular handage of Esmarch may be applied to any region of the 
 
ESMARCH'S TRIANGULAR BANDAGE. 
 
 455 
 
 body and, wliere no roller bundage is to be liad, it may be used to advan- 
 tage. It consists of a triangular piece of muslin of the shape shown in 
 Fig. 4. The size may be 
 varied according to the part 
 of the body for Mrhich the 
 bandage is intended. 
 
 To cover a dressing on 
 the crown of the head the 
 bandage may be applied as 
 follows : Lay the base along 
 the forehead, its edge paral- 
 lel to the eyebrows. Allow 
 the apex to hang down the 
 back of the neck. Carry the 
 
 ends back of the head, cross them below the bony bump which exists in 
 this region, bring them forward and tie them in a square knot on the 
 
 Fig. 4. — Esmarch's triangular bandage. 
 A, base ; B, ape.x ; C, D, Vja.sal ends. 
 
 Fig. 5. — Tri angular bandage applied as a sling and as a retentive bandage 
 
 TO VARIOUS regions. 
 
 forehead. Bring up the apex from behind and pin it to the bandage on 
 top of the head. 
 
450 
 
 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 Rolling a Band- 
 age by Hand. 
 
 Folded into a cravat, this bandage may be aj^plied circularly or in a 
 figure of S to the head or to the trunk and limbs. The ends may be 
 pinned or tied in a knot. Fig. 5 illustrates the application of this band- 
 age to various parts. The figure explains itself. 
 
 Boiler bandages are, as stated, long, narrow strips of cloth ; loosely 
 woven cambric, unbleached muslin, and, for certain purposes, fiannel are 
 the materials from which they are commonly made ; 
 but any fabric which is not too thick may be substi- 
 tuted. Their width varies from one inch for fingers 
 and toes, to four and a half indies or more for the thigh and trunk. 
 Their length is commonly from eight to twelve yards. These bandages 
 may be rolled by hand as follows : Tear the cloth into strips of the de- 
 sired width. Beginning at one end, 
 fold the cloth into a cylinder for eight 
 inches and continue the process by 
 holding the ends of the cylinder be- 
 tween the thumb and forefinger of 
 the right hand, allowing the unrolled 
 part of the bandage to hang over the 
 back of the left hand between the 
 forefinger and thumb. IS^ow, by ro- 
 tating the cylinder held in the right 
 hand and guiding the free part with 
 the left hand, the edges of the cylin- 
 der may be kept even and the band- 
 age rolled tightly (see Fig. 6), A 
 bandage can not be applied nicely unless it is rolled very tight, and for 
 this reason tnachine-made bandages are better in every way and should 
 be used where obtainable. 
 
 In applying a roller bandage to a liinb, ahoaijs begin at the point far- 
 thest away from the trunk and bandage toward the trunk. Apply the 
 outside of the bandage to the limb. Hold the roll in 
 the palm of one hand, the end of the bandage in the 
 other. Apply the end of the bandage to the limb and 
 take two turns around the limb with the roll, includ- 
 ing the end in the turns so that it will not slip. Keep the hand which 
 holds the roll as close as possible to the limb all the time. Otherwise you 
 can not apply the bandage properly. As the roll passes behind the limb 
 it may be changed from hand to hand, and again it may be changed in 
 like manner when it passes across the front of the limb. 
 Try to keep up an even tension on the bandage. 
 
 It is better for an unskilled person not to try to follow any set rules 
 for the application of bandages, but simply to roll the bandage on, ioV 
 
 Fig. 6. — Rolling a bandage by hand. 
 
 Hniv to Apply 
 ■ a Bandage 
 to a Limb. 
 
PRINCIPLES OF BANDAGING. 
 
 457 
 
 lowing the natural dii-cction wliicli the bandage takes, so that the turns 
 will lie flat. This advice will be understood better when yon come to 
 apply a bandage. A symmetrical appearance of 
 the turns is of no consequence. Simply try to put 
 the bandage on so that it covers every part of the 
 dressing and a little more — i. e., begin the band- 
 age below the point to which the 
 dressing which is next the wound 
 extends and carry it up to a point 
 above the upper limit of the same. 
 There are several ways of ap- 
 plying a bandage to a limb. It 
 
 may be rolled 
 
 about the part 
 
 in a spiral, each 
 turn overlapping the one below it 
 
 for a short distance. This is called the spiral method, and is applicable 
 when there is no marked increase in the size of the limb from below 
 upward (see Fig. 8). 
 
 The figure-of-8 method is more generally applicable. It makes the 
 firmest and most durable bandage, aud, when properly applied, does not 
 
 The Spiral 
 Method. 
 
 Fig. 7. — Antiseptic dues; 
 
 Fig. 8. — Application of a roller bandage 
 to the arm by the spiral method. 
 
 Fig. 9. — Application of a roller banbage 
 
 TO THE arm by the FIGUBE-OF-S METHOD. 
 
45S 
 
 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 Tlie Fi;/ure-of-S 
 Method. 
 
 slip or get loose. The method of ap]>Hcation is shown in Fig. 9. The 
 
 bandage is begun bv a few circuhir turns, and is then passed obHquely 
 np ami across the front of 
 the limb, then straight 
 across behind the limb, and 
 
 then obliquely down across the front of the 
 
 liuib, cutting the lirst obli(jue turn at right 
 
 angles. By similar turns the limb is covered 
 
 from below upwards, each turn overlapping 
 
 the preceding one one quarter or one third 
 
 the width of the bandage. 
 
 A modification (see Fig. 9) of the fignre- 
 
 of-8 method is applicable to most joints and 
 
 to the junction of the limbs with the trunk. 
 
 In the latter case the bandage is called a spiea. 
 
 Its application is shown in Fig. 10. 
 
 The writer believes that bandaging can not be 
 learned from printed instructions. It is not an intel- 
 lectual process, but a practical art. He would there- 
 fore urge npon such of his readers as wish to learn how to bandage, or 
 
 who are likely to be placed under circumstances where such knowdedge 
 
 will be of use, to take a few lessons from some one who knows how. 
 
 In that way sufficient skill can be acquired in a short time to meet any 
 
 emergency of this character which is likely to arise. 
 
 Fig. 10. — Si'icA HAxnAiiK ai-im.iei) 
 
 TO THE SMOILDEU. 
 
 The Spica 
 Bandage. 
 
 INFLAMED WOUNDS AND THEIR TREATMENT. 
 
 "When wounded tissues are already inhabited by the bacteria of in- 
 flammation, we speak of them as inflamed wounds. 
 
 At present we shall confine ourselves to the consideration of the forms 
 of inflammation which are caused by the so-called "pyogenic bacteria" — 
 {. e., the bacteria which, by their growth and multipli- 
 cation in the tissues, cause the formation of pus or 
 matter. There are several varieties of these bacteria, but the action of all 
 of them is similar and a special description of each kind is needless. 
 
 When a fresh wound becomes infected \vitli these 
 germs a very varied series of symptoms may be pro- 
 duced. At times, the interference with healing is slight, 
 and again, from apparently a precisely similar kind of 
 infection, a progressive inflammation of the tissues may 
 be caused, attended with such severe symptoms of poisoning of the entire 
 system that death is a matter of a few days. AVe do not know exactly 
 why this is so, but some of the factors which help the bacteria in their 
 
 Pyogenic Barteria. 
 
 Varied Symptoyns 
 resulting from 
 Infection by Py- 
 ogenic Bacteria. 
 
INFECTION BY PYOGENIC BACTERIA. 459 
 
 attacks upon the tissues liavc already been mentioned. Sometimes the 
 inflammation may be confined to the immediate neiglibourhood of the 
 wound. There may be only a moderate amount of pain, heat, redness, 
 and swelling, and a moderate discharge of pus. 
 
 At other times, the poisons generated by the bacteria, and tlje bacteria 
 themselves, are taken up by the lymphatic vessels of the part and find 
 their way to the adjoining set of lymphatic glands, where they cause in- 
 flammation in these structures and often abscesses. When such is the 
 case, one sees red, inflamed lines on the skin, passing from the wound to 
 the lymphatic glands. The glands themselves become swollen and tender. 
 The patient usually has fever and other symptoms of illness. The action 
 of the lymphatic glands, under such circumstances, is a protective one, 
 because the bacteria usually can not pass the inflamed gland, which acts 
 like a kind of filter, and, while the gland itself may be destroyed, the 
 system at large may suflier but little. 
 
 At other times, when the discharge has no adequate avenue of escape, 
 
 serious changes are produced. The matter accumulates in the deeper 
 
 parts of the wound and soon the increasing tension 
 
 j4 T) ^cp s ^p s 
 
 causes it to burrow into the surrounding tissues, and 
 abscesses of greater or less extent may be formed, which continue to 
 grow until the matter either finds an outlet by destroying the overlying 
 tissues and finally the skin, or until an outlet is made by the surgeon's 
 knife. Under such circumstances, one finds usually present great pain 
 and severe constitutional symptoms which may end in death if the ab- 
 scess is not opened with the knife. Often this relief is afforded too late. 
 In these cases much tissue is often destroyed, and tedious healing and 
 crippled limbs are a frequent consequence of such inflammations. 
 
 In injuries, especially where much bruising of the tissues has occurred, 
 
 and occasionally in clean-cut wounds, quite a different train of events takes 
 
 place. The inflamed wound does not discharge much 
 
 Progredient or matter, only a little watery, bloody fluid ; but the tissues 
 
 Proqi'essive ? ./ ./ ^ ./ ^ 
 
 Septic Phleqmon ^^.pidly die, and this local death spreads beneath the 
 skin, so that in a few days the whole limb may be in- 
 volved in the process. There is no bad odour, no gangrene properly so 
 called, but an enormously rapid spreading of the bacteria in the tissues 
 which are killed without undergoing putrefaction. 
 
 If life is prolonged, the dead tissues soften and large collections of 
 matter are formed beneath the skin and between the muscles and some- 
 times in the joints. The skin itself may be involved in the process from 
 the first. It then appears dark red in colour, and hard or doughy to the 
 feel, and, if the tension be not relieved by very large cuts, finally dies 
 over considerable areas. Sometimes the skin is not much changed and 
 the inflammation spreads widely beneath it, the extent of the trouble be- 
 
400 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 comin£^ apparent only when incisions are made for its relief. In such 
 cases the severest symptoms of poisoning are present, and .the patient fre- 
 quently succumbs in a few days. 
 
 AVhen the bacteria which cause putrefaction are also present, we have 
 the worst intiamniatory condition which surgeons ever sec. The history 
 
 of such a case is often as follows : A cliai-iic from a 
 Gaseous Gantjrene. , , a i i xi "i i.i x- 
 
 shotgun has torn a great ragged hole througii tlie tore- 
 
 arni or elbow. AVithin three or four days the jiatient is seen by a sur- 
 geon, who tinds the following conditions: The patient looks very ill; he 
 is weak and stupid, lie may have fever, or his temperature may be 
 below the normal ; the pulse is rapid and feeble. The wounded arm is 
 enormously swollen. The hand and forearm are black. The shoulder 
 and upper arm are of a dusky-red colour, and the whole limb and the 
 chest upon the M'ounded side crackle when pressed upon. From the 
 presence of gas beneath the skin, a horrible stench is given off from the 
 part. Amputation is done at once ; the tissues bleed but little, and look 
 and smell like meat which lias been kept too long. If the limb is cut off 
 at the highest possible point and very early, life may be saved ; but 
 usually a fatal result occurs speedily. This disease is called "gaseous 
 gangrene." Since the " antiseptic " treatment of wounds has been gen- 
 erally adopted by surgeons, this condition is rarely seen. 
 
 These are a few of the ways in which the bacteria affect wounds. We 
 shall have occasion to mention some others hereafter. 
 
 If the writer urged upon his readers the wisdom of seeking surgical 
 aid in cases of recent wounds, he must emphasize the same advice in re- 
 gard to wounds which are inflamed. An inflamed wound positively re- 
 quires skilled attention, and when it is remembered that the smallest 
 infected wound may cost the individual his life, the truth of this state- 
 nient can not be gainsaid. A few practical suggestions may be of value. 
 
 When a wound is infected with bacteria a certain time elapses before 
 the symptoms of inflammation appear. This period is rarely less than 
 twenty-four hours, and is often thirty-six or forty-eight hours. The first 
 symptoms are usually pain and redness about the wound, and, if the poi- 
 soning is severe, fever, and sometimes a chill. 
 
 The most hnportant thing in the treatment of infiamed vjounds is 
 
 to allow the discharge to escape iii the freest possible manner. If this 
 
 condition can be maintained, the system is usually able 
 
 The Treatment ^^ destroy the bacteria and to get rid of their poison- 
 
 of Inflained '' t i i ■ i i i 
 
 VTounds. ^^^^ products. lo accomplish this tlie wound must be 
 
 kept wide open, and nothing must be allowed to in- 
 terfere with the flow of pus. 
 
 If the redness spreads and throbbing pain is felt in the part, espe- 
 cially if great tenderness is felt on pressure near the wound, it usually 
 
A FKEE OUTLET FOR PUS. 401 
 
 means that matter is accutniilutiri<^ in the tissues beneath tlie skin. Tlie 
 matter must then be let out l^y free cuts with a knife. Tlie condition 
 admits of no delay. When the bacteria have once entered the tissues, tlie 
 application of antiseptic solutions to the wounded part is only of moder- 
 ate value. The one indication is to let out the matter at once, and to 
 relieve all tension by incisions. A small puncture with the point of a 
 knife is not sufKcient. The intiamed tissues should be very freely divided, 
 so that no pocket remains in which pus can accumulate. A very large 
 cut in the skin is of no consequence compared to the danger of allowing 
 the pus, containing myriads of bacteria and their poisonous products, to 
 be absorbed into the system. 
 
 The wound having been thoroughly opened, various antiseptic solu- 
 tions are used to destroy tlie bacteria which remain free in the wound, 
 
 and to assist the system to get rid of those residing 
 r'^S I r ^ within the tissues. A wound may be thoroughly washed 
 
 out wdth corrosive-sublimate solution (1 to 1,000), and 
 
 the dressing subsequently kept wet with a weaker solution of the same 
 
 (1 to 3,000) or, better still, the following solution may be used to saturate 
 
 the dressings : Take of sugar of lead, twenty-five parts ; alum, five parts ; 
 
 water, five hundred parts. Mix. This is harmless and effective. It 
 
 should be used cold. There are many other solutions in use for similar 
 
 purposes, but this one can be obtained almost anywhere, and there is 
 
 none better. 
 
 The solution above given is used in the following way : The gauze or 
 
 other material is applied thickly in and about the wound, and the dressing 
 
 is extended even more widely than in the case of the 
 How to Apply Anti- j . j- i j i i .■ i a r. 
 
 ,. o 7 J- dressings tor clean wounds already mentioned. After 
 
 septic Solutions. ... . . 
 
 the dressing is in place, it is saturated with the solution 
 
 and every hour or two more of the solution is poured on, and the dress- 
 ing thus kept constantly wet. This procedure seems to aid the tissues 
 considerably in disposing of the bacteria. A badly inflamed wound 
 should be dressed daily, and any new pocket of pus which can be discov- 
 ered by gentle pressure in the neighbourhood should be opened up freely 
 with the knife. There is no application which will tal'e the place of a 
 free opening for the escape of wound discharge. 
 .. ^ .. T- I The limb should be kept in an elevated position 
 
 constantly, which will help to diminish the swelling 
 and overcrowding of the blood-vessels. 
 
 A WORD IN REGARD TO POULTICES. 
 
 "When an inflamed part is painful, it means that the products of in- 
 flammation are so crowded in the tissues that a considerable amount of 
 pressure or tension exists, the sensitive nerves are compi-essed, and pain 
 
462 SUEGICAL INJURIES AND SURGICAL DISEASES. 
 
 is the result. This is true wliothor the inflammation is the resuU of a 
 wound, a boil, a carbuncle, an abscess, or any acute intianuuation caused 
 by pns microbes. 
 
 Ordinarily, one of two results of the crowding of the protlucts c)f in- 
 
 flannnatiou occurs. The tissues may succeed in destroying the bacteria 
 
 before the inflammation has advanced so far that pus or 
 
 BcsuKs of (he matter is formed. This is accomplished largely by the 
 
 Crowding of the activity of fixed tissue-cells and white blood cells, which. 
 
 Inflammation ^^ before stated, are crowded in and about the inflamed 
 
 area, and act as a barrier to the further progress of the 
 
 bacteria. In the inflamed tissue there is another substance formed called 
 
 fibrin, which acts as a mechanical obstacle to the advance of the bacteria. 
 
 When the inflammation subsides without the formation of pus, the process 
 
 is said to have undergone resolution. AVhere the pus microbes are present 
 
 in considerable numbers, this is a less common result than the second, which 
 
 ends in the formation of an accumulation of pus more or less extensive. 
 
 Except where pus exists in minute quantities only, it does not remain 
 quiescent. The pus microbes continue to grow and to invade the sur- 
 rounding structures in the direction of the least resist- 
 The Aggressive .^^^^^^ Under favourable circumstances, the inflamma- 
 
 p ,,. ," tory process is limited in the direction of the deeper 
 
 structures, and the pus finds its way more or less direct- 
 ly to the surface of the wound, or, in the case of an abscess, a portion of 
 the skin overlying the purulent mass is killed by the interference with its 
 circulation and by the direct action of the microbes on the cells of which 
 the skin is composed, and finally perforation takes place and the impris- 
 oned matter escapes. It has been truly said, " Nature is a good physician 
 but a poor surgeon " ; frequently the efforts of the tissues are onl}' partly 
 successful, and the surgeon's art is needed to expedite or make possible 
 the cure. 
 
 As has been stated already, the materials from which poultices are 
 
 commonly made contain bacteria. Even the center of a baked loaf of 
 
 bread may contain living microbes in considerable num- 
 
 Piniltices favour ])ers. Although possibly free from bacteria when ap- 
 tlie Development tit ., , ^ ^ t ^ n 
 
 of Bacteria phed, the warm moist bread-crumb, the Imseed or flax- 
 
 seed meal, form an ideal soil for the rapid multiplica- 
 tion of such microbes as are sure to gain access to it from the wound or 
 from the surrounding skin. 
 
 It is impossible to mix the materials from which poultices are made 
 with antiseptics in such a manner as to render them unfit for the growth 
 of microbes. These facts alone are sufficient to show that a poultice is 
 an unsuitable dressing for a wound. 
 
 The action of a poultice is to paralyze the efforts which the tissues 
 
POULTICES THE BANE OF SURGEONS. 463 
 
 make to limit the l>jicteria to a small area. Under the enervating effect 
 of the heat and moisture, the barrier of cells and fibrin which holds the 
 microbes in check is broken down and melted, the blood-vessels lose their 
 tone, and the white cells escape from their interior in greatly increased 
 numbers, but these cells are enfeebled and are rapidly converted into pus 
 by the action of the microbes. The tissues become wet and soggy, and 
 new areas are laid open for the entrance of the bacteria and their poison- 
 ous products. It is true that oftentimes the tension is relieved, and that, 
 for a while at least, pain is diminished or abolished ; but this result is 
 accomplished at the cost of a wider area of infection. In other words, 
 the action of a poultice is to spread the poison and to render the tissues 
 less liahle to resist the advance of the Ijacteria. 
 
 During the past few years the writer has seen several thousand cases 
 
 of wounds and acute suppurative inflammations of various kinds which 
 
 had been treated with poultices, and he can speak feel- 
 
 The Pernicious inffly and perhaps with that authority which a moder- 
 
 Restdts of ° -^ .^ ^ . ,11 v -^ ^- • 
 
 Poxdticma ^^^ experience can give, and he has no hesitation m 
 
 saying that he has never seen a case among those which 
 have come under his notice whose condition had not been made worse by 
 poulticing, and that hundreds of permanently crippled hands and arms 
 and not a few lost lives were due directly to this most pernicious form of 
 treatment. He would, therefore, urge his readers never to apply a poul- 
 tice to a wound of any sort, or to any form of acute inflammation where 
 pus is already present or is likely to be produced. A cut with a knife is 
 the surest, quickest, and best way to get rid of retained matter, wherever 
 it is situated, and the cut can not be made too early. 
 
 From the time a wound is made until the last skin cell takes its place 
 on the healing surface and thus completes the protective covering of the 
 
 deeper parts, infection with pus microbes may take 
 
 Fossibihhes of place, but a wound when fresh is much more suscep- 
 
 Pmmcrobe7 *^^^® *° their influence than it is at a later period, when 
 
 the healing process is already under way. While this 
 is true of the pus microbes, it does not obtain in the cases of certain 
 other bacteria, notably of the germs of erysipelas. This fact makes the 
 protection of wounds by an antiseptic dressing imperative until healing 
 is complete. 
 
 COLD. 
 
 The continued reduction of the temperature of an inflamed part dur- 
 ing the early stages before pus has formed is sometimes useful to dimin- 
 ish the pain and to cause contraction of the blood-vessels and consequent 
 diminution of congestion. It also may have the effect of stopping the 
 growth of the bacteria, because a temperature lower than that of the 
 body is commonly unfavourable to their development. Cold should not 
 
464: SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 be used after pus luis foruied ; it then has a bad effect upon the vitality 
 of the tissues. 
 
 Cold may be conveniently api)lied by means of a rubber ba^: or a pig's 
 bladder tilled with cracked ice. Its ajiplication shonUl be continuous. 
 
 Cold is not generally used in the treatment of iullaiued wounds, but 
 in inflammations beneath the skin Avhcre suppuration is threatened. 
 
 POISONED WOUNDS AND THEIR TREATMENT. 
 
 "When a poisonous animal virus, or any animal or vegetable poison 
 
 other than the bacteria, is introduced into the tissues through a wound, 
 
 we speak of the condition as a " poisoned wound." 
 
 The Nature and rpj^^ wound may be a mere scratch or the poison may 
 
 sone/womuU ^^ carried deeply into the tissues. Examples of such 
 
 wounds are the bites of venomous serpents and lizards, 
 
 the stings and bites of insects, and the wounds made by arrows or other 
 
 weapons, the points of which have been smeared with poison. In snake 
 
 bites the venom is forcibly injected into the wound through the hollow 
 
 or grooved fangs which convey it from the poison glands. The effects, 
 
 local and general, of such wounds vary greatly according to the character 
 
 of the poison and the amount which is introduced into the wound. The 
 
 health and strength of the individual are also not without influence. 
 
 The poisonous snakes of North America are the rattlesnake, the 
 American raoccason, and the copperhead. The poison of all venomous 
 snakes is similar in its eft'ects, the severity of the symp- 
 toms depending upon the factors mentioned above and 
 upon the rapidity of absorption. 
 
 AVhen the venom is injected directly into a vein, the system is perme- 
 ated by the poison in a few seconds or in a minute or two at most, and 
 symptoms of sudden mental and physical collapse come on at once. 
 AVhen the wound is a mere abrasion, or when the skin and the tissues 
 just beneath it, in regions where blood-vessels are not very numerous, 
 alone are infected, the absorption of the poison may be delayed and 
 severe symptoms may be absent. Very commonly terror is extreme, and 
 may cause a condition of profound shock after the bite of a harndess 
 reptile. 
 
 The usual symptoms of snake bite are severe pain in the wound, 
 local swelling and discolouration of the skin, muscular weakness, a rapid, 
 feeble pulse, coldness of the extremities, clammy sweat, 
 headache, embarrassed breathing, nausea and vomiting, 
 and, if the result is to be a fatal one, convulsions, unconsciousness, and 
 death. If the individual survives the immediate effects of the poison, the 
 swelling spreads widely and is often followed by death of the swollen 
 
SYMPTOMS AND TREATMENT OF SNAKE BITE. 405 
 
 tissues to a greater or less extent. Ueatli may occur in an liour or may 
 be delayed for several days. 
 
 Tliere is no effective antidote for snake hite. The lirri[> should l>e 
 constricted at once above the wound by means of an improvised tourni- 
 quet, which must be twisted as tiii-htly as possible. The 
 Treatment. . o ./ i 
 
 wound itself may be cut out with a knife which goes 
 
 around it three fourths of an inch from its margin, or the wound may 
 be sucked by the individual himself or by another who has no abrasion 
 of the lips or inside of the mouth. This treatment may be followed by 
 a cut which greatly enlarges the wound and allows the venom to be 
 washed out by the flow of blood, and at the same time makes the poison 
 more accessible to the action of a red-hot iron, a live coal, or to a strong 
 solution of permanganate of potassium, or to any strong mineral acid. 
 These agents destroy the tissues which contain the poison and the poison 
 itself. 
 
 To stimulate the enfeebled heart any strong liquor may be given in 
 large doses. Care should be taken not to kill the patient with alcohol. 
 Remember that children are easily poisoned with liquor. 
 
 A solution of permanganate of potassium, one grain to the ounce of 
 water, may also be injected through a hollow needle into the parts around 
 the wound with the idea of destroying such poison as may still be present. 
 Ammonia water has been thought to act in a similar manner, but it is of 
 doubtful efficacy. 
 
 Persons have sometimes saved their own lives by the immediate am- 
 putation of the wounded finger or toe. 
 
 Investigations made recently in the Pasteur Institute at Paris by Dr. 
 Calraette point to a probable solution of the problem of preventive inocu- 
 lationa in snake bites. 
 
 Dr. Cahnette found that the blood serum of an animal dead of the 
 bite of the cobra (the serpent which destroys so many human lives in 
 India), when injected in small quantities into the tissues of other animals, 
 produced in the animal inoculated complete immunity from the cobra 
 venom. The inoculations were made with increasing quantities of serum 
 and four days were required to complete the protection. 
 
 Dr. Calmette also found that a solution of chloride of lime in water, 
 freshly prepared, would, when injected into the tissues of an animal re- 
 cently bitten by a cobra, prevent the deadly eSect of the poison. These 
 injections had to be made within an hour from the time the bite was re- 
 ceived, and a considerable quantity of the solution had to be used. The 
 action of the chloride of lime is to prevent the coagulation of the blood 
 which the venom produces and the consequent interference with the cir- 
 culation of blood in the lungs. 
 
 These experiments have, as yet, been confined to the lower animals, 
 32 
 
460 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 and it is tlierefore too soon to assert positively tliut tlioy will bo as suc- 
 cessful in man. 
 
 The tarantula, a large, poisonous spider inhabiting the warmer parts 
 of America, produces by its bite symptoms similar in kind but milder in 
 deii-ree than those iust described. The treatment of tarantula bite is the 
 same as that of snake bite, but need not be so heroic, since death rarely 
 occurs. 
 
 The stings of bees, wasps, anil hornets produce ixiinful but not dan- 
 gerous symptoms. Treatment. — Remove the sting if it be left behind, 
 and apply an alkaline solution to the part — ammonia 
 The Stings of Bees, ^ solution of washing soda. Wet clay is a 
 
 etc. 
 
 popular and effective remedy. 
 
 Ammonia water relieves the irritation of the skin produced by the 
 bites of fleas, bedbugs, and mosquitoes. 
 
 The active ingredient of the substances used by the savage natives of 
 Africa to poison the points of their arrows is usually the juice of some 
 plant. Frequently other ingredients are added, such as 
 Poisoned-arrow pondered red ants, the heads of poisonous serpents, or 
 the body juices of the larvse of certain beetles Avhich 
 feed upon poisonous plants and thus become themselves poisonous. Pu- 
 trid animal matter is sometimes mixed with the other materials. 
 
 An examination of the poisoned arrow-heads brought from various 
 parts of Africa has shown that many of them contain a poisonous sub- 
 stance similar to or identical with the drug called Strojjhanthus, which is 
 obtained from the juice of an African tree and is largely used in civilized 
 medicine as a heart stimulant. Its action is first to stimulate and then, 
 in larger doses, to paralyze the heart. 
 
 Some of the men accompanying Stanley in his journey up the Congo 
 Kiver died in a few minutes after being wounded with arrows so small 
 that the puncture was not much larger than the prick of a darning-needle. 
 Those who survived the immediate effects suffered from inflammation 
 and gangrene of the wound, and a considerable number of those wounded 
 died, after some days, of tetanus. The most effective remedy seemed to 
 be the injection into the tissues about the wound of a solution of car- 
 bonate of ammonia. 
 
 The natives of some of the countries of South America use a poison 
 on their arrows and darts called " curare." This is a violent poison, and 
 causes paralysis of all the voluntary muscles of the body. 
 
 The treatment of poisoned-arrow Avounds would be the extraction of 
 the arrow-head as soon as possible, constriction of the 
 
 TreMtment. ti , • ,... it-/- 
 
 Jimb to prevent absorption, and incision and disintec- 
 tion of the wound by one of the methods already given. The removal of 
 the head of the arrow is rendered difficult by so contriving it that pull- 
 
QUIET THE CHIEF DESIDERATUM. 407 
 
 ing on the shaft of the arrow usually breaks off the liead and leaves it 
 embedded in the tissues. 
 
 GENERAL TREATMENT OF THE WOUNDED. 
 
 Under the treatment of sliock and excessive bleeding the writer Ijas 
 
 already indicated what should be done for persons suffering from these 
 
 conditions. 
 
 Generally the quieter the wounded jx^trt is kept after it is once 
 
 dressed, the hetter, and the same principle ajjpMes to 
 
 ' the individual himself. 
 
 If a wound does not become infected, little or no general treatment is 
 
 required. After the most severe surgical operations there is commonly 
 
 very little pain, and only a temporary constitutional depression, providing 
 
 no infection with pus microbes takes place. 
 
 When infection occurs, the system is depressed by the continual ab- 
 
 „ . , , sorption of poisonous products, and plenty of any kind 
 
 of food that the patient can take, especially milk, 
 
 eggs, and strong soups, must be given to support the strength. If there 
 
 is no appetite, it is better to give food at regular and short intervals in 
 
 small doses. Whiskey, strychnine, and various other 
 Slifuulcints. d ' .1 ' 
 
 tonic drugs are used to support the circulation and vital 
 
 powers. Morphine is used to relieve pain and to enable the patient to 
 sleep. (See Medicines and Treatment}) 
 
 The so-called antipyretics — quinine, antipyrine, etc. — are not commonly 
 used to diminish the height of the fever following infected wounds, be- 
 cause these drugs have only a temporary effect, and depress the heart and 
 the general vitality of the patient. Sponging the body 
 with alcohol and water, or with tepid water alone, is of 
 use to lower the temperature. These applications are usually refreshing, 
 and help to keep the skin in a healthy condition. They may be repeated 
 several times daily, if agreeable. 
 
 The bowels should be kept open, and much water may be taken with 
 
 advantage by the mouth, to encourage the action of the 
 
 ^ wels kidneys, through which many bacteria are eliminated 
 
 from the system. 
 
 As in any disease accompanied by continued fever, special attention 
 
 should be paid to the mouth. An antiseptic mouth wash of some sort 
 
 should be used frequently. There is nothing better or 
 
 -^ {, more refreshing for this purpose than a solution of 
 
 peroxide of hydrogen used one half strength. Lister- 
 
 ine, diluted with an equal quantity of water, answers the purpose well. 
 
46S SUEGICAL lyJTRIES AND SUEGICAL DISEASES. 
 
 COXTUSIOXS. 
 
 Blows with blunt instruments, falls from a height, crushing injuries 
 from various causes, often result in more or less extensive bruising or 
 laceration of the deeper tissues without any break in the skin. "We call 
 such injuries ^iibcvta neons icoun<h or cont unions. 
 
 The gravity of such conditions varies with the amount of injury done 
 to the deeper parts and with the importance of the injured organs. 
 
 A constant accompaniment of contusions is the laceration of a certain 
 
 number of blood-vessels, usually capillaries and small veins, wliich causes 
 
 an eflFusion of blood beneath the skin. This effusion of 
 
 EfusionofBlmd ^^^^ ^^^_^^ beneath the skin ^ives rise to the swelling 
 
 beneath the bktn. ■, ^i r -i- j- • 
 
 which follows a bruise and to the fannhar discolouration 
 
 of the skin which is known as a black-and-blue mark. The arteries, on 
 account of their tough and elastic walls, usually escape rupture. Occasion- 
 ally a large artery is ruptured. Then a pulsating swelling full of blood 
 
 is formed which mav ^ive rise to serious svmptoms, and, 
 False or Traumatic .^. ^^^ ^^^^^ ^ ^.'^ -^^^ ^^^^^ ^ ^^^ ^.^^ ^^.^^^j 
 
 Aneurism, , , , i • i e 
 
 result may take place from ulceration and rupture or 
 
 the swelling, and consequent loss of blood. 
 
 Contusions • which cause the rupture of important organs like the 
 
 lungs, the liver, the intestine, the bladder, or where very extensive 
 
 laceration of the soft parts and crushing of the bones 
 
 of a limb are produced, are very commonly attended by 
 
 grave symptoms of shock, and may result fatally from this cause alone. 
 
 "VThen inward bleeding in large amounts takes place into one of the 
 
 body cavities — the chest, the abdomen — symptoms may be produced due 
 
 to the withdrawal of the blood from the circulation — 
 
 rj I i. t., svmptoms of hgemorrhaofe — or the effused blood 
 
 M(Bmorrhage. . r e 
 
 may, by pressure upon the viscera contained within the 
 
 cavity, cause symptoms of various kinds. In the chest, effused blood 
 
 may produce embarrassed breathing or interference with the action of 
 
 the heart. In the abdomen, the symptoms produced by the pressure of 
 
 effused blood are usually not marked, shock is often present, and a varied 
 
 train of symptoms due to the injuries of special organs. W^ithin the 
 
 skull, with its unyielding walls and very delicate contents, the presence 
 
 of a clot of blood may give rise to serious or fatal symptoms which will 
 
 be spoken of under Injuries of the ShuU. 
 Injuries of -NVrre-s rr-t • • • £ j i • • . .-l 
 
 J ,,' , ilie miuries of nerves and muscles give rise to the 
 
 ana Jlusfles. •* ^ , = 
 
 same loss of function which occurs in open wounds, 
 but complete recovery is the rule unless considerable intervals are left 
 between the divided structures after healing is complete. 
 
 The pain caused by contusions varies greatly, according to the nerve- 
 
■skiiauGe. ifsSiiiafjd 1 flood hu-t eauie a ^oc»3 ■fiba] ^af . 
 
 „^* • ■ ucfc. tiifc HiDG Tiitrt 
 
 r ]T3upLaiie£, *Dd 
 atniaarwacfi nSiis sJktt lEgindSss anMfl k itafeprw ing!) ^jy ttfe sjrsieEn am t^»e fiaiDB 
 mimm^^ .. Yhs <z^:' ' ^'j "" ' " " ^ ■■' ~ ' ■ ' " ' • ' camsef a Line 
 
 ■jjr'^SagfcMnTikBri ngii - ■■ :'-■•-.- ^;, :---.-_ • -___ LrioTn chsjigi^^ 
 
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 mjanrj nsmfiiks, femt. wBrtpm a ecJua&fnaMe '.BffvitT Sksi ^srilii l*k»Dd esdsls. 
 
 ffiUk-.i vwiiiSi aa T^^aesay lirsrwin^ tmidi^ asmains, smroimded "bj sear-'lassnfc. 
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 ti^iDS^ t&e ifeaLd jjEins ans isms^irei laj" siisMTLiiiim, amd fbe "H- rrng pans 
 see TT grtmnnfegl Iby iDff^ i5s5QS 'M Tilr-j^ innS, t£ff l^T si3a2-lHsn£u if ihf; Fnaee to 
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 TSffi imssr irnnnn ncmt Brntr iSi^isBjje "bgrwBsn 'Epsn "w^DiiTids and eDntnaons 
 
 jiTses frnn Ti^ ~: — 'nsi iSb- nmhr&frgn ^rn cfeis R'bsxnsr to lihe smTsn^ 
 
 : "e rsaelsrm. HstEiee sabgntartf-ois injinifs. Vhefn 
 
 j^ (Dwrn^mmm. ^~ -'^^ ^ f^ ^^ io^xfir, Tnaj le snuiasrnt l» 
 
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 ffiEEfiwaoiirjuji.ik' ^.isianajim i®ir^sr TEbe sauaEks m. ithe wnPT pl-tf^., snd a Hiz-rr 
 ojr iisss *Esz5sish^ saiisfise ^sselIk. Eainfik* sn^niraiaan ■DiSEins in s. eo3j- 
 tinsJxTjgi wTJrffn^, a>® fesalk in i&b -jJlnTrFi ^ ' «."H4 ir ^ . TThik i^wt; snd DEbers nf iiks 
 laiOkir-ai^car Buawe Ifed ie. :a !«osid .deal 'of inT--^n5£23ar>2L Tbf eoziclnaan 
 liZiniTTrfi ET 25 TtFriBj. , ^ in a. 33S£]iiSk' indisiidiial. s .eBrnEm uninltfir oi piK 
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 ^r-^>^ VHiV»g n;# cfiH iignTBg TPi ililHmiai : P- - -~_ - ^t^:" ~ " ". '- "j disDQ^ 
 
 liSi icjHm ; Hsoar ^*sfli ana Smjaiay ; ^ -ii-r ii^ij _.■!: .,: '_^_ ~__^Tediies 
 
 ^i£ "wntjffillirr ^ iflte panlt. 'SBae acmffiKSsiSass aiifi^ aesEiife xhere End isrDdnfe "flieor 
 
470 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 Subcutaneous bleeding, even from an artery of some size, often stops 
 of itself from the pressure of the effused blood. Pressure by a moder- 
 ately lirm bandage may be used, however, to aid Nature, 
 
 Treatment of also elevation of the limb, and the application of cold 
 
 Contusions. ~ . , . , . , 
 
 in the torm of an ice-bag, or an evaporating lotion, such 
 
 as water and alcohol, equal parts ; extract of witch hazel, diluted with 
 
 water; or the solution of sugar of lead, alum and water may be used. 
 
 These applications may be continued for a few hours or longer if the 
 
 swelling seems to grow larger and the discolouration of the skin spreads 
 
 rapidly. 
 
 Cold should not be used in severe contusions where the skin is cold 
 and inserisitt've, for fear of further diminishing its vitality. In such 
 cases, the limb should be cleaned thoroughly and disinfected, as though 
 there were an open wound, a light dry antiseptic dressing should be ap- 
 plied, the limb enveloped thickly in ordinary cotton-batting, and over this 
 a bandage, to hold it in place, put on rather loosely. The limb should be 
 elevated and supported on pillows, or a board covered with some soft 
 material. Prominent bony points should be protected by thick pads of 
 cotton, to prevent the injurious effect of pressure. 
 
 Slight wounds of the skin over a contusion should always be treated 
 antiseptically. 
 
 In contusions of moderate severity, the main object of the treatment 
 is to cause the early absorption of the effused blood. This is accomplished 
 by massage, always rid)bing toward the trunk., begin- 
 assage. ning with gentle rubbing and increasing the pressure 
 
 after a few minutes, when the tissues become less sensitive. The rubbing 
 may be continued for ten minutes, and should be done once or twice a 
 day. A valuable aid to massage is an ointment composed of one part of 
 ichthyol and ten parts of lard. Tiiis should be rubbed in during massage. 
 
 Douching with hot and then with cold water also aids in the absorp- 
 tion of the blood, and well may be used in conjunction with the measures 
 
 just described. By these means considerable effusion 
 Douching. ' , j , t' • £ j 
 
 may be made to disappear m a lew days. 
 
 "When infection with pus microbes takes place and pus forms, the 
 
 treatment is that of abscess and inflamed wounds. The treatment of 
 
 contusions of special regions will be mentioned under the Injuries of 
 
 Special Regions. 
 
ACUTE ABSCESS: SYMPTOMS AND TREATMENT. 471 
 
 CHAPTER II. 
 SURGICAL DISEASES OF THE SOFT PARTS. 
 
 ACUTE ABSCESS. 
 
 An acute abscess is a collection of pus in the tissues, due to infection 
 with pus microbes tlirough a wound in the skin or mucous membrane, 
 or to an infection proceeding from a similar inflammation somewhere else 
 in the body. 
 
 A favourite site for abscess is in the loose tissue beneath the skin. 
 
 The symptoms of abscess are pain, fever, and, if the inflammation is 
 near the surface, heat and redness of the skin and a peculiar elastic feel- 
 ing known && fluctuation, due to the presence of the 
 
 Symptoms. -« j a ^i • ^ ^ • j- .i 
 
 connned pus. Another miportant sign of the presence 
 
 of pus is extreme localized tenderness on pressure, especially in sensitive 
 regions. The pain of abscess varies greatly. In sensitive regions a drop 
 or two of pus may cause intense suifering, while in loose tissues scantily 
 supplied with nerves, a very large accumulation of pus may give rise to 
 but little pain. The fever depends upon the absorption of poisonous 
 products, and varies greatly in degree with the size and situation of the 
 abscess. The fever and pain usually subside immediately after the pus is 
 evacuated. The redness and heat of the skin indicate that the pus is near 
 the surface. The redness is usually most intense over the centre of the 
 abscess and shades off gradually into the surrounding healthy skin. All 
 the symptoms of acute abscess are commonly developed in a few days. 
 
 The treatment of abscess is to let out the pus through a cut as soon 
 as its presence may be detected. The cut should be made over the point 
 of greatest tenderness and extended in a direction such 
 that gravity will assist the subsequent drainage of the 
 cavity. If the abscess is large, more than one opening may be needed. 
 Drainage should be maintained by the introduction into the abscess 
 cavity hy the most direct route of a piece of clean, soft, rubber tube. 
 When the abscess is not deep the incision itself maj' be sufiicient to se- 
 cure a proper drainage, or a small piece of antiseptic gauze may be 
 packed loosely into the opening, which will suffice to prevent the closure 
 of the wound and a reaccumulation of the pus. The opening of an ab- 
 scess should be done with all the antiseptic precautions described in 
 the treatment of wounds and an antiseptic dressing should be applied. 
 Washing out the cavity of an acute abscess may generally be omitted, 
 as it is very painful and does not materially aid in the cure. A free exit 
 for the pus is the essential jpart of the treatnient. 
 
47-2 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 In acute abscesses of nioderate size, wliicli have been ])roperly ojiened, 
 the drainage-tube usually may be removed permanently after three or 
 four davs. AVhen the cavity has ceased to di>cliariie pus the presence of 
 a drainage-tube delays the healing. 
 
 Sometimes healing proceeds rapidly uj) to a certain point, but a nar- 
 row tubular tract is left in the tissues which refuses to close and dis- 
 charges continually a little pus. "\Ve then resort to various stimulating 
 applications to hasten the closure of the sinus, as it is called. We inject 
 into the tract through a small glass syringe Peruvian balsam or tincture 
 of iodine. Frequently such applications repeated every day or two will 
 lead to a speedy cure. If not, we suspect the presence of dead or in- 
 flamed bone or some other dead tissue, for the removal of which a sur- 
 gical operation may be necessary. 
 
 It is a good rule to open abscesses early. The patient will thus be 
 spared suffering and danger from the absorption of poisonous products, 
 and the size of the scar will be reduced to a mininmm. 
 
 Tlie general liealth should be supported by tonics, and the general 
 rules given for the care of patients suffering from inffamed wounds a])ply 
 also here. Absolute rest for the part is important. 
 
 During the early stages of the disease cold may be nsed with the idea 
 of preventing the formation of pus. An ice-bag or a cold, wet antiseptic 
 dressing — as previously described for inflamed wounds — may be nsed, 
 and the limb elevated. These measures sometimes succeed. They 
 should not be used after high fever, fluctuation and extreme tenderness 
 give evidence of the presence of pus. 
 
 BOILS. 
 
 A boil is an acute localized inflammation of the skin caused by infec- 
 tion with pus microbes. The infection usually takes place around the 
 root of a hair, in a sweat-gland, or in one of the sebaceous glands of the 
 skin. As a general rule, the process ends in the formation of a small 
 abscess and the death of a small portion of the skin. Boils are accom- 
 panied by pain and discomfort and often by sliglit fever. They may 
 apjiear upon any portion of the skin, the most common sites being the 
 back of the neck, the back, the buttocks, the armpit, and the face. 
 They are apt to occur when the general health is impaired from any 
 cause, especially during convalescence from fevers, and are not uncom- 
 mon among those who change their underclothing infrequently and 
 bathe rarely. 
 
 A boil usually begins as a small, red, tender, ele- 
 vated spot in the skin resembling an ordinary pimple. The redness and 
 swelling increa.se, and after a few days a small abscess is formed. The 
 inflamed area varies in diameter from a quarter of an inch to an inch 
 
BOILS AND CARBUNCLES. 473 
 
 ,aiid a half, and seldom extends into tlie deeper parts, alt]ioii;:^li it may 
 rarely be the starting-point of a progressive and serious inflammation, 
 especially about the face. 
 
 If the boil is not opened in a few days, a small portion of the skin 
 dies and comes away, allowing the pus to escaj)e. This discharge of pus 
 is usually followed by the discharge through the opening of a bit of dead 
 tissue, vulgarly known as the core of the boil. The inflammation then 
 subsides rapidly, and the httle cavity heals from the bottom. 
 
 The treatment of boils is local and general. The effort to abort l^oils 
 
 is usually unsuccessful. Wet dressings of sugar of lead and alum solution 
 
 , „, , , may be tried, or of a sohition of three parts of ichthvol 
 
 in one hundred parts of water. A cloth wet with either 
 
 solution may be kept on the part. The best treatment is to open the 
 
 boil early by a small cut, and thus let out the pus and relieve the tension. 
 
 Immediate relief from pain is obtained, and usually a rapid cure is the 
 
 result. A wet dressing of either of the above solutions may then be 
 
 applied. The general treatment consists in the administration of iron 
 
 and strychnine or some other tonic, and in attention to the skin. A 
 
 , ,^ , , daily hot bath should be taken with plenty of strone: 
 General Jreatment. mi ^r 11 <• i i 
 
 soap. Ihe "green soap of the pharmacists is good. 
 
 The baths remove from the surface of the skin and from the skin glands 
 or pores the bacteria which cause the trouble. Russian or Turkish baths 
 taken two or three times a week answer the same purpose. The internal 
 use of the sulphide of calcium so often prescribed to prevent the recur- 
 rence of boils is of doubtful efficacy. 
 
 CARBUNCLE. 
 
 A carbuncle may be described as a number of boils situated close 
 together. The area of inflamed tissue varies in size from an inch to six 
 or more inches in diameter. The skin and the tissues beneath it are 
 inflamed, and sometimes the muscles are invaded. The inflamed tissues 
 die and undergo purulent softening. It is more common in old people 
 and in the debilitated, and is a frequent complication of diabetes. In the 
 robust, the result is usually favourable ; in the feeble and diabetic, the dis- 
 ease often ends in septicaemia or pysemia and death. 
 
 Carbuncle occurs most often on the back of the neck, on the back, 
 and on the face. In the last situation it may produce death by exten- 
 sion of the inflammation to the brain and its mem- 
 branes. ' It begms as a hard, painful, tender swellmg 
 beneath the skin. There are fever, prostration, and other symptoms of 
 septic poisoning. The skin becomes red and inflamed over the swelling, 
 and is finally perforated, usually in several places. Pus exudes through 
 the openings. If not operated upon early, a good deal of skin may die 
 
47i SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 and leave a surface of dead tissue beiiL-ath of varialjle depth, whicli is 
 
 slowly separated from the living parts. The cavity heals in a tedious 
 
 manner from the bottom. By the death of portions of skin and the 
 
 deeper tissues here and there a honeycombed condition may be produced. 
 
 In the early stages, the application of an ice-bag may serve to limit 
 
 the inliaunnation to some extent. The only treatment which serves to 
 
 shorten the disease and to preserve life is the operative 
 Ireatmettt. ^ e ^ ^ , i • ,i i ■ 
 
 removal oi tlie dead and nmamed tissues, saving as 
 
 imu'li as possible of the skin, followed by thorough disinfection of the 
 cavity and the ajtplication of an antiseptic dressing. The general treat- 
 ment does not dill'er from that of inflamed wounds. It is needless to say 
 that the services of a surgeon are recpiired. 
 
 GANGRENE AND NECROSIS. 
 
 The term c^ano-rene, in its most modern sio-nificance, is used to desiff- 
 nate the changes produced in tissues already dead by the growth in them 
 of the bacteria of putrefaction. 
 
 Necrosis means death of the tissues from any cause. Among such 
 causes may be mentioned : Mechanical violence, cold, heat, caustics, com- 
 plete stoppage of the arterial blood supply (which may 
 
 ' .f " . be sudden, from ini'ury or from pluffi^inff of the vessel 
 
 Jyecrosis. / , . , , 
 
 by material carried from the lining of a diseased heart ; 
 or gradual, from disease of the vessel itself), complete stoppage of the 
 large veins of a limb from disease or injury, continuous pressure (an 
 example of which is a bedsore), diseases of the nervous system, the contin- 
 ued use for food of bread made from diseased rye, and, finally, the growth 
 in the tissues of various forms of bacteria other than the putrefactive 
 bacteria. 
 
 A detailed description of these conditions must be sought for in works 
 on general surgery. To a non-medical person, the only practical bearing 
 of this topic relates to such knowledge as would enable him to recognise 
 the commoner conditions of necrosis on the surface of the body. 
 
 AVe have spoken of I^rogressive Gaseous Gangrene. It is a disease 
 
 the nature and seriousness of which are not likely to be overlooked by 
 
 any one. AVe have also mentioned certain inflammatory conditions caused 
 
 by pus microbes and attended by necrosis or death of the tissues, and we 
 
 shall here confine ourselves to the consideration of the symptoms of 
 
 necrosis as it occurs in the extremities under the com- 
 True or Moist ~ 
 
 ^, mon name oi ffanorrene. 
 
 AVe distinguish two types of this condition, accord- 
 ing as infection with putrefactive bacteria is present or absent. First, 
 True or Moist Gangrene^ where the dead tissues putrefy as the result of 
 
TRUE GANGRENE AND MUMMIFICATION. 475 
 
 the growth of the pntrcfactive bacteria, tlic pus rnicroljos attack the 
 hving parts adjacent, and a inure or less intense {)oisoning of tlic system 
 occurs from the absorption of bacterial products. Second, Dry Gan- 
 grene or Mummification^ in which the dead part dries, 
 ^'Iwrnli/lZZi. shrinks, becomes hard, and does not undergo putrefac- 
 tion. Infection with pus microbes is absent, or, if it 
 occurs at the line of separation of the living from the dead parts, it is 
 usually slight. Hence systemic poisoning is absent or not severe. This 
 form of necrosis is most common in the aged. It usually begins in one 
 of the toes, often in the great toe, and is due to failure of nutrition from 
 gradual obliteration of the arteries. 
 
 When the main artery of a limb is destroyed by an injury, or plugged 
 
 by a clot, no pulsation can be felt in the vessels of the limb below the 
 
 point of injury or the situation of the clot, as the case 
 
 may be. If the smaller vessels are unable to carry on 
 
 the circulation, the pulsation does not return, and gangrene may be 
 
 expected. 
 
 Pain. — If a large artery is suddenly plugged, severe pain is commonly 
 felt in the entire limb. Where the stoppage is gradual, moderate pain 
 may be felt for weeks or months. Acute inflammation ending in gan- 
 grene is attended by severe pain, which ceases or grows less when death 
 of the tissues is complete. 
 
 Tenderness. — As long as the prick of a needle can be felt, the sus- 
 pected part is not dead. 
 
 Tetnjperatxire. — When acute inflammation ends in gangrene, the part 
 does not become cold until death is complete. Gangrene caused by grad- 
 ual interference with the nutrition of a limb is preceded by coldness of 
 the skin. This is usually true of gangrene caused by sudden plugging 
 or destruction of the main artery. 
 
 Swelling. — In moist gangrene, the tissues swell from imbibition of 
 fluids from the blood-vessels and surrounding structures. If gas is pro- 
 duced, the swelling increases. In Asejjtic or Dry Gangrene the part 
 shrinks and becomes hard. 
 
 Gas in the tissues is produced by certain of the putrefactive bacteria. 
 It consists of sulphuretted hydrogen (having the well-known odour of 
 bad eggs) and of certain of the decomposition products of fat. Its pres- 
 ence is easily detected by pressing the limb with the tips of the fingers, 
 when a crackling sound and sensation are noticed. 
 
 Colour. — When caused by stoppage of an artery, death of the tissues 
 is preceded by an unnatural paleness of the skin, followed by a leaden 
 grey discoloration, which gradually changes into a greenish black. In 
 moist gangrene, blisters containing blood-stained fluid form on the sur- 
 face. 
 
470. SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 Condition of iJic Tissues. — In inoi.<t oang-riMie, the dead tissues become 
 soft, and an offensive fluid exudes from the surface. In dry ase])tic gan- 
 errene, the dead tissues slirink and become liard, as before stated, and 
 emit no bad odour. The extent of the process dejiends upon the previous 
 vitality of the tissues, upon tlie size and number of the vessels obstructed, 
 upon the amount of infection, and upon the virulence of tlie bacteria. 
 
 In the moist variety, \vhere pus microbes are present, the living tissues 
 are separated from the dead by suppuration when gangrene is arrested. 
 In aseptic gangrene, absorption of the dead tissue takes place if the mass 
 is not too large, otherwise it is diminished in size by the activity of the 
 living cells, and separation takes place by the formation between the liv- 
 ing and the dead parts of a wall of such tissue as was described as form- 
 ino- in the healinsr of clean wounds. 
 
 In aseptic gangrene, there are no symptoms of general poisoning. In 
 
 the moist, putrefactive variety, the general symptoms 
 General Symptoms. ^, „ i • i. i.- • i • i 
 
 are those oi a more or less intense septicnemia, which 
 
 will be spoken of elsewhere. 
 
 It is obvious that no line of treatment can be proposed which would 
 be practicable for a non-medical person to carry out. The rule among 
 surgeons is that, where no symptoms of general poison- 
 ing exist, the dead tissues are not to be removed until a 
 distinct line of separation occurs. Wliere dangerous symptoms of poi- 
 soning are present and the death and infection of the tissues are spread- 
 ing, amputation, done early and at a point far removed from the disease, 
 offers the best chance for recovery. When gangrene is threatened from 
 impeded circulation the limb should be cleaned, covered M'ith a dry anti- 
 septic dressing, wrapped loosely in cotton-batting, and slightly elevated. 
 For the prevention of gangrene from pressure the reader is referred to 
 the article on JS^ursioig the Sick, under the head of bedsores. 
 
 In the aged and in those suffering from diabetes, trivial wounds 
 should receive the most careful antiseptic treatment. The general treat- 
 ment consists in the administration of the most nourishing food, tonics, 
 and alcohol in the form of wine or liquor. It is similar to the general 
 treatment of inflamed wounds. 
 
 ERYSIPELAS. 
 
 Erysipelas is an acute, contagions inflammation of the skin and mu- 
 cous membranes, caused by a special microbe. 
 
 Infection takes place through a wound or abrasion, 
 Means of Infection. , n » • i j- j- ne, l • i. i 
 
 large or small. A period oi irom ntteen to sixty hours 
 
 elapses from the time of inoculation to the development of the disease. 
 
 The disease is carried readily from one ]:)erson to another by fingers, 
 
ERYSIPELAS: SYMPTOMS AND PROGNOSIS. 477 
 
 sponges, instrumer)ts, etc., and, before tlie mode of infection was under- 
 stood, epidemics of the disease were very frequent. After childbirth 
 women are very susceptible to infection with erysipelas through the geni- 
 tal tract. In these cases a rapidly fatal form of septica3mia is produced. 
 Pure erysipelas is not attended by the formation of pus. 
 
 The disease is often ushered in by a chill, or, in children, by a convul- 
 sion, followed by fever which sometimes rises in a few hours to 103° to 
 104° Fahr. The pulse is at first full, and the rapidity 
 " about 100. Later in the disease the pulse may become 
 
 more rapid and feeble. ^Nausea and vomiting are common. Loss of 
 appetite, headache, and prostration are usually marked. Delirium is fre- 
 quent, especially in erysipelas about the head. In a few hours or in a 
 day the inflammation of the skin appears. If near a wound, the dis- 
 charge of pus from the wound is rather diminished than increased. The 
 inflamed skin is bright rosy red, firm to the touch, and slightly elevated. 
 The swelling is most marked about the face and eyelids, and in other 
 regions where the tissues are of loose texture. The inflammation spreads 
 rapidly in irregular, wavy lines, always with a sharply marked border. 
 Often the inflammation disappears in the spot first affected, while advanc- 
 ing elsewhere. Blisters are frequently formed on the surface. They 
 may coalesce into large blebs filled wdth watery fluid. If infection with 
 pus microbes takes place this watery fluid may become purulent, or, in 
 severe types of the disease, bloody. A burning or itching is complained 
 of in the inflamed skin. Severe pain is not present. 
 
 The duration of the disease is variable, from two or three days to 
 several weeks, depending upon whether the process remains confined to a 
 narrow area or spreads from one place to another over 
 a large extent of surface. In the robust, erysipelas is 
 rarely fatal. In the debilitated, and especially in those who habitually 
 drink to excess, it is a very dangerous disease. One attack predisposes 
 to others. 
 
 Erysipelas of the face and scalp is usually attended by high fever, 
 prostration, and often by delirium. A fatal result may occur without 
 special complications, or extension to the brain or its membi-anes may 
 produce death. 
 
 Erysipelas of the mucous membranes is most common in the throat. 
 It may occur alone or as a complication. It is dangerous, owing to the 
 swelling which may close the opening into the windpipe, and thus pro- 
 duce asphyxiation and death. 
 
 Secondary infection from pus microbes may produce abscesses be- 
 neath the skin or a condition previously described under the name of 
 Progressive Sej)tic Phlegmon^ with much destruction of tissue and often 
 fatal poisoning. 
 
4TS SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 Ervsipolas is ordinarily followed bv a scaling- ott' of tlio skin over the 
 previously inllanied area. 
 
 Toopk' with severe attacks of erysipelas are coniinonly very ill in- 
 deed. The general treatment consists in giving plenty 
 lea men . ^^^ easily digested food, with stimulants, tonics, and 
 
 opium, -when needed to jn-oduee sleep. 
 
 Ervsipolas is so variable in its duration that it is not easy to say what 
 application succeeds best. Prol)ably no local application has any very 
 marked effect in arresting the iiillanunution. The number of remedies 
 which have been used and lauded is very great. Among those which 
 seem to have some effect in limiting the spread of the disease, and to do 
 much to allay the discomfort of the patient, may be mentioned the fol- 
 lowing : A solution of ichthyol, 3 to 5 parts in 100 parts of water. An 
 ointment of ichthyol, 10 parts in 90 parts of lard. A solution of carbolic 
 acid, 1 part ; water, 100 parts. An ointment of carbolic acid, 1 part ; 
 lard, 50 parts. A solution of corrosive sublimate, 1 part ; water, 5,000 
 to 10,000 parts. A solution of the snlpho-carbolate of sodium, 1 part ; 
 water, 100 parts. The solution of sugar of lead and alum before men- 
 tioned, A solution containing sugar of lead, two teaspoonf uls ; lauda- 
 num, one tablespoonful ; water, one pint. 
 
 Cloths wet with these solutions are laid npon the inflamed part, and 
 more of the solution is poured on from time to time. On the face a 
 mask of sheet lint or several layers of gauze may be applied, with holes 
 cut for the eyes, nose, and month. 
 
 Carbolic acid applied to a large surface of skin may cause systemic 
 poisoning, even in weak solutions. The symptoms are an olive-green or 
 smoky discoloration of the nrine, whicli, in some cases, may become almost 
 black. The general symptoms are headache, giddiness, loss of appetite, 
 and vomiting. In severe cases, other symptoms are added — cramps of the 
 nniscles, collapse, unconsciousness, and death. The local application of 
 carbolic acid should, of course, be stopped at once when symptoms of 
 intoxication appear. 
 
 Corrosive-sublimate solutions sometimes produce an intense and very 
 persistent inflammation of the skin when the applications are long 
 continued. 
 
 The ointments are spread on lint or smeared over the surface of the 
 skin. 
 
 A series of hot soap-and-water baths should be taken after an attack 
 of erysipelas to get rid of the contagion as far- as possible. The hair 
 should receive especial attention. The clothes, bedding, and woodwork 
 of a room should be washed with soap and water, and afterward with 
 l-to-1,000 corrosive sublimate. The walls should be rubbed down with 
 bread crumb. 
 
CAUSE AND EFFECTS OF BLOOD-POISONING. 479 
 
 SEPTICEMIA OR SEPTIC INFECTION. 
 
 Under tins name are included a very varied sei-ie.s of .symptoms pro- 
 duced by the growth of pus microbes in the tissues. 1'he writer iias 
 ah'cady indicated the more important symptoms of some 
 of the forms of septicaemia in the preceding cliapter, 
 under the head of Infla'tned Wounds and tJteir Treatrrtent. Tlie products 
 of bacterial growth are absorbed from a localized inflammation and poison 
 the system. In severe cases {Progressive Septicainia), the bacteria enter 
 the blood-current and multiply therein, furnishing another source of poi- 
 son, and interfering with the functions of vital organs. The bacteria may 
 gain access to the tissues through a wound of the skin or mucous mem- 
 branes, large or small, or through an ulcerated surface of any kind. 
 
 The general symptoms vary much in intensity, according to the extent 
 and character of the local inflammation from which the disease originated, 
 the amount of poison absorbed, and the number of bac 
 " teria present in the blood. The most constant general 
 
 symptoms are fever and jprostration. The initial symptoms begin from 
 twenty-four to seventy-two hours after infection has taken place. In 
 some cases the first symptom is a chill, regularly followed by fever and 
 prostration. The pulse is rapid and, in severe cases, very feeble early 
 in the disease. Patients with septicaemia are stupid and apathetic, as a 
 rule, and do not appreciate the danger they are in. 
 
 The course of the disease may be very short, a fatal result occurring in 
 
 forty-eight hours or less, as in some cases of general peritonitis, following 
 
 perforation of the intestine from injury or disease, in 
 
 which the contents of the bowel escaj^e into the cavity 
 
 of the belly, and cause a violent and rapidly fatal form of inflammation. 
 
 In some cases life may be prolonged for weeks or months, the patient 
 dying finally from exhaustion or pyaemia. Recovery depends upon the 
 possibility of disinfecting the original seat of the inflammation, so that 
 the source of the poison may be cut off, upon the power of the tissues to 
 destroy the bacteria which have gained access to the blood, and upon the 
 strength of the individual. 
 
 PYMMIA. 
 
 Pyaemia is caused usually by purulent inflammation in the interior of 
 a vein. The infection of the vein takes place from a neighbouring in- 
 flamed wound or other local source of bacteria. A clot 
 containing bacteria is formed in the inflamed vein, the 
 clot softens, and portions of it are carried by the blood-current to distant 
 organs, where the bacteria produce new inflamed areas and abscesses. 
 
4S0 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 The characteristic features of pya?niia (ireyevt/\ mIuiIi varies ninch 
 and suddenly in intensity, going up and down from hour to hour and 
 from day to day ; iri-eguhir chills, each chill being sue- 
 " ceeded by a rise of temjicrature, M-hich in turn is fol- 
 
 lowed usually by a sudden fall and sweating; and //Kf/'lrd prostration. 
 
 The local symptoms depend upon the origiiud inlianunation and upon 
 the secondary abscesses, which may occur in the lungs, the kidneys, the 
 joints, the muscles, beneath the skin, or, in fact, in any situation. 
 
 The disease may run an acute or chronic course. In the acute cases 
 there are usually many small abscesses, and death occurs at the end of two 
 or three weeks. The patient emaciates ra})i(lly, there is 
 great thirst and profound weakness, the skin is dry and 
 ctf a yellowish colour, there is coTuplete loss of appetite. As the fatal ter- 
 mination approaclies, delirium and stupor are usually present, and possibly 
 diarrluea. Death takes place usually from gradual failure of the heart, 
 or, at times, suddenl}-, from plugging of the artery which carries the blood 
 from the heart to the lungs. In chronic cases life may be prolonged for 
 many months. The patient finally recovers or dies of exhaustion. 
 
 Both pyaemia and septiciiemia have become much less frequent since 
 the antiseptic treatment of wounds has been generally adopted. 
 
 TETANUS. 
 
 Tetanus, or lock-jaw, as it is popularly called, is a disease produced 
 by a rod-shaped bacterium, the bacillus tetani, which regularly inhabits 
 the soil and grows only in the absence of atmospheric air. The disease 
 is most frequent in warm climates. 
 
 Infection takes place through a wound. The tetanus microbe does 
 
 not cause suppuration, and may not interfere with the healing of a wound, 
 
 but produces poisons which, being absorbed, cause in- 
 Means of Infection. ^ • •. .• <? ,i \ ^ 
 
 tense irritation ot tlie nervous system, and continuous, 
 
 spasmodic contraction of the muscles, particularly of the muscles about 
 
 the head, neck, and back. Accidental wounds about the hands and feet 
 
 are especially likely to be contaminated with soil and dust, and hence 
 
 such wounds are most apt to be followed by tetanus. Deep ])unctured 
 
 wounds furnish the best protection to the bacteria from the air, and in 
 
 them the bacteria of tetanus find a suitable soil. 
 
 The time elapsing from infection to the development of the disease 
 
 varies from twenty-four hours to several weeks. Cases that develop early 
 
 run an acute and fatal course. Death may take place 
 
 in from twenty-four hours to a week. Chronic cases 
 
 develop slowly and late, and are much less fatal. About seventy-five per 
 
 cent of all cases of tetanus end in death. 
 
ACUTE AND CHRONIC LOCK-JAW. 481 
 
 In acute cases the disease often l)e<^iiis witli pain in the back of tlie 
 neck, followed by inability to open the mouth from spasm of the muscles 
 that move the jaw. There is sometimes a chill, and 
 always fever and a rapid, feeble pulse. The spasms 
 extend from one i^roup of muscles to auotlier, involving successively the 
 muscles of the jaws, the neck, the back, and finally the muscles of resjura- 
 tion that move the ribs and the diaphragm. 
 
 When the muscles of the back are in a state of spasm, the body is 
 arched backwai'd, so that, when lying face upward, the ])atient rests upon 
 the back of the head and the heels, a condition known as — 
 
 Opidhotonos. — The affected muscles remain hard and contracted, but 
 further spasmodic contractions occur from time to time. The spasms 
 are attended by excruciating pain. The inaljility to open the mouth, 
 sometimes accompanied by difficulty in swallowing, makes it hard to feed 
 these patients. Rapid emaciation and weakness result from this condi- 
 tion, and also from the pain and inability to sleep. Death often occurs 
 from spasm of the muscles that move the ribs and the diaphragm. The 
 patient can not breathe, and is asphyxiated. If the fii'st attack of this 
 kind is not fatal, the second or third is apt to be so. 
 
 Chronic Tetanus.- — In chronic cases there is no fever, and the con- 
 tractions and spasms are limited to the jaws and to some of the muscles 
 of the back. These cases last from four to six weeks or longer, and end 
 in death from exhaustion, or in recovery. 
 
 The careful antiseptic treatment of all accidental wounds, however 
 
 small, is the best preventive against this disease. When 
 
 the disease has developed in the acute form, there is, 
 
 with one exception, to be mentioned hereafter, no form of treatment that 
 
 can save life. 
 
 In all cases, loth acute and chronic, the patient should he Izept abso- 
 lutely quiet in a darkened room and protected from loud noises and 
 draughts of air. Chloroform should be administered by inhalations to 
 relieve the spasms, and morphine and chloral in full doses to procure 
 sleep. The patient should be fed through a rubber tube passed into the 
 nose and down the throat, or between the teeth, if there be space. The 
 wound should be carefully disinfected, and any foreign bodies which it 
 contains should be removed. 
 
 It remains to speak of a form of treatment which promises better 
 results. It has been found that animals may be protected against tetanus 
 in several ways. The following is one : To a culture 
 of tetanus bacilli is added a small percentage of iodine 
 trichloride or an extract of the thymus gland of a sheep. These sub- 
 stances diminish the virulence of the microbes. 
 
 The fluid containing the tetanus bacilli so modified is injected, in 
 33 
 
4S2 SUEGICAL INJURIES AND SURGICAL DISEASES. 
 
 small but increasing doses, into some large animal — a horse or a large clog. 
 Tlie animal is ill for a time after each injection, hut recovers. A point 
 is tinally reached when the subject of the experiment can receive largo 
 doses of virulent tetanus bacilli without suffering ill effects from it. The 
 blood-serum of this aninuil acquires the property of protecting other 
 animals from the disease, and, when injected into the tissues in large 
 doses, will cure tetanus that has already devel()j>e</. 
 
 Such blood-serum has been used successfully in the ti-eatment of a 
 number of cases of tetanus in tlie human being. Other ways have also 
 been tried successfully to produce the same results. Substances have 
 been prepared from the bacilli themselves which possess curative prop- 
 erties when injected under the skin of individuals suffering from this 
 disease. 
 
 HYDROPHOBIA, RABIES, CANINE MADNESS. 
 
 Hydrophobia is a disease caused by a specific poison the nature of 
 which is unknown. It is almost certainly due to a microbe. In human 
 beings it is usually contracted from the bite of a ral)id 
 animal — commonly a dog, very rarely a fox or a wolf. 
 The poison exists in the saliva of the diseased animal. Although hydro- 
 phobia is a rare disease, the fearful nature of the malady renders a 
 knowledge of its symptoms in the dog of some practical importance. 
 
 In all cases where a human being is bitten by an animal suspected of 
 being mad, the latter should be confined and closely watched. Should 
 madness fail to develop, much needless anxiety will be prevented. 
 
 In the dog the disease may be divided into three stages. During the 
 
 first stage the animal shows a change of disposition, becomes dull and 
 
 ill-natured, avoids his master and companions, and is 
 
 Symptoms i7i a Dog. ^^ ^ • t , • • ^ ^ 
 
 verj' restless, wandering about in an aimless way and 
 
 occasionally snapping at real or imaginary objects. Sometimes he ex- 
 hibits unusual evidences of affection and tries to lick the faces and hands 
 of his friends, thus exposing them to the danger of infection. Great 
 thirst exists throughout the disease, and during the first stage the 
 animal is still able to swallow and drinks with avidity. 
 
 During the second stage the animal wanders about continually with 
 bloodshot eyes, foaming at the mouth, his head down, and his tail be- 
 tween his legs. He rarely goes out of his way to attack any one, but 
 when interfered with becomes furious, and will bite at anything M'ithin 
 reach. During this stage the animal still tries to drink, but the spasm of 
 the throat muscles renders the act of swallowing difficult or impossible. 
 
 The third stage is characterized by exhaustion and jjaralysis, and ends 
 in death. 
 
HYDROPHOBIA IN MAN. 483 
 
 The time between infection and the development of the disease in the 
 
 dog is usually from six to twelve weeks, but it may be lonii;er or shorter 
 
 — from six days to eleven months. The duration of the 
 
 erio( of disease, which almost always ends in death, is from four 
 
 I'nc libation. ' -^ , ' 
 
 to ten days. In man the time between infection and 
 
 the development of the disease is variable. It is usually about six weeks, 
 
 but may be less, or may be extended to eight months. 
 
 There are sometimes premonitory symptoms lasting for a few days. 
 
 Itching, tenderness, and pain in the scar are sometimes noticed. The 
 
 patient may suffer from depression of spirits and loss of 
 Symptoms in Man. ^ rm' ^ , /• , 7 7 • 7-7 
 
 sleep. II16 true symptoms of the dtsease begin by a 
 
 feeling of constriction and choking in the throat and difficulty 'In 
 
 swallmving. 
 
 For the progress of the disease the writer quotes from Fleming : 
 
 The difficulty in swallowing rapidly increases, and it is not long before the 
 act becomes impossible unless it is attempted with determination, though even 
 then it excites the most painful spasms in the back of the throat, with other in- 
 describable sensations, all of which appall the patient and cause him to dread 
 the very thought of liquids. Singular nervous paroxysms or tremblings become 
 manifest, and sensations of stricture and oppression are felt about the throat 
 and chest. Breathing is painful and embarrassed and interrupted with frequent 
 sighs, or a peculiar kind of sobbing movement; there is a sense of impending 
 suffocation and of necessity for fresh air. . . . Shuddering tremors, sometimes 
 amounting to general convulsions, run through the whole frame, and a fearful 
 expression of anxiety, terror, and despair is depicted on the countenance. 
 
 The mouth and throat are constantly full of saliva and sticky mucus 
 which is frequently expectorated. There is fever, and the pulse becomes 
 rapid and feeble as the disease progresses. The mental faculties are usu- 
 ally clear, although there may be hallucinations of sight and hearing. 
 The most distressing symptom is an ever-present fear of death which no 
 amount of reassurance can influence. 
 
 Death occurs usually from exhaustion, with much difficulty of breath- 
 ing, and sometimes convulsions. The average duration of the disease is 
 four days. There is no recorded case of recovery from 
 hydrophobia after the disease has once developed. 
 
 The immediate treatment of the bite of a rabid animal consists in 
 ajDplying an elastic constrictor to the limb above the wound at once, and 
 
 ^ in summoning medical aid without delay. The wound 
 
 and surrounding tissues should be cut out bodily. 
 
 Rather less certain is the cauterization of the wound witli a hot iron or 
 
 with caustics, such as caustic potash, nitric acid, sulphuric acid, or some 
 
 other caustic. Those mentioned are the best. 
 
 Of one hundred and thirty -four cases of persons bitten by animals 
 believed to have been mad, in which the wound was cauterized, sixty- 
 
484: SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 eight escaped and forty-two died. Among cases untreated, the mortality 
 is about sixty-six per cent. 
 
 The inoculation treatment for tlie prevention of rabies, as devised and 
 practised by Pasteur, has diminished the mortality amon<]^ those bitten by 
 rabid animals to less than one in a hundred. The inoculation tiuid is 
 prepared in the following way : The spinal cords of rabbits dead of 
 hvdrophobia are dried for a certain number of days in warm air free 
 from bacteria. The longer the cord is dried, the less the virulence of 
 the contained virus. Emulsions of such cords are injected in gradually 
 increasinor strengths beneath the skin of the bitten individual. Thus, in 
 the majority of cases, immunity is produced, and the disease does not 
 develop. 
 
 SURGICAL TUBERCULOSIS. 
 
 In the popular mind the word tuberculosis is associated chiefly with 
 
 consumption of the lungs, but the same microbe which produces this 
 
 disease is the cause of a o-reat number of inflamnuitory 
 
 T,""'"^- processes, affectinof at times nearly every tissue in the 
 
 Conception. ^ ' ° -, ^ ^ 
 
 body. The skin, the mucous membranes, the sheaths 
 
 of the muscles and of the tendons, the various glandular oi-gans, the 
 lymphatics, the lining of the large body cavities, the joints, and the bones, 
 are all very often the seat of tubercular inllammations. So widely preva- 
 lent is this disease that were tuberculosis to cease to exist, a very large 
 part of the surgeon's occupation would be gone. For-' 
 
 'f, '.' tunatelv, many of these affections can be cured by 
 
 Bacillus. •' ' -^ •' 
 
 surgical means. The changes produced by the tubercle 
 
 bacillus are similar in character, no matter in what tissue the process is 
 
 located. 
 
 Localized tuhercular infiamvixatlons regularly run a chronic course, 
 
 the duration of the process extending over a period of months or of 
 
 years. The action of the bacilli upon the tissues is an 
 
 ^ T „ , . irritative rather than a destructive one, and results in 
 
 Inflammations. , , / 
 
 the production of new tissue resembling in some respects 
 the tissue formed in the healing of wounds, but differing from it in im- 
 portant ways. The irritation sometimes results in a pouring out from the 
 blood-vessels of watery fluid, fibrin, and white blood cells, but the tubercle 
 bacillus does not produce suppuration like the pus microbes. The new 
 tissue which is produced is always poorly supplied with blood-vessels, and 
 is very prone to undergo degeneration of a peculiar kind, known as cheesy 
 degeneration, from the whitish yellow, crumbly material into which it is 
 converted. 
 
 The way in which tubercular inflammations begin is characteristic of 
 the disease. AVhen one or several tubercle bacilli have been brought by 
 
A CHARACTERISTIC OF TUBERCULOSLS. 485 
 
 the blood or lyinph current to a part and liavt; found a lorl^nient in the 
 tissues, an irritative process is started around eacli hafilhis or group of 
 
 bacilli, resulting in the formation of a little mass of 
 Inception and . \ \ ,• . i 1 1 i . / ? ; 
 
 .J. , tubercle tissue — the so-called iuoercCe (jranule — some- 
 
 times so small as scarcely to be seen by the naked eye- 
 When newly formed, these granules are of a grey color and are trans- 
 lucent. Older and larger ones are often yellow, or white and opaque. 
 Other granules form in the neighbourhood, and, when joined together, they 
 form little masses as large as the head of a pin, or even as large as, a pea. 
 These contain tubercle bacilli and cells of various kinds held in a delicate 
 framework of connective tissue. Around the affected area there is formed 
 a wall of new cells which helps to stay the spread of the disease. Under 
 favourable circumstances this layer of new cells is converted after a time 
 into dense connective tissue, which effectually shuts in the diseased area, 
 and by a starving-out process results in a cure by depriving the tubercle 
 bacilli of nutriment. They live, however, for a very long time under 
 such circumstances, often in the form of spores, and an injury, or any- 
 thing which causes the barrier to give way, may set them at liberty and 
 allow them to multiply, thus producing a relapse ; or the infectious ma- 
 terial may be carried by the lymphatics to the nearest lymphatic glands, 
 producing tuberculosis in these structures. 
 
 When the tubercle bacilli escape from a tubercular area and enter the 
 blood current, one or several new sites of tubercular inflammation may 
 be started in distant parts, or the whole system may be so filled with 
 microbes that death occurs in a few weeks from the intense poisoning 
 and interference with the functions of important organs, especially the 
 lungs and the brain. In the majority of cases the inflammation gradu- 
 ally extends, invading more and more of the suri-ounding structures. 
 The manner in which extension takes place will be explained in the 
 description of tubercular inflammations of the different tissues. 
 
 As has been said, a constant characteristic of all tubercular processes 
 
 is that the newly formed tissue tends to undergo degeneration and to 
 
 break down into cheesy masses. The degeneration be- 
 
 Deaeneration ^^^^ ^^ ^^^ centre of each nodule and extends to its 
 circumference. 
 
 Subsequent liquefaction of the broken-down tissues gives rise to what 
 
 are called cold or tubercular abscesses. The fluid which they contain is 
 
 not true pus, although it is similar in appearance. 
 Cold or Tuhercular mi i i • rm ti 
 
 Abscesses ihese abscesses run a chronic course. Ihey usually 
 
 spread slowly by the force of gravity and find their way 
 between the muscles for long distances, infecting the tissues in the neigh- 
 bourhood and reaching the skin often at a point far distant from the orig- 
 inal disease. Such abscesses are not painful, and are not attended by the 
 
4SG SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 sii^ns of acute intlainmatioii. The skin over a eolcl abscess is often paler 
 than normal. 
 
 If an individual, the subject of a localized tubercular process, can be 
 
 placed under circumstances such that the jjeneral health is improved, the 
 
 resulting increased activity of the healthy tissues may 
 
 Limitation ami eaiise a temporary or permanent limitation of the dis- 
 
 rp , ". • ease in the way already mentioned. Under such cir- 
 
 cumstances a deposit of the salts of lime may occur in 
 
 the deuenerated tissues. Imprcned local conditions, such as complete 
 
 rest of a tuberculous joint, may also result in spontaneous cure. 
 
 Occasionally infection of a tuberculous area with pus microbes may 
 
 result in a rajiid destruction and elimination of the tuberculous tissue, and 
 
 consequently in the cure of the disease. This is true 
 
 njecionu'i I only of small lesions situated near the surface of the 
 
 Fus JltcroOcs. '' n • n -1 
 
 body, where the |)roducts of iniiamniatKui have the 
 freest exit. "When large and deeply seated tubercular areas become in- 
 fected with pus microbes, the result is usually profuse suppuration of the 
 whole infected tract and septicsemia, ending sooner or later in the death 
 of the individual. 
 
 As the reader will be told in Diseases of Digestive Organs^ Heart 
 
 and Lungs, infection with tuberculosis occurs most commonly in the 
 
 respiratory tract. The medium of contagion is most 
 
 e la of II er- Qf^g^ the dried expectoration of those suffering from 
 cular Infection. . « , i t /• • • t 
 
 tuberculosis of the lungs, infection m the digestive 
 
 tract is not rare, however, and occasionally infection takes place through 
 
 the glands of the skin. 
 
 Inoculation tuberculosis — i. e., infection through an open wound — is 
 
 rather uncommon, because the tubercle bacillus grows but slowly, and 
 
 the bacilli are very apt to be washed away or carried off 
 
 mmtn ion -j^ ^^^^ wound discharge ; but such infection does occa- 
 
 Tubercidosis. -' , . . 
 
 sionally occur, and gives rise to a local tubercular 
 
 process which may remain as such or spread to the neighbouring lymphatic 
 glands. 
 
 While open wounds are rarely infected with tuberculosis, minute abra- 
 sions of the skin and mucous membranes, especially about the scalp, face, 
 and mucous membrane of the mouth, are common avenues of entrance 
 for the tul)ercle bacilli. Inflamed patches of skin caused by acute or 
 chronic eczema about the scalp and face are probably a not uncommon 
 source of infection of the lymphatic glands of the neck. In the cases 
 where the bacilli enter through a minute wound of the skin or through a 
 patch of ordinary inflammation, the tubercular process usually first makes 
 its appearance in the lymphatic glands, the bacilli being carried by white 
 blood cells from the point of entry in the skin to these structures. The 
 
THE ORIGIN AND DEVELOPMENT OF LUPUS. 487 
 
 glands, as in the case of infection with pus microbes, act as a filter to 
 protect the system at large. 
 
 Tlie facts in regard to hereditary and acquired susceptibility to tuber- 
 culosis will be found in Diseases of Uigestive Organs^ lleart and Lungs. 
 
 THE SYMPTOMS AND TREATMENT OF SURGICAL TUBER- 
 CULOSIS OF THE VARIOUS TISSUES AND ORGANS. 
 
 TUBERCULOSIS OP THE SKIN— LUPUS. 
 
 Tuberculosis of the skin occurs most frequently about the face and 
 hands, but may develop on any part of the body. 
 
 The disease usually is due to direct infection through some minute 
 
 abrasion of the surface or through the orifice of a gland of the skin — a 
 
 pore. At the point of inoculation a small, brownish-red 
 
 Incep ion. lump forms in the skin, varying in size from a pin's 
 
 head to a split pea. Often several or many lumps appear, either succes- 
 sively or simultaneously. They are not tender nor painful. The in- 
 flamed skin feels firm and elastic to the touch, and is at first covered with 
 scaly thickened epidermis. 
 
 The process may never advance beyond this stage throughout its long 
 course, wdiich usually extends over a period of many years. iSTew lumps 
 appear near the old, and gradually a large part of the 
 isoty. ^^^^ ^^^^ ^^ invaded. Often the process heals in one 
 
 place while advancing elsewhere. In a large proportion of cases the for- 
 mation of these little lumps is followed by ulceration. A slowly progres- 
 sive destruction of tissue takes place, which gradually advances, leaving 
 large scars and hideous deformities in its wake. In some cases the skin 
 alone is destroyed, in others the deeper parts are invaded, and the bones 
 of the face may be thus extensively exposed. In some cases much new 
 tissue is produced, causing an unsightly thickening of the parts. Each 
 of these forms of the disease may exist alone or in combination with the 
 others. Many of these cases die of tuberculosis of the lungs, the local 
 process being rarely fatal. 
 
 Persons who w^ork much in a dissecting-room, and those who make 
 
 post-mortem examinations, are sometimes infected with tuberculosis 
 
 through minute abrasions of the fingers and hands. 
 
 Dangers of the The d'isease shows itself as a slowlv growing wartlike 
 
 Dissecting-room. " '~ ^ i rpi 
 
 lump in the skin, of a dark red or purple colour, ihe 
 
 centre of the lump commonly ulcerates after a time and a chronic 
 ulcer is produced, which crusts over and discharges but little pus. The 
 ulcerative process slowly spreads beneath the crust, and rarely heals un- 
 less the entire diseased area is removed by operation or destroyed by 
 
4S8 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 caustics. The disease may remain localized, or, in some cases, extensive 
 destruction of the skin and deeper parts may result. 
 
 The treatment of tuberculosis of the skin is local and general. The 
 local treatment consists in the earliest possible operative removal of the 
 diseased tissues. Relapses are common. The general 
 treatment consists in the administration of arsenic, iron, 
 cod-liver oil, and other tonic drugs. The care of the general health by 
 abundant strengthening diet, out-of-door life, baths, and other hygienic 
 measures are important. 
 
 For a description of tuberculosis of the tongue and mucous membrane 
 of the mouth, see Stn-(/icaI Diseases of Sjyeeial Regloiis. 
 
 TUBERCULOSIS OF THE LYMPHATIC GLAND3. 
 
 Tuberculosis of the lymphatic glands is a common form of the disease. 
 In fact, a very large proportion of all inllammations of the lymphatic 
 glands are of this character. 
 
 The disease occurs most frequently between the ages of fifteen and 
 
 thirty, but may occur at any period of life. The glands most often affected 
 
 are those situated in the neck. The bacilli enter the 
 
 ocmon, ncep I n, ^-g^^^gg throuoh some triflino; abrasion of the skin of the 
 and History. » ^ 
 
 face or scalp, or through the mucous membrane of the 
 
 mouth or throat, and sometimes through the cavity in a decayed tooth. 
 The glands of the armpit and groin are less commonly involved. The 
 bacilli do not often cause any change at the point of inoculation, but are 
 carried by the lymph current to the lymphatic glands, where they pro- 
 duce a chronic inflammation, gradually converting the gland into a cheesy 
 mass. Direct extension to the surrounding tissues occurs late. The 
 strong fibrous capsule which surrounds the gland usually affords for 
 a long period an efficient barrier to the spread of the disease. "When 
 perforation of the capsule does occur, tuberculosis of the tissues in the 
 neighbourhood is the result. 
 
 The glands first attacked are often those situated just behind the angle 
 of the lower jaw, and from these the bacilli in most cases gain access to 
 other glands which lie along the large muscle at the side of the neck, and 
 to the deeper chain, which accompany the great blood-vessels on either 
 side of the windpipe. Gland after gland is thus successively infected, and 
 after the last gland at the root of the neck is passed, the bacilli enter the 
 blood current and the individual may die of acute general tuberculosis. 
 This result is fortunately not very frecpient, because the process may, in 
 some cases, remain confined to one or oidy a few glands, and after a time 
 cure itself, or remain quiescent for many years. 
 
 At times the infected glands soften and form a cold abscess which 
 breaks through the skin, leaving behind a hole. This hole remains open 
 
OF THE LYMPHATIC GLANDS AND BONES. 489 
 
 for a long time and discliargos a little thin yellow lluid. li' infection 
 with pus microbes takes" place, suppuration of the tubercular tissue and of 
 the surroundin<^ healthy structures over a greater or less area ensues. If 
 the amount of tuberculous material be small and near the surface, a rapid 
 elimination of the tuberculous material may take place, resulting in a cure. 
 More commonly the tubercular infection is only increased in extent. 
 
 A jDainless, slowly progressive enlargement of one or more lymphatic 
 glands — forming kernels, as they are called, beneath the skin, and situated 
 
 in the positions above mentioned, varying in size from 
 
 Symptoms. . , -. / 7 r 
 
 a pea to a mass as large as an egg (made up of many 
 
 glands matted together by new inflammatory tissue) — is always suggestive 
 
 of tuberculosis. A number of other diseases may resemble tuberculosis 
 
 of the lymphatic glands. Only a surgeon can make a correct diagnosis 
 
 of the condition. 
 
 The earliest possible operative removal of the infected glands offers 
 
 the best and only positive assurance of a cure. When done before many 
 
 glands have been invaded, and when there is no infec- 
 
 tion of the surrounding tissues, the operation is easy and 
 
 almost devoid of danger. At a later period, when abscesses have formed, 
 
 when all the tissues are matted together by inflammatory products, and 
 
 many cheesy glands must be removed, the operation is difiicult, and a 
 
 return of the disease is common. The general treatment is the same as 
 
 for other forms of tuberculosis. 
 
 TUBERCULOSIS OP THE BONES. 
 
 Tuberculosis of the bones is, with the exception of 'tuberculosis of the 
 
 lungs and lymphatic glands, the most frequent form of the disease. It 
 
 commonly occurs during childhood and early adult life 
 
 Inception. ^ ^^ ,^ '^ • 1 , 
 
 Mmile the bones are growing, but no age is exempt. 
 The ends of the long bones are especially liable to be affected. The 
 bacilli are carried by the blood from a cheesy lymphatic gland or other 
 source of tuberculous material and lodge in the bone, producing changes 
 the results of which are modified by the close proximity of the disease 
 to the joints. 
 
 The area of bone first affected may be as large as a pea. It is seldom 
 larger than a walnut. The bacilli multiply and produce tubercle tissue 
 in the bone, which may undergo softening and liquefaction, forming a 
 cavity in the bone filled with a white fluid resembling pus, in which little 
 particles of bone may be seen on inspection or felt with the fingers. 
 Sometimes the diseased bone dies en masse and is found as a dead frag- 
 ment of whitish-yellow colour surrounded by a layer of tubercle tissue. 
 
 If a portion of cheesy material of appreciable size is carried by the 
 blood current from a distant part and lodges in the end of one of the long 
 
4110 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 bones near a joint, the minute artery in which the tuberculous material 
 lodges is plugged and the portion of bone which the artery supplied be- 
 comes tuberculous and dies, forming a more or less wedge-shaped mass of 
 dead bone, the apex of which is at the point phigged, its base directed 
 towards or })rojecting into the neighbouring joint. 
 
 There may be one or several areas of disease in the same bone. Many 
 bones throughout the body may be simultaneously or successively attacked. 
 The former condition is uncommon. A rare but most serious condition 
 is diffuse tubercular disease of the entire or greater portion of the shaft 
 of a long bone. 
 
 The subsequent course of localized tubercular inflammations in bone 
 
 is variable. Spontaneous cure may take place by the enclosure of the 
 
 disease in a wall of new tissue, which prevents its ex- 
 
 ^i'l'^^r,- tension. The tubercle tissue may disappear entirely by 
 
 the Disease. -^ ^ ' -'J 
 
 absorption, its place being taken by a scar. Even small 
 portions of dead bone may be removed in this way. Around such old 
 tubercular processes a layer of condensed bone of ivorylike hardness is 
 often formed which serves to limit the spread of the disease. More 
 commonly the tubercle tissue undergoes degeneration and softening, the 
 area of infection increases in size and reaches the surface of the bone, 
 linally breaking through into the soft parts of the limb, or, what is more 
 common and much more serious, the rupture takes place into the neigh- 
 bouring joint. In the former case a cold or tubercular abscess is produced 
 which often grows to a very large size, though the disease of the bone 
 may be small in extent. The characteristic burrowing of these abscesses 
 in the direction of least resistance and from the force of gravity has 
 already been mentioned. If not opened, the abscess finally causes tuber- 
 culosis of the overlying skin and perforation, with the discharge of a white, 
 creainy fluid containing fragments of cheesy material. Tlie wall of such 
 abscesses consists of a layer of soft tubercle tissue. Around the opening 
 in the skin an elevated fringe of similar tissue is formed of a greyish- 
 pink colour. The ease with which this soft tissue can be scraped away 
 from the healthy parts, and its peculiar colour and relation to the surround- 
 ing skin, makes the recognition of its character easy, and serves to distin- 
 guish a Uibercxdar sinus, as it is called, from any other disease. The 
 opening, once formed, does not tend to heal, and may contiTme to dis- 
 charge more or less tubercular material for months or years. The results 
 of perforation into a joint will be spoken of under Tuherculosis of the 
 Joints. 
 
 In the fingers and toes of young children a peculiar form of tubercu- 
 losis occurs which leads to a dilatation of the bone, giving to the finger 
 or toe a spindle shape, as though the bone were inflated with air {spina 
 ventosa). The disease rarely affects the joints, and may heal spontane- 
 
TUBERCULOSIS OF THE BONES AND JOINTS. 491 
 
 ously, or leave some enlurgcincrit of tlic bono behind, or lead to the for- 
 mation of a tubercular abscess and perforation of the skin and more or 
 less complete destruction of the bone. 
 
 Persons with bone tuberculosis may appear to be in perfect health, or 
 
 they may be pale and ansemic. Very sliicht fever may 
 Symptoms. ^ , . -J o j 
 
 be present every evening. 
 
 Pain. — Pain is usually present, but varies greatly in amount. It is 
 increased by using the limb and is worse at night. Among children, 
 restlessness at night, grinding of the teeth, and bad dreams are sometimes 
 the first symptoms noticed. The pain is not always felt in the seat of the 
 disease. Tuberculosis in the thigh bone near the hip-joint causes pain in 
 the knee, and spinal disease often causes pain in the pit of the stomach or 
 in the shoulders and arms. Tenderness over a bone the seat of tubercular 
 disease is a very constant symptom, and is one of the surest signs of this 
 condition. 
 
 Swelling. — Except when the bone is dilated as the result of disease in 
 its interior {spina ventosa), there is no swelling nntil the bone is per- 
 forated. When this occurs a soft swelling is produced which increases 
 slowly in size unless the tubercle tissue has undergone degeneration, in 
 which case a cold abscess is formed. These abscesses often grow very 
 rapidly and burrow as before described. 
 
 Redness. — Redness is absent until the skin is about to be perforated, 
 when it presents a dusky-red or purple colour. The limb almost always 
 becomes smaller than its fellow as the result of wasting of the tissues. 
 
 The chances of recovery from bone tuberculosis are better than is the 
 case with tuberculosis of the joints, skin, or internal organs. Spontaneous 
 cure is possible at any time, and if the diseased bone can 
 be removed by operation the chances of complete re- 
 covery are good, although children who have suffered from tuberculosis 
 of the bones are apt to develop the disease elsewhere later in life. 
 
 The general treatment of tuberculosis has already been mentioned. 
 
 Complete rest for the diseased part is of the utmost importance. It 
 may be obtained best by the use of some form of fixed dressing, such as 
 plaster of Paris, which gives support and renders motion 
 of the joint near the seat of the disease impossible. If 
 the disease progresses in spite of palliative treatment, the removal by 
 operation of the diseased tissues offers the best chance of cure. The most 
 satisfactory results are obtained if the operation is done before the joints 
 are involved and before the soft parts are extensively diseased. 
 
 TUBERCULOSIS OF THE JOIXTS. 
 
 Tuberculosis of the joints is most often due to extension of the disease 
 from the bones. Less commonly the lining membrane of the joint is first 
 
402 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 affected. The structures which form the joint become the seat of tuber- 
 cular intlaniination, and are changed and destroyed in such a manner tliat 
 the function of the joint is interfered with seriously. Some of the more 
 important results of this interference the writer will attempt to indicate 
 in the following pages. The details of the process are rather intricate, 
 and must be sought for in works on general surgery. 
 
 Surllific/. — Swelling in joints the seat of tubercular disease depends 
 upon the accumulation within the joint cavity or in the surrounding parts 
 of the products of tubercular inllammation. In one form of the disease, not 
 uncommon in the shoulder joint, the amount of new tissue ])roduced is 
 small, the head of the bone degenerates and undergoes partial absorption, 
 tliere is no swelling, but a diminution in size, the joint becomes stiff and 
 painful, and the muscles about the joint wither. The process is usually 
 very chronic. 
 
 In other cases the affected joint is swollen from the accumulation in 
 its interior of watery fluid or tubercular pus. Such swelling may be very 
 great. 
 
 In some cases much new tubercle tissue is produced in and al)out the 
 joint, giving rise to marked swelling. This is the most common form 
 of the disease. In tliese cases the thin white skin stretched over the 
 swollen joint gave rise to the old name of white swelling by which this 
 disease was known. 
 
 Pain. — Pain is always present but is a variable symptom. Some 
 patients suffer excruciating pain with only a moderate amount of dis- 
 ease, while others, in whom the disoi-ganization is more extensive, 
 go about on the limb and suffer but little. The pain is often worse 
 at night, and is sometimes increased by spasm of the muscles of the 
 limb and the consequent crowding together of the diseased joint sur- 
 faces. 
 
 Deformity. — As the result of destruction of the ends of the bones, 
 softening of the ligaments which serve to hold the bones in place, and 
 permanent contraction and shortening of the muscles about the affected 
 joint, deformities more or less marked are produced. 
 
 Tubercular disease of the spine destroys the integrity of the bony 
 column. One or more of the thick solid masses of bone which form what 
 are called the bodies of the vertebrae are destroyed, the result of which is 
 that the portions of the spine above and below the seat of destruction fall 
 together at an angle to All the gap, producing a projection backward 
 which corresponds to the loss of substance in the bones, a condition com- 
 monly known as humped hack. 
 
 Disease of the hip gives rise to a bending upward of the thigh toward 
 the body, the foot being at first turned outwards and at a later period 
 inwards. 
 
TUBERCULAR INFLAMMATIONS OF THE JOINTS. 49.'^ 
 
 The forcariri is bent upon tJie arm in disease of the elhow and tlie 
 palm of the hand turned downwards. 
 
 Complete or partial dislocation of the diseased joints is common in the 
 later stages of the more severe cases. The ends of the bones are partly 
 destroyed and are changed in shape. The ligaments are weakened, and 
 the contracted muscles pull the bones into their abnormal position, the 
 deformity gradually increasing with time. In children the growth of the 
 bones is interfered with, the affected limb does not increase in length as 
 fast as its sound fellow, and the bones become more porous. They con- 
 tain much fat and are soft and fragile. 
 
 Tubercular inflammations of the joints are characterized by a chronic 
 
 but irregular course. The changes in the bones and soft parts usually 
 
 progress quite slowly, and there are often long periods 
 
 ,, j^. when the disease seems to come to a standstill, or the 
 
 the Disease, _ . ' _ 
 
 symptoms improve greatly only to get worse again. If 
 abscesses form and rupture, the condition of the patient becomes at once 
 more serious, for he is now exposed to the danger of infection with pus 
 microbes. If this occurs, all the symptoms become acute ; the parts be- 
 come red, hot, and swollen. Fever develops rapidly and, if the joint be 
 large and the original abscess extensive, acute septicsemia, ending in speedy 
 death, may be the result. More often prolonged suppuration, ending in 
 degeneration of the kidneys and exhaustion of the vital forces, causes 
 death after a protracted illness. 
 
 A typical case of tubercular disease of the knee-joint in a child, where 
 the disease is untreated, might be deseribed as follows : The disease may 
 
 follow a slight injury, or some severe general disease. 
 Typical Case -.^ , ' i j- • v t 
 
 Ch'ld More commonly no such predisposing cause can be dis- 
 
 covered. The first symptom noticed is often slight 
 lameness or pain after exercise in the affected joint. JSTothing else may 
 be complained of for weeks or months. If the knee be examined at this 
 time, it ma,y be noticed that the furrows which lie on either side of the 
 knee cap are absent on the affected side. After a time the swelling, pain, 
 and tenderness become more marked, the child holds the knee joint a little 
 bent, and attempts to straighten it cause pain. The use of the limb for 
 walking is attended with great discomfort, and finally its use becomes im- 
 possible. Sooner or later elastic swellings appear in the neighbourhood of 
 the joint ; the skin over the centre of the swellings becomes red or purple 
 in colour, and is finally perforated and much tubercular pus escapes ; the 
 rupture of the abscess is followed by infection with pus microbes and a 
 rapid change for the worse in the local trouble. The child develops a 
 hectic fever in the afternoon, loses its appetite, emaciates and loses strength. 
 Each new abscess is followed by symptoms of fresh infection and further 
 loss of strength. The knee becomes more bent, and displacement of the 
 
IIU SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 sliin bone in a backward direction takes place. From the exhausting 
 drain ujion the system degeneration of the kidneys occurs and the child 
 finally dies worn out. 
 
 Of course not every case has such a gloomy history. The disease may 
 be interrupted at any time, and improvement and even cure may take 
 place. In a certain proportion of cases, especially among children, the 
 disease leads to obliteration, more or less complete, of the joint cavity, 
 replacement of the tubercle tissue by new lil)rous tissue, and bony or 
 fibrous union between the bones. The joint then remains permanently 
 stiff in a more or less favourable position. If only a part of the joint 
 cavity be obliterated, spontaneous cure is possible with a limited range of 
 motion ; or in the most favourable cases the functions of the joint may be 
 unimpaired. The chances of complete recovery are better among childi-en 
 than among adults. Persons with joint tuberculosis not infrequently de- 
 velop consumption of the lungs. Acute general tuberculosis occurs occa- 
 sionally as the result of an incomplete operation upon the diseased joint, 
 or without apparent cause. 
 
 The general treatment does not differ from that of tubercular processes 
 
 elsewhere in the body. The local treatment consists first of measures 
 
 which serve to keep the inflamed joint quiet and to pre- 
 TreatmeTit , . 
 
 vent, as far as possible, the crowding together of the 
 
 diseased joint surfaces. These indications are best fulfilled by the appli- 
 cation of some form of fixed apparatus, of which a very great variety are 
 in use. Second, of operative measures the aim of which is to remove 
 completely the diseased tissues or to correct deformities, or often of both 
 objects combined. 
 
 In children the treatment of tuberculosis of the joints by means of 
 apparatus which keep the diseased parts quiet while allowing of free 
 movement of the rest of the body is often attended by the happiest re- 
 sults. Such treatment must, however, be begun early and carried out 
 with scrupulous care for a long period. The writer can not urge too 
 strongly upon his readers the wisdom of seeking surgical advice when a 
 child shows evidence of trouble in a joint. 
 
BURNS OF THE FIEST, SECOND, AND THIED DEGREES. 405 
 
 CHAPTER III. 
 
 EFFECTS OF HEAT, COLD, AND CAUSTICS. 
 BURNS. 
 
 Burns are caused by the action of hot substances and caustics upon 
 the tissues. According to the duration and intensity of the action these 
 agents produce injuries of different grades of severity whicli, for conven- 
 ience of description, are usually divided into three degrees. 
 
 Burns of the first degree commonly result from momentary exposure 
 
 to steam, flame, or some hot fluid. The changes produced are redness 
 
 and swelling of the skin. More or less intense pain is 
 Of the First Degree. n /' n, /• • , i -n 
 
 usually felt tor some mmutes or hours. Kecovery is 
 
 rapid unless a great extent of surface is burned. The outside layer of 
 skin usually peels off at the end of a week. 
 
 In burns of the second degree blisters are formed on the burned sur- 
 face. They may appear at once or after some hours. The blisters are 
 filled with watery fluid sometimes tinged with blood. 
 
 r. The outside or horny layer of the skin is raised from 
 
 Degree. _ . 
 
 the surface of the true skin beneath. Such burns are 
 caused by flame, by steam, by boiling water or other hot fluid, by strong 
 acids, and by caustic alkalies. The pain is much more severe than in 
 burns of the first degree, and after the blisters have ruptured the indi- 
 vidual is exposed to the danger of infection with pus microbes through 
 the raw surface. Under favourable circumstances the horny layer of the 
 skin is replaced by a growth of new cells from the true skin beneath, and 
 healing is complete in a week or ten days. 
 
 In burns of the third degree eschars are produced — i. e., portions of 
 the skin or deeper tissues are killed and come away as sloughs. In this 
 
 class are included burns of every degree of severity, 
 Decree from those which cause the death of a small portion of 
 
 skin to those in which an entire limb is burned to a 
 cinder. When merely killed, not charred, the skin over the burned area 
 is of an ashen -grey, brown, or whitish-yellow colour, and is tough, resem- 
 bling parchment. The dead parts are slowly cast oft' from the living by 
 the formation of a layer of new tissue at the line of separation. The pro- 
 cess often takes several weeks for its completion. A raw surface remains, 
 which must fill up from the bottom and edges. The skin covering for 
 such raw surfaces is formed in a slow and tedious manner. A large burn 
 often requires many months to heal. The resulting scars contract and 
 often produce unsightly and troublesome deformities ; the chin is some- 
 times drawn down on the chest, the eyelids everted, the limbs bent and 
 
49(3 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 reudered partlv or wliolly useless. AVlien only a part of the true skin is 
 destroyed and islands of living skin cells are left here and there, healing 
 proceeds niueh more rapidly, and the resulting sears are not so apt to 
 cause deformity. 
 
 The yravifij (fahurn (h'j)en(7s more upon the extent of surf ace in- 
 volved than uj?on the depth of the injury. Burns that extend over half 
 the surface of the body are always fatal, although they he only of the 
 lirst and second degrees, and in feeble persons and alcoholics a much less 
 extensive burn comnionly ends in death. 
 
 Large burns frecjuently present each of the thi-ee degrees of injury to 
 
 the tissues at the same time. The patient usually complains greatly of 
 
 pain; is restless, throwing himself about and crying out 
 
 General Symptoms ^^^^^-^^^^^^-^^^ ^ -pj^^ ^^^j^^^j -^ ^^^^^^^^^ entirely clear at first. 
 
 of Burns. " . , i , , r 
 
 The pulse is rapid and feeble, and the temperature ot 
 
 the body below the normal. In very severe cases death may occur 
 immediately or after some hours or a day, with the symptoms of 
 delirium, unconsciousness, and collapse. There is usually a diminished 
 amount of urine, which may be bloody in colour. Great thirst is a com- 
 mon symptom. 
 
 In less severe cases death may be postponed for a week, and then take 
 place from pneumonia or from exhaustion and diarrhcea, accompanied 
 occasionally by ulceration of the bowel near the stomach. If the patient 
 lives for forty-eight hours after being burned the chances of recovery 
 from the immediate eifects of the injury are good ; but the individual is 
 still exposed to the dangers of septicaemia, erysipelas, and prolonged sup- 
 puration from infection of the burned surfaces. 
 
 The local treatment varies somewhat, according to the depth of the 
 
 Inirn. In burns of the first degree, where the skin is merely reddened, 
 
 the application of cold cream, or an ointment composed 
 
 of carbolic acid one part, lard or vaseline one hundred 
 
 parts, to the surface, usually relieves the pain speedily. Cloths wet with 
 
 a strong solution of baking soda accom])lish the same result. 
 
 In burns of the second degree, where blisters are produced, several 
 forms of treatment may be employed. The best, in the opinion of the 
 writer, is the following : The burned surface and the surrounding skin 
 are thoroughly cleaned with soap and water and disinfected with sublimate 
 solution, 1 to 1,000 ; the blisters are then removed with a scissors, and the 
 parts dressed with clean gauze or soft clean cotton cloths soaked in a solu- 
 tion of ichthyol, 3 parts to 100 parts of water. This dressing, which re- 
 lieves the pain more quickly than any other, should be kept constantly 
 moist by pouring on more of the solution from time to time. It is anti- 
 septic and under it the raw surface usually heals rapidly with little or no 
 suppuration. The dressing may be left unchanged for several days, often 
 
FROSTBITE OF THE FIRST, SECOND, AND THIRD DEGREES. 407 
 
 until healing is complete, and its removal at an eai'lier period causes but 
 little pain. 
 
 The early treatment of burns of the third degree has for its object, 
 primarily, the prevention of infection. To that end the parts are disin- 
 fected as above described, and the wet ichthyol dressing applied, or tiie 
 dead tissues may be dusted lightly vv^ith iodoform powder and dressed 
 with dry antiseptic gauze. Wlien a portion of a limb is completely 
 charred, the question of amputation must be decided by a surgeon. 
 
 To prevent, as far as possible, the deformities resulting from deep and 
 extensive burns, surgeons employ measures of various kinds. A favour- 
 able position of the limb is maintained by the use of splints, and the heal- 
 ing of the raw surface is hastened by transplantiTig upon it portions of 
 healthy cuticle taken from other parts of the body. By this means very 
 extensive raw surfaces may be healed completely in two weeks, and de- 
 formities entirely prevented which would otherwise be inevitable. The 
 cleaning and disinfection of extensive burns is best accomplished under 
 ether or chloroform. For the pain, morphine should be given hypoder- 
 mically or by the stomach, in a full dose of one quarter to one third of a 
 grain, which should be repeated as often as necessary to keep the patient 
 fairly comfortable. Whiskey in full doses should be given to stimulate 
 the enfeebled heart. Hot bottles should be used if the extremities ai-e 
 cold. The general treatment is, in fact, the treatment of shock. 
 
 FROSTBITE. 
 
 The effects of cold upon the human body are local and general. The 
 
 local effects may be divided, as in the case of burns, into three degrees. 
 
 The parts of the body most often affected are the fingers 
 Of the First, Second, , , ., ' i .i t ^ j.i -^ ^ ^i 
 
 dTh'dD ^ toes, the nose and the ears. In frostbites of the 
 
 first degree the part becomes white, cold, shrunken, and 
 numb. Subsequent exposure to warmth is attended by redness, swelling, 
 and tingling pain, which may last for some hours or days. Frostbites of 
 the second degree are followed by marked swelling and intensely painful 
 congestion, with the subsequent formation of blisters upon the skin. The 
 part often remains of a dark-blue colour for a week or more. Frostbites 
 of this degree pass without any marked distinction of early symptoms into 
 the third deo-ree, in which the tissues fail to rea^ain their vitality and be- 
 come gangrenous. The dark-blue colour of the skin changes after some 
 days to a cherry-red, which grows darker, and finally turns to black. The 
 variety of gangrene produced depends, as has already been stated, upon 
 whether or not infection with the microbes of suppuration and putrefac- 
 tion takes place. 
 
 Frostbite not severe enough to cause gangrene is sometimes followed 
 by increased susceptibility to cold in the affected part, which may last for 
 34 
 
49S SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 a long period, each slight exposure being followed by pain, redness, and 
 swelling. Frostbite is sometimes followed by permanent paralysis of the 
 blood-vessels of the skin of the affected member. The 
 skin remains permanently blue. Such a condition is 
 occasionally observed after frostbite of the nose. Chilblains are usually 
 till' results of repeated frostbites of the first or second degrees. The toes 
 and iiiiirers are most commonly affected. The symptoms in mild cases 
 are itching, pain and swelling of the affected toes. In more severe cases 
 blisters and even ulcers may form. The pain and itching are usually 
 most annoying on entering a warm room from out of doors, and in bed 
 at night. 
 
 Tlie general symptoms of exposure to extreme cold are, first, a marked 
 stimulation of the circulation and a feeling of well-being. If the exposure 
 be too prolonged, a sense of general pain and weariness 
 enera ymp oms. f^ij^^g^ ^Yien numbness of the extremities and an in- 
 tense desire to sleep. If the individual gives up to this desire, death by 
 freezing occurs after a variable time. The entire body becomes stiff and 
 the surface icy cold. The heart beats more and more feebly ; the breath- 
 ing becomes shallow. Such a condition may last for a number of hours 
 and yet resuscitation may be possible as long as the heart has not ceased 
 to pulsate. 
 
 Sudden exposure of a frozen or partly frozen part to a high tempera- 
 ture is always followed by intense congestion, and the occurrence of gan- 
 grene is thereby favoured. Therefore a very gradual 
 return to a normal temperature should be aimed at. To 
 this end the frost-bitten part should be rubbed with ice water and after- 
 wards with equal parts of alcohol and water. As the circulation begins to 
 return and the temperature of the part approaches the normal, the limb 
 should be suspended in a vertical position, or at least elevated, to limit, as 
 far as possible, the intense congestion and the consequent pain and swell- 
 ing which are apt to occur after the circulation is re-established. During 
 this period of reaction the limb should be covered with cloths wet with 
 cold water, or an evaporating lotion of alcohol and water (equal parts), or 
 with the solution of alum, sugar of lead, and water already mentioned in 
 a preceding chapter, under Infained WomuJs and their Treatment^ or 
 with the lead and opium wash (sugar of lead two teaspoonfuls, laudanum 
 four teaspoonfuls, water one pint). After the pain and congestion have 
 passed away the treatment will depend upon the severity of the injury to 
 the tissues. In frostbites of the first degree no other treatment than that 
 indicated above is necessary. "When blisters form, the limb should be 
 scrubbed and disinfected and enveloped in a dressing of dry antiseptic 
 gauze. If the blisters are painful they may be opened before the dressing 
 is applied. 
 
GANGRENE: SYMPTOMS, TREATMENT, AND PROGNOSIS. 499 
 
 Gangrene is indicated by a gradual cliange in tljc colour of the frozen 
 part from dark blue to cherry-red, gradually growing darker and finally 
 turnine; black, and by persistent loss of sensibility. 
 Usually gangrene due to freezing is developed slowl}', 
 and it may be quite impossible to tell for many days wliether a member 
 will live or die. The extent of the gangrene is also hard to predict until 
 a line of separation occurs marked by a more or less intense inflammation 
 at the border of the living tissues. When a limh has heen so severely 
 •frozen that gangrene is thought possible, the greatest care should he used 
 to prevent infection. The limb should be cleaned carefully and disin- 
 fected, as before described, especial attention being paid to any abrasions 
 of the surface. Blisters which have already ruptured should be cut away 
 with scissors, the raw surface beneatli disinfected, dried, and dusted with 
 iodoform. The whole limb should then be covered with dry antiseptic 
 gauze and a lightly applied bandage. This dressing should then be en- 
 veloped in cotton batting and the limb elevated. Unless fever or other 
 sign of infection develops, this dressing should not be disturbed for a 
 week or more. 
 
 After the formation of a litie of separation, which in these cases takes 
 
 place slowly, the dead parts are cast off from the living, and an ulcer is 
 
 left which heals more or less rapidly according to its 
 Sloughiyig Off. . ,,, , r • .• c^ ^ 
 
 Size and the absence or presence 01 iniection. feuch 
 
 ulcers may be stimulated to more rapid healing by the application to the 
 raw surface of gauze soaked in Peruvian balsam or of powdered naphtha- 
 line. When the ulcer is large it is best treated by the application of 
 skin grafts. When a considerable part of a limb becomes gangrenous 
 the treatment is amputation. 
 
 TREATMENT OF THE CONSTITUTIONAL EFFECTS OF COLD. 
 
 When unconsciousness and general stiffness of the body exist, the pa- 
 tient should be undressed and placed on a bed in a cold room. If the 
 breathing fails, artificial respiration should be kept up according to the 
 method described in the article on Medicines and Treatment. Friction 
 with cold water should be made upon the extremities and trunk. If the 
 action of the heart is very feeble, whiskey may be administered by the 
 mouth if the patient can swallow, or, if not, by the rectum, or with a 
 hypodermic syringe. As the circulation improves, the temperature of 
 the room should be gradually increased and warm stimulants administered, 
 in small doses at first, and later liberally. These patients may remain in 
 a stupid condition for several days and usually do not escape without the 
 loss of portions of one or several limbs. 
 
 Persons affiicted with chilblains are usually not in robust health. Cod- 
 liver oil, iron, and other tonics are therefore useful. Such persons should 
 
500 
 
 SUEGICAL INJURIES AND SURGICAL DISEASES. 
 
 wear woollen t^tockiiigs and warm gloves from the beginning of cold 
 weather. If chilblains form, the pain, swelling, and iteliing usually can 
 be relieved by wet dressings of lead-and-opium wash, or of the Icad-and- 
 alnni solution. Cloths wet with one of these solutions may be worn at 
 niirht. Friction with an anodyne liniment is also useful. The following 
 is a good one: Take of camphor, chloral, chloroform, and ether, of each 
 two teaspoonfuls ; laudanum and oil of sassafras, of each one teaspoonfnl ; 
 and soap liniment, as much as may be sufficient to make one pint. Mix 
 the ingredients and use to rub the affected fingers or toes. When ulcers 
 form as the result of chilblains they should be treated with antiseptic 
 dressiuiTS. 
 
 CHAPTER ly. 
 INJURIES AND DISEASES OF THE BONES. 
 
 FRACTURES. 
 
 FRACxrREs or broken bones result from mechanical violence applied 
 to the body from without (fracture by external violence), or they are due 
 to sudden violent contraction of the muscles of the individual (fracture 
 
 Fio. 11. — Comminuted frac- 
 
 TrKE OK THE LOWER END OF 
 THE HUMERfS, CAUSED BY A 
 FALL fPON THE ELBOW. 
 
 Fig. 12. — Tkansveuse fkatture of the 
 FEMUR. (Stiiiison.; 
 
 by muscular action). The break may occur in the bone at the point where 
 the force is applied (fracture by direct violence), or in another part of the 
 bone, or in some other bone (fracture by indirect violence). For exam- 
 ple, a blow upon the collar-bone breaks the bone at the point struck. The 
 break is a fracture by direct violence. A fall uj)on the hand causes a 
 
VARIETIES OF FRACTUKE. 
 
 501 
 
 fracture of tlie collar-hone. In this case the force is transmitted through 
 
 the bones of the forearm, arm, and shoulder-blade. This is a fracture ])y 
 
 indirect violence. In order to save himself froin fallinj^, an individual 
 
 makes a violent effort to straighten 
 
 his leg at the knee. The knee-pan is 
 
 torn in two by the contraction of the 
 
 muscles on the front of the thigh. 
 
 The fracture is the result of muscular 
 
 action. 
 
 When a bone is broken into several small fragments the injury is 
 called a G07yiniinuted fracture. According to the direction of the line of 
 fracture w^ith reference to the long axis of the bone, we speak of fractures 
 as transverse, oblique, longitudinal, toothed, Y-shaped, and T-shaped. 
 When the broken ends of the bone communicate directly with a wound 
 
 Fig. 13.- 
 
 -OlJI-IQUK FRACTURE OK THE CLAVI- 
 CLE. CStiiii.son.; 
 
 Fig. 15. — Toothed 
 Fig. 14. — Longitudi- fracture of the 
 
 NAL fracture OF THE FEMUR. (StilU- 
 
 TiBiA. (Stimson.) son.) 
 
 Fig. 16. — Y-shapeo frac- Fig. 17. — T-shaped frac- 
 ture OF THE CONDYLES TURE OF THE LOWER END 
 OF THE HUMERUS, CAUSED OF THE FEMUR, CAUSED 
 BV A FALL UPON THE EL- BY A FALL UPON THE 
 
 BOW. (Bruns.) knee. (Bruns.) 
 
 in the skin the fracture is compound. Wlien no such communication 
 exists the fracture is simple. When a fracture is accompanied by injury 
 of important organs, large blood-vessels or nerves, or when the break 
 communicates directly with a joint or other body cavity, it is called a 
 comiMcated fracture. Among children and young adults in whom the 
 bones are less brittle than in older persons, incomplete or greerh-stick 
 
 fractures occur. The bone bends and 
 its convex side splinters as does a green 
 stick under similar circumstances. The 
 concave side, on the contrary, is com- 
 pressed. Another form of incomplete 
 fracture is a simple crack or fissure in the bone, which may occur at any 
 period of life. When one fragment is driven into the other and remains 
 fixed in that position the fracture is called impacted. 
 
 Fio. 18. — ^Incomplete fracture (greex- 
 
 STICK fracture) of THE CLAVICLE. 
 
502 
 
 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 Pain and 
 
 Temhrnefis. 
 
 THE SUBJECTIVE AND OBJECTIVE SYMPTOMS OF FRACTURE. 
 
 Pain is a constant symptom of fracture. It is usually severe, and is 
 increased by movement of the injured part. The pain is felt at the seat 
 of fracture ; but if nerve trunks are pressed upon by the 
 displaced fragments 
 there may be also in- 
 tense pain along the course of the af- 
 fected nerves. Extreme tenderness over 
 the point of fracture is ahvays pres- 
 ent. 
 
 If the broken bone be grasped with 
 the lingers upon either side of the frac- 
 ture, efforts to bend the bone or to move 
 the fragments one upon the other will 
 reveal a point of mo- 
 tion where none should 
 This is a positive sign of frac- 
 ture. This sign is absent in impacted 
 fractures and in some incomplete frac- 
 tures. Therefore, while its presence 
 proves the existence of fracture, its ab- 
 sence does not prove that no fracture 
 exists. By movements so directed that 
 the broken ends of the bone are made 
 
 Abnormal MobilUij. 
 
 exist 
 
 Fig. 19. — Impacted fracture of the neck 
 
 OF THE FEMUK. (StimSOD.) 
 
 Crepitus or Orating. 
 
 to rub one against the other, a grating can be felt 
 
 and sometimes heard. Tiiis sign is absent in incom- 
 plete and impacted fractures, and where the soft parts have slipped 
 between the broken ends ; also sometimes when the muscles have 
 drawn the broken ends past one another, or where the muscles have 
 drawn the fragments apart, hence its absence does not prove that no 
 fracture exists. 
 
 Loss or impairment of the power of voluntary motion is a frequent 
 sign of fracture. Fractures of the shaft of the thigh bone or of the upper 
 arm bone are usually attended by complete inability to 
 move the injured limb. When only one of a pair of 
 bones is broken, as in the leg and forearm, the impairment of function is 
 commonly not complete. The uninjured bone serves as a splint or sup- 
 port for the other, and the individual may still be able to walk, or to use 
 the forearm, as the case may be. The same is true of impacted fractures. 
 The loss of power seems to depend in part upon pain, or the fear of pain. 
 In.sensitive persons, and those who break a bone while intoxicated, not 
 infrequently use the limb, greatly to their own disadvantage. The ends 
 
 Loss of Function. 
 
SYMPTOMS OF FRACTURE. 
 
 503 
 
 of the bone may thus be driven tlirough tlie fekin and a .sim]j]e fracture 
 changed to one which is compound. 
 
 More or less marked deformity may he produced by tlie displacement 
 of the broken f i-agments. The fragments may be displaced in such a way 
 that they make an angle one with the other, the vertex 
 of the angle being at the point of fracture. The broken 
 ends may be pulled past one another by muscular contraction, producing 
 shortening of the limb by overriding, as it is called. In certain instances 
 the fragments may be pulled apart by the same means. The fragments 
 may be displaced laterally, or one or both fragments may be rotated about 
 the long axis of the limb, producing a twisted appearance. Several kinds 
 of deformity may be combined in the same fracture. 
 
 From the laceration of blood-vessels and consequent effusion of blood 
 at the seat of fracture, from the interference with the return of blood 
 through the veins, caused by direct pressure of the dis- 
 placed fragments, and from the inflammation following 
 the injury, swelling of the limb is produced. The 
 swelling is most marked near the fracture. It makes 
 its appearance soon after 
 the injury and may in- 
 crease for several days. 
 If the fragments are not 
 soon replaced in their nor- 
 mal relations the swell- 
 ing is apt to be excessive. 
 It is made much worse 
 by improperly applied, 
 dressings. This symp- 
 tom gradually subsides as 
 healing progresses. After 
 the bones have united 
 and the use of the limb 
 
 Swelling and 
 Discoloration 
 of the Skin. 
 
 Fig. 20.- 
 
 The different varieties of displacehexts of the 
 fragmekts. 
 
 is resumed, a return of 
 the swelling is common. 
 
 It may persist for many months. Soon after a fracture the skin over the 
 broken bone may become red and hot. This heat aud redness usually 
 subside after a few days if the fragments are put in good position and 
 kept quiet. Black-and-blue marks often form in the skin of the limb, at 
 once or after several days. They sometimes appear at some distance 
 below the seat of fracture. They are not infrequently accompanied by 
 the formation of blisters on the skin, filled with blood-stained fluid. 
 
 The symptoms of compound fractures are like those already described, 
 with the addition of an open wound which communicates with the broken 
 
iO-i 
 
 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 Symptoms of 
 Compound 
 Fractiireti. 
 
 ends of tlie bone. Sometimes one of the fragments may project tlirough 
 a hole in the skin. Compound fractures are serious injuries on account 
 of tlie danger of infection with bacteria. When caused 
 by crushing injuries and bullet wounds they are often 
 complicated by extensive laceration of the soft parts 
 and by injuries of arteries, nerves, and joints. Un- 
 der careful antiseptic treatment compound fractures heal as well as simple 
 fractures. AVhen not so treated, infection is almost certain to take place, 
 and the bruised tissues forming the walls of a deep cavity are in a poor 
 position to combat the bacteria. Septiciemia, pyaemia, tetanus, prolonged 
 suppuration with burrowing of pus, and the formation of abscesses are 
 frequent results of such infection. Healing is delayed. Portions of the 
 broken bone die and come away, or are removed by operation, and the 
 individual, if he survives, passes through a long and painful illness. Even 
 after healing is complete there is apt to be a good deal of pain and ten- 
 derness in the scar, and the injured limb regains its normal 
 condition very slowly. Amputation is sometimes the only 
 treatment for compound fractures with severe complica- 
 ting injuries. 
 
 REPAIR OF FRACTURES. 
 
 
 The ends of the broken bones are united by a growth 
 of new tissue from the bone itself and from the layer of 
 tissue which immediately surrounds it — the pe^'iosteum. 
 The new tissue is at first soft and fibrous, and forms a 
 rounded mass of some size inclosing the broken ends. 
 Gradually, as the swelling subsides, the new tissue, or cal- 
 lus, as it is called, becomes harder and smaller, the salts 
 of lime are deposited in it, and when healing is complete 
 it will have been converted into true bone. The duration 
 of the process varies according to the size of the bone, the 
 more or less accurate contact of the broken ends, the more 
 or less complete immobilization of the fragments, and, to 
 some extent, with the age and health of the individual. 
 The thigh bone requires from six to eight weeks to unite. 
 Both bones of the leg about the same time. The arm bone 
 six weeks. The bones of the forearm four or five weeks. 
 The ribs three weeks. The collar bone four weeks. The 
 small bones of the hand two or three weeks. These state- 
 ments refer to adults. In children the time required for 
 union is shorter. 
 
 Under certain circumstances bony union does not take place, and the 
 ends of the bone are united by a more or less extensive mass of fibrous 
 tissue. Such union may be firm enough to make a useful limb, or it may 
 
 Fio. 21. — Fibrous 
 
 UNION AFTER 
 
 FRACTURE OF 
 
 THE PATELLA. 
 
 (Stimson.) 
 
COMPLICATIONS OP FRACTURES. 
 
 ;o5 
 
 be so loose that the functions of the member are seriously interfered with. 
 When the latter condition exists, it is customary to cut down upon the 
 seat of fracture and to remove the fibrous tissue between the fragments. 
 A thin section of bone is then sawn from the end 
 of each fragment. Holes are drilled througli the 
 end of each piece. Through the drill holes heavy 
 strands of catgut are passed. The fragments are 
 brought into accurate apposition and the catgut 
 strands are tied tightly so as to keep the bony sur- 
 faces in close contact. Firm bony union is the re- 
 sult of this operation. In certain situations fibrous 
 union is the rule. Fractures of the kneepan, of the 
 bone at the tip of the elbow (the olecranon process 
 of the ulna), and of the narrow part of the neck of 
 the thigh bone usually unite by fibrous tissue merely. 
 If untreated or improperly treated, fractures usually 
 unite with more or less marked deformity, which is 
 permanent. The amount of new bone produced in 
 such cases is often large, and may seriously impair 
 the functions of the limb by pressure upon the ves- 
 sels and nerves and by mechanically impeding the 
 motions of the joints. Such bad consequences can 
 sometimes be remedied by chiselling away the excess 
 of bone or by refracturing the bone and restoring 
 the fragments to their normal positions. 
 
 Certain untoward consequences of fractures have 
 been mentioned. There are others of more or less 
 common occurrence. Among persons addicted to the excessive use of 
 alcohol delirium tremens is a frequent complication. In the writer'^ 
 
 experience, the chances of recovery from delirium tre- 
 Complications. n -i-i • • /», , t* 
 
 mens joUowtng serious fractures are not good. A 
 
 large proportion of these patients die. It is usual to administer whiskey, 
 liquid food, and powerful sedatives. A rare complication of fractures 
 is the condition known as fatty embolism of the lungs. The fat from 
 the marrow of the broken bone enters the veins and lodges in the small 
 blood-vessels of the lungs. If such lodgment takes place in large amount, 
 the functions of the lungs may be interfered with and the individual may 
 die suddenly with symptoms of embarrassed breathing and shock. Gan- 
 grene may follow fracture, as the result of injury to the blood-vessels, 
 or from undue constriction of the limb by tight bandages. Stiffness of 
 the joints is nearly always present after fractures. It is very troublesome 
 in the joints of the fingers after fractures near the wrist, and may be 
 permanent in the aged. 
 
 Fig. 22. — Deformity fol- 
 lowing FRACTURE OF THE 
 LEG NEAR THE ANKLE. 
 
 (Stimson.) 
 
506 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 TREATMENT OF FRACTURES. 
 
 The general rules for the treatinent of fractures are to get the broken 
 bones back into their natural positions as soon as possible, and to keep 
 them quiet until healing is complete. To accomplish the setting or re- 
 duction of a fracture may be very easy or very difficult. The writer will 
 endeavour to give some simple directions for the early treatment of frac- 
 tures, which he hopes may be of use in the absence of a surgeon. It is 
 well to remember that reduction can usually be effected as well at the end 
 of a week as immediately after the injury, hence no pains should be spared 
 to reach a competent surgeon, though several days must elapse before he 
 can be seen. 
 
 When an individual has been injured, and it is believed that a fracture 
 may exist, great care should be taken not to make a bad matter worse by 
 encouraging the patient to get up or to use the limb. Before attempting 
 to move the patient a careful examination should Urst be made to deter- 
 mine whether signs of fracture exist. The clothing 
 Examination. i i i , ^ ■, . ^ , ^^ • • ^ 
 
 sliould be removed it necessary to expose the injured 
 
 part. This should be done with extreme gentleness, and if the attempt 
 causes pain it is better to cut the garments in the long axis of the limb 
 with a shears or knife. In many instances the deformity will at once re- 
 veal the presence of fracture. If not, then abnormal mobility, local pain 
 and tenderness, and perhaps slight displacement of the fragments which 
 may be felt with the tips of the lingers, should be looked for. All manipu- 
 lations should be made slowly and gently. "Where deformity is slight, it 
 often may be appreciated at once by comparing the injured with the 
 sound side of the body. 
 
 Having determined that there is a fracture, it will usually be Mnse and 
 
 often necessary to apply some form of temporary dressing which will 
 
 keep the broken bone quiet and allow the patient to be 
 
 K moved with tlie least amount of suffering and danc:er 
 
 Dressings. _ & f? 
 
 of further injury. "Where the fracture is of the upper 
 extremity, forearm, arm, or collar-l>one, there is nothing better than a 
 triangular sling hung around the neck. If the fracture is of the upper- 
 arm bone — the humerus — the hand and wrist alone should be supported 
 by the sling. If the forearm or collar-bone is broken the sling should 
 be spread out so as to support the entire forearm. The skirt of the 
 coat may be pinned up and made to answer the same purpose. If the 
 fracture is of the lower extremity it will be necessary to a]iply some 
 artificial support to the limb to keep the fragments quiet. Such sup- 
 ports are called splints. They may be made from the most varied ma- 
 terials. Thin strips of wood of any kind, such as shingles or the sides of 
 boxes, pieces of tin or sheet iron, wire gauze, the bark or branches of 
 
ON THE SETTING OF FRACTURES. 507 
 
 trees, umbrellas, swords or guns, broomsticks, bundles of straw, pieces of 
 stout leather, rolls of cloth, pillows, may all be utilized for this purpose. 
 In fractures of the leg the splints should be a little wider than the limb if 
 possible. They should be long enough to extend from the knee to a point 
 several inches below the sole of the foot. If the injury is at or near the 
 knee the splints should extend from below the knee to a point well up on 
 the thigh. If the thigh is broken the splint should extend from below 
 the foot to the armpit. Two splints should be applied in fractures of the 
 leg — one on the outer, the other on the inner side of the limb. To pre- 
 vent the injurious and painful effects of pressure, splints must always be 
 padded with some soft material. The padding may consist of cotton, 
 oakum, pieces of cloth, moss, grass, or any other soft material procurable. 
 It should be applied in such a way that the point of fracture and all 
 prominent bony points are relieved from pressure. The splints may be 
 held in place by bandages, adhesive plaster, handkerchiefs, straps, cords, 
 wire, or strips of cloth torn from the clothing. 
 
 Before applying the splints it is well to try and put the bones back 
 into their normal relations — in other words, to set the fracture. There 
 
 are various obstacles which may make this difficult, 
 Setting Fractures. ,, ,i • , •.• <> ,i c, , , 
 
 among them the interposition of the soit parts between 
 
 the fragments and the contraction of the muscles, or the fragments may 
 be impacted. To overcome the action of the muscles, which tends alwaj's 
 to keep the fragments in their unnatural position, we employ extension 
 and counter-extension and coaptation of the broken ends. The meaning 
 of these terms is simply this : The limb is grasped below the point of 
 fracture and pulled upon steadily and strongly in the line of its long axis. 
 This is called making extension. Some one else grasps the limb above 
 the fracture and pulls in the opposite direction. That is called making 
 counter-extension. After a few seconds or a minute the muscles of the 
 limb become tired, and frequently the broken bone slips easily into place. 
 If it does not, we may employ coaptation of the fragments — i. e., while 
 the limb is pulled upon, a third person tries by direct pressure upon the 
 broken ends to bring them into place. These measures are often success- 
 ful. They should be employed gently and without hurry. If they do 
 not succeed there is probably some obstacle to reduction which will re- 
 quire the knowledge of a skilful surgeon to overcome. 
 
 The padded splints should be ready before the attempt at reduction is 
 
 made, so that thej^ may be applied at once as soon as the bones are in 
 
 place, lest the displacement recur while the splints are 
 
 of Snlints being prepared. The splints should be laid against the 
 
 outer and inner sides of the limb, and while being held 
 
 in position a second person should bind them firmly to the limb with 
 
 bandages, handkerchiefs, or other material. Is^o bandage should be ap- 
 
5US 
 
 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 plied beneath the splints to a freshly-broken limb, for fear of strangula- 
 tion. No direct pressure should come uj^on the seat of fracture. The 
 liml) should not be constricted at any ])oint. In fi-actures of the thigh 
 the splint should be applied to the outside of the limb, and should extend 
 from below the foot to the arm])it. The outside of the ankle should be 
 well padded and the foot bound to the splint so that the limb cannot ro- 
 tate on its long a.\is. In order to be of any service in retaining the 
 broken bone in position the splint must be bound in place while exten- 
 sion is made on the foot. A second sjilint may be applied to the inner 
 side of the limb in fractures of the middle of the tliigh bone. It may 
 extend from the knee to the groin. 
 
 TREATiMENT OP COMPOUND FRACTURES. 
 
 Arterial hfemorrhage should be stopped by pressure, according to one 
 of the methods already given. The skin of the limb and the wound should 
 be cleaned and disinfected superficially and covered with a dressing of 
 antiseptic gauze. If the deformity be great it should be remedied accord- 
 ing to the preceding directions. The upper extremity should be sup- 
 ported by a sling, the lower extremity by splints. If the materials neces- 
 sary for thorough disinfection are not at hand it is far better not to 
 interfere with the wound in any way. Infection will surely he followed hy 
 the most disastrous results. Allow a clot to form on the wounded sur- 
 face and protect it with clean towels or handkerchiefs ; otherwise leave it 
 alone. 
 
 The popular impression that fractures are injuries requiring the 
 prompt attention of a surgeon has its foundation in fact ; and in truth no 
 
 branch of surgical art requires more technical skill and 
 
 judgment for its suc- 
 cessful practice. With this caution 
 tiie writer offers the following sugges- 
 tions for the treatment of fractures of 
 special bones when no surgeon can be 
 reached. The proper treatment of 
 many forms of fracture is of course 
 quite out of the question without pre- 
 vious surgical training: 
 
 FRACTURES OF THE COLLAR-BONE. 
 
 The collar - bone is more often 
 broken than any other bone in the 
 body. Fracture is caused in the larg- 
 est number of cases by indirect vio- 
 lence, such as falls on the shoulder, fio. 2.3.— The kikst strip. 
 
 Prompt Attention. 
 
FRACTURES OF THE COLLAR-BONE AND RIBS. 
 
 ioy 
 
 elbow, or hand. The usual situation of tlic fracture is near the middle 
 of the bone. The local deformity is easy to see and to feel, and often 
 easy to overcome by liftin<r the shoulder outwards, upwards, and back- 
 wards. The fragments are sometimes very hard to keep in i)lace, but 
 
 Fig. 24. — Sayre's dressing for fractured 
 CLAVICLE. (Front view.) 
 
 Fig. 25. — Sayre's second strip for fractuf.ed 
 CLAVICLE. (Buck view.) 
 
 the displacement rarely gives rise to serious disability. A good dressing 
 is that of Sayre. (See Figs. 23, 24, 25.) The bands are made of heavy 
 adhesive plaster — not rubber plaster. The latter causes marked irritation 
 of the skin when used in this manner. A bandage round the body, in- 
 cluding the arm of the injured side, and a sling for the forearm, are often 
 the only dressing necessary. Bony union occurs in about four weeks. 
 
 FRACTURES OF THE RIBS. 
 
 Causes. — Direct ,or indirect violence, rarely muscular action (violent 
 coughing). 
 
 Symptoms. — Pain in the side, increased on drawing a deep breath ; 
 local tenderness, sometimes mobility and grating of the fragments, and, if 
 the lung is ruptured, cough and spitting of blood. Occasionally crackling 
 of the tissues on pressure over the ribs near the fracture, from air be- 
 neath the skin. 
 
 Treatment. — A band of rubber plaster eight inches wide tightly ap- 
 plied round the entire chest to limit the motion of the ribs. It should 
 be put on while the lungs are emptied as far as possible of air. Or a 
 broad roller bandage applied in the same manner. Morphine or opium 
 to relieve the cough and pain. Union of the fragments in three or four 
 weeks. 
 
510 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 FRACTURES OF TllH III'MERUS— THE BONE OF THE UPPER ARM. 
 
 Delayed union or failure of union is more coniinon than after frac- 
 ture of any other bone. The break may occur near the upper end of the 
 bone, in the shaft, or at the lower end. Direct or indirect violence, rarely 
 muscular action (throwing a stone), is the cause. 
 
 Fractures of the upper end may occur in one of several situations. A 
 practical knowledge of anatomy is necessary for the recognition of these 
 varieties. In the commonest form the fracture takes 
 ■ place outside the joint. The upjier end of the lower 
 fragment lies to the inner side — i. e., is dis])laced towards the armpit. 
 There is complete loss of power in the arm, pain and tenderness. If the 
 upper end of the bone be grasped ])etween the fingers of the left hand 
 and gentle rotary movements of the arm be made with the right hand, 
 which grasps the elbow, it will be appreciated that the upper end of the 
 bone does not move with the shaft. Grating of the fragments can also 
 l)e felt in some cases. Reduction can usually be eilected by extension and 
 coaptation. A sling which supports the wrist forms a good temporary 
 dressing ; in addition a folded towel may be placed in the armpit and 
 the limb bandaged to the body. Union in five or six wrecks. 
 
 Fractures of the shaft of the bone usually give all the signs of 
 fracture, and are easy to recognise. The temporary 
 dressing may be the same as for fractures of the 
 upper end of the bone. 
 
 Fractures of the lower end of the bone are serious on account of the 
 interference with the motions of the elbow joint which may remain after 
 union is complete. The exact nature of the injury is 
 sometimes obscured by swelling. The lines of fracture 
 vary in different cases. Among the commoner varieties are the follow- 
 ing : 1st. The wide lower end of the bone is broken square off — i. e., the 
 line of fracture is transverse. The lower fragment and the forearm are 
 displaced backwards. The relations between the bone at the tip of the 
 elbow and the bony prominences on the outer and inner sides of the lower 
 end of the humerus are preserved. In dislocations of the ell)0w these re- 
 lations are altered. The normal relations can be seen on the uninjured 
 side. 2d. In addition to the transverse fracture, the lower fragment is 
 divided into two pieces vertically. This is known as a T-shaped fracture, 
 from the resemblance of the lines of fracture to a capital letter T. 3d. 
 The lines of fracture resemble a capital letter Y. The fracture enters the 
 joint in both the T-shaped and Y-shaped varieties. 4th. One or other 
 of the bony prominences which project at either side of the elbow is sep- 
 arated from the shaft of the bone. The line of fracture may or may not 
 enter the joint. A sling to support the forearm is a good temporary 
 
FRACTURES OF THE ELBOW AND FOREARM. 
 
 511 
 
 dressing. The permanent dressing of tliese fractures can liardlj bo made 
 except by a surgeon. 
 
 FRACTURE OP THE TIP OF 'J'lIE ELBOW. 
 
 Fracture of tlie olecranon process of tlie ulna (the Ijone which forms 
 the prominent tip of the elbow) is rather rare. Tlie cause is usually a fall 
 upon the elbow. The upper fragment is pulled away from the lower one 
 by the action of the large muscle at the back of the ai-ni. There is ina- 
 bility to straighten the elbow joint actively. 
 
 Treatment. — In order to keep the fragments in contact, the limb must 
 usually be kept in an extended position at first — i. «?,, the elbow not bent. 
 A long splint along the front of the limb is generally used to accomplish 
 this result. After ten days or two weeks the elbow may be bent to some 
 extent and kept so. It is thought that the subsequent stiffness of the 
 joint is less when this practice is followed. Union is nearly always 
 fibrous. Failure of union is treated by sewing the fragments together. 
 
 FRACTURES OP THE BONES OF THE FOREARM. 
 
 The bones of the forearm may be broken in any situation by direct or 
 indirect violence. If the bones are broken at or near the same level the 
 deformity is commonly marked. 
 
 A very common fracture (Colles's fracture) is that of the lower end of 
 the radius, the bone which lies upon the outer or thumb side of the limb. 
 The lower fragment is tilted backwards and the hand is 
 displaced slightly to the outer side, producing what is 
 called the silver-fork deformity. After reduction has 
 been effected by extension and direct pressure upon the broken ends, the 
 forearm should be placed between two splints, one on the back, the other 
 on the front of the limb. 
 The splints shonld ex- 
 tend from the vicinity IMW-'.'L'I ..iii'' i'H:.,. 
 of the elbow to the base 
 of the fingers. The 
 forearm should be bent 
 at right angles to the 
 arm, and the thumb 
 should be directed up- 
 wards while the splints are being applied. Care should be taken that 
 the inside splint is not too long so that it presses on the tissues at the 
 bend of the elbow. The splints should be as wide as the widest part 
 of the forearm, a sling used to support the limb, and the patient encour- 
 aged to move the fingers frequently so that the joints may not become 
 stiff. 
 
 Of the Loiver End 
 of the Radius. 
 
 Fig. 26. — Silvee-fobk deformity in fracture of the lower 
 
 END OF THE RADIUS (CoLLEs's FRACTURE). (iStimSOn.) 
 
512 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 Fractures of the bones of tbc liaiid nearest the \vri8t can usually be 
 recognised by the deformity, a more or less prominent lump or an irregu- 
 larity of outline on the back of the hand being present 
 Of the Bones -^^ most cases. After reduction by extension and pres- 
 
 of the Hand i ,. i i j n i j 
 
 nearest the Wrist ^"^"® ^"^ lingers may be closed over a roller bandage or 
 
 any other linn cylindrical body uf suitable size placed in 
 the palm and bandaged in this position. 
 
 FRACTURES OF THE BONES OF THE FINGERS. 
 
 Fractures, when occurring in the first bone next the hand, may be 
 treated as above. Fractures occurring in the second and third bones of 
 the fingers may be treated by bandaging the finger to a straight splint 
 placed on its palmar surface, extending back to the junction of the finger 
 with the hand. The splints should be worn for about five weeks in frac- 
 tures of the bones of the forearm, for two or three weeks in fractures of 
 the bones of the hand and fingers. 
 
 FRACTURES OF THE THKiH BONE OR FEMUR. 
 
 The bone may be broken near its upper end, in the shaft, or near its 
 lower end. Fractures near the upper end occur frequently among elderly 
 people, oftener in women than in men. Falls upon the knee or hip are 
 common causes. Owing to the fact that the bones of the aged are very 
 porous and therefore very brittle, these fractures sometimes occur as the 
 result of very slight degrees of violence, such as a stumble or a misstep. 
 The break takes place in the constricted portion of bone known as the 
 neck, which joins the head to the shaft of the femur, or at the junction 
 of the shaft with the neck. The fragments are sometimes impacted. 
 
 Pain, inability to raise the limb from the ground when the patient lies 
 upon his back, shortening of the limb, and sometimes grating of the frag- 
 ments characterize this fracture. The whole limb is 
 
 yrnp oms an usually rotated outwards so that the toes of the injured 
 Prognosis. •' , ,. ,. /• i i i 
 
 limb point away from the median line of the body. 
 
 The injury is a very serious one on account of the advanced age of these 
 patients, who bear confinement to bed very badly. Death is not uncom- 
 mon during the first three weeks following the injury, from exhaustion 
 and pneumonia. The chances of bony union when the fracture is through 
 the narrow part of the neck of the bone are not good, hence impaction is 
 a favourable circumstance. "When the fracture takes place at the junction 
 of the shaft with the neck, bony union is the rule. In any case, much 
 stiffness at the hip joint, a permanQnt limp, and marked disability are 
 regular consequences of the injury. Even if no union occurs between 
 the fragments, the patient may still have a useful limb. Very strong 
 
FRACTURES OF THE FEMUR. 513 
 
 lij^amcnts pass from the bones of tlie pelvis to the upper part of the 
 thigh bone, and upon these the weight of the body is sustained. 
 
 Abundant food, stimulation, careful nursing, cleanliness, and the pre- 
 vention of bedsores are the first indications for treatment in these 
 cases. The patient should lie upon a smooth, firm 
 
 ^'fP CttTTlGTbt 
 
 bed. It is customary to make permanent extension 
 upon the limb by means of a weight and pulley in order to diminish 
 the shortening. A short description of the apparatus used will be 
 found under Fractures of the Shaft of the Femur. If the patient bears 
 confinement well, extension may be continued until some union has oc- 
 curred — for six weeks or more. If the strength fails, some form of fixed 
 dressing, such as plaster of Paris, may be applied to the limb, including 
 the pelvis, and the patient got out of bed on crutches as soon as possible. 
 Otiier means have been devised to obtain bony union and better results in 
 fractures of the neck of the femur. The fragments have been brought 
 into apposition and nailed together in a few cases. A special apparatus 
 has been devised to keep the bones in contact by means of a fii-m pad and 
 screw pressure applied on the outer side of the hip. These methods 
 have given good results in some cases. 
 
 FRACTURES OF THE SHAFT OF THE FEMUR. 
 
 Causes, direct or indirect violence. The line of fracture is usually 
 oblique. There is often over-riding. The lower end of the upper frag- 
 ment sometimes projects forwards, and may perforate the skin on the 
 front of the limb. The diagnosis can often be made on sight from the 
 deformity. Gentle movements of the limb always show abnormal 
 mobility. The limb is shortened. 
 
 The application of a long splint on the outer side of the limb has 
 already been spoken of as a temporary measure. The permanent dress- 
 ing must be made by a surgeon. Two forms of dressing 
 
 Treatment. . , '-r ^, iiti.it 
 
 are m general use. in one, the whole limb, including 
 
 the pelvis, is encased in plaster of Paris soon after the injury. Extension 
 is made on the foot while the dressing is being applied. With this form 
 of dressing the patient may get about on crutches after ten days or a fort- 
 night. The other form of treatment, which gives more certain results, 
 consists of continuous extension and coaptation. 
 
 Extension is made by means of two strips of heavy adhesive plaster 
 which are laid alons; the outer and inner sides of the leo- and thigh from 
 
 „ , . a point somewhat above the seat of fracture to a few 
 
 Extension. . ^ 
 
 inches above the ankle. The strips are heated, laid 
 
 upon the skin, and covered with a bandage. The lower ends of the strips 
 
 are carried down beyond the foot and fastened to the ends of a stick of 
 
 wood which is longer than the sole is wide, and serves to prevent pressure 
 
 35 
 
iU 
 
 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 upon the ankle bones. To tlie centre of the stick a cord is fastened, which 
 ])assos throuirli a pulley at the foot of the bed. To the end of the cord a 
 weifijlit is attached. The foot of the bed is raised a few inches on blocks, 
 
 Fig. 27. — Apparati's for makin« ms- 
 
 TINUOUS EXTENSION IN FRACTUUES OK 
 THE FEMI:R. 
 
 Coaptation. 
 
 so that the body furnishes counter-extension. The weight varies from 
 five to twenty pounds, and is regulated by the size of the patient and the 
 persistence of the shortening. 
 
 Coaptation is obtained by numerous thin strips of wood well padded 
 and bound about the circumference of the thigh at the point of fracture. 
 
 To overcome the tendency to rotation of the fragments 
 
 about the long axis of the bone, the leg is laid upon a 
 board or framework having at its lower end a vertical foot-piece, to which 
 the foot of the patient is bound with bandages. The board slides upon a 
 little track, upon which it rests in the bed. This apparatus, when prop- 
 erl}' applied, is comfortable and gives good results. The shortening in 
 uncomplicated cases rarely exceeds an inch. The extension is usually 
 kept up for a month or six weeks, or longer when necessary. Union is 
 usually firm in from six to eight weeks. 
 
 In all injuries of the lower extremity which confine the individual to 
 his bed, it is important that the injured part should be relieved irova the 
 
 pressure of the bedclothing. In order to accomplish 
 Bedclcthina *^'^^ ^^ arched framework of wire or wood may be used 
 
 to maintain a space above and around the limb. Such 
 a framework is shown in Fig. 28. Something which answers the purpose 
 very well can be made froui three straight sticks of wood and several 
 barrel hoops taken from a Hour barrel. 
 
THE USE OF WIRE OR WOODEN SCREENS. 
 
 .15 
 
 This framework is not simply used to make tlie }>ati(;rit inore com- 
 fortable, but for more important reasons. When a patient lies in bed 
 . continuously for a lon^ period, and especially where he 
 
 is weak and cannot change his position from time to 
 time, but must lie upon liis back pretty constantly, from this or other 
 causes the feet tend to fall downwards and forwards from their own 
 weight, so that the sole of the foot looks directly backwards and the back 
 of the foot forms a straight line with the front of the leg. If this posi- 
 tion is maintained for several 
 weeks, it may become difficult or 
 impossible to bring tlie foot at 
 right angles to the leg, the mus- 
 cles on the back of the leg become 
 shorter, the ankle joint becomes 
 stiff, and when the individual has 
 recovered and tries to walk, it is 
 found that the sole of the foot 
 can no longer be applied to the 
 ground. This is a most annoying 
 result, which should always be 
 foreseen and guarded against by 
 relieving the limb from pressure and by supporting t^e soles of the feet 
 against pillows or a padded block at the foot of the bed. 
 
 Fractures of the lower end of the femur are serious, from the prox- 
 imity of the knee joint, which is often injured. There is sometimes 
 much splintering of the fragments, and the fracture is 
 not infrequently compound. The treatment is con- 
 tinuous extension where that is applicable. In some 
 cases a good deal of difficulty is experienced in keeping the fnigments in 
 position, and resort must be had to other apparatus of various kinds — 
 suspension of the limb with an anterior metal splint, the double inclined 
 plane, plaster-of-Paris dressings, and others. For a description of these 
 apparatus the reader is referred to works on fractures. 
 
 Fio. 28. — Wire or -wooden screen to keep the 
 
 BEDCLOTHING FROM RESTING UPON FRACTURED 
 LIMBS. 
 
 Of the Lower End 
 of the Femur. 
 
 FEACTURE OF THE KNEE-PAN. 
 
 Fractures of the knee-pan or patella are usually the result of mnscular 
 action, occasionally of direct violence. In the former variety the patient 
 stumbles or falls, makes a violent effort to save himself, and the patella is 
 fractured as the result of the contraction of the muscles of the front of 
 the thigh. The fracture is usually transverse, and the fragments may be 
 separated one or more inches b}' the continued traction of the muscles 
 upon the upper fragment. 
 
 At the time of the accident the patient feels a sharp pain in the knee, 
 
516 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 and perhaps licars the bone snap. There is complete inability to straighten 
 
 the leg at the knee, and the separated fragments can easily be felt and 
 
 moved independently of one another. Soon after the 
 
 " r. . accident there is coinnionlv an extensive eirusion of 
 
 Froq Hosts. . _ • 
 
 blood into the knee joint, marked swelling, and ecchy- 
 
 mosis (black and blue). Union is most often librous, with a greater or 
 less separation of the fragments. Close tibrous nnion is, however, not 
 uncommon, and bony union has been observed. In the majoi-ity of cases 
 of simple fracture, M'hen jn-ojierly treated, the functions of the knee joint 
 are but slightly impaired. "When the splints are discarded and the pa- 
 tient begins to use the liinb, at the end of eight weeks or more, there is 
 alwaj'S much stiffness of the joint. This diminishes with time and use, 
 and after some months may disappear entirely. Even when the librous 
 band which joins the fragment is quite long, extension of the knee can 
 usually be performed in a satisfactory manner. 
 
 The limb should be placed on a padded splint as -wide as the thigh 
 
 and long enough to reach from a point just above the heel to the fold of 
 
 the buttock. The splint should be secured to the limb 
 
 Temporary and . bandages. During the first few days following the 
 Subsequent -^ _ ? . . *= ,. . '\ ^ . ^ . 
 
 Treatment accident it IS often necessary to limit the eiiusion into 
 
 and the inflammation of the knee joint by the applica- 
 tion of cold, in the form of an ice bag laid over the knee, the limb being 
 kept quiet on a posterior splint meanwhile. 
 
 As soon as the swelling and inflammation have subsided somewhat, 
 the aim of the treatment is to bring the fragments as nearly as possible 
 into contact, and to obtain close union between them. This can be 
 
 FlO. 2'J. — AuNEW's SPLINT FOB FRACTURE OF THE PATELLA. (AgnCW.) 
 
 accomplished more or less successfully by a number of devices, some of 
 which act directly, such as hooks which are inserted into the fragments 
 and approximated by means of a screw. These are seldom used at pres- 
 ent. Other appliances act through the medium of the soft parts, such as 
 strips of adhesive plaster or elastic, which are applied above and below 
 the fragments and are fastened to a splint behind the limb. (See Fig. 
 29.) There are many other forms of a])paratus which depend upon the 
 same principle. They aie nearly all effective. 
 
FRACTURES OF THE KNEE-PAN AND LEG. 517 
 
 When tlie frap;ments cannot be broii^lit together on account of a great 
 effusion of blood into the joint, or when one is tilted so tliat its broken 
 surface cannot be bronglit against the broken surface of the other, or wlien 
 tlie soft parts fall between them, the treatment is to open the joint freely 
 by a transverse cut across its front, to wash out the blood clots, pare the 
 broken surfaces, and sew the fragments together with catgut. The results 
 of this operation are excellent. Bony union is obtained. It should be 
 done only when the most perfect antisepsis is attainable. Failure in this 
 respect means suppuration of the joint and permanent stiffness of the 
 knee as the most favourable result, or amputation of the thigh to save the 
 patient from death by pysemia or septicsemia in less favourable cases. 
 
 FRACTURES OF THE LEG. 
 
 There are two bones in the leg— a large one, the shin bone, or tibia, 
 and a smaller one, the fibula. Either may be broken alone, or both 
 together. . 
 
 Fractures of the tibia may occur at either end or in the shaft of the 
 bone. Fractures of the upper end are sometimes sei-ious on account of 
 complicating injuries to the knee joint. The temporary 
 Ends of the Tibia treatment may consist of lateral splints or a long poste- 
 rior splint. The permanent treatment is varied to suit 
 the individual case. It may consist of permanent extension, a posterior 
 splint, or a plaster-of-Paris dressing. 
 
 "When due to indirect violence, fractures of the shaft of the tibia 
 
 occur most often at the junction of the middle third with the lower third 
 
 of the bone. The fibula rarely escapes fracture at the 
 Fracture of the ^. ^-^ . n i i ' , i • i i , i 
 
 Shaft of the Tibia ^^^^® tmie. it is usually broken at a higher level than 
 
 the tibia. The line of fracture in the tibia may be 
 
 transverse, oblique, or V-shaped. In the last case a sharp point exists at 
 
 the lower end of the upper fragment, which may perforate the skin. 
 
 Reduction may be accomplished by extension and counter-extension. It 
 
 is not always easy. The nature of the injury is not difficult to recognise, 
 
 all the signs of fracture being commonly present. 
 
 The temporary dressing consists of lateral splints, applied as already 
 
 described. The permanent dressing may consist of apparatus of various 
 
 kinds. The most popular dressing in Xew York city 
 
 emporary an ^^ ^^^ present time is the plaster-of-Paris splint. This 
 Jrer7nanent -^ ,. , . , , 
 
 Dressing. ^^^J ^e applied in such a way as to surround the limb 
 
 partly or wholly. In the latter case, if applied directly 
 
 after the injury, the fracture is reduced and the limb covered with a thick 
 
 layer of cotton batting, over which the plaster is applied in the following 
 
 manner : Roller bandages of gauze or crinoline are prepared by rubbing 
 
 dry plaster thickly into the meshes of the cloth as the bandages are rolled ; 
 
51S 
 
 SCRGICAL INJURIES AND SURGICAL DISEASES. 
 
 ^vhen wanted for use, one or two bandages at a time are immersed in cold 
 water until thoroughly wet ; the water is then squeezed out and the 
 bandao-e applied like an ordinary roller. jVo tensioti kJ(o>iI<I he put upon 
 the handiK/e as it is rolled ahout the liinh^ lest un- 
 due constriction le produced. After several layers 
 have been applied, the surface of the bandage is 
 wet and dry plat^ter rubbed in with the hand. The 
 splint is carefully supported until the plaster is 
 firm, which should be in a few minutes if the plas- 
 ter is fresh and of good (piality. 'J'his dressing 
 should extend from the toes to the knee or above 
 it. If the toes get blue and cold the bandage is 
 too tiii'lit, and must be cut down the front with a 
 knife at once. If, as the swelling of the limb sub- 
 sides, the splint gets loose, it is replaced by another, 
 applied without padding. Tliese fra(,'tures requii'e 
 from six to eight weeks to unite. The ankle is left 
 stiff for some time, and the leg usually swells and 
 remains blue and tender for many months. An- 
 noying eczematous eruptions often occur on the 
 skin of the limb, and neuralgic pains are not un- 
 common. Some of these annoying results may be 
 modified by daily douching of the limb first with 
 hot and then with cold water, by massage and 
 bandaging. These measures are useful in the after- 
 treatment of all fractured limbs. 
 
 The commonest fracture of the lower part of 
 the leo; is known as Pott's fracture. The cause is 
 
 a sudden violent wrench of the 
 Pott's Fracture. , , , -, rpi xji i • 
 
 ankle outwards, ihe libula is 
 
 broken near its lower end. The tibia is broken 
 near the pointed tip of its lower end. The tibia 
 and fibula are often separated from one another 
 and a small portion of the til)ia torn off where it 
 is attaclied to the fibula. The entire foot is dis- 
 placed outwards. This is a serious fracture. It 
 is easy to recognise from the outward displace- 
 ment of the foot and the prominent edge of the lower end of the tiln'a, 
 which can be seen and felt beneath the skin at the inner side of the ankle. 
 (See Fig. 31.) 
 
 The temporary treatment may consist of side splints. The success of 
 the permanent treatment depends upon the completeness wnth which re- 
 duction of the displacement is effected and maintained. To accomplish 
 
 Fig. 30. — Plaster-of-Pakis 
 dressing in fracture of 
 
 THE LEG. 
 
DEFORMITY IN POTT'S FRACTURE. 
 
 il'J 
 
 Treatment. 
 
 and maintain reduction may be very difficult, as tlie many IjatJ rc.sultK 
 following this fracture bear witness. When i-eduction has been eflected 
 
 (best under an anaisthetlc) 
 
 a plaster-of- Paris dressing is 
 usually applied. The entire foot must be 
 pushed strongly inwards and held at right 
 angles to the leg while the plaster is ap- 
 plied. The dressing should extend from the 
 toes to the knee. Union is firm in from 
 four to six weeks. If perfect reduction has 
 been maintained the functional result is ex- 
 cellent, otherwise the sole of the foot looks 
 outwards. The point of support upon which 
 the weight of the body rests is out of line, 
 and a painful and permanent deformity is the 
 
 1 Fig. 31. — Deformity in Pott's 
 
 result. FKACTUEE. (Stimsou.; 
 
 Symptoms. 
 
 FRACTURES OF THE NOSE. 
 
 The bones forming the bridge of the nose are the most frequent seat 
 of the fracture. The cause is direct violence. The injury may be asso- 
 ciated with fracture of the base of the skull. 
 
 The symptoms of fracture of the nose are pain, tenderness, and de- 
 formity. The fragments are displaced backwards and to one side. 
 Bleeding from the nose may be present. In some cases 
 a considerable amount of blood may be lost, but dan- 
 gerous haemorrhage is very rare. Sometimes air is forced into the tissues 
 of the eyelids and cheeks through rents in the mucous membrane of the 
 nasal cavity during violent blowing of the nose after the injury. 
 
 If there is no displacement the treatment consists in syringing out the 
 nasal cavity frequently with a weak solution of salt in boiled water, or 
 witli a solution of boric acid in water (1 to 50). The 
 syringing should be done with a small glass syringe, 
 very gently. Displacement should be corrected by introducing into the 
 nose through the nostril a small smooth steel instrument and prying the 
 bones into place, using the fingers of the left hand to mould the frag- 
 ments from the outside. A strong hairpin might be used for this pur- 
 pose. Reduction may have to be repeated several times on successive 
 days. No external dressing is of any use to prevent the recurrence of 
 displacement. Excessive swelling of the nose may be treated by wet 
 dressings of ichthyol, or of alum and sugar-of-lead solution. Excessive 
 bleeding may be stopped by plugging the nostril with a strip of gauze or 
 with a narrow strip torn from a handkerchief. Union is complete in 
 from two to three weeks. 
 
 Treatment. 
 
520 
 
 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 Si/mptoms. 
 
 Treatment. 
 
 FRACTURES OF THE LOWER JAW. 
 
 Fractures of tlie lower jaw are caused by direct violence. The break 
 most often occurs in the middle line in front, or to one side, near the 
 middle line. Fractures near the back teeth or behind the teeth are less 
 common. 
 
 Pain, usually bleeding from the mouth, deformity, recognised by 
 irrei'-ularitv in the line of the teeth, and inability to bring the teeth 
 together, are present, together with abnormal mobility, 
 which can be appreciated by grasping the fragments on 
 either side between the forefingers and thumbs, the fingers on the teeth, 
 the thumbs under the chin, and trying to move the fragments in different 
 tlirections. 
 
 When there is no displacement (Fig. 32), a bandage, such as is shown 
 in the cut, suffices to keep the fragments quiet. A fluid diet and scrupulous 
 attention to the cleanliness of the mouth are necessary, 
 A cheap and effective mouth wash for this purpose is a 
 solution of permanganate of potassium in water (1 to 1,000). It should be 
 used every two hours. The gums and teeth should be cleaned mechanic- 
 allv several times a day with swabs of cotton twisted around the end of 
 
 a small stick and moistened with the above 
 solution. When much displacement ex- 
 ists which tends to recur, the best treat- 
 ment is an interdental splint of hard rub- 
 ber or some similar material. These splints 
 are made by dentists. A cast of the teeth 
 of both jaws is made in plaster of Paris. 
 From this cast an exact model of the 
 teeth of both jaws is obtained. Upon 
 this model the dentist constructs the splint, 
 which consists of a piece of hard rubber 
 containing upon its upper sui"face an im- 
 pression of the upi^er teeth and upon its 
 lower surface an impression of the lower 
 teeth. The impressions represent the 
 normal relations of the teeth of both 
 jaws. The displacement is reduced and 
 the splint is put into the mouth and adjusted so that each tooth fits 
 into the impression made to receive it. A bandage beneath the chin 
 holds the lower jaw firmly against the sjilint. A hole is left in front, 
 through which liquid food may be introduced through a rubber tube. 
 The results of this form of treatment are excellent. Union occurs in 
 four or five weeks. 
 
 Fiii. 32. — Four-tailed bandage for 
 
 FRACTURE OF THE LOWER JAW. (StilU- 
 
 son.) 
 
INJURIES TO THE VERTEBRAE. 521 
 
 FRACTURES OP THE SPINE. 
 
 Fractures of the vertebras — the bones forming the spinal column — are 
 comparatively rare. They may be produced as the result of direct or in- 
 direct violence, very rarely by muscular action. A violent forward 
 bending of the spinal column, such as results from the fall of a heavy 
 stone or a portion of a wall upon a workman's back while he stands in a 
 slightly stooping posture, is one of the ways in which tliese fractures 
 occur. The break may be in any part of the l)ack. Tlicre are two situ- 
 ations in which a' larger proportion of fractures occur than elsewhere. 
 These are at the junction of less flexible parts of the spinal column with 
 those which are more flexible — namely, in the lower part of the neck and 
 low down in the back, just below the last rib. In a general way, the 
 higher up in the spinal column the fracture occurs, the poorer the chances 
 of recovery. The spinal cord may be completely crushed by the edges of 
 the displaced bones. It may be merely compressed by a portion of bone 
 or a blood-clot, or — rarely — it may be uninjured. In a certain propor- 
 tion of cases, when the injury is situated high up in the neck, death is 
 instantaneous from paralysis of the muscles of respiration. In other 
 cases, when a lower portion of the cord is injured, life may be prolonged 
 for a longer or shorter period. When the spinal cord is not seriously 
 injured, recovery, complete or partial, may take place. 
 
 Paralysis of motion and sensation in those parts of the body supplied 
 by the nerves given off from the spinal cord below the point at Tvhich it 
 is injured is regularly present. Local deformity can 
 ■ sometimes be felt in the back. There may be a projec- 
 
 tion or a depression of the broken vertebrae. There is sometimes angular 
 deformity. The rectum and bladder are usually paralyzed, producing 
 retention of urine and incontinence of faeces. If the patient survives for 
 a few days or weeks, bedsores and inflammation of the paralyzed bladder 
 are apt to develop. Improvement is announced by tingling pains in the 
 legs and by a change for the better in the condition of the bladder and 
 rectum. Return of active motion in the limbs occurs later if at all. 
 
 The greatest care should be used in moving and transporting these 
 patients, lest the injury to the spinal cord be increased. The back should 
 be supported durino^ transportation bv cushions or pil- 
 lows, or bags filled with sand, and all movements of the 
 patient should be made with extreme gentleness. The subsequent treat- 
 ment consists in putting the patient upon a water bed, to prevent, as far 
 as possible, the formation of bedsores, in attention to the bladder, and in 
 scrupulous cleanliness. The operative treatment of these cases, by cutting 
 down upon the spine in the back and elevating or removing the depressed 
 fragments of bone and blood-clots which may be pressing upon the cord, 
 
522 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 has been attended witli good results in a few cases. If actual destruction 
 of the cord exists, no improvement can be expected as the result of 
 operation. In some eases, efforts to remedy the displacement of the 
 bones bv extension and counter-extension made n})on the head anil le<!;s 
 and direct j^ressure upon the broken vcrtebriv liave been attended by 
 (rood results. The eilorr should only bo made by a surgeon. A plaster- 
 of-Paris jacket may be applied subse(jucntly. 
 
 ACUTE SUPPURATIVE IXFLAIMM ATlOX OF TIIK BONE. 
 
 As the result of infection with pus microbes, acute sup]iurative in- 
 flammation of bone may follow compound fractures, amputation wounds, 
 and wounds of the soft jiarts in which a surface of bone 
 is or is not exposed. The treatment of these conditions 
 is, in general, the treatment of inllamed wounds. One form of acute in- 
 flammation of bone, which occurs rather frequently and the early recog- 
 nition of which is of great importance, since the life of the patient may 
 depend upon prompt and eflicient treatment, is caused by infection of the 
 marrow of the bones with pus microbes. It occurs nearly always during 
 the period when the bones are growing, and often attacks primarily the 
 lower part of the thigh bone and the upper part of the shin bone, 
 although many bones throughout the body may be affected at the same 
 time. The inflammation of the bones sometimes follows severe general 
 diseases, such as typhoid fever, measles, scarlet fever, diphtheria, or small- 
 pox. Sometimes exposure to cold and wet, overfatigue, or a slight 
 bruise over the bone are the only causes apparent. Occasionally the 
 attack is preceded by bronchitis or diarrhoea. Of course none of these 
 causes alone are suflicient to produce the disease without the localization 
 of the pus microbes in the bone, and we must suppose that in some cases, 
 at least, the diseased conditions which precede the bone inflammation have 
 allowed the entrance of the bacteria into the circulating blood, or have 
 produced a condition of diminished resistance in the tissues in which the 
 bacteria develop, or that both these results have been produced. 
 
 The local process in the bone consists of a rapid growth of pus 
 microbes in the bone marrow, the formation of pus, and a more or less 
 rapid extension of the purulent inflammation through- 
 out the whole or greater part of the marrow cavity. 
 Subsequently the pus finds its way to the surface of the bone ; from this 
 point the inflammation spreads beneath the layer of tissue surrounding 
 the bone — the periosteum (from which the bone derives much of its nutri- 
 ment) — in every direction. Thus the entire shaft of a long bone may be 
 bared of its surrounding envelope of periosteum. The soft parts of the 
 liml3 are next invaded, and very large abscesses are often produced. The 
 neighbouring joint often becomes the seat of suppurative inflammation. 
 
ACUTE SUPPURATIVE INFLAMMATKJN OF BONE. 523 
 
 By the action of the poisons produced by the piii^ microbes, and from tiie 
 interference with the circulation and consequently with the nutrition of 
 the bone, due to intense congestion, and from the separation of the perios- 
 teum, necrosis or death of the bone occurs. The necrosis may involve the 
 entire shaft of the bone or only a part. Sometimes the layer of cartilage 
 which lies between the shaft proper and the ex])anded end of the bone 
 which forms a part of a joint is destroyed by suppuration. The end is 
 thus separated from the shaft. This accident may result in an interfer- 
 ence with the subsequent growth of the bone. Pyagmia, resulting from 
 the purulent inilammation of the veins within the bone and the produc- 
 tion of infective clots which soften and are carried to other parts of the 
 body, is one of the ways in which a fatal result is sometimes produced. 
 
 In the most severe cases the disease runs its course very rapidly, death 
 occurring within a few days. These patients usually have a chill, fol- 
 lowed by high fever, great prostration, delirium, stupor, 
 coma, and death. The nature of the disease is often 
 not recognised during life. In less severe cases, the chill, fever, and pros- 
 tration are followed by pain of an intense boring, throbbing character in 
 one or more of the extremities. The power of voluntary motion is lost 
 in the affected limb, and passive movements are attended by an increase 
 of pain. During the early stages of the disease, and until the soft parts 
 surrounding the bone are invaded, swelling of the limb and redness of the 
 skin are commonly absent. A most important sign during the first few 
 days of the disease is the presence of extreme tenderness over the affected 
 bone, the centre of which corresponds to the centre of the inflammatory 
 process. As soon as the inflammation reaches tlie surface of the bone, 
 which event usually occurs after a week or more, an accumulation of pus 
 forms between the bone and the periosteum, the limb swells, and the 
 periosteum flnally ruptures, allowing the pus to escape into the soft parts 
 of the limb. The formation of large abscesses follows. The perforation 
 of the bone and the escape of the pus into the soft parts is usually fol- 
 lowed by a diminution of the pain. If the patient does not succumb to 
 septicaemia or pyaemia, the subsequent course of these cases is, that death 
 of the whole or a portion of the shaft of the bone takes place. After 
 weeks or months the dead part, or sequestrum, as it is called, is separated 
 from the living bone and remains embedded in the more or less massive 
 layer of new bone which has been formed around it. There are usually 
 one or more sinuses in the skin which discharge pus and lead through the 
 soft parts and through the new bone to the sequestrum. 
 
 Very early evacuation of the pus contained within the bone through 
 an opening made with a chisel, and thorough disinfection of the cavity 
 before the inflammation has had time to spread widely within the bone 
 and to invade the soft parts, is often the means of saving life, and usually 
 
524: SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 prevents the widespread destruction of bone M'hicli may otherwise take 
 
 place. Hence the importance of recoii;nisino; tlie disease as soon as possi- 
 
 l>lc. Jf seen for the first time at a later lu'riod, wide 
 Treat inf lit. ... . , ,, ■,, \ , 
 
 incisions m tlie sott parts are necessary to allow of the 
 
 escape of the pus, and free openiuii's into and disinfection of the diseased 
 cavity within the bone. If death of a portion of the shaft of the bone 
 has already taken place, it is customary to ])rovide for adequate drainage 
 and to await the separation of the sc(iuostrum before removing it by 
 operation. In the must severe cases ampnraridii may be necessary to save 
 life. Where many bones are diseased, or the patient is exhausted by 
 pyaimia or sei>ticaMnia. this treatment may be impracticable or ineffectual. 
 Suppuration of a joint is treated by incision into and disinfection of the 
 joint and the insertion into the joint cavity of one or more rubber drain- 
 age-tubes. The general treatment consists in the administration of abun- 
 dant nutritious food and stimulants, wath opium to relieve pain. 
 
 RICKETS. 
 
 Rickets is a condition of malnutrition characterised by a diminished 
 amount of lime salts in, and an abnormal softness of, the bones, as the re- 
 sult of which characteristic deformities are produced. The disease occurs 
 in infants and young children, usually during the lirst two years of life, 
 occasionally later. Improper feeding and bad hygienic surroundings are 
 the chief causes of the disease. Rickets of a severe type is rarely seen in 
 America except among Italians and negroes. 
 
 Restlessness at night, profuse perspiration, constipation, and an in- 
 creased quantity of urine are among the early symptoms. The children 
 are usuallv pot-bellied and the forehead is often bulg- 
 
 SymptomS. . " ^ ^ • ^ ^ -, mi 
 
 mg. llie appearance of the teetli is delayed. ihe 
 bones are soft, and the ends of the long bones, especially the anterior ends 
 of the ribs and the lower end of the radius, are enlarged. Bowlegs and 
 knock-knee, due to curvatures of the femur and tibia, are present in 
 many cases. The diameter of the chest is increased from before back- 
 ward and diminished from side to side, producing the deformity known 
 as pigeon breast. Deformities of the bones of the pelvis are not uncom- 
 mon. The disease is usually recovered from, but the deformities of the 
 bones are in some cases permanent. 
 
 Proper and abundant food, and life out-of-doors under good hygienic 
 
 surroundings, are the essentials of the treatment. Tonic drugs, among 
 
 others cod-liver oil, syrup of the iodide of iron, and the 
 
 lactophosphate of lime, are given Avith advantage. The 
 
 deformities of the bones sometimes need to be corrected by operation. 
 
 For Syphilitic Inflammation of Bone., see Yenereal Diseases., treated 
 of in a subsequent chaj)ter of this article. 
 
CONTUSIONS AND SPEAINS. 525 
 
 CHAPTER V. 
 INJURIES AND DISEASES OF JOINTS. 
 
 INJURIES OF JOINTS. CONTUSIONS. 
 
 Contusions of joints are produced by meclianical violence applied 
 tlirongli the medium of blunt objects. As in the case of fractures, the 
 violence may be direct or indirect. The injury pro- 
 duced consists of a more or less extensive crushing of 
 the soft parts around the joint, of the lining membrane of the joint, and 
 of the ends of the bones. Severe contusions of joints are often compli- 
 cated by fractures. 
 
 When no fracture exists, the symptoms consist of swelling from dis- 
 tention of the joint cavity and the surrounding soft parts Mnth effused 
 blood, of slight or moderate pain felt chiefly when the 
 joint is moved, more or less marked disability, and later 
 of black-and-blue marks in the skin. The individual -usually holds the 
 joint slightly bent. Each joint has its own position in which distention 
 of its cavity is attended by the least discomfort. 
 
 Early and vigorous massage is the best means of causing the absorp- 
 tion of the effused blood. It should be used for fifteen 
 or twenty minutes twice daily. Pressure with a rubber 
 elastic bandage and active motion of the joint also hasten the cure. 
 
 SPRAINS. 
 
 When the ligaments which hold the bones in place are unduly stretched 
 or torn we speak of the injury as a sprain. The lining memljrane of the 
 joint is often torn and crushed at the same time. The 
 muscles and tendons passing over the joint may also be 
 stretched or ru^Dtured in severe cases. The force which produces a sprain 
 may act in such a way that the normal range of motion of the joint in a 
 certain direction is exceeded, or the joint may be moved in a direction in 
 which normally little or no motion takes place. For examjDle, the joints 
 between the small bones of the fingers can be normally moved so that 
 the finger is bent or straightened, or, surgically speaking, flexed or 
 extended. If the finger is extended too far the ligaments which bind 
 the bones together are torn and a sprain is produced. On the other 
 hand, very little motion from side to side takes place between the bones 
 of the fingers, and comparatively slight movements of this kind result 
 in a sprain. The force which produces a sprain is exerted in such a 
 way that, did it continue to act, the surfaces of bone which enter into 
 
52G SURGICAX INJURIES AND SURGICAL DISEASES. 
 
 tlie joint would no longer remain in contact — in other words, a disloca- 
 tion would be produced. 
 
 Sudden, violent pain is felt at the time of the accident. In severe 
 
 sprains the disability may be complete from the first. In less severe cases 
 
 the disability may be slight for some hours. AVithin a 
 
 ymp o»K nu ^^^^ hours the iniured part becomes swollen and painful 
 J^rogiiositi. ... . . 
 
 from effusion of blood into and around the joint. At- 
 tempts to use the limb are now attended by severe pain. After a day or 
 two black-and-blue marks apjiear in the skin around the joint. The re- 
 sults of sprains, when proj^erly treated, are usually favourable. Severe 
 sprains, however, are sometimes followed by chronic iiiilanmiation of the 
 joint of a serious character. The joint may become pi'rmaiientlv stiff or 
 lemain unnaturally movable and weak. The time required for recovery 
 from a sju-ain varies, according to the severity of the injury, from a M'eek 
 to many months. The joints most often sprained are the ankle and the 
 wrist, less often the knee. 
 
 The opinions of surgeons as to the ti-eatment of sprains are to some 
 extent divided. There are those who depend almost entirely upon mas- 
 sage and upon active and passive motion of the joint 
 from the first. Others believe that prolonged immobil- 
 isation of the joint is of great consequence. The writer believes that the 
 following plan of treatment represents fairly the method pursued by the 
 majority of surgeons in New York city : Sprain of the ankle, being the 
 commonest form of the injury, may serve as an example. As soon as 
 possible after the accident the foot and ankle should be immersed in a 
 pail of water as hot as caii be borne. The water should be kept at the 
 highest possible temperature by adding more hot water from time to time. 
 The immersion should be continued for an hour and a half or two hours. 
 The foot and ankle should then be encased in a plaster-of- Paris splint 
 w-ell padded with cotton batting. If this cannot be done, the next best 
 thing is to pad the foot and ankle with cotton batting and to apply over 
 this a firm bandage, so as to exercise considerable pressure on the limb. 
 The foot should be kept elevated for the first forty-eight hours, and after 
 that the patient may go about on crutches. After acute inflammatory 
 swelling has subsided somewhat, at the end of five days or a week, the 
 bandage should be removed and the joint massaged vigorously twice a 
 day. In addition to the massage, prolonged daily douching with hot and 
 then with cold water is of benefit. During massage, passive movements 
 of the joint should be made. After the douching and massage the plas- 
 ter splint or bandage should be replaced and worn throughout the day. 
 Plaster splints are removed by cutting through the plaster with a knife 
 along the median line of the limb. If this is done carefully and the 
 layer of plaster is not too thick, the splint can be opened by pulling on 
 
THE MECHANISM OF DISLOCATIONS. 527 
 
 the two cut edges so tliat tlie lirnlj cuii l^e lifted out of it. The padding 
 within the plaster casing can tlxin Ite renewed and tlie s]>lirit replaced on 
 the limb, if desired, and snrronnded hy a bandage to hold it in position. 
 Under this treatment sprains of the ankle are usually recovered from in 
 a fortnight, unless the injury is very severe. 
 
 DISLOCATIONS. 
 
 When the surfaces of bone which normally form part of a joint 
 are displaced permanently from one another, the joint is said to be dislo- 
 cated. 
 
 Dislocations are ordinarily produced by mechanical violence, which 
 may be direct (as is the case with fracture), indirect, or muscular. A dis- 
 location may be associated with other injuries, such as 
 
 Clan f>p ' •/ ? 
 
 fractures, wounds of the skin, the muscles, the blood- 
 vessels, or the nerves. Usually dislocations are produced by violence act- 
 ing upon a healthy joint. They may also occur as the result of disease, 
 when they are called spontaneous. Occasionally they are congenital — i. e., 
 the individual is born with one or more joints dislocated. By far the 
 most common dislocation is that of the shoulder joint. Next in frequency 
 is the elbow, and then the hip and the lingers. 
 
 The mechanism of dislocations resembles that of sprains, except that 
 the violence is greater ; the ligaments of the joint are not merely torn, 
 
 but the ends of the bones are also forced out of place. 
 Mechanism. „, , • i • i ,i • • i i 
 
 ihe most common way m which this occurs is that the 
 
 shaft of one of the bones acts as a lever. Motion of a portion of the 
 bone near a joint is arrested at a certain point by a strong, tense ligament, 
 a neighbouring bony prominence, or by the edge of the articular surface 
 of the other bone forming a fulcrum. The shaft of the bone continues 
 to move, and its articular extremity is literally pried a^vay from its posi- 
 tion in the joint. The extent to which the ligaments of the joint are torn 
 varies much in different cases ; usually the head of the dislocated bone 
 tears a rent in the ligaments which surround it and projects through the 
 rent into the neighbouring soft parts. On account of the relative strength 
 or weakness of particular ligaments the dislocation usually takes place in 
 certain definite directions, which are always the same when the position 
 of the limb and the direction of the force are identical. The dislocated 
 bone does not commonly move very far from the joint cavit}". because it 
 is restrained by the ligaments which remain untorn, and a knowledge of 
 the relations of these untorn portions to the end of the bone is of the 
 greatest consequence in determining what movements of the limb must 
 be made in order to restore the bones to their natural relations. 
 
 The repair of dislocations after reduction has been made usually pro- 
 ceeds rapidly and without severe inflammatory symptoms. The rent 
 
o'2S 
 
 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 Jiepair. 
 
 Prognosis. 
 
 Symptoms. 
 
 througli whicli the dislocation took place heals. The cllused blood is 
 absorbed, and the stiffness of the joint which Avas present at lirst disap- 
 pears. If, however, the injury to the soft parts is 
 severe, including laceration of important blood-vessels 
 or nerves, if the dislocation is compound, if the efforts at reduction have 
 been prolonged and forcible, if the health of the individual is impaired, 
 or if the joint is used too soon, various untoward results may follow. 
 
 llupture of important vessels may cause death from luvmorrhage, gan- 
 grene of the limb, or the formation of an anenrism. Infection will lead 
 to suppuration and permanent stiffness of the joint or 
 death from ^lyajmia or septicaemia. Rupture of large 
 nerve trunks M-ill produce paralysis of a part or the whole of the liinl). 
 Too early nse may produce a recurrence of the dislocation, and intiannna- 
 tion and temporary or permanent stiffness of the joint ; or in some cases 
 a M'cak and flail-like joint results. Occasionally the dislocation may be- 
 come habitual — /. e., the displacement may recur from time to time as the 
 result of slight degrees of violence. For a description of these conditions 
 the reader is referred to works on dislocations. 
 
 Deformity. — It is often easy to recognise certain dislocations at a 
 glance by the attitude of the patient and the change in the appearance of 
 the limb. Thus, in the commonest form of dislocation 
 of the shoulder, where the head of the bone is displaced 
 inward, the patient stands or sits with his body inclined toward the injured 
 side. The elbow is separated from the body and the forearm is bent 
 
 across the abdomen. The promi- 
 nence of the fleshy part of the shoul- 
 der is diminished, and the outer part 
 of the shoulder-blade seems, in poorly 
 developed individuals (Fig. 33), to 
 overhang the arm. The most impor- 
 tant signs of dislocations are the pres- 
 ence of the end of the dislocated bone 
 in a new situation outside the joint, 
 and its absence from the normal situ- 
 ation. These two signs are some- 
 times very easy to establish. In other 
 cases their recognition may be difii- 
 cult or impossible. In joints which 
 are not thickl}^ covered by soft parts, 
 like the knee, the position of the 
 bones is easy to determine ; in the 
 hip, which is thickly covered with 
 
 Fio. 33. — Inwakd dislocation of tue , . , . m i o n 
 
 siioi-LDEK. (Stimson.) musclcs, it may be nnpossible. bwell- 
 
DISLOCATIONS: SYMPTOMS AND REDUCTION. 529 
 
 in^<^, wliicli may take |)]acc ra])i(]]j after a dislocation, often olj.scnres tlie 
 relations of tlie ])art.s and makes it iinpoK.sibie to feel tlie position of tlie 
 bones. Tlie dislocated limb may be really or a|)[nirent-ly lon;^er or shorter 
 than the sound one. 
 
 LosK of Mohility. — Passive movements of the limb arc usually re- 
 strained by the tense condition of those ligaments which remain untorn 
 and sometimes by spasm of the muscles and the fear of pain. Movements 
 can be made only in those directions which serve to relax the untorn por- 
 tions of the ligaments, or which at least do not render them more tense. 
 They vary in direction for each form of dislocation. 
 
 Pain. — Immediately following a dislocation pain of greater or less 
 severity is felt. It may be due to the tension of tlie tissues about the 
 joint or upon their laceration. In the former case it disappears at once 
 when reduction is effected, in the latter it does not. Tingling or numb- 
 ness of the limb is caused by laceration, stretching, or pressure upon the 
 nerve trunks. If the nerves are torn the numbness may be permanent, 
 and it is well to remember that the surgeon cannot be blamed for its con- 
 tinuance provided it existed before the dislocation was reduced. 
 
 Loss of Fxtnction. — In many cases the loss of function is complete, 
 the limb is useless. Often, however, the patient continues to use the 
 limb in a more or less limited way, and the dislocation may thus 
 remain permanently unrecognised and unreduced. 
 
 Owing to the fact that dislocations ahvays require a surgeon for 
 
 their safe reduction, the writer believes that it would be fruitless to 
 
 give instructions in a work of this character for the 
 Reduction, ,. . , „ .,,.,. 
 
 diagnosis and treatment oi special dislocations. An 
 
 accurate knowledge of anatomy is an absolute prerequisite for an 
 intelligent understanding of the subject, and ill-directed attempts at 
 reduction are fraught with such grave dangers to life and limb that 
 they cannot be too severely condemned. 
 
 A few words as to the way in which reduction of dislocations is 
 effected may, however, be of interest. From the history of the acci- 
 dent, and the position of the dislocated bones with reference to one 
 another, the surgeon tries to discover in what direction the force acted 
 to produce the dislocation, and in what portion of the ligaments the 
 rent occurred through which the bone escaped. A knowledge of the 
 position of the limb at the time of the accident is of assistance in 
 determining these points. From his anatomical knowledge he should 
 then know what ligaments and muscles must be relaxed and what bony 
 prominences avoided in order to unlock the bone from its abnormal 
 position, open the rent in the torn ligaments, and replace the bone in 
 its normal position. In many instances these anatomical facts have 
 been carefully studied out from dislocations artificially produced on 
 36 
 
530 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 dead bodies and from dissections made in cases where persons died 
 with dislocated joints. And certain definite manipulatioTis liave been 
 found to be necessary in order to reduce particulai- forms of disloca- 
 tion. Not very numy years ago it was tlie custom to reduce many 
 dislocations by pulling forcibly on the limb by means of powerful pul- 
 leys or by the combined efforts of several individuals. This treatment 
 was often effective, but accidents of the most lamentable character oc- 
 curred. Among them may be mentioned rupture of the large blood-ves- 
 sels and nerves, and fractures. Sometimes the skin of the limb would give 
 wav and the part would be tlayed in consequence, and occasionally it hajv 
 pened that the entire limb was pulled away from the trunk. 
 
 At the present time tliese methods have given place to gentler ones 
 which depend fur their success upon anatomical knowledge and skill, and 
 
 do not require a ijreat expenditure of force for their 
 Modem Methods. ,. , , ^'rr\ • i. c • i 4.- £ i.\ 
 
 accomplishment, iliej' consist or mannnilations oi the 
 
 liml) of various kinds, such astlexion and extension, rotation, abduction and 
 adduction. These movements are combined with moderate traction or 
 direct pulling upon the limh. In recent dislocations these measures are 
 often successful at once. If they fail, the patient is given ether to relax 
 the muscles and the manipulations are repeated — usually with success. 
 After reduction is accomplished the liml) is kept quiet with bandages for 
 ten days or more, when active motion is gradually resumed. Swelling 
 and inflammation are treated by wet dressings and the pressure of 
 bandages. The sooner a dislocation is reduced the better. After a week 
 reduction can usually be effected easily, but a delay of many weeks or 
 months may render replacement imjDossible. The muscles become short- 
 ened, the end of the dislocated bone becomes firmly adherent to the sur- 
 rounding parts, and the joint-cavity is gradually obliterated. Such a limb 
 may, however, be quite movable and useful. 
 
 INFLAMMATION OF JOINTS. 
 
 Inflammations of the joints are called synovitis. They may be either 
 acute or chronic. The acute inflammations may be divided, according to 
 the character of the inflammatory product, into two principal varieties. 
 In the first the cavity of the joint is distended with watery fluid which 
 niav contain shreds of fibrin. In the second the joint contains pus. 
 
 ACUTE SEROUS SYNOVITIS. 
 
 In tlie first variety, which is known as acute serous synovitis or 
 arthritis, or, when a considerable amount of fil)rin is present in the exuda- 
 tion, as acute sero-fibrinous synovitis, the lining membrane of the joint is 
 swollen and the small blood-vessels of the membrane are dilated. 
 
ACUTE SEROUS AND ACUTE PURULENT SYNOVITIS. .531 
 
 The symptoms are pain in tlie joint, increased by motion, tenderness, 
 swelling, and distention of the joint-cavity with fluid, and sometimes in- 
 creased lieat and redness of the skin. Tlie joint is held 
 ^'^'^OMuok''^ in a slightly bent position. Fever is absent or not higli, 
 except when the inflammation is tlie result of some 
 disease which is regularly attended by fever. The disease is generally 
 recovered from rapidly under suitable treatment, or it may become 
 chronic, or pass under certain circumstances into the purulent form. 
 
 ACUTE PURULENT SYNOVITIS. 
 
 The second variety, in which the joint contains pus, is known as acute 
 purulent synovitis or arthritis. In the mildest cases the lining membrane 
 of the joint and the ligaments are swollen and congested, and the lining 
 membrane is coated with fibrin and pus. In more severe cases all the 
 joint structures undergo suppuration. The cartilages are softened and 
 destroyed to a greater or less extent. The joint may be perforated 
 with the production of abscesses in the surrounding tissues, and the 
 bones may be involved in the inflammation. In the most severe cases 
 a putrid inflammation takes place, with the formation of the gases of 
 putrefaction. 
 
 The disease often begins with a chill, followed by high fever and 
 marked prostration. The joint swells rapidly, and the swelling often ex- 
 tends over the entire limb. There is intense pain in- 
 Symptoins and -, , , , ,, t . , .,. 
 
 Outlook creased by movement, and usually complete inability to 
 
 use the extremity. The skin over the joint is red and 
 hot. The subsequent course of the disease depends upon the severity of 
 the process and the promptness of the treatment. Under favourable 
 circumstances recovery may take place with a movable joint. In other 
 cases the joint is obliterated and remains permanently stiff ; the ends of 
 the bones unite by fibrous tissue or new bone. In more severe cases sep- 
 ticaemia or pyaemia cause death, or amputation of the limb may be the 
 means of saving life. 
 
 The causes of acute inflammation of the joints are very various. The 
 serous or sero-fibrinous form may be due to injuries, such as contusions, 
 
 sprains, dislocations, and fractures in the neighbourhood 
 Causes. r ^-i • • ^ t^ -n -, 
 
 01 the joints. Jixposure to cold and wet is sometimes 
 
 assigned as a cause. The disease occurs in the course of many of the 
 acute infectious diseases, such as typhoid fever, diphtheria, mumps, and 
 measles ; also in gonorrhoea and syphilis, and, finally, in acute rheumatism 
 of the joints. 
 
 The purulent variety is always attended by the presence of bacteria in 
 the fluid contained in the joint. The disease may be due to direct infec- 
 tion through a wound in the skin which opens the joint, or from a local 
 
532 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 inflammatory process in the bones or soft parts from whk-li direct infec- 
 tion of the joint takes place. Often the process is secondary to some 
 other disease, such as pyjemia, dysentery, small-pox, measles, scarlet fever, 
 diphtheria. In these cases infection takes place through the blood, and 
 one or several joints may be involved. In pyaemia the pnrulent effusion 
 into the joints mav appear very suddenly and without any of the symp- 
 toms of acute inflanunation. Acute rheumatism is probably also an acute 
 infectious disease caused by bacteria, with localisation of the microbes in 
 the joints and in the Hning of the heart. For a description of acute 
 rheumatism of the joints and gout the reader is referred to the article 
 in this work on D/'.-iccises hi Genend. 
 
 The treatment of acute serous synovitis consists, in the early stages, of 
 immobilisation of the limb on a splint in an elevated position, in the ap- 
 plication of cold to the joint by means of an ice bag, or 
 of cold wet dressings. AVhen the pain and effusion 
 have subsided somewhat, it is customary to use massage and pressure to 
 hasten the absorption of the fluid. Pressure may be applied by means of 
 a rubber bandage in which the limb is enveloped. Once or twice daily 
 tlie bandage is removed and the limb is douched and massaged. The pa- 
 tient is also allowed to use the limb moderately. Under this form of 
 treatment recovery is usually rapid, the joint returning to its normal 
 condition in from one to several weeks. If the effusion does not dis- 
 appear and becomes chronic, the fluid is sometimes withdrawn from 
 the joint through a hollow needle under the strictest antiseptic precau- 
 tions, after which pressure is reapplied. The operation may need to be 
 repeated. 
 
 The treatment of acute suppurative inflammation of the joints de- 
 pends upon the severity of the infection. In the mildest cases, where the 
 effusion consists of serum and fibrin, with only a small amount of pus, the 
 so-called " catarrhal synovitis," evacuation of the fluid through a needle 
 or through one or several small incisions into the joint, and tlie subse- 
 quent washing out of the joint-cavity with a solution of carbolic acid or a 
 solution of corrosive sublimate (1 to 1,000), followed by an antiseptic 
 dressing and complete rest of the joint for several weeks, may suffice. 
 In the more severe cases, where constitutional symptoms are present and 
 the effused fluid is distinctly purulent in character, the joint must be 
 freely opened, washed out with an antiseptic solution, and drained at de- 
 pendent points through rubber tubes inserted into the joint-cavity. Ab- 
 scesses in the soft parts must be freely opened and the limb dressed, 
 immobilised, and elevated. Should the fever persist and the discharge of 
 pus continue in spite of thorough drainage and disinfection of the joint, 
 it may be necessary to remove the ends of the bones which form the 
 joint, or in the severest cases to amputate the limb. When many joints 
 
WOUNDS AND CHRONIC INFLAMMATIONS OF THE JOINTS, tj'y.i 
 
 are involved, as is sometimes the case in pjuemia, the condition is almost 
 hopeless. 
 
 In favourable cases, where the joint-cavity is not destroyed and some 
 motion remains, massage and passive motion are used to increase the mo- 
 bility after the inflammatory process has entirely subsided. Ijut in all 
 cases v^^here a stiff joint is to be feared the limb should be placed and kept 
 in the position in which it will be most useful — the knee joint very sHghtly 
 bent, the elbow bent to nearly a right angle, the foot at right angles to 
 the leg. The constitutional treatment is supporting and stimulating. 
 
 CHRONIC INFLAMMATIONS OF THE JOINTS. 
 
 Tuberculosis of the joints has been spoken of elsewhere. For a de- 
 scription of the other chronic disturbances of the joints, the reader is 
 referi-ed to works on surgical pathology and to the article on Diseases 
 in General in this book. Certain deformities involving the joints will be 
 mentioned under Surgery of Special Regions. 
 
 WOUNDS OF JOINTS. 
 
 Wounds of the soft parts overlying a joint but which do not penetrate 
 the joint-cavity are of no greater importance than wounds elsewhere, ex- 
 cept that if there is much loss of substance the result- 
 ^y , ing scar may, by contraction, interfere with the free 
 
 movement of the limb. For instance, if a large piece 
 of skin is lost from the bend of the elbow on the front of the limb, the 
 contraction of the scar may render complete extension of the elbow joint 
 impossible. 
 
 Such wounds should be dressed with the limb in a position which will 
 prevent contraction as far as possible. In the condition named above 
 the elbow should be kept straight, not bent. Such wounds are most rap- 
 idly healed, and the contraction best prevented by the application of skin 
 grafts to the raw surface at once or after a week, when the healing pro- 
 cess is well under way. 
 
 Wounds which penetrate joints are very serious injuries, on account 
 of the danger of acute suppurative inflammation of the joint which fol- 
 lows infection of the joint-cavity. The diawnosis of a 
 Tir J penetrating wound of a joint is easy when the wound 
 
 gapes so that the white glistening cartilages which 
 cover the ends of the bones can be seen. AYhen the interior of the joint 
 is not visible, penetration can be inferred from the escape through the 
 wound, soon after the injury, of a transparent sticky fluid (the synovial 
 fluid), which serves to lubricate the joint surfaces. When in doubt as to 
 Mdiether a wound penetrates a joint or not, it is best to treat the wound 
 as though the joint were opened. 
 
534 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 The entire liml) should be cleaned and disinfected, as described in 
 tlie TfKtirncnt of Woinu/s, and the wound itself should be thoroughly 
 douched wirh boiled water or corrosive-suMiniate Sdlution (1 to 1,000), 
 It is unwise to probe the wound or to intr(.)duce a linger into the joint. 
 Foreign bodies should be removed. A large antise]>tic dressing should 
 be applied antl the limb immobilized on a splint. If infection has already 
 occurred, the synovial Jluid will be mixed with jnis and the joint will be 
 painful. The treatment is then the treatment of acute purulent inliam- 
 uiation of joints, as already given. 
 
 CHAPTER YI. 
 TUMOURS. 
 
 The Latin word tumo7\ a swelling, has received in medical language 
 
 a special meaning. A tumour may be defined as '' an increase in volume 
 
 through a growth of new tissue, which fulfils no useful 
 
 purpose in the organism," and whicli often departs in 
 
 some degree from the normal type of tissue in which it occurs. All the 
 
 inflammatory swellings, whether acute or chronic, are excluded from what 
 
 we call tumours. 
 
 Tumours may be divided into a number of groups, according to the 
 
 character of the tissue of which they are composed. Thus many tumours 
 
 consist chiefly of tissue wliich is derived from and re- 
 Classification. , , , ^ ^ ^ • ^ 
 
 sembles more or less closely what is known as connect- 
 ive tissue — the kind of tissue which forms the framework of the entire 
 body. To this group belong the tumours which are composed of fibrous 
 tissue, of bone, cartilage, fatty tissue, of blood and lymph vessels, and 
 lastly the tumours which have received the name of fleshy tumours or 
 sarcomata. Another group includes those tumours which are made up of 
 muscle tissue ; a third, those made up of nerve tissue ; a fourth, those 
 made up largely of cells which resemble or are derived from the cells of 
 the skin and mucous membrane and the cells which line the interior of 
 glands like the breast and the salivary glands. To this group belong the 
 different forms of cancer. Still another group of tumours are composed 
 of various types of tissue quite irregularly distributed. Such tumours are 
 called mixed tumours. In them are sometimes found bones, hair, teeth, 
 portions of skin, brain substance, fat, and other tissues. 
 
 To account for the occurrence of tumours is not always easy. Certain 
 circumstances seem to favour their growth. Thus cancer occurs more 
 commonly in advanced life. The sarcomata sometimes follow an injury. 
 
BENIGN AND MALIGNANT TUMOURS. ^'4r, 
 
 Cancers occur in Bituutions wlicrc the tissncs arc exposed to prolonged 
 mechanical or cliemical irritation — on tlie lower lip and tongue of exces- 
 sive smokers, for instance. An attractive tlieory, 
 •which explains the occurrence of many tumours, is that 
 durin:^ the earliest development of the body minute portions of tissue 
 have been displaced from the situations in which they belong. That later 
 in life these displaced tissue cells may begin to grow and multiply, form- 
 ing a tumour which in this case does not resemble the kind of tissue in 
 which it originated. There remain, however, a large number of tumours 
 for the occurrence of which no cause can be assigned. 
 
 Ttimours all have one characteristiG in connrnon. The new g^rjiMh of 
 tissue, once started, shows no tendency to limit itself, hut keeps on grovj- 
 ing indefinitely. The growth may be very slow ; certain kinds of tu- 
 mours may exist for many years without attaining a great size, while 
 others spread with great rapidity. 
 
 The eifects of tumours on the organism vary greatly in importance. 
 
 There are many tumours which are inconvenient simply from their size 
 
 and weight or from the deformity which they produce. 
 
 " But the same tumour which upon the shoulder or back 
 
 might merely cause trifling inconvenience, would, were it growing within 
 
 the cavity of the skull, be productive of the most serious consequences. 
 
 Certain peculiarities in the mode of growth of tumours of different 
 
 kinds are important. Many tumours are composed of cells which do not 
 
 depart in any way, either in size, shape, or manner of 
 Benign Tumours. ^' j- ' ^^ i x- x xi i i tii 
 
 arrangement, from the normal tissues 01 tiie body, iliey 
 
 grow, as a rule, quite slowly, separating the tissues around them mechanic- 
 ally as they increase in size. The line of separation between the tumour 
 and the surrounding tissues remains sharply marked. They are often 
 surrounded by a distinct capsule of connective tissue, and can sometimes 
 be shelled out of this inclosing envelope like an orange out of its rind. 
 When removed by operation they show no tendency to return. They are 
 classed among the innocent or benign tumours. 
 
 Very different in their mode of growth from these are the so-called 
 
 malignant tumours. Starting in tissue which may or may not resemble 
 
 the tissue of which the tumour is composed, they are 
 
 "^ " / characterized by rapid e-rowth. The cells of which the 
 
 Jumours. j r » 
 
 tumour is composed may resemble more or less closely 
 the normal tissue cells, or the cells may be imperfectly developed like cer- 
 tain cells which are found in the embryo, or many of the cells may be of 
 an unusual or bizarre form. The relation of the cells to the connective- 
 tissue framework of the tumour is often peculiar, and sometimes charac- 
 teristic. The growth of the tumour is accomplished at the expense of the 
 surrounding tissues. The tumour cells multiply rapidly and penetrate 
 
536 SUEGICAL INJURIES AND SURGICAL DISEASES. 
 
 into the substance of tlie normal structures, displacing the healthy tissue 
 cells and causing their destruction. This iniiltration, as it is called, takes 
 place in all directions, and invades any and every structure without regard 
 to its character. Skin, fat, muscle, blood-vessels, nerves, bones, are in- 
 vaded, and the healthy elements of the body arc thus replaced by tumour 
 tissue. The blood sujiply of the part is often greatly increased by this 
 unusual call for nutriment, but often the enlargement of the blood-vessels 
 does not keep pace with the rapid growth, so that while the tumour is 
 advancing in one direction its older jiortions are degenerating and under- 
 going necrosis for want of nutriment. In this way death of the skin 
 overlying the tumour may occur, and nlceration. Unless carefully pro- 
 tected from infection, putrefaction of the raw surface may result, or sup- 
 puration and a low grade of septica?mia. 
 
 The sjtread of the disease is, however, not confined to the immediate 
 vicinity of the tumour. The lymphatic channels are invaded and tumour 
 cells are carried by the lymph current to the neighbonring lymphatic 
 glands, in which secondary tumours having all the characteristics of the 
 original growth are formed. The cancers and the sarcomata comprise 
 the greatest number of malignant new growths. The former spread to 
 distant parts chiefly through the lymphatics, the latter chiefly through the 
 veins. As the result of ulceration the walls of the blood-vessels may be 
 destroyed, and serious or fatal bleeding may take place. 
 
 The formation of secondary tumours is not confined to the regions in 
 the immediate neighbourhood of the primary growth. They may appear 
 in distant parts and in large numbers. 
 
 In all cases when inalignant tumours are removed a strong tendency 
 to return manifests itself, and the recurrence may take place at once, from 
 
 portions of the tumour which are left behind, or later, 
 Prognosis. „ , • ,i • ,^ , i 
 
 alter months or years, m the scar, m the nearest lym- 
 phatic glands, or in the internal organs. This tendency to recurrence va- 
 ries greatly. Some of the cancers and sarcomata are comparatively benign, 
 while other forms grow with great rapidity and involve distant regions at 
 a very early period. The inevitable result of a malignant tumour which 
 is not removed by operation is the destruction of the life of the individual. 
 Death may occur after months or years, and may be the result of a variety 
 of causes. The increaso in size of the tumour may, by pressure, interfere 
 seriously wirli the functions of vital organs. For instance, a tumour 
 within the skull may interfere by pressure with vital portions of the 
 brain and produce death. A tumour in the stomach, situated at either 
 orifice of the organ, may, by narrowing the inlet or outlet, cause death by 
 starvation. A tumour of the lung or kidney may completely destroy the 
 functional activity of the orgaa by i*eplacement of the normal tissues by 
 tumour tissue. Yery often death from a malignant tumour takes place 
 
ADVANTAGES OF EARLY OPERATION. 537 
 
 from a variety of causes operating at tlie same time. Tlx-rc may exist a 
 large ulcerated suppurating area on the surface of tlie tiunour thirough 
 which the patient continually absorbs bacterial poison. Bleeding from 
 the raw surface takes place and reduces the patient's strengtli. The pain 
 and sleeplessness which are often present from pressui-e on the nerve 
 trunks add a further depressing element. The secondary tumours which 
 may exist elsewhere in the body produce their own destructive results. 
 The patient thus steadily loses ground and becomes gradually weaker until 
 death from exhaustion takes place. 
 
 A special description of the different varieties of new growth, witli 
 their localization, mode of growth, and physical characters, would require 
 a separate volume, and could hardly prove of much prac- 
 tical value in a work intended for popular reading ; but 
 certain facts in regard to the treatment of tumours may be of interest. A 
 very important fact of a practical nature may first be stated — namely, that 
 a lump or enlargement appearing anywhere in or upon the surface of the 
 hody is to he regarded with suspicion^ and should always be submitted to 
 a surgeon for examination at the earliest possible moment, and for this 
 reason : While many tumours begin as innocent or benign growths and so 
 remain, a certain proportion may and do after a time change in character 
 and become malignant. Further, the dangers from the removal of a small 
 tumour may amount to nothing, whereas at a later period the mere opera- 
 tion may be difficult and dangerous. The chances of complete removal 
 and cure of a malignant tumour are comparatively good during an early 
 stage of its development. In a certain proportion of cases the tumour 
 does not return, and this proportion is far greater when the operation is 
 done early, when the tumour is small. When the growth has formed 
 attachments to the surrounding parts and has extensively invaded the 
 lymphatic glands, or when secondary tumours have been formed through 
 the entrance of tumour tissue into the circulating blood, cure is not to be 
 expected. 
 
 The quickest, least painful, least dangerous, and surest means of eradi- 
 cating a new growth is, as a rule to which there are few exceptions, to cut 
 it out with a knife. Other means, such as caustics, appear less dreadful 
 to the patient, but they are for the most part tedious, painful, and uncer- 
 tain in their results. To no condition do these remarks apply with more 
 force than to the new growths which so commonly occur in the female 
 breast. As a rule, they should be removed as soon as a surgeon can say 
 that a tumour is present. If done at a very early period the resulting de- 
 formity will be slight, except in cases where the tumour is evidently of a 
 malignant character. In cases where it is evident at the time of the opera- 
 tion that a cancerous tumour of the breast exists, the entire breast, the 
 large muscle on the front of the chest, and the contents of the armpit as 
 
538 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 liigli up as the collar bono (iliould be removed in every case. Tliis exten- 
 sive operation, Mliieli certainly soniuls very formidable, is not attended bj' 
 great danirer, the movements of the aim are i>reserved to a surnrisins: de- 
 gree, and the percentage of actii;il en res is vei-y much greater than under 
 auY other form of treatment. 
 
 Even if the operation does nut result in cuih\ the renu>val of malig- 
 nant new growths. M'hen the condition admits of the eradication of all the 
 evidently diseased tissues, is of advantage. The jiatient is relieved at once 
 from the presence of the tumour uiidh which his or her mind is centred 
 to the exclusion of everything else. The wound usually heals completely 
 Avithin a fortnight. The sympto)ns ju-oduced by the mechanical pressure 
 of the tumour, such as neuralgic pains, are stopped at once. The mental 
 condition of the patient is usually hopeful until the recurrence takes place. 
 Life is usually considerably prolonged, and the patient enjoys a period of 
 comfort. The recurrence may not take place for several years. The re- 
 current ffrowth is sometimes of a less malignant character than the ori<2;i- 
 nal tumour and its removal may result in cure. The recurrence may take 
 place in internal organs, and death may thereby be rendered comparatively 
 painless and free from the antecedent suffering which an extensive malig- 
 nant growth on the surface of the body usually entails. 
 
 . CHAPTER Vn. 
 
 SURGICAL INJURIES AND SURGICAL DISEASES OF SPECIAL 
 
 REGIONS.— INJURIES AND DISEASES OF THE 
 
 HEAD AND FACE. 
 
 INJURIES OF THE SCALP.— CONTUSIONS. 
 
 The skin of the scalp is closely adherent to a dense layer of tissue 
 beneath it. AVhen laceration of blood-vessels occurs just beneath the skin 
 the close connection between it and the deeper layer 
 ' prevents the effused blood from spreading far, and a 
 
 sharply marked, tense swelling is formed at the seat of the injury, pro- 
 ducing bumps, as they are called, familiar to every one. Between the 
 dense deeper layer of tissue and the periosteum of the skull, on the con- 
 trary, the connections are loose, and haemorrhage in this situation fre- 
 quently spreads over a wide area. These injuries, when not complicated 
 by an open wound or an injury to the skull or its contents, are not serious. 
 The bleeding beneath tlie skin usually ceases speedily, or it can be stopped 
 readily by cold and pressure, and the effused blood is usually absorbed. 
 
 One practical point in connection with the deeper extravasations may 
 
CONTUSIONS AND INFECTED WOUNDS. 5;j!) 
 
 be mentioned. After some hours or days tlie outer Ijordcr of tlio clot 
 may be felt as a hard rim, over which the examining finder slips and 
 seems to pass, on pressure, more deeply towards the centre of the swell- 
 ing, giving rise to the impression that the skull is actually depressed at 
 this point. The hard rim of the clot is mistaken for the skull itself. By 
 rubbing and pressing for a moment the hard rim can be made to disappear, 
 and no apparent depression of the skull remains. 
 
 When bleeding takes place between the skull and its periosteum, new 
 bone is sometimes produced, which leads to temporary or permanent 
 thickening of the skull at this point. This condition may be followed by 
 nervous symptoms, occasionally by epilepsy. 
 
 If the swelling increases in size rapidly, an ice bag or a firm pad anr] 
 bandage may be used to stop it. After twenty-four hours the application 
 of cold may be stopped, and a firm pad and bandage may 
 be worn until the swelling has disappeared. Massage 
 over the effused blood clot, practised twice daily for ten or fifteen min- 
 utes, hastens absorption. The smallest wound of the skin should be 
 treated antiseptically. 
 
 Wounds of the scalp bleed profusely. The hremorrhage may be 
 stopped temporarily by finger pressure, and permanently by a tampon or 
 a pad of antiseptic gauze. The scalp should always be shaved for an inch 
 or two around the wound, and the most careful antiseptic precautions 
 should be observed. When large portions of the scalp are stripped away, 
 as sometimes happens in machinery and other accidents, the wound should 
 be carefully cleaned and the torn portions replaced. Wounds of the 
 scalp heal very rapidly unless infected. 
 
 INFECTED WOUNDS OF THE SCALP. 
 
 An infected wound of the scalp should always be regarded as a very 
 serious condition. Infection may be recognised by pain and a swollen, 
 boggy condition of the skin around the wound. There 
 may be a discharge of pus from the wound or none. 
 The danger arises from burrowing of pus beneath the scalp, which takes 
 place insidiously and rapidly, and from the possible spread of the infec- 
 tion to the brain and its membranes through veins in the scalp which 
 communicate with the interior of the skull, or through the skull itself. 
 
 An infected wound of the scalp needs prompt and energetic treatment. 
 The limits of the inflamed cavity should be freely exposed from one end 
 „, , , to the other by a cut made as nearly as possible from 
 
 before backward, for in this direction fewer blood- 
 vessels will be divided. The Avound should be thoroughly disinfected 
 with sublimate solution (1 to 1,000), lightly packed with iodoform gauze 
 or with sublimated gauze over which a mass of gauze wet with three-per- 
 
540 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 cent, iflithyol solution, or -with the solution of sugar of lead and alum, 
 should be placed and held in position with a bandage. The dressing 
 should lie changed daily until it is certain that the inllannuation is not 
 advancing. 
 
 ■FRACTURES OP THE SKULL. 
 
 Fractures of the skull are serious, not so much on account of the injury 
 
 to the bones themselves, but because the contents of the skull, the brain 
 
 and its membranes, are apt to be directly or indirectly 
 Of the Yerlex and • i i nii .< . i. i i •" xi 
 
 r. /» involved, llie fracture may take place in the convex. 
 
 Base; Causes. _ ' . . 
 
 dome-like portion of the skull which lies above and be- 
 hind the eyes and the ears, when it is known as ?^ fracture of the vertex^ 
 or the floor of the skull which supports the lower surface of the brain 
 may be the seat of fracture, in which case it is spoken of as 2i fracture of 
 the base. Fractures of the vertex of the skull are commonly the result of 
 direct violence, blows or falls upon the head being common causes. Frac- 
 tures of the base of the skull are more often the result of indirect violence. 
 For example, a fall upon the buttocks may cause a fracture of the base 
 of the skull, the force being transmitted through the spinal column, or a 
 fall upon the vertex may produce a similar fracture. Fractures of the 
 vertex, when due to direct violence, may be attended by depression of the 
 fragments so that pieces of bone are driven into or pressed upon the 
 brain. The inner surface of the skull is harder and more brittle than the 
 outer surface, and the splintering of the inner table, as it is called, may 
 be more extensive than the injury to the outer table would indicate. 
 There may or may not be a wound in the skin communicating with the 
 fracture. 
 
 The signs and symptoms of fracture of the skull arc partly those of 
 injury to the bones and partly those produced by the injury to the brain 
 and its membranes. A simple fissure of the skull with- 
 out any wound of the skin gives no distinctive symp- 
 toms. Depression can often be felt through the scalp as a distinct con- 
 cavity on tlie surface of the skull, or an edge of bone can sometimes be 
 felt bordering the depression. In the case of compound fractures of the 
 vertex the injury may be quite apparent to the eye or finger, or when the 
 brain is torn, brain substance may escape through the wound. Fractures 
 of the base of the skull are often attended by the effusion of blood into 
 the eyelids and conjunctivae when the fracture is situated in the anterior 
 part of the skull, or by the escape of blood and watery fluid (the cerebro- 
 spinal fluid) from the external ear, when the fracture is situated farther 
 back. The symptoms of injury to the brain and its membranes may be 
 divided into three categories : co)icussfO)i, compression^ and laceration of 
 the hraln. These conditions, however, often coexist, and it may be im- 
 
CONCUSSION AND COMPRESSION OF THE BRAIN. 541 
 
 possible to determine at once wlilch of tlie tlirce is producing certain of 
 the symptoms from wlii(;]i tlic patient sullers. 
 
 Concussion of tlie brain is produced by mechanical violence such that 
 
 the brain suffers a severe shock without undergoing any changes in its 
 
 substance appreciable to the naked eye. The symptoms 
 
 Concussion of the ^£ concussion of the brain appear at once after the acci- 
 
 Brain; Cause ^ , _ii ^ , ,• ^ 
 
 and Symptoms. ^^^nt. Tliey are complete or partial unconsciousness, 
 
 momentary or prolonged, followed by headache, vomit- 
 ing, and giddiness. The temperature of the body may be increased or 
 diminished. The pulse is usually weak and slow. The breathing is often 
 superficial at first, but in some cases deep and snoring. The sensibility of 
 the skin is diminished. The pupils of the eyes may be dilated or con- 
 tracted. They contract on exposure to a bright light. The period of 
 unconsciousness or stupor may last only a few seconds or be prolonged 
 for days. A period of excitement follows, during which the patient is 
 irritable and complains of headache. The face is flushed and the pulse 
 rapid and forcible. The shorter the period of unconsciousness the better 
 the chances of recovery. Concussion of the brain is sometimes followed 
 by a condition of nervous prostration resembling nervous prostration 
 from other causes. 
 
 The early treatment is that of shock, except that alcohol is not admin- 
 istered. During the stage of excitement an ice bas^ on 
 
 Treatment. ... . 
 
 the head and the administration of bromides, phenacetine, 
 
 and other quieting drugs are useful. In every case of concussion of the 
 brain fracture of the skull should be looked for. 
 
 Compression of the brain may be caused by a depressed fracture of 
 the skull ; by the presence of a foreign body in the cranial cavity — a bul- 
 let, for example ; by the presence of extravasated blood 
 Compression of the ^i^\^{^ the skull, caused by the rupture of blood-vessels 
 Brain ; Cause. i , • /. , i • i t i , -i 
 
 Symptoms and resulting Ironi external violence or disease ; and by the 
 
 Prognosis. rapid accumulation of pus or other fluid within the skull, 
 
 due to infection with pus microbes through a wound 
 or through the blood. The condition is often complicated by the symp- 
 toms of concussion and laceration of the brain, and sometimes acute alco- 
 holism, disease of the kidneys, apoplexy, and opium poisoning must be 
 excluded before a diagnosis can be reached. When due to a depressed 
 fracture of the skull or to the entrance of a foreign body into the brain 
 the symptoms usually appear at once. When due to the rupture of a 
 blood-vessel the symptoms may come on slowly, after several hours, when 
 the mass of effused blood has attained a considerable size. Under these 
 circumstances the symptoms of compression will be preceded by headache 
 and a feeling of fulness in the head. The face is flushed. The pulse is 
 rapid. As the pressure within the skull increases, nausea and vomiting 
 
:a-2 surgical injueies and surgical diseases. 
 
 inav occur. The individual gruduallv falls into a condition of stupor, and 
 tinally of complete unconsciousness. There may now develop paralysis 
 of motion on one or both sides of the body, complete or partial. If one 
 side of the brain is affected, the paralysis will be on the opposite side of 
 the body from the injury to the brain, 'ilie j)U|)ils oi the eyes are often 
 contracted or dilated, or of unequal size. They do not contract when ex- 
 posed to light. There may be squinting. The pulse becomes slow and 
 full, the breathing deep and snoring. There is often a rise of tempera- 
 ture. From this condition of coma the patient can not be aruusod by any 
 amount of shouting or shaking. The coma may be gradually recovered 
 from as the brain accustoms itself to the increased pressure, or death may 
 occur after hours or days from paralysis of respiration, or later from in- 
 flammation of the brain or its membranes. 
 
 Laceration of the brain as the result of mechanical violence may be 
 attended by no sym]-»toms unless special parts of the brain are injured, in 
 M-liich case there may be a great variety of paralyses, 
 Laceration of f he depending upon the portions of the brain which are in- 
 SuniDfom^ and 3"^'^^' ^^^^^^ ^^ ^^^^ ^^ speech, blindness, inability to con- 
 Prognosis. ti'ol the action of the muscles, so that combined move- 
 
 ments which serve some definite and useful purpose — 
 such as walking — ai-e no longer possible (ataxia, or loss of the power of 
 muscular co-ordination), paralysis of respiration and death, paralysis of 
 one or more limbs or of the face. Fractures of the skull and wounds of 
 the brain and its membranes are especially liable to infection with pus 
 microbes. "When such infection takes place the inflammatoi'y product is 
 apt to cause such serious disturbances within the skull that death, preceded 
 by headache, delirium, convulsions, and coma, is a frequent consequence. 
 The treatment of compression of the brain from depressed bone or a 
 blood-clot on the surface of the brain is to elevate the depressed bone and 
 remove loose splinters with suitable instruments. To 
 remove blood-clots and stop any bleeding which may 
 still be going on within the skull, a hole is made through the skull with a 
 chisel and mallet, or with a boring instrument, and the blood-clots are 
 scooped out and the bleeding point tied if necessary. When no external 
 wound or fracture of the skull exists, the location of the clot must be de- 
 termined by the symptoms. This can be done only when the paralysis is 
 such that a definite region of the brain is known to be involved. The 
 treatment of inflammatory complications is to let out the pus when that is 
 possil)le. 
 
 The diagnosis of opium poisoning can generally be made fi-om the 
 apjiearance of the pupils of the eyes, which are contracted to pin-point 
 size, and from the very slow breathing. There is no paralysis, and the 
 patient can often be aroused momentarily. In coma from disease of the 
 
WOUNDS OF THE FACE. 543 
 
 kidneys the legs are often swollen, and the skin of tlie faee may Lave a 
 
 waxy look. In apoplexy there is complete unconsciousness, paralysis of 
 
 one or both sides of the hody, and snoring breathing. 
 
 ijjcr la rjj^g signs of fracture of the skull are absent. In acute 
 
 Diagno>iis oj Coma. .... 
 
 alcoholic intoxication the patient smells of alcohol. 
 
 There is no paralysis. The pu])ils of the eyes are often contracted. A 
 
 smart blow on the cheek will usually arouse the patient momentarily, 
 
 wlien the pupils of the eyes will dilate. In case of doubt the patient 
 
 should be treated as though he had a fracture of the skull or some serious 
 
 disease, and he should be sent to a hospital, not to a police station-house. 
 
 THE FACE. 
 
 Owang to the extremely rich blood supply of the face, injuries of this 
 
 region heal with great rapidity. A clean-cut wound of the face, the edges 
 
 of which are properly brought together, is usually com- 
 Woxmds of the Face. ^ , ^ ^ ^ 3 • 1 J^^ \ ^^ • 1 
 
 pletely healed m a week, so that the scar is scarcely 
 
 visible except on close inspection. Wounds of the face bleed very freely, 
 and dangerous hgemorrhage may take place if one of the larger arteries is 
 cut. The best temporary measure to stop the bleeding is finger pressure 
 applied to the bleeding point. In some cases of wounds of the cheeks 
 and lips the whole thickness of the part may be compressed between the 
 fingers and thumb, a finger or two being introduced into the mouth. 
 Arterial bleeding from one of the larger arteries of the face usually re- 
 quires a ligature or deep stitches to stop it permanently, although a tam- 
 pon may be successful in some situations. Careful stitching of wounds 
 of the face is necessary to avoid scarring, therefore a surgeon should be 
 seen if possible. This is particularly true of wounds of the eyelids, nose, 
 and lips. Infected wounds of the face require, as elsewhere, thorough 
 disinfection and a free opening for the escape of pus. Contusions of the 
 eyelids are a common accident and lead to the condition known as a black 
 
 eye. The eyeball itself is seldom injured by blunt force, 
 
 owing to the protection which is afforded by the bony 
 margin of the orbit. During the first few hours after the receipt of the 
 injury cold applications may be made to the part. Later, gentle massage 
 will remove the discoloration in a few days. A poultice applied over the 
 eye leads to great sw^elling and disfigurement, and should never be ap- 
 plied. 
 
 Boils and carbuncles of the face should be opened early and dressed 
 with a wet antiseptic dressing. A special form of carbuncle occurs on 
 
 the face, which is attended by a rapid spread of the in- 
 atid Anthrav ' Aammation through the veins to the interior of the 
 
 skull, and death from inflammation of the membranes 
 of the brain. Early incision and disinfection offer the only hope of sav- 
 
544 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 ing life. Anthrax, or malignant pustule of the face, occurs among per- 
 sons vrho handle liides and wool. Occasionally antlirax results from the 
 bites of Hies which have fed upon the body of an animal dead of anthrax. 
 The diseased hides carry the anthrax bacillus, which, when brought by 
 dirty fingers iii contact with a minute wound on the face, causes, in three 
 or four days, the formation of a painful inflamed s]>(>t. 'riic centre of 
 the spot is occupied l^y a blister containing bloody fluid. In a few hours 
 the blister dries to a black crust. Around this centre the swelling and 
 redness spread rapidly, and after a variable period, usually after a few 
 days, the bacilli enter the blood curi'ent and multiply everywhere in the 
 body, and the individual dies in eight or ten days from the beginning of 
 the disease, from high fever, ])rostratioii. delii-iuni, diarrluen, and collapse. 
 The best treatment is to cut out the pustule at an early period and disin- 
 fect the wound with corrosive-sublimate solution (I to 500), or with a 
 solution of chloride of zinc (forty grains to the ounce of water). If done 
 before constitutional infection has taken place recovery is the rule. 
 Erysipelas and lupus of the face have been spoken of elsewhere. 
 A great variety of tumours occur upon the face. The most important 
 is cancer. Prolonged local irritation seems to have some effect in its 
 
 production — for example, can-cer of the lip in smokers. 
 
 The disease is much more common in men than in 
 women, and rarely occurs before the fortieth year of life. Scars, warts, 
 horns, wens, and other innocent growths upon the face often form the 
 starting point of cancer. If an ulcer forms upon the surface of such a 
 growth, which scabs over but does not heal, if the base of the ulcer be- 
 comes hard and the hardness spreads in width and depth, or if a cauli- 
 flower-like growth springs up from the base or edges of the ulcer, the 
 diagnosis of cancer is almost certain, and the sooner it is removed by 
 operation the better the prospect of cure. 
 
 Harelip is a deformity of the upper lip, due t(^ a failure of union be- 
 tween the j)arts in the embr}"©. The cleft is situated on one or both sides 
 
 of the median line. It is sometimes combined with 
 
 cleft palate. Babies with harelip can sometimes nurse 
 at the breast. If cleft palate exists at the same time they can not, and 
 must be fed from a l>ottle with a large, long rubber teat. The time ordi- 
 narily chosen to operate for the relief of the deformity is between the 
 fifth vveek and the sixth month of life. Earlier operations are attended 
 by a higher mortality. 
 
 THE NOSE. 
 
 For fractures of the nose, see JFracUtrcs. 
 
 Foreign bodies usually gain access to the nasal cavities from the front. 
 They are sometimes intentionally introduced by children and insane per- 
 
FOREIGN BODIES IN THE NOSE AND IN THE EYE. 545 
 
 sons. Among such foreign bodies may be mentioned peas, beans, pins, 
 
 pebbles, beads, and shoe buttons. Occasionally vomited matters gain 
 
 access to the nose from 1)e]iirid. Intestinal round worms 
 Foreiqn Bodien. , • n i i .1 • i.i • ri-"! 
 
 have occasionally readied tlie nose m tins way. iJie 
 
 symptoms produced are pain, and, if the foreign body is not removed, 
 inflammation and sometimes disease of the bones. The foreign bo(]y may 
 form the nucleus of a stone composed of the salts of lime. 
 
 The foreign body, wlien visible, may be seized with a forceps and re- 
 moved. A bent loop of wire may be passed beyond it and withdrawn, 
 carrying the foreign body in front of it. If a surgeon 
 can be reached it is better not to interfere, lest unskilled 
 efforts force the foreign body still further into the nose. 
 
 Bleeding from the nose may occur as the result of wounds or in the 
 
 course of diseases, such as tumours within the nose, 
 
 erysipelas, typhoid fever, etc. Among " bleeders " 
 
 serious nose-bleed is not uncommon. The blood usually comes from 
 
 the front part of the nasal cavity. 
 
 In slight cases a recumbent position, face downward, and firm closure 
 of the nostrils with the fingers for a few minutes, will usually suffice. 
 The patient should avoid blowing the nose for some 
 time after the bleeding has ceased. If this simple 
 measure does not suffice, snuffing up of ice water or of water containing 
 a little alum may be tried. In severer cases it may be necessary to plug 
 the nose from in front through the nostrils, or to plug the outlet of the 
 nose into the throat behind as well. This latter method is always effect- 
 ive, but it is difficult to accomplish, and should only be attempted by a 
 
 surgeon. 
 
 THE EYE. 
 
 A foreign body, such as a cinder or a minute bit of iron, can easily be 
 wiped away from the fold of the lower lid with the end of a match cov- 
 ered with a little cotton. "When the foreign body lies 
 
 ^^^^fJ^ w ^^^ beneath the upper lid its removal may be a little more 
 difficult. The patient sits facing a bright light and 
 rests his head against the operator's chest, who stands behind him. The 
 operator places the tip of the forefinger of his left hand against the upper 
 eyelid, and with the forefinger and thumb of his right hand he grasps the 
 edge of the upper lid lightly but firmly, pulls it downward, then turns it 
 upward and bach ward over the tip of the left forefinger, thus turning the 
 lid inside out. If properly done, the lid will remain in this position. The 
 foreign body may then be sought for and wiped away with a match cov- 
 ered with cotton. AVhen bits of iron or other bodies are embedded in 
 the transparent front of the eye or cornea they must be removed with a 
 needle. The operation is a delicate one, and should not be attempted 
 37 
 
54:6 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 except wliere a siiriieon can not be reaelied. Cocaine solution — four per 
 cent. — dropped in the eye renders the operation painless. 
 
 Wouiuls lit' the evehall anil wounds eonii)licated by 
 
 Woinidsnt the ^j^^^ presence of a foreign body embedded in the ball of 
 EuehalL and . , ' .... ' , , . , , 
 
 , . ,.^^^ the eye are serious injuries, and always re(]uire the care 
 
 of an eye specialist. If improperly treated, the sight 
 
 of both eyes may be lost. 
 
 Intlaniniations of the eyes should never be treated at home, but always 
 
 by a competent eye surgeon. 
 
 THE EAR. 
 
 Ill addition to such foreign bodies as gain access to the nose, insects 
 
 oceasionallv find their way into the external ear. Flies may lay their 
 
 effffs in the canal, and these hatch out into maggots. 
 
 Foreign Bodies m rpj^^ extraction of foreign bodies from the ear demands 
 
 the External , i t t ^ ^ n .^ ^ ^ y 
 
 Auditoni Canal S^'^^^ care lest the delicate membrane of tJie drundiead 
 be injured. Large masses of wax sometimes collect in 
 the ear and give rise to ringing sounds and deafness. These, as well as 
 foreign bodies, can often be removed by washing out the canal with warm 
 water and salt. A large syringe should be used for the purpose, and 
 the ear should be pulled upward and backward and the stream of water 
 directed a little upward or downward, not directly into the canal. The 
 syringing should be done gently, and several pints of water may have to 
 be injected before the wax or foreign body comes away. The instru- 
 nientul removal of foreign bodies from the ear must be left to a surgeon. 
 Maggots and live insects are best removed by pouring warmed olive oil 
 into the ear. The dead insects may then be washed out with warm water 
 and a syringe. 
 
 Boils often occur in the external auditory canal. The affection is 
 
 very painful. Sometimes the recognition of the boil is 
 
 Boils in the obscured bv swelling. The treatment is early incision. 
 
 External Auditory . o ^ ^ ^^ • ' -, ^ • ^^ mi 
 
 Q^iyifil After tlie boil is opened the pain usually ceases, ihe 
 
 canal may then be cleaned by very gentle syringing 
 with a warm solution of boric acid in water (1 to 50). 
 
 Rupture of the drumhead of the ear may be the result of direct vio- 
 lence from the entrance of foreign bodies into the canal, of indirect vio- 
 lence from blows upon the head, or of falls. A most 
 
 up lire Of e fi-equent cause is a blow or a so-called box upon the ear. 
 
 Drumhead. i i i i i r 
 
 Tiie symptoms of rupture of the drumhead from exter- 
 nal violence are pain, partial deafness, and sometimes the symptoms of 
 concussion of the brain. The treatment is to keep the patient (]uiet and 
 to plug the canal lightly with antiseptic cotton. Injections should not 
 be used. The rupture usually heals readily if uncomplicated. 
 
INFLAMMATION OF THE MIDDLE EAR. 547 
 
 Acute cabirrliaJ iiiflaininiLfcion of the middle ear, of the uir cliarnber 
 
 wliich lies belli iid the drumliead, is a frequent disease among children. 
 
 It occurs as a complication of catarrhal iuilammations 
 
 Acute Catarrhal ^^ ^.j^^ ^j^^.^^j. ^^^^ ^^^^^ ^^^^-j j^^ ^j^^ coui'se of the eruptive 
 
 JnJlammatKm of i i • 1 mi 
 
 the Iliddle A'ar. ftjvers and typhoid, ihe symptoms are pain in the ear, 
 
 deafness, giddiness, and buzzing in the ear. Sometimes 
 there is high fever, with delirium and tenderness over the mastoid process 
 of the temporal bone, the prominent bony point behind the ear. The 
 treatment consists of puncture of the drumhead in severe cases to let out 
 the retained secretion, and of inflation of the middle ear through the 
 Eustachian tube. The disease often becomes chronic, and is a frequent 
 cause of deafness. 
 
 Acute suppurative inflammation of the middle ear is the result of in- 
 fection with pus microbes through wounds, or in the course of fe})rile 
 
 diseases. The symptoms are those of catarrhal inflam- 
 Acute Suppurative i.* 1 i. " r -^^ ^i 
 
 r J, \. ^ mation, but much more severe. Death may occur in 
 inflammation of , . •' 
 
 the Middle Ear. soiiie cases from a spread of the inflammation to the 
 membranes of the brain. The treatment consists of 
 puncture of the drumhead and antiseptic irrigations of the ear. The 
 disease often becomes chronic, and is then a constant menace to the life 
 of the individual from the danger of the spread of the inflammation to 
 the membranes of the brain. 
 
 THE TONGUE, MOUTH, AND THROAT. 
 
 "Wounds of the tongue occur from catching the organ between the 
 teeth during epileptic attacks, and from falls or blows beneath the chin ; 
 also from sharp foreign bodies contained in the food, 
 rj.^^ ' and from gunshot wounds. Other accidental wounds 
 
 of the tongue are rare. Wounds of the tongue heal 
 readily. They should be sewed up when not very small. The bleeding 
 usually ceases as soon as the stitches are put in. The patient should use 
 a mouth M^ash of listerine, boric acid (1 to 50), or permanganate of potas- 
 sium (1 to 1,000). 
 
 Bees and wasps may be introduced into the mouth on fruit, and sting 
 
 the tongue, causing pain and considerable swelling. A weak solution of 
 
 ammonia water used as a mouth wash is the best treat- 
 
 Acute Inflam- ment. If the swelling of the tongue is extreme, scarili- 
 
 mation and ,• x J.^ £ x ^i j. •i.\ ^ i •<■ 
 
 „ , , cation of the suriace of the tongue with a sharp knife 
 
 Itwercular ^ ^ 
 
 Ulceratio7i. will relieve it. 
 
 Acute inflammation of the tongue occurs as the re- 
 sult of infected wounds of the organ, from extension of an acute inflam- 
 mation in the neighbourhood, and in the course of acute febrile diseases. 
 The tongue swells rapidly, and may reach double its normal size. Treat- 
 
548 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 ment by antiseptic mouth washes is usually successful. If an abscess 
 forms it must be opened early. 
 
 Tubercular ulceration of the tongue occurs in persons who have con- 
 sumption of the lungs, or as an independent affection. A superficial 
 torpid ulcer forms ujion the upper surface of the tongue, or the disease 
 begins as a hard lump in the sul)stance of the tongue, which breaks down 
 and forms a deep excavated ulcer. The base of the ulcer is usually yel- 
 lowish white. The edges are pinkish red. and often soft and friable. 
 There are frequently small secondary nodules in the neighbourhood. 
 The aifection is very painful. The treatment is excision of the ulcer. 
 The chances of recovery are not good. These patients usually die of 
 tuberculosis of the lungs or intestine. 
 
 The most frequent tumour of the tongue, as well as the most impor- 
 tant, is cancer. The disease occurs late in life — from the fortieth to the 
 sixtieth year. Local irritations, pipe-smoking, a jagged 
 tooth, or a chronic localized inflammation or ulceration 
 of the tongue, form the starting point of the disease. The sides and tip 
 of the tongue are the usual seats of the growth, which forms a hard cir- 
 cumscribed lump or a deep excavated ulcer, the edges of which often 
 sprout up into masses resembling a cockscomb. Ulceration develops 
 sooner or later in nearly every case. The growth is usually rapid, and 
 is attended by distressing symptoms. The secretion of saliva is profuse. 
 There is intense pain radiating to the ear. The 1^'mphatic glands on both 
 sides beneath the jaw are soon involved. The discharge from the ulcer 
 decomposes, and the patient's breath has a horrible odour. The jaw be- 
 comes fixed, so that the mouth can no longer be opened freely. Death 
 occurs in a year or eighteen months from pneumonia, septicsemia, or ex- 
 haustion. 
 
 Any chronic affection of the tongue in an elderly person should re- 
 ceive prompt attention. If operated upon at an early period, cure of 
 cancer of the tongue is obtained in about ten per cent, 
 of the cases. Even if the disease returns, life will be 
 prolonged and rendered much more comfortable. 
 
 One of the most common of the iimocent tumours of the mouth is the 
 so-called ranula (a little frog), a translucent sac containing slimy fluid 
 situated under the tongue in the floor of the mouth. The cyst occui-s 
 from the plugging of the outlets of certain mucous glands which lie in 
 this situation. The disease causes discomfort from its size. The treat- 
 ment is to cut out the wall of the sac with scissors. Mere incision does 
 not cure. 
 
 IcJithyosis or leueoma of the tongue is a chronic inflammatory process, 
 occurring generally in old people. The affected surface of the tongue is 
 converted into a smooth, pearl-grey, shining membrane of variable extent. 
 
TONGUE-TIE, CLEFT PALATE, AND INFLAMMATION. 549 
 
 The disease is sometimes a forerniincr of cancer. ^J'lio treatment coTisists 
 in the avoidance of smoking and clicwin<^ tohu(;co, in antiseptic mouth 
 washes, and in tlie destruction of tlie airectcfi snrfuce witlj tin; actual 
 cautery. 
 
 Wlien the little band which extends from the under sui-facc of the 
 tongue in front to the floor of the mouth is too shoi't and rcaclies too far 
 toward tlie tip of the tongue, it may interfere with the 
 ^ * movements of the tongue in infants and, later on, with 
 
 speech. When this is the case the band may be cut with a scissors close 
 to the floor of the mouth, not close to the tongue. The operation is sel- 
 dom necessary and is often done needlessly. 
 
 The congenital defect in the hard and soft palate which goes by this 
 name gives rise to more or less serious symptoms, according to the size 
 of the opening which exists between the mouth and the 
 nose. The defect in the roof of the mouth (the hard 
 palate) is situated on one or both sides of the median line. The defect in 
 the soft palate is always centi-al. When cleft palate is combined witli 
 harelip it may be very difficult to nourish the infant. Such children can 
 not take the breast. They must be fed from a bottle to which a large, 
 long soft-rubber nipple is attached. Sometimes they must be fed with a 
 spoon. Later on, when the child begins to talk, the voice has a disagree- 
 able nasal quality, or, in some cases, intelligible speech is impossible. 
 
 The deformity may be treated by an operation in which the soft tissues 
 on either side of the roof of the mouth are loosened from the bones and 
 sewed together in the median line. The cleft in the soft palate is treated 
 by paring the edges of the fissure and sewing them together. It is cus- 
 tomary to wait until the child is five or six 3'ears old before operating, a 
 certain degree of intelligence on the part of the patient being necessary 
 to insure success. The defect may also be covered by a hard-rubber or 
 metal plate worn in the roof of the mouth. 
 
 Catarrhal and ulcerative inflammation of the gums and mucous lining 
 of the cheeks may occur as the result of irritation from diseased teeth, 
 from mercurial poisoning, from want of cleanliness of 
 a arria an ^j^^ mouth, and in the course of fevers. In the catarrhal 
 
 Inflammation. form the gums and the mucous membrane of the cheeks 
 are swollen and tender ; there is an increased secretion 
 of mucus. The treatment consists of cleanliness and the use of antiseptic 
 mouth washes, among others a solution of chlorate of potassium (a tea- 
 spoonful to a glass of hot water), peroxide of hydrogen, and potassium- 
 [)ermanganate solution. Painting the gums with tincture of iodine once 
 or twice a day is also of service. 
 
 Aphthce, or cankers in the mouth, and the disease known by the vulgar 
 name of " sprue,'''' are caused by the growth of a vegetable fungus resem- 
 
550 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 Lling the yeast plant on the niueous niembrane of the cheeks, gums, and 
 tongue. Cankers appear as small white spots on the mucous membrane, 
 surrounded bv a narrow inflamed margin. They are quite painful. The 
 spots may be lightly touched with a stick of nitrate of silver. A mouth 
 wash of potassium-chlorate solution, or some other antiseptic mouth wash, 
 should l)e used every few hours. The mouths of teething children who 
 develop sprue should be washed out several times daily with a solution of 
 boric acid (1 to 50). If the child is nursing, the mother's nipples should 
 be washed with wai-m water and Castile soap, and then with the same 
 solution after each nursing. The breasts should be covered with a clean 
 cloth to prevent infection from the clothing. 
 
 The ulcerative form of inflannnation of the gums is common in chronic 
 mercurial poisoning. The treatment is the same as in the catarrhal form. 
 The ulcers may be touched with nitrate of silver or with a solution of 
 chromic acid (two per cent.). 
 
 A severe form of ulcerative inflammation of the cheeks and gums is 
 called noma. It attacks feeble children, sometimes during convalescence 
 from fevers. The disease is a progressive gangrene of the check. It 
 usually begins as a purple or livid spot near the corner of the mouth and 
 rapidly extends, perforating the cheek and often involving the bones of 
 the face. There is apt to be profound constitutional depression, and un- 
 less the diseased tissues are i-enioved early and the wound thoroughly dis- 
 infected — best with the actual cautery — death will take place from septic 
 poisoning in a few days. 
 
 The symptoms are pain in the throat, swelling, and redness of the soft 
 
 palate and tonsil. There is fever and prostration, and 
 
 scessof e sometimes a chill at the beojinning of the disease. As 
 
 Tonsil— Quinsy , „, „ , „ '^ ^ ^ . . . 
 
 Sore Throat. "^^ swelling 01 the tonsil increases there is pain and 
 
 difficulty in swallowing and inability to open the mouth 
 widely. In severe cases breathing may be interfered with. 
 
 The treatment is to open the abscess early by a small cut made from 
 above, downward and inward, in the centre of the swelling. The edge of 
 the knife should not be directed outward. As soon as the pus escapes the 
 patient is relieved. An antiseptic mouth wash should be used subse- 
 quently. 
 
 Enlargement of the tonsils, as the result of chronic inflammation, is 
 common among children, and is often productive of serious symptoms. 
 
 Breathing is interfered with, and the children are unable 
 
 f ,i rr -7 to ffet enouo^h oxvfiren into the luno;s. The development 
 of the lonsils. ^ » ., & cs i 
 
 of the body suffers in consequence. During sleep the 
 month is held open and the children snore. Chronic inflammation of the 
 pharynx is usually present also. The patients are obliged to cough and 
 clear their throats frequently. The accumulation of mucus in the throat 
 
DECAY OF THE TEETH AND ALVEOLAR ABSCESS. 551 
 
 is especially aiiiio_yiiig in the moniinij;, uiif] the ailurtH to get rid of it may 
 lead to vomiting. 
 
 The treatment consists of removal of the tonsils l^y a cutting operation 
 or with the cautery. The treatment of chronic pharyngitis consists in 
 the application of caustics, or of stimulating and soothing applications, 
 according to the necessities of the case. 
 
 Caries, or decay of the teeth, is caused hy the growth of certain mi- 
 crobes in the teeth. The microbes produce acids, which dissolve the 
 
 earthy material which gives the teeth their hardness. 
 Decay of the Teeth. ,i . , . .1 . .1 , . ^^ • 
 
 thus destroying tlie tooth substance. Various causes 
 
 predispose to decay of the teeth — want of cleanliness and care of the 
 
 teeth, heredity, severe general diseases, and pregnancy. 
 
 The symptoms of caries of the teeth are discoloration, the formation 
 of cavities in the teeth, and toothache. Severe toothache usually does not 
 occur until the pulp cavity is opened. Suppurative inflammation of the 
 pulp gives rise to intense pain and is caused by infection with pus mi- 
 crobes. The disease may lead to the formation of an abscess between the 
 root of the tooth and its bony socket, or to inflammation of the jaw itself. 
 
 The treatment of caries of the teeth is to remove the diseased tissue 
 and to fill the cavity with gold, amalgam, or other filling. 
 
 Abscess between the tooth and the jaw, and infiammation of the jaw 
 
 itself, usually necessitates removal of the tooth. The pus accumulates 
 
 between the tooth and the jaw and pushes the tooth 
 Abscess between the ,-, , n •. ^ , ,1' . •, t rr., 
 
 T th dJ partly out 01 its socket, so that it seems longer, ihe 
 
 spontaneous pain is usually severe. It is increased by 
 mechanical pressure. There is often fever. Tlie abscess may perforate 
 between the tooth and the gum or through the gum, or through the skin 
 of the face or neck, or into the antrum of Highmore (a cavity in the upper 
 jaw connected with the nose). Large abscesses in the soft parts may be 
 produced, and occasionally death occurs from septictemia, pj-gemia, or ex- 
 tension of the inflammation to the brain. 
 
 After the pus has been evacuated by removing the tooth, or incision, 
 or both, extreme care must be used to keep the mouth clean by the use of 
 mouth washes. If the tooth is not withdrawn, chronic suppuration, with 
 occasional attacks of acute trouble when the outlet for the pus becomes 
 blocked, will be the usual history of these cases. All operative measures 
 upon the teeth should be accompanied by the same painstaking antiseptic 
 measures which are used in the treatment of wounds. 
 
 The so-called tartar, composed in part of the salts of lime, which is 
 deposited on the teeth, especially at the border of the gums, should be re- 
 moved by a dentist as often as it forms. Its accumulation interferes with 
 the nutrition of the teeth and may cause them to become loose and fall out. 
 
 For fractures of the lower jaw, see J^ractures. 
 
552 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 C'lIAPTEU Vlll. 
 INJURIES AND DISEASES OF THE NECK. 
 
 Ix.u'UiES of the neck are dangerons on account of the many important 
 structures situated in this region, among them the larynx, the windpipe, 
 the gullet, large arteries and veins, important nerves upon the integrity 
 of which breathing and the action of the heart in part depend, and the 
 spinal column, containing the spinal cord. 
 
 The subcutaneous injuries of the neck occur from blows and falls, 
 
 from the passage of the wheel of a vehicle over the neck, from assaults in 
 
 which the neck is violently grasped by the fingers of 
 
 Subcutaneous ^i •^ . n .1 t .• n ^• , ^ 
 
 r . . the assailant, from the application oi a li<;ature around 
 
 Injuries. ■ ^ J ... 
 
 the neck, and from hanging. The injuries produced 
 are of the most varied character. The larynx or the windpipe may be 
 crushed or torn apart. The hyoid bone, which lies just above the larynx, 
 may be fractured. 
 
 The symptoms produced by the injuries to the air passages are pain, 
 often spitting of blood, and mechanical interference with breathing, and 
 sometimes the escape of air into the tissues of the neck, 
 ' producing diffuse swelling, which crackles on pressure. 
 
 If unrelieved, death from strangulation may occur very rapidly. To en- 
 able the individual to breathe it is sometimes necessary to insert a tube 
 into the windpipe at a point below the level of the injury. This opera- 
 tion is called tracheotomy. 
 
 In cases where a ligature is tied about the neck, and in hanging, sui- 
 cidal or otherwise, death occurs from strangulation — i. 6\, from stoppage 
 of the breathing and from interference with the circulation of the blood 
 in the brain. According to the greater or less suddenness and complete- 
 ness of the constriction, death may occur very rapidly or be delayed for 
 many minutes. In the former case the face is swollen and livid, the 
 tongue is protruded and often bitten, there is a bloody foam about the 
 lips, the hands are clenched, and the signs of congestion of the surface of 
 the body are marked. The mark of the cord upon the neck is red and 
 depressed. Such a condition is commonly found after judicial or homi- 
 cidal hanging, and where a cord is suddenly and tightly tied al)out the 
 neck. In addition there may be extensive laceration of the windpipe and 
 of the muscles and blood-vessels of the neck. The spinal bones may be 
 fractured or dislocated. 
 
 Wounds of the neck are more common as the result of attempts at 
 suicide or murder than from other causes. The incised wounds of the 
 neck which are made with a knife or razor with suicidal intent usually 
 
SUICIDAL AND HOMICIDAL WOUNDS OF THE NECK. 
 
 pass obliquely ucroKs t:h(3 Me(;k at tlic; Icvcil of or above tli(; larynx. The 
 direction of the cut is commonly from left to ri<^lit and from above down- 
 ward. The wound may, but does not usually, sever the internal Jiii^ular 
 , . , „, , vein or the carotid artery. The air passages are often 
 of the Neck. ^PC"Gd and many of the smaller blood-vessels may be 
 divided, resultiuir in fatal bleeding. A suicidal stab 
 wound of the neck often readies the large vessels. Such wounds are, 
 liowever, less common. Homicidal wounds of the neck are usually situ- 
 ated, not in the median line of the body, but to one side. There are often 
 sevei-al wounds, and they are more commonly punctured than incised. 
 More force is usually employed in their production tlian when they are 
 self-inflicted. When the common carotid artery or the internal jugular 
 vein are opened, death may take place at once or after several minutes. 
 A special danger from wounds of the neck which open the air passages is 
 the entrance of blood, and later of wound discharge into the windpipe and 
 lungs. Immediate suffocation is often produced by the former, death 
 from pneumonia by the latter. Wounds of the large veins of the neck 
 are dangerous, from bleeding and also from the entrance of air into the 
 open vein. The act of inspiration sucks in the air through the hole in 
 the vein in the same way that air enters the chest through the windpipe 
 in natural breathing. This accident is sometimes followed by sudden 
 death from interference with the action of the heart. 
 
 To stop arterial bleeding from wounds of the neck temporarily, finger 
 pressure in the wound may be used. In case this is not practicable, the 
 common carotid artery may be compressed against the 
 front of the spinal column at a point below the wound. 
 This artery, which supplies the head and face with blood, lies on the side 
 of tlie neck beneath the 
 large muscle (the sterno- 
 cleido - mastoid muscle) 
 which passes from the 
 prominent bony point be- 
 hind the ear to the junc- 
 tion of the collar bone with 
 the breast bone. The 
 course of the vessel is in 
 a line drawn from the 
 junction of the collar bone 
 with the breast bone, to a 
 point midway between the 
 prominent bone behind the 
 ear and the angle of the 
 
 lower jaw. ine vessel is Fig. 34. — Digital compressioji* of comjion cakotid artery. 
 
 Treatment. 
 
551 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 most convtMiieiitly coin])ressed iioar tlir middle of the iierk. The pres- 
 sure may be applied with the thiiiiil) at the anterior border of the sterno- 
 mastoid musele, and should be direeted backward against the spine (see 
 Fig. 84). Dinct jingcr preaaure in the bent temporary weans of stoj)piiHj 
 hleediinjfrom the large veins in the neck. Pressure of this character iu 
 wounds of the neck lias been the means of saving a good many lives. 
 
 The symptoms and treatment of wounds of the gullet and of the ncM-ves 
 of the neek must be sought for in works on regional surgery. 
 
 Infected wounds of the neck are particularly dangerous from the 
 
 possibility of the spread of the inliammation downward into the cavity of 
 
 the chest. Such wounds should be opened in such a 
 
 1!, ,/"!"'* way that the pus has the freest possible outlet. Infiam- 
 of the ^.eck. • ^ i j. j- " 
 
 matory processes of the neck are of frequent occurrence. 
 
 The Ivmiiliatie ehannels of the scalp, face, mouth, and throat are very 
 abundant, ami these parts are eoiistaiitly e.\[)()se(l to infection of one kind 
 or another. As has been stated, the bacteria of su])puration very com- 
 monly spread through the lymphatic channels, and in the lymphatic glands 
 of the neck they very often find a lodgment and produce suppuration. 
 Some of the inflammatory processes of the neck, and frequently the most 
 serious ones, spread by contimiity of tissue directly from an inflamed 
 point on the skin of the neck, face, scalp, or mucous membrane of the 
 mouth and throat, sometimes from an abscess at the root of a tooth, or 
 from an inflammation of one of the bones of the face. 
 
 The symptoms of abscess of the neck do not differ in kind from ab- 
 scesses elsewhere. The pain is apt to be severe and the constitutional 
 depression and fev^er marked. When the abscess is 
 
 l/mp cms an (deeply seated there may be little or no redness of the 
 
 Ireatment. ^ •' ^ •' 
 
 skin for some time, and the swelling may be quite dif- 
 fuse. Extreme local pain and tendeimess, with fever, will usually point 
 to a correct diagnosis. In these cases no time should be lost in temporiz- 
 ing measures. The abscess should be opened at once, no matter how 
 deeply it may be situated. By this means, suffering, excessive scarring, 
 and perhaps death from septicemia will be avoided. Rapidl}' progressive 
 phlegmon of the neck, characterized by a hard, brawny, diffuse swelling, 
 a purple discoloration of the skin, pain in chewing and swallowing, and 
 great prostration, is a very serious disease. Even under the most ener- 
 getic treatment extensive necrosis of the skin and subcutaneous tissues is 
 apt to occur, and death from a spread of the infection into the cavity of 
 the chest is not uncommon. The treatment is early and free incisions 
 into the inflamed tissues and energetic disinfection of the wounds. 
 
 Acute suppurative inflammation of the parotid gland, the large salivary 
 eland which is situated on the side of the face in front of the ear, occurs 
 as the result of wounds of the gland, but more conmionly in the course 
 
PAROTID, SUBMAXILLARY, AND LYMPHATIC GLANDS. 555 
 
 of fevers, and in pyjiiniia and septicaemia. In a lar^t; j)ro])(ji'tion of tlie 
 cases probably want of attention to tlie cleanliness of tiie mouth Las 
 
 inucli to do with the infection of the jL^land. 
 
 Acule Suppurative The disease is characterized ]>y liigh fever, freqiient- 
 
 Inflammation j accompanied by delirium, severe pain in tlie face. 
 
 Gland fixation of the jaw, and marked swelling. If not opened 
 
 early the pus finds its way upward or downward, cau.-,in(( 
 
 sometimes inflammation of the membranes of the brain and death, o)-, in 
 
 other cases, a large abscess of the face and neck. 
 
 Abscesses beneath the jaw, in the neighbourliood of the suljmaxillary 
 gland, occur sometimes in the form of an epidemic disease. They have 
 received a special name from the physician who first described the condi- 
 tion — " Angina Ludovici." Fevers, wounds, and septic diseases are also 
 followed by such abscesses. The symptoms are similar to those of abscess 
 of the parotid, but not so severe. The treatment is early incision. 
 
 Tuberculosis of the lymphatic glands of the neck has already been 
 described. The remaining enlargements of these glands belong in part 
 to the so-called diseases of the blood — leucaemia and pseudo-leucjemia, 
 to syphilis, and to the domain of tumours — primary in the glands, or 
 secondary to malignant tumours elsewhere. Tor a description of these 
 conditions the reader is refen-ed to more extensive works on general 
 medicine and surgery. 
 
 FOREIGN BODIES IN THE LARYNX. 
 
 Portions of food, vomited matter, bones, coins, peas, beans, pins, collar 
 buttons, etc., are sometimes sucked into the larynx. If the foreign body 
 is large enough to close the opening completely and is not expelled by 
 coughing or removed at once, death occurs immediately from asphyxia. 
 In other cases the foreign body may remain in the larynx, giving rise to 
 pain, cough, hoarseness, or loss of voice, and more or less difficulty in 
 breathing. If the foreign body passes through the larynx into the trachea 
 it may be coughed up or remain without producing serious symptoms, or, 
 more commonly, bronchitis, septic pneumonia, and abscess of the lung 
 destroy the individual, unless operative extraction proves successful. 
 
 A foreign body which threatens to cause death by choking can often 
 be removed with the tip of the index finger inserted into the throat. 
 The finger should be protected from the teeth by fore- 
 ing the handle of a table knife or something similar well 
 back between the molar teeth. If this fails the patient may be inverted 
 and struck smartly between the shoulders. The instrumental removal of 
 foreign bodies from the larynx can only be done by a physician. 
 
 The operation of tracheotomy, or the insertion of a tube into the 
 windpipe through a cut in the skin of the neck, is done when some ob- 
 
556 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 striiction to breatliin2: exists above the point at wliii-li the tube is inserted, 
 
 such as a tiinumr which jirojeets into or ]'>resses iqion the trachea ; also 
 
 as a ]ireeaiitionarv measure in certain opei'ations wliieh 
 Tracheotomy. • . ..i •* ^ .. xi i i j r 
 
 open into the air passages, to prevent tlie blood ironi 
 
 running into the trachea. The operation is also dtme in order to remove 
 foreign bodies from- the trachea and bronchial tubes. In cases of dij)h- 
 theria the operation is sometimes done to enable the patient to breathe 
 when the larynx is partly closed by false membrane. Instead of this cut- 
 ting operation, a small tube is sometimes passed through the mouth through 
 the larynx, and allowed to remain ui situ until the in- 
 llammation has subsided. Neither operation has any 
 direct curative effect upon the disease, but either may save life by pre- 
 venting asphyxia. In order to be of use, these operations should be done 
 before the signs of asphyxiation become marked. 
 
 THE CESOPHAGUS OR GULLET. 
 
 A great variety of substances may be swallowed accidentally or inten- 
 tionally and become impacted in the gullet. In a large proportion of 
 
 cases thev pass on into the stomach or are vomited. 
 Foreign Bodies -,xn ■ i ' • • xi i j.\ a. 
 
 . ,. ^ „ , When they remain m tlie oesophagus tlie symptoms 
 
 171 the Gullet. •' _ _ i t> J i 
 
 produced vary with the size and shape of the body. If 
 
 the foreign body is large, complete inability to swallow may exist, and 
 
 compression of the trachea may lead to ditiiculty in breathing. Sharp 
 
 bodies, such as needles, pins, and bones, may cause severe pain if they 
 
 become impacted with their long diameters across the oesophagus. The 
 
 remote results are ulceration of the oesophagus, perforation followed 
 
 by phlegmonous inliammation of the loose tissues wdthin the chest, and 
 
 death. Perforation into the trachea, pleura, or lung may lead to septic 
 
 pneumonia ; perforation of the large vessels of the chest, to death from 
 
 haemorrhage. 
 
 If the foreign body is situated at the entrance to the gullet it may 
 sometimes be extracted with the linger. AVhen lower down, instrumental 
 extraction will be necessary. It can only be done by a surgeon. 
 
 Cancer of the oesophagus occurs in old people. The symptoms are 
 
 gradually increasing ditiiculty in swallowing and loss of Hesh and strength. 
 
 The duration of life is from one to two years. In a 
 
 few cases, where the cancer was situated high np, it 
 
 has been cut out successfully. An artificial opening is sometimes made 
 
 into the stomach, through \vhich the patient may be nourished. 
 
 THE THYROID GLAND. 
 
 The thyroid gland is situated in the neck, just below^ and on either 
 side of the larynx. Its functions are very important for the health of 
 
AFFECTIONS OF THE THYROID GLAND. 557 
 
 the organism. In certain regions a good many children are born with 
 the thyroid gland undeveloped. Such childi'cn are senii-idiotic. Thoy 
 do not develop like other children, but remain small 
 and squat of stature. The complexion is pasty; the 
 face is expressionless, heavy, and hideous. These individuals are known 
 as cretins. 
 
 Tlie disease known as myxedema is caused Ijy wasting away of the 
 thyroid gland. Patients suffering from this disease are melancholy and 
 stupid ; the hands, face, and feet are swollen ; the skin 
 y^^ '^ ■ '• ^g rough ; the temperature of the body is below nor- 
 mal, and the patients present many of the symptoms of chronic inflam- 
 mation of the kidneys, for which this disease is often mistaken. 
 
 Cretinism and myxoedema can be improved and the latter sometimes 
 cured by feeding the patient with the thyroid glands of sheep, or with a 
 glycerin extract of the same. 
 
 Goitre, or enlargement of the thyroid gland, occurs in several forms. 
 One of these is peculiar to certain regions, notably to some of the valleys 
 of the Swiss Alps, where it seems to depend upon cli- 
 matic conditions and upon the character of the water. 
 Enlargement of the thyroid gland is also associated with a nervous affec- 
 tion of the heart. 
 
 True tumours of the thyroid gland are not uncommon. Great en- 
 largement of the thyroid is attended by symptoms of interference with 
 
 breathinsi: by pressure upon the windpipe. In this 
 Tumours o ./ 1 r ^ i 1 
 
 country the largest proportion of thyroid enlargements 
 
 occur as encapsulated cysts. They produce considerable deformity. The 
 treatment of these cysts by other than radical operative removal is un- 
 certain and unsatisfactory. The operation in competent hands results 
 in cure with but slight risk. 
 
 CHAPTEK IX. 
 THE THORAX. 
 
 Simple contusions of the thorax without injury of the internal organs 
 run a favourable course. The treatment consists of cold, compression. 
 and massage. Severe contusions of the chest, with in- 
 juries of the heart, lungs, and great blood-vessels, are 
 very serious. Shock is usually marked. Internal bleeding often proves 
 fatal. If the lung is ruptured there is often spitting of blood. If frac- 
 ture of the ribs coexists, air is often forced out under the chest wall. 
 
55S SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 producing a swelling which crackles on pressure. There is difficulty in 
 breathing from the accumulation of extravasated blood within the chest. 
 The treatment is in general the treatment of shock. 
 
 For fracture of the ribs, see J^ractuns. 
 
 Non-penetrating wounds of the thorax do not present any special 
 
 peculiarities. Penetrating wounds of the thorax are always dangerous 
 
 injuries. AVounds of tlie heart or of the great blood-vessels of the chest 
 
 are nearly always immediately fatal. Wounds of the 
 
 0KH<6 oj le \yy^^„ aj.g dangerous from the possibility of infection and 
 subsequent suppuration. AVhen the wound of the skin 
 is of considerable size, the mere opening of the ])leural cavity is attended 
 with some immediate risk from interference with breathing. Air rushes 
 in through the hole in the chest wall, and the lung collapses and can no 
 longer be used for breathing. 
 
 The immediate treatment of these wounds is simply to treat them 
 
 antisepticallv. If the patient survives and infection 
 Treatment. " , , , . i . 
 
 occurs, other treatment may be necessary at a later 
 
 period. It can only be carried out by a sui-geon. 
 
 THE BREAST. 
 
 Contusions and wounds of tlic breast heal readily. In some cases a 
 
 contusion of the breast may be followed by the growth of a malignant 
 
 tumour, sarcoma, or cancer. During lactation — i. e., 
 
 ^'"m"*'7*""'^ the nursing period— the breast, upon and around the 
 
 Treatment nipple, often becomes fissured and sometimes nlcer- 
 
 ated. Such fissures should be carefully cleaned after 
 
 each nursing with a boric-acid solution, and protected from infection 
 
 by clean cloths. Ulcers should be touched lightly with a stick of nitrate 
 
 of silver every two days or so, until healing progresses well. Nursing 
 
 of the child should be stopped on the affected side and a breast pump 
 
 used until the fissure or ulcer is cured. Neglect of these precautions 
 
 often leads to infection with bacteria and abscess of the breast or 
 
 erysipelas. 
 
 Abscesses of the breast occur most often during the nursing period. 
 
 They are due to infection. A painful, tender swelling is formed in the 
 
 breast. As the disease progresses, there is fever and 
 
 rp ' more or less prostration, and, when the pus approaches 
 
 the surface, redness of the skin and the elastic feeling 
 
 called fluctuation, due to the presence of pus. 
 
 If not opened earl}", such abscesses may spread widely and destroy a 
 large portion of the gland. Occasionally the breast becomes riddled with 
 abscess cavities, and the infection spreads to the loose tissues between the 
 breast and the chest wall. In such cases there is danger of death from 
 
ANGULAR DEFORMITY OF THE SPINE. 559 
 
 pyasmia and septiciX3iriia, and arnpiitatiiji) of tlio breast may be ueces.sary. 
 
 Abscesses of the hreast s/undd not be 'poulticed. 
 
 Tumours of the breast occur in consi(]era]jl(; variety. 
 Tumours. -.g- t i. 1 1 • ' 
 
 Many arc malignant or become so ; some are benign. 
 
 They should receive the attention of a surgeon at the earlie.-t possible 
 
 moment. 
 
 THE SPINE. 
 
 Fractures of the spine have been spoken of under Fractures. 
 
 Humpback, kyphosis, or angular deformity of the spine occurs as tlie 
 
 result of rickets, and from weakness of the muscles and ligaments of the 
 
 spine ; also from disease of the spinal vertebrae, espe- 
 
 ump O.CC, cmses ^-^p f^.^j,^ tuberculosis of these bones. (See also Frac- 
 
 Ci'YhcL I T'Pflit'iYLG'Ytt 
 
 tures.) When due to rickets, the deformity is usually 
 noticed during tlie second or third year of life. When due to weakness 
 of the muscles and the ligaments, it is most common in poorly nourished 
 girls between the ages of ten and sixteen. In both instances the deformity 
 is rather an excessive bowing of the spine in the upper part of the back 
 than a sharp angular bending such as occurs from fractures and tubercu- 
 losis of the bones. 
 
 The rachitic form is treated by care of the general health (see Riclc- 
 ets), and by allowing the child to lie upon a firm, smooth bed, with the 
 back supported by a suitable cushion. Later on some supporting appa- 
 ratus may be necessary. The rounded back, which occurs in feeble young 
 girls, is treated by urging the child to walk and sit erect, by suitable ex- 
 ercises, braces, and attention to the general health. 
 
 Tuberculosis of the spine, which leads to true angular deformity, is 
 
 most common among children between the ages of three and ten years. 
 
 The effect of tubercular inflammation on the bones of 
 
 Tuberculosis; the spine has already been mentioned. Three impor- 
 
 bymptoms, ^^^^^^ ^^^^ ^^ signs and symptoms may be produced : 
 
 Prognosis, -, mi c 1 i ^ ^ • ^ 
 
 and Treatment -•-• ^^^^ early symptoms, referable to the changes m the 
 bones themselves and the surrounding soft parts, are as 
 follows : The child is easily fatigued by standing and sitting upright ; 
 pain is complained of in the back or belly ; there is tenderness over the 
 diseased vertebrae in the back; deformity — i.e., a hump — is gradually 
 developed; the child holds the spine rigid; if asked to pick np some- 
 thing from the floor, the back is held stiff and the body bends forward 
 at the hips; the trunk is supported meanwhile by resting the hands 
 against the thighs ; crowding of the vertebrae together by pressure on 
 top of the head causes pain. 2. Pressure on the spinal cord, caused by 
 displacement of the bones, may give rise to complete or partial paralysis 
 of the lower extremities, bladder, and rectum. 3. The formation of 
 tubercular abscesses which are apt to burrow from the force of gravity. 
 
5G0 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 According to the seat of the disease, the abscess may reach the surface 
 in tlie back of the throat, under the skin of the back, in the lower part of 
 the front of the belly, in the groin, or in the thigh. Rupture of the ab- 
 scess into internal cavities and organs is less frequent. The disease nmy 
 prove fatal in a variety of ways, which have been sufficiently indicated 
 alreadv under tuberculosis. Cure, with more or less deformity, is possible 
 at any stage. 
 
 The sooner the child is furnished with a suitable supporting apparatus, 
 such as a plaster jacket, the better the chances of recovery and the less 
 the resulting deformity. The general treatment is the same as for the 
 other forms of tuberculosis. 
 
 Lateral curvature of the sjiine, or scoliosis, occurs in several forms 
 
 and from various causes. The commonest and most 
 
 "^I" 'f'" '""^ important of these is the so-called J Lih It udl Scoliosis. 
 of the Ibpine. ^ r i i • i i ^ 
 
 It occurs most often in feeble girls between the ages of 
 
 eiirht and sixteen years. 
 
 The deformity develops very often from a habit of sitting improperly 
 at school, especially while writing. The benches upon which children 
 are obliged to sit are often so constructed that a bent 
 and twisted position of the spinal column is favoured. 
 The bones of the spine grow thicker on one side than on the other, and 
 the whole spinal column is twisted or rotated on its long axis. The con- 
 vexity of the curve is usually to the right, and is commonly situated in the 
 dorsal region — i. <?., the region of the ribs. The shape of the chest is also 
 changed. The ribs curve more sharply forward on the convex side, and 
 the size of the chest cavity on that side is diminished. On the opposite 
 side the cavity of the chest is increased in all its diameters except the ver- 
 tical one. Compensatory curves in the opposite direction are developed 
 in the spinal column, in the neck, and in the loin or lumbar region. The 
 bones of the pelvis may also be twisted out of shape. The muscles and 
 liffaments of the back and chest are lenc^thened on the convex side and 
 shortened on the concave. After a time these dt'formities tend to become 
 permanent. 
 
 The early recognition of lateral curvature of the spine is of the great- 
 est consequence, for after the deformity is thoroughly developed it is 
 usually impossible to correct it entirely. 
 
 The first symptom noticed is an elevation of the shoulder on the con- 
 vex side of the curve and an undue prominence of the 
 shoulder-blade on the same side. The opposite hip is 
 more prominent. The spine itself may show little or no apparent devia- 
 tion from a straight line at this time. 
 
 When these signs are noticed the child should be put under treatment 
 without delay. Physical exercise out of doors, gymnastics, and abundant 
 
CONTUSIONS AND WOUNDS OF THE ABDOMEN. 601 
 
 food are important. Tlio child slionld sit upon a proper seat wliile study- 
 ing and writing, and in such a yjosition that the spine may be held straight 
 without discomfort. Tlie sitting posture should not he 
 maintained too long. It is well that such children 
 should lie supine upon a hard bed for an hour or more during the middle 
 of the day. 
 
 When the deformity is already developed other treatment is necessary. 
 The child is suspended by the shoulders and neck so that the weight of 
 the body overcomes the curvature of the spine as far as possible. In this 
 position a plaster-of-Paris corset is applied, which is renewed from time 
 to time as the deformity grows less. 
 
 For a description of the numerous exercises and apparatus used in the 
 treatment the reader is referred to works on orthopaedic surgery. 
 
 CHAPTER X. 
 INJURIES AND DISEASES OF THE ABDOMEN. 
 
 Contusions and wounds of the abdomen, in which the injury is con- 
 fined to the wall of the belly, the cavity itself and its contents remaining 
 unopened and uninjured, are of no more serious import 
 
 „ ., ,. than similar injuries elsewhere. When, however, the 
 
 Considerations. -^ ^ _ . ' , ' 
 
 peritoneal or belly cavity is exposed to infection through 
 an external wound, or through a wound or rupture of the intestine, stom- 
 ach, or urinary bladder, a most serious condition exists, in which even the 
 most prompt and careful treatment may fail to save life. In these cases 
 death is caused by internal bleeding or by acute general suppurative peri- 
 tonitis — i. e., suppurative inflammation of the lining of the belly and of 
 the outer or peritoneal surface of the abdominal viscera. 
 
 CONTUSIONS AND WOUNDS OF THE BELLY WALL. 
 
 Contusions of the belly wall are attended, as elsewhere, by rupture of 
 a certain number of blood-vessels and by black-and-blue marks. The 
 treatment consists of cold, pressure, and massage. 
 
 Wounds of the belly wall, when they do not penetrate into the cavity 
 of the peritonaeum, are treated wdth ordinary antiseptic precautions. 
 When muscles are divided it is very important that their divided ends 
 should be sewed together, to prevent a weak place in the abdomen through 
 which some part of the abdominal contents may subsequently protrude, 
 forming a hernia. See Hernia. 
 38 
 
562 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 INJURIES OP TllK ABDOMINAL CAVITY AND ITS CONTENTS. 
 
 Severe contusions of the abtlonien may cause ruj^ture of any of the 
 contents of the belly and death from internal bleeding, or, when a portion 
 of the intestinal tract is ruptured, escape of its contents may take place, 
 causing a i-apidly fatal peritonitis. 
 
 Such injuries, when caused by a blunt instrument, such as a heavy 
 club, wagon-pole, hoof of a horse, etc., or by falling or being thrown 
 against some solid blunt object, as a post or projecting 
 ^ ■'' ■ piece of stone, are usually, but not always, attended by 
 
 shock. AVlien the general symptoms of bleeding appear, or peritonitis 
 makes itself manifest (see Peritoniti(<\ a surgeon will in suitable cases 
 open the belly, tie off the bleeding points with catgut, or sew up the torn 
 intestine, stomach, or other ruptured organ, and clean the peritoneal 
 cavity. If the ojieration is dune early many lives can be saved in this 
 manner. 
 
 In the absence of a surgeon, severe contusions of the abdomen sliould 
 be treated by stimulants when necessary to combat grave symptoms of 
 shock. An ice bag should be placed over the contused region, and opium 
 should be given in full doses to keep the intestines quiet and thus tend to 
 prevent the escape of their contents and promote healing. It should be 
 understood that Nature makes an attempt, sometimes successful, to pre- 
 vent the escape of the contents of the ruptured stomach or bowel by the 
 rapid formation of adhesions between the torn portion and the peritoneal 
 covering of the belly wall, or the surface of some other organ. These 
 adhesions form very rapidly and may seal up the opening in twenty-four 
 hours. If Nature's effort is only partly successful, a localized abscess may 
 be produced, surrounded by adhesions which shut it off from the general 
 cavity of the peritonaeum. Such abscesses can often be opened success- 
 fully. If the stomach and bowel are comparatively empty at the time of 
 the accident, the chances of such adhesions forming are much better than 
 when these oro-ans are distended with food and eras. 
 
 Penetrating wounds of the abdomen may open into the peritoneal 
 cavity merely, or affect also one or other of the abdominal viscera. To 
 the dangers spoken of under contusions are added the risk of infection 
 from without through the wound in the belly wall. 
 
 The treatment of such wounds in the absence of a surgeon may be 
 stated in a few words. If gas and intestinal contents are seen to escape 
 through the wound, give opium enough to quiet pain. 
 The patient will almost surely die. If a portion of the 
 intestine has escaped through the wound and is opened so that its con- 
 tents are escaping externally, pull out enough of the gut to be sure that 
 no intestinal contents can get into the belly. Pack the space between the 
 
INJURIES OF THE ABDOMEN : PERITONITIS. 50:^ 
 
 edp;es of the wound and the <(nt Ji^htly with clean gauze and give the 
 patient moderate doses of opium. If there is no other wound of tlie gut, 
 recovery may take ])lace witli the formatir»n of an a/rtijicial anufi^ as it 
 is called, which may be sul)sequently closed by operation. If the gut or 
 any other organ protrudes through the wound, hut is not itself wounded, 
 clean it with boiled water and push it back into the belly. The part 
 M-hich came out last should be pushed back first. Give opium in mod- 
 erate doses. If an organ protrudes and is wounded so that it bleeds it 
 should be left outside, cleaned with boiled water, and the Inemorrhage 
 stopped by pressure with gauze packing. It may be replaced by a sur- 
 geon later. In all cases a large antiseptic dressing should be applied, 
 and the body surrounded by a broad bandage extending from the hips to 
 the chest, and held in place by pins. The skin around the external wound 
 should be disinfected as thoroughly as possible ; but never allow corrosive 
 sublimate or any other strong antiseptic to enter the cavity of the belly. 
 
 The treatment of gunshot wounds of the abdomen in the absence of 
 a surgeon is to clean the external wound, apply an antiseptic dressing, 
 and give full doses of opium. 
 
 When in doubt as to whether a wound jpenetrates into the helly or not, 
 do not explore it with either finger or prohe i clean it, apply a dressing, 
 and await developments. 
 
 In all cases of severe injury to the belly, food should not be given 
 by the mouth for the first twenty-four or thirty-six hours. Thirst 
 may be quenched by allowing the patient to swallow small pieces of ice 
 whole. Whiskey may be given by the rectum in small doses as often 
 as necessary to support the patient's strength. 
 
 PERITONITIS, 
 
 Inflammation of the peritonaeum in its acute form, which alone will 
 be considered in this article, occurs from a variety of causes. Chief 
 among them are wounds such as we have spoken of ; 
 also surgical operations on the interior of the abdo- 
 men in which strict antisepsis has not been observed ; further, ulcerative 
 processes in the alimentary canal which perforate the wall of the gut 
 and allow the escape of its contents into the peritoneal cavity. Among 
 these processes may be mentioned typhoid fever, perforating ulcer of 
 the stomach, and inflammation of the vermiform appendix. Infection 
 of the peritonaeum may also occur by direct extension of inflammation 
 from any of the abdominal organs or from the spine or the cavity of 
 the chest. 
 
 Peritonitis sometimes occurs as a complication of pyaemia, septicae- 
 mia, and in the course of the eruptive fevers. According to the 
 severity of the process, the inflammatory product which is poured out 
 
564: SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 into the peritoneal cavity may consist of watery tiuid, of watery Huid 
 and fibrin, or of pus with more or less fibrin and watery liiiid added 
 thereto. The purulent variety is the one which chiefiy interests sur- 
 ijeons, and that alone will be described. We distinguish (1) a diffuse 
 purulent peritonitis in which the whole or the greater part of the perito- 
 neal cavity is intlamfed ; (2) a form in which Nature partly succeeds in 
 limiting the inflammation by an exudation of fibrin and the formation 
 of adhesions around the inflamed area, but where the inflammation con- 
 tinues to spread more or less rapidly and becomes general after a variable 
 time nnless promptly treated ; (3) a form in which the limiting adhesions 
 shut off the pus completely from the general cavity. This form, too, may 
 become general from rupture of the abscess into the healthy peritonaeum. 
 In other cases rupture takes place into the gut, or the ]nis may finally 
 perforate the abdominal wall and escape externally. 
 
 Diffuse purulent or septic peritonitis following perforation of the 
 irut from any cause, or due to infection of a wound of the peritonaeum, 
 runs in some cases a very rapid course ; the pus microbes develop so 
 large a dose of poisonous material that the individual succumbs to the 
 constitutional infection in one or several days without any very marked 
 changes in the peritona-um taking place. In other cases a more or less 
 copious exudation of pus and fibrin is produced. The former tends to 
 gravitate to the pelvis, and to form large purulent collections in this 
 region. Once fairly started, these two forms of peritonitis are rarely 
 recovered from under any form of treatment. Less fatal and more 
 amenable to treatment are the slowly progressive form and that in 
 which a circumscribed abscess is produced. A small proportion of 
 the cases of general purulent peritonitis when operated upon at an 
 early period do recover, but their number is small and will probably 
 remain so. 
 
 A prominent symptom of all cases of purulent peritonitis is vomiting. 
 The vomited material is usually of a green colour, and in the later stages 
 of the disease may resemble the contents of the lower 
 bowel. There is sometimes a chill at the beginning of 
 the disease followed by fever, which may rise in a few hours to 104° or 
 105° Fahr., and usually remains elevated until death or recovery. In 
 some of the most rapid and severe cases, however, the temperature may 
 be but little elevated, or even below the normal. The pulse is frequent 
 — 110 to 140 beats to the minute — and feeble. The belly is swollen from 
 distention of the intestine with gas. In bad cases the swelling may be- 
 come extreme. There is intense spontaneous pain in the ahdomen, which 
 may be referred to the site of the inflammation or not. There is great 
 tenderness on pressure over the abdomen. During the early stages of 
 the disease the tenderness is often greatest over the point whence the in- 
 
CAUSES OF PERITONITIS. 505 
 
 flamrnation started. Absolute constipation exists in the majoi'ity of cases. 
 In severe attacks the face has a pinched and drawn a])pearance, and is 
 of an ashen-grey colour. The eyes are sunken. 
 
 Among the coniinonest causes of peritonitis is infiarntnation of tlic 
 vermiform appendix. This little organ, whicli is represented in some of 
 the lower animals by a large l)lind pouch connected with 
 Causes: Inflamma- the large intestine, and serving the purpose of a store- 
 ton 0/ be eimi- Yiq^^q for food, has in man outlived its usefulness. It 
 form Appendix, . , 1 • i • 1 /• 1 
 
 or Appendicitis. ^^ Situated on the right side of the belly, low down, near 
 
 the junction of the small with the large intestine, of 
 which latter it forms a part. The appendix is a hollow tube about as 
 large around as a lead pencil, and varying in length from an inch to 
 five or more inches. It empties at its l)ase into the large intestine. The 
 tip is closed. 
 
 The vermiform appendix is an organ which is undergoing involution, 
 
 as we sa}' — that is, in man it has ceased to be of use, and shows signs of 
 
 . imperfect development and of other changes which 
 
 probably presage complete disappearance in the course 
 of time. For example, in a certain proportion of cases it is represented 
 by a little cord without any canal in its interior. In other cases it is bent 
 upon itself at a point a little way removed from the large intestine. This 
 bending causes a narrowing of the calibre at that point. 
 
 Little masses of dried and hardened intestinal contents are apt to form 
 in the interior of the appendix. Whether from loss of functional activity, 
 
 or from the narrowing of its calibre, or from the pres- 
 
 Foreign Bodies. c ^^ ^ ^ ^ • ^ • • r ^^ \ 
 
 ence 01 little iiard masses withm it, or irom all these 
 causes combined, it frequently happens that the contents of the appendix 
 become dammed up in its interior and can not escape into the large intes- 
 tine. The circumstances are now favourable for an attack of inflamma- 
 tion. The idea that cherry-stones, grape-seeds, and the like are a fre- 
 quent cause of appendicitis is not borne out by experience. Such bodies 
 are occasionally found in the appendices of those who have died of other 
 diseases, and rarely in cases of inflammation of the appendix, but there 
 is no good reason for believing that they exercise an influence in the pro- 
 duction of the disease. 
 
 No matter how produced, obstruction of the calibre of the appendix 
 favours inflammation by producing congestion of its mucous lining, thus 
 
 creating a good soil for the growth of those bacteria 
 Obstruction. . . . . 
 
 which regularly inhabit the large intestine. The mere 
 
 meclianical pressure of a hardened mass of intestinal contents may pro- 
 duce a place of diminished resistance, or even necrosis of the mucous 
 membrane and an ulcer. 
 
 The character of the inflammation varies in different cases. In a large 
 
566 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 proportion of these a catarrluil intlaiuination results. The appendix be- 
 comes distended with catarrhal secretion, but finally succeeds in emptyiTig 
 itself into the large intestine. The symptoms of such 
 ^"on'Tk""^ an attack are pain in the abdomen, which may be gen- 
 eral at first, or confined to the region of the stomach, 
 or in nuiny cases there is pain from the beginning of the disease in the 
 right side of the belly, low down, a little above the brim of the pelvis. 
 Local tenderness is always present, and is often most marked at a point 
 midway between the navel and the prominent bony point which can be 
 felt at the front of the crest of the haunch bone or ilium (the anterior 
 superior sjiinc of the ilium ; see article on T/ie Anatojinj of iJie Huiiuin 
 Body). In some cases a distinct swelling can be felt in tliis regitm, and 
 the belly will be found more rigid on the right side. In addition the 
 patient will usually have fever, and the pulse will be increased in fre- 
 quency. There is often constipation and very often vomiting. In 
 favourable cases the symptoms will all subside in a few days — as soon 
 as the obstruction has been overcome. In cases where the inflammation 
 has been a little more intense a slight amount of fibrinous exudation takes 
 place from the peritom^um near the appendix. There will often be a 
 distinct tumour in the region of the appendix. The attack lasts a little 
 longer, and the patient suft'ers from pain and tenderness in the region of 
 the appendix for weeks or months. The fibrin is partly supplanted by 
 fibrous tissue, and the appendix is thus rendered adherent to the surround- 
 ing structures. 
 
 In cases where the inflammation is so severe that ulceration and per- 
 foration of the wall of the appendix takes place, the symptoms vary ac- 
 cording to the rapidity of the ulcerative process and the behaviour of the 
 peritonaeum. If the ulceration takes place slowly the peritonaeum will 
 begin to pour out fibrin and to form limiting adhesions before perfora- 
 tion is complete. And when perforation does occur, the general cavity 
 of the peritonaeum will be shut off and a localized abscess will be pro- 
 duced. The attack may begin mildly, but the patient will become con- 
 tinually more ill instead of better. All the signs and symptoms will in- 
 crease in severity, and the abscess will continue to increase in size until it 
 l)ursts in one of several directions — for example, through the skin, into 
 the intestine, urinary bladder, genital tract of the female, cavity of the 
 thorax — or until the patient dies of septicaemia. When the perforation 
 is a little more rapid a progressive peritonitis may be set up, resulting in 
 death unless operated upon early. In the worst cases sudden ]K;rf oration 
 takes place, apparently witliin a few hours or a day or two from the be- 
 ginning of the attack. In these cases there may be no adhesions formed 
 to limit the spread of the poisonous material, and the patient may sud- 
 denly have very severe pain in X\w al)(lomen, pass into a condition of shock 
 
OPERATIVE INTERFERENCE IN APPENDICITIS. 507 
 
 from which he does not rally, or develop all tlie signs of dilfiise purulent 
 peritonitis. Still another form of iniiamuiation may occur in the ap- 
 pendix. The whole or a part of the organ may undergo gangrene 
 from the severity of the infection. These cases usually run a rapid 
 course. They sometimes result in a localized abscess, but are quite 
 often attended by progressive or diffuse peritonitis and a severe form 
 of septicaemia. The milder forms of the disease are apt to recur from 
 time to time. Each succeeding attack may be milder or more severe 
 than the last, and any one of them may result in perforation and tlie 
 formation of an abscess, or death from peritonitis. In some cases re- 
 peated attacks probably end in cure by obliteration of the calil^re of the 
 appendix. In other cases the patient has one severe attack after another 
 at more or less frequent intervals, and suffers more or less pain and 
 discomfort a good deal of the time, so that his health is impaired in 
 consequence, and he is no longer able to carry on his affairs with com- 
 fort and regularity. 
 
 While in any given case the question of operation must be decided by 
 a surgeon, it may be said in general that, in those cases where the symp- 
 toms point to perforation and peritonitis, to gangrene 
 
 Treatment. „ - ,, , ,i £. \ 
 
 of the appendix, or to the presence oi an abscess, imme- 
 diate operation offers the best chance of recovery. In cases where re- 
 peated attacks of moderate severity occur, but at rather frequent intervals, 
 and where considerable discomfort is present between the acute attacks, 
 the majority of surgeons agree that removal of the appendix during a 
 quiescent interval is attended by slight risk only, and is preferable to non- 
 interference. 
 
 When performed during an acute attack, and where the presence of 
 pus is certain or probal:)le, the abdomen is opened by a cut over the situ- 
 ation of the appendix. Great care is taken during the evacuation of the 
 abscess to prevent infection of healthy peritonaeum. To this end a small 
 opening is made into the abscess at first, through which its contents are 
 allowed to escape slowly, sponges being used to mop up the pus a few 
 drops at a time. The surrounding intestines are protected by pads of 
 gauze or sponges. The abscess cavity is finally wiped dry and clean, and 
 the appendix is sought for and removed if practicable. When diffuse 
 peritonitis exists the abdomen is sometimes washed out with a weak, hot 
 solution of boiled salt and water. In every case where pus is found the 
 wound is packed with strips of gauze and left open. In some cases a 
 large glass drainage-tube is inserted into the most dependent portion of 
 the peritoneal cavity. When the operation is done in the interval be- 
 tween two attacks, and no pus is found, the appendix is removed and the 
 wound closed with stitches. In these cases the muscular layers of the 
 belly wall are sometimes split and not cut across, in order to avoid a sub- 
 
568 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 sequent weak place in the abdomen, which is very apt to follow the trans- 
 verse division of the muscles. 
 
 The chances of recovery from operations done duriiiiij an interval 
 between two attacks are excellent. The percentage of deaths is very 
 small. AVhen done for a localized abscess, the chances of recovery are 
 also very good indeed, but when diffuse peritonitis is present recovery is, 
 as already stated, very rare. 
 
 FOREIGN BODIES IN THE ALIMENTARY CANAL. 
 
 Foreign bodies may gain access to the alimentary canal through the 
 mouth, or through the anus, or through a wound in the abdomen, or a 
 gallstone may ulcerate through the gall bladder and wall of the intestine. 
 Occasionally concretions are formed in the intestine consisting of the salts 
 of lime and magnesia. Such concretions may be formed around a gall- 
 stone, or a cherry or peach pit as a nucleus. Insane and hysterical per- 
 sons sometimes swallow intentionally foreign bodies of various kinds in 
 large numbers, such as needles, pins, knives, forks, spoons, etc. Only for- 
 eign bodies which have been swallowed will be spoken of here. 
 
 The larger the foreign body, and the more irregular its shape, the 
 more likely it is to become impacted and cause trouble. In a great ma- 
 jority of instances, however, no symptoms are produced, 
 ymp otns. ^^^ ^j^^ foreign body is passed through the lower bowel 
 without difficulty. "When such is not the case, the foreign body may re- 
 main in the stomach or become impacted in some part of the intestine. 
 The symptoms of impaction are pain, and sometimes the symptoms of 
 acute obstruction of the bowel. If ulceration and perforation occur, the 
 formation of a localized abscess or diffuse purulent peritonitis is the 
 result. 
 
 Purgatives should not be administered. The patient should be fed on 
 mashed potatoes in large amount. In this way the foreign body will be 
 inclosed in a mass of soft material and will be much 
 less likely to injure the intestine. In case the foreign 
 body is not passed, and pain and tenderness of the abdomen develop, 
 opium should be given in moderate doses and a surgeon should be called 
 at once. It may be necessary to cut down upon the foreign body and 
 remove it. 
 
 INTESTINAL OBSTRUCTION. 
 
 Obstruction of the bowel may occur from many causes. The obstruc- 
 tion may be acute or chronic. The condition is one of mechanical stop- 
 page of the bowel such that its contents can not pass. 
 
 Among the causes of acute obstruction are : The presence of foreign 
 bodies in the gut ; twists in the bowel ; fibrous bands which constrict the 
 
ACUTE AND CHRONIC INTESTINAL OBSTRUCTION. 569 
 
 gut; heriiise (see Jle7'nia)\ the condition known as intussuscejAion, in 
 
 which one portion of gut becomes invaginated into 
 Acute Ob drudion ; ^, a ^ i ^ .• . i- • .-, 
 
 ,, another. Acute ol)struction occurs most often in tlie 
 
 Causes. _ ^ ... 
 
 small intestine. The condition is an absolutely fatal 
 
 one in a few days unless relieved. 
 
 The symptoms are absolute constipation ; frequent and distref.sing 
 vomiting; distention of the abdomen from the accumulation of gas in the 
 
 intestine ; pain in the abdomen of a spasmodic charac- 
 
 Symptoms. ^ , , . , . . ^ . , i . ... 
 
 ter, less contmuous and less intense than in peritonitis ; 
 
 and tenderness of the abdomen, also less severe than in peritonitis. The 
 
 vomited matters consist at first of the contents of the stomach, later of 
 
 the contents of the bowel above the seat of obstruction. The vomited 
 
 matter is usually of a dark colour and emits a fetid odour. There is 
 
 sometimes fever. The pulse becomes more and more rapid and feeble, 
 
 and unless the obstruction is relieved the patient passes into a condition 
 
 of collapse and dies. 
 
 Purgatives should not be administered. Large injections of soap and 
 
 water into the rectum, made slowly and gently with a fountain syringe, 
 
 ^ while the patient rests upon his elbows and knees, may 
 
 Treatment. • j a ^ i -\ ^ . ■> j 
 
 be tried. A surgeon should be seen at once, since a 
 
 delay of twenty-four hours may render the case hopeless. Operation for 
 
 the relief of acute intestinal obstruction, if undertaken early, offers a fair 
 
 prospect of saving life. If delayed until the patient is exhausted and the 
 
 bowel paralyzed by overdistention, recovery is very rare. 
 
 Chronic intestinal obstruction occurs most often in the large intestine 
 
 as the result of cancer of the gut, sometimes from fibrous 
 
 Chronic Oistruc- , • , i,- -u j n ^ ,^ ^^^ r 
 
 ,. . ^ strictures wnicn gradually encroach upon the calibre of 
 
 the canal, and occasionally from chronic invagination of 
 
 the bowel. In old people, accumulation of intestinal contents in the large 
 
 intestine may simulate chronic intestinal obstruction. 
 
 Gradually increasing difficulty in procuring a natural evacuation of 
 
 the bowels is regularly present. There may also be diarrhoea from time 
 
 to time, due to catarrhal inflammation of the e^ut above 
 
 Symptoms. ^, . r ^ . .• a ,i 
 
 the seat oi obstruction. As the passage grows narrower, 
 
 swelling of the abdomen and colicky pains are developed. Death occurs 
 from exhaustion or from acute obstruction. 
 
 The only possible relief in these cases is to be derived from operation. 
 The operation may aim to cure the condition. In this case the diseased 
 ^ , , portion of gut is cut out and the healthv ends sewed 
 
 together. Or, if this is found to be impractical)le, the 
 disease may be left in situ, and the healthy gut above and below the ob- 
 struction may be joined together in one of several ways, thus switching 
 off, so to speak, the diseased part from the rest of the canal. "When the 
 
570 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 obstruction is situated low down in tlie ]ai'^e intestine, an artitieial open- 
 ing may sometimes be made tbrough the abdomen or loin into the gut 
 above the obstruction. The edges of the opening in the gut are joined 
 to the skin and the contents of tlie bowel arc allowed to esca]ic through 
 this artificial anus, as it is called. 
 
 In old people who suffer from accumulation of iieees in the large 
 intestine there is often a long history of constipation followed by diar- 
 rhoea. The dilated intestine can often be felt lilied with large doughy 
 masses through the abdominal wall. Examination of the rectum with 
 the finger shows it to be tilled with hardened fteces. The treatment is to 
 remove the contents of the rectum with the fingers or M'ith a spoon, and 
 to clean out the remainder of the large intestine by copious enemata. To 
 prevent subse(|uent attacks, stimulating laxatives should be administered 
 regularly. Massage of the belly is also of use. 
 
 INJURIES AND DISEASES OF THE ANUS AND RECTUM. 
 
 "Wounds of the anus and rectum other than those made during surgical 
 operations are comparatively rare. They sometimes occur from impale- 
 ment npon a sharply pointed object such as a fence 
 
 . J D / picket, upon which the individual falls in a sitting pos- 
 
 Atius and Kectum. i ' i o i 
 
 ture; occasionally from being gored by a bull. Lacera- 
 tions of the vagina and rectum are not uncommon during labour. Wounds 
 which extend deeply into the rectum may penetrate into the peritoneal 
 cavity and be attended by fatal peritonitis. 
 
 Bleeding from wounds of the rectum is often dangerous, the more so 
 because the blood may accumulate in the gut and not escape outwardly, 
 and the bleeding may thus be unsuspected. 
 
 AVhile uncomplicated, wounds of this region usually heal readily, in 
 spite of the contact of the contents of the bowel with the raw surface, yet 
 a surgeon or physician will alone be able to determine the gravity of the 
 injury, and hence inspection by such a one is desirable Iti every case. 
 
 Foreign bodies in the rectum may have been swallowed or introduced 
 
 through the anus. AVhen large and irregular in shape they may become 
 
 impacted and give rise to pain, constipation, or com- 
 
 oreign oe les m pj^.^-^ obstruction. In some cases ulceration and perfora- 
 te Rectum ; . . . . . 
 Treatment. ^^*^''^ ^"^*^ ^''^ peritonfeum, urinary bladder, or vagma 
 
 may occur. 
 If the foreign body fails to pass naturally, it may sometimes be ex- 
 tracted with the fingers. If not, a surgeon must i)e called. 
 
 PAINFUL FISSURE OF THE ANUS. 
 
 As the result of slight tears in the mucous membrane of the anus from 
 the passage of hardened freces, a shallow, chronic ulcer may be produced 
 
FISSURE OF THE ANUS AND HAEMORRHOIDS. 571 
 
 just witliin tliegrip of the .spliiiictor muscle. I'he ufreetion is a very pain- 
 ful one. Tlie very sensitive nerve endings of tlio part are exposed on tlie 
 surface of the ulcer. During each movement of the bowels these nerves 
 are irritated, and the sphincter muscle is thus thrown into a condition of 
 spasm. The pain produced thereby is severe, and is felt not so much at 
 the time the bowels are moving as afterward — often for several hours. 
 After the bowels move there may be the escape of a few drops of blood. 
 These individuals often believe that they are suffering from piles. 
 
 The bowels should be kept freely opened, and if the ulcer is very 
 small a few applications to its surface of a solution of nitrate of silver — 
 
 twenty to forty grains to the ounce of water, at intervals 
 
 Treatmeni. ./ ./ o ? 
 
 of two or three days— may effect a cure. If this fails the 
 disease can be surely cured by cleaning out the boM^els with a brisk ca- 
 thartic, giving the patient ether, and stretching the sphincter muscle widely 
 ■with the thumbs of both hands inserted into the bowel. A knife is some- 
 times drawn lightly through the base of the ulcer also. By this opera- 
 tion the sphincter muscle is completely paralyzed for some days. The 
 sensitive nerves are relieved from irritation and the ulcer heals rapidly. 
 
 HEMORRHOIDS (PILES). 
 
 Haemorrhoids are commonly the result of chronic constipation. Any 
 condition which produces congestion of the lower bowel, such as preg- 
 nancy, large tumours in the pelvis, displacements of the 
 Cause, Varieties, , j. £ x\. ^^ i r xi i j. j- 
 
 „ , uterus, diseases oi the liver and of the heart, predisposes 
 
 byniptoms. _' • . . 
 
 to their occurrence. They consist of little tumours of a 
 blue or dark-red colour composed chiefly of dilated veins, which appear 
 either just at the margin of the anus, partly within the sphincter muscle, 
 or higher up, well within the bowel and above the external sphincter 
 muscle. The symptoms and importance of these two varieties vary. 
 
 The first or external form of haemorrhoid is a more or less tender, 
 painful tumour which rarely bleeds, and causes generally merely a mod- 
 erate degree of pain and annoyance. The pile can be 
 
 „- J, -7 seen and felt at the margin of the anus as a dark-blue 
 Hccmorrnoids. _ _ ^ ^ 
 
 swelling which never retreats into the bowel. Attacks 
 
 of acute inflammation occur in such piles. There is often considerable 
 
 fever and constitutional depression and intense pain. The pile becomes 
 
 swollen, hot, red, tender, and very painful. It may even suppurate. 
 
 During an acute attack of inflammation there is nothing better than 
 
 rest in bed and the application of a large pad of gauze wet with lead-and- 
 
 opium wash, the formula for which was given under 
 Treatment. , , 
 
 Erysipelas. If suppuration occurs the abscess must be 
 
 opened. Kadical cure of these piles by cutting them off with a scissors is 
 
 simple. The operation can often be done with cocaine. 
 
572 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 Internal piles are much more serious, lu such cases the principal 
 
 symptom is bleeding, which may be so excessiv'e that the patient's strength 
 
 is greatly reduced thereby. The bleeding may be 
 
 Intenud almost constant, but usually takes place only when the 
 
 Ilcemorrhoids. . i • •" ^i -i r^ j. i 
 
 bowels move. .\t this time the piles oiten protrude 
 
 from the anus. They may become greatly swollen so that their reduction 
 becomes impossible and gangrene of the mass may result, sometimes ac- 
 companied l)y grave symptoms of septicaemia or by pyaemia. 
 
 The palliative treatment of internal piles consists in the avoidance of 
 
 constipation by the nse of la.xatives and the cnltivation of regular habits 
 
 in regard to the action of the bowels. A sedentary life 
 
 Trea men . ^^^^^ excessive eating and drinking are to be avoided. 
 
 The curative treatment consists in the operative removal of the piles by 
 one of several methods, for a description of which the reader is referred 
 to works on diseases of the rectum. AVlien properly performed, the 
 operation is not dangerous, and cure is usually effected. 
 
 FISTULA IN A NO. 
 
 A perforating ulcer within the rectum or an abscess close to the rec- 
 tum wliich is opened through the skin, or bursts into the rectum, or ex- 
 ternally, or both, is the cause of this condition. When 
 \andies and fQ^med, the disease presents three varieties. There may 
 be an unnatural passage through the tissues which com- 
 municates at one end with the rectum and ends at the other in a hole in 
 the skin near the anus. This is called a complete Jistula. There may be 
 an opening in the rectum and none in the skin. This is called a hlind 
 or incomj)Jde internal fistula. There may be an opening in the skin and 
 none into the rectum. This is called a hlijid or incomplete external fis- 
 tula. A certain number of these fistulfe are tubercular in charactei-. 
 Such are commonly associated with tuberctilosis of the lungs and 
 intestine. 
 
 The disease is essentially a chronic one, and gives rise to much pain 
 
 and discomfort. "When an external opening exists, more or less pus es- 
 
 ca])es through it. When the fistula is complete, gas and 
 
 semifluid intestinal contents find their way through the 
 
 external opening from time to time. 
 
 The treatment of fistula in ano of all three varieties is the same. It 
 
 consists of stretching the sphincter muscle and dividing the tissues which 
 
 intervene between the canal of the fistula and the gut. 
 
 rea men . r^^^^ unhealthy tissue which lines the fistula is then 
 
 scraped or cut away and the wound kept as clean as possible until it heals 
 
 from the bottom. Other forms of treatment are of doubtful efficacy. 
 
 The treatment of tubercular fistula in ano is the same, unless the dis- 
 
HERNIA: VARIETY OF FORMS. 573 
 
 ease of the lungs is far advanced and progressive, wlien palliative meas- 
 ures should be used. 
 
 CANCER OI*^ 'I'flE JIKCTUM. 
 
 This disease occurs after the fortieth year of life. The symptoms 
 
 come on gradually. They are constipation, a bearing-down feeling and 
 
 straining at stool, a discharge of blood and mucus from 
 Symptoms and , i i i i • rm i i 
 
 Diagnosis. "^® Dowel, and severe pain, ihe stools have sometimes 
 
 a ribbonlike shape. Diarrhoea occurs from time to 
 time. The diagnosis is made by inserting the finger into the rectum, 
 when a hard, often ragged mass will be felt within the bowel, which nar- 
 rows its calibre so that often the finger can not be passed through it. 
 These patients gradually lose flesh and strength, and die after intense 
 suffering from exhaustion or extension of the disease to other organs. 
 
 In a certain proportion of cases the diseased portion of the rectum 
 can be cut away Math success. A number of cures have resulted from 
 
 „ , , the operation. When this is not practicable on ac- 
 
 Ireatment. j- ^ • i • i 
 
 count of the size or high situation of the growth, an 
 
 artificial anus may be made on the left side of the belly low down or in 
 
 the loin. This operation gives the patient great relief and prolongs life. 
 
 HERNIA (RUPTURE). 
 
 The unnatural protrusion of an organ through the wall of a cavitv 
 which normally contains it is called hernia. In the case of the organs of 
 
 the belly the condition is vulgarly known as rupture. 
 
 Hernia oi the abdominal organs occurs m many situa- 
 tions. There are three in which it is far more frequent than the rest : 
 First, inguinal hernia. The intestine usually, or occasionally some other 
 
 organ, protrudes through the canal which normally ex- 
 
 Ingmnal Hernia. . , . ^ , . . , . . „ , „ 
 
 ists 111 the inguinal i-egion or groin for the passage of 
 
 the testicle and spermatic cord in the male, and the round ligament in 
 the female, pushing a pouch of peritonaeum in front of it, which subse- 
 quently becomes what is known as the hernial sac. A swelling is thus 
 produced in the groin, or in some cases the hernia travels farther down- 
 ward into the scrotum of the male, or into the labium majus of the 
 female. This is the most frequent form of hernia. It is much more 
 common in men than in women. Second, femoral hernia. The hernial 
 
 , ^ . protrusion takes place into the thiffh along the inner 
 l! emoral Hernia. ., „, \ -, •, •, -, , 
 
 Side of the great blood-vessels where they pass from 
 
 the abdomen to the thigh. The tumour appears below the fold which 
 
 separates the thigh from the abdomen, at the junction of the front with 
 
 the inner surface of the thigh. About one tenth of all herniaB are of 
 
 this variety. It is more common in women than in men. Third, um- 
 
574 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 bilieal hernia. The protrusion takes place thruugli the uaveL This form 
 
 of hernia occurs chietiy in infants and in middle-aged, fat women. There 
 
 are numerous other situations in which herniie occur, 
 Umbilical Henna. , , .. j> i • i i ^ • i 
 
 and each form of hernia has several anatomical va- 
 rieties, for a descri])tion of which the reader is referred to works on 
 surgery. 
 
 The symptoms of hernia are the sudden or gradual appearance of a 
 tumour in one of the situations above specitied. There is often a drag- 
 ging feeling in the abdomen and a moderate amount of 
 Si/mpfomsand .^^ ^^^^^ discomfort at the site of the liernial protru- 
 
 Frognosis. ^ • n i i ±- ^ • • 
 
 sion. If untreated, a considerable part oi the intestine 
 
 may descend into the liernial sac and give rise to a good deal of discom- 
 fort and deformity from the mere size of the swelling. In the majority 
 of cases when recent, and in some cases throughout the life of the in- 
 dividual, the protruded organs can be replaced by pressure in the re- 
 cumbent position. In many cases, however, if the hernia be habitually 
 allowed to remain unreduced, adhesions form between the intestine or 
 other or^an and the sac which contains it. The hernia can then no 
 longer be pushed back into the belly, but remains pennanently outside 
 in the hernial sac. 
 
 The mere displacement of the organs contained in a hernia does not 
 in itself constitute a dangerous condition, but every individual who goes 
 about with an unreduced hernia has nevertheless a sword constantly over 
 his head. He runs a grave risk of having his hernia become strangulated, 
 which means simply this : From causes which it is here needless to de- 
 scribe the contents of the sac get pinched at the point where the hernia 
 emerges from the belly, and when this occurs the tumour can no longer 
 be replaced. If it be a loop of intestine which is thus constricted, the pa- 
 tient suddenly has severe pain, becomes very ill, develops all the symptoms 
 of obstruction of the bowel, and, if not relieved, the contents of the hernial 
 sac become gangrenous, and the death of the individual is usually a matter 
 of a very few days. 
 
 The diagnosis of hernia is l)ased chiefly u]>on the situation of the 
 
 tumour, u]ion the fact that often it can be pushed back 
 Diagnosis. •^.^.1111 i i • i i • • ^ 
 
 into the l)elly, and upon a decided expansive impulse 
 
 transmitted to the hand which grasps the tumour when the patient coughs. 
 
 The diagnosis of strangulated hernia is l)ased upon the presence of a 
 tender painful swelling in one of the situations in which lieriiiiB occur, 
 and usually upon the presence of the symj)toms of intestinal obstruction. 
 There is no impulse on coughing. 
 
 Strangulated hernia can sometimes be reduced by gentle manipulation 
 of the tumour. This method is not practised at present except where 
 the hernia has been strangulated only a few hours and goes back after 
 
STRANGULATED AND NON-STRANGULATED HERNIA. 575 
 
 the gentlest manipulation. The administration of ctli(;r or c])lor(jforin 
 greatly facilitates reduction. When strangulation has existed for many 
 
 hours this method is dangerous ; a perforated or gan- 
 Treatment of Siran- , x- • i. i- i ^ ^ ^ ^ • 
 
 gulated Jlenua. g'-^»^"« 1^<>P ^^ mtestine may be pushed back into 
 
 the belly, or the manipulations may cause a rupture of 
 the already weakened wall of the intestine, or such additi(jnal injury 
 that perforation takes place after i-eduction has been accomplished. 
 In all of these instances death is almost certain to occur from perito- 
 nitis. 
 
 In case the strangulation is not very recent, the safest procedure is an 
 operation performed at the earliest possible moment. A cut is made 
 over the hernia, the sac is opened, the point of constriction is found, and 
 the constricting band is divided. If, now, the strangulated intestine re- 
 sumes its normal appearance with the return of blood to its vessels, it is 
 replaced in the abdomen and the wound closed by stitches in one of sev- 
 eral ways. If the gut is perforated or gangrenous, it is either left in 
 situ to slough off with the formation of an artificial anus, or the gangre- 
 nous part may be cut away and an artificial anus established at once ; or, 
 the gangrenous portion having been removed, the healthy ends of the 
 gut are united by stitches and returned to the abdomen ; or the gangre- 
 nous portion is left in situ, the belly is opened by another cut, and a loop 
 of intestine above the gangrenous portion is united to one below. Each 
 of these methods has its advantages in special cases. A choice is de- 
 termined by the local and general condition of the patient and the 
 operative skill of the surgeon. 
 
 The treatment of non-strangulated hernia is of two kinds. In re- 
 ducible hernia, a belt having a pad attached which presses upon the hernial 
 
 orifice and prevents the descent of the hernia is worn 
 Treatment of ^\^^y[^^^ the day and removed at night. Such a belt is 
 ly on-strangulated n . t i i t i ^ ^ • o 
 
 Hernia. called a truss. It should keep the herma from escaping 
 
 under all circumstances, and should be comfortable. In 
 very young subjects this treatment may result in cure. When the hernial 
 orifice is very large, and in irreducible hernise, its application may be im- 
 practicable. The other form of treatment is operation. The object to be 
 attained is obliteration of the sac into which the hernia descends, and 
 closure of the wound in such a manner, by means of stitches, that the 
 hernia can not recur. The fulfilment of this latter aim has occupied the 
 attention of surgeons throughout the world. Many operations have 'been 
 devised for the cure of hernia. None up to the present time can be said 
 to accomplish the desired result in every instance. Those which have 
 hitherto given the best results are the operation of Bassini, of Italy, and 
 that of William S, Halsted, of Baltimore, For a description of them 
 the reader is referred to recent works on surgery. A very large propor- 
 
5TG SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 tion of cases are tliiis cured — /. <., the hernia does not recur, and the 
 patient is not obliged to wear a truss. 
 
 The indications for operations on liernia are, first. stran<::ulation ; sec- 
 ond, inability to retain the hernia with a truss; third, when the hernia is 
 irreducible and the individual is prevented from pursn- 
 Luiiratiomforaud . j^.^ oecupatiou in conse.niencc thereof, or is sub- 
 against Operation. » . ,. , ,. i- • i i r 
 
 jected to pain, disturbances of digestion, and attacks oi 
 
 intlanuiKition in the hernial sac, or where new portions of intestine come 
 down from time to time which can not be kept replaced ; fourth, among 
 labourino; men, who often neglect themselves and fail to wear constantly 
 a properly fitting truss. 
 
 The contra-indications to operation arc, first, chronic alcoholism ; sec- 
 ond, a very lax, fatty, and flabby condition of the tissues of the abdominal 
 wall ; third, diseases which render any surgical operation more dangerous, 
 such as chronic disease of the kidneys, diabetes, etc. ; fourth, in cases of 
 very large and ancient hernia in which it may be impossible to replace 
 the intestine in the contracted abdominal cavity. 
 
 in'DROCELE. 
 
 A chronic inflammation of the sac which incloses the testicle, at- 
 tended by the gradual accumulation of watery fluid within the sac, is 
 called Injdrocele. The symptoms produced are chiefly 
 *' discomfort from the size and weight of the accumula- 
 
 tion. The diagnosis is made from the fact that the swelling is trans- 
 lucent when interposed between the eye and a briglit light. There is 
 no impulse on coughing. 
 
 The treatment is palliative, b}^ drawing off the fluid through a hollow 
 needle, after which it may be expected to reaccumulate ; or curative, by 
 opening the sac, destroying its inner surface with 
 iodine or carbolic acid, partly closing the wound by 
 stitches, and allowing the central ]iortion of it to heal from the bottom. 
 Confinement to bed for a week or ten days is necessary after the opera- 
 tion. 
 
 VARICOCELE. 
 
 Enlargement of the veins of the spermatic cord has received this 
 name. The enlarged and tortuous veins can be felt and often seen in tliL' 
 scrotum, resembling a bunch of worms. Dragging pain 
 is felt in the testicle, and sometimes there is wasting of 
 this organ. The disease usually occurs upon the left side. A considerable 
 degree of nervous apprehension and melancholy sometimes accompanies 
 this condition. 
 
 The treatment is palliative, by means of a suspensory bandage which 
 
COURSE OF THE BRACHIAL ARTERY. 
 
 hii 
 
 supports tlie testicles, cold l)atlis, physical (jxercisc, and toni(;s; and cura- 
 tive, by operative removal of tlie veins. The best and easiest operation, 
 in the oijinion of the writer, consists in cuttiriii; out an 
 
 TTGCitTYlCTht 
 
 inch or more of the dilated veins and sewing the two 
 stumps together, thus creating a natural suspensoi-y Iniudage. 'J'he wound 
 lieals very rapidly. 
 
 CIIAPTEP. XL 
 THE UPPER EXTREMITY AND AXILLA {THE ARMPIT). 
 
 The fractures and dislocations in the neighbourhood of the shoulder 
 joint have already been mentioned. 
 
 The most important tumours which occur in the vicinity of tlie 
 
 \ ■■f r^ A 
 
 Fig. 35. — ^Line showing the coukse 
 of the bkachial artery. 
 
 ElG. 86. — DiGITAI. COMPRESSION OF 
 THE BRACHIAL ARTERV. 
 
 shoulder joint are rapidly growing, malignant sarcomata of the humerus. 
 Amputation at the shoulder joint is the only treatment. 
 
 For contusions, sprains, and inflammations of the shoulder joint, see 
 Joints. 
 
 The main artery (the brachial) and veins of the upper extremity lie 
 upon the inner side of the limb. The course of the 
 artery is indicated, when the arm is held at right angles 
 to the trunk, by a line drawn from the bony point which 
 can be felt just beneath the collar bone near the junction of its outer 
 
 Tlie Brachial 
 Artery. 
 
57S SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 ;ind iiiiddle thirds i^the curaeoid process of tlie scapula), aloni^ the inner 
 side of the arm to the middle of the front of the bend of the elbow. 
 
 During the middle part of its course the artery can easily be com- 
 pressed against the bone by grasping the arm and pressing outward with 
 the lingers about half way between the front and the 
 
 ' *" '« * «. hack of the limb. The thumb may be used to make 
 
 (umpression. •' 
 
 counter-pressure upon the outer surface of the limb, or 
 
 tiie thumb may be used to compress the artery and the lingers for coun- 
 rer-pressure (see Figs. 35 and 3G). When compressing the artery near the 
 elbow joint the pressure must be exerted backward and outward. The 
 artery may also be controlled by the means described under haemorrhage 
 in general — /. e., by a tourniquet or elastic constrictor. Pressure upon 
 the main artery of the arm will stop bleeding from the forearm and hand. 
 Wounds of the large ve'nis of the ann. can he controlled hy direct 
 pressure with the fingev or H'itli u pad and handage applied over the 
 hi ending 2>oint. 
 
 The axilla or armpit is a fre(|uent site for boils and superficial ab- 
 scesses. Tliese often originate from want of cleanliness. The treatment 
 
 is early incision and an antiseptic dressing. The arm 
 The Axilla. i i/i i .• r 
 
 should be kept m a slmg. 
 
 Deep abscesses originating in the lymphatic glands of the axilla are of 
 frequent occurrence. Infection usually takes place from an inflamed 
 wound or abscess of the lingers, hand, or arm. Fever and prostration 
 are often marked. If the pus is not allowed to escape freely death is not 
 uncommon. The local symptoms of heat, redness, and swelling may be 
 masked at first by the deep situation of the abscess, but tenderness and 
 pain are always present to a marked degree and furnish a guide for the 
 incision. 
 
 Tubercular inflammation of the lymphatic glands of the axilla occurs 
 occasionally. The same painless, hard, slowly growing swellings are 
 formed here as in the neck. The treatment is extirpation of the affected 
 glands. 
 
 For diseases and injuries c)f the elljow, see -Joints. 
 
 WOUXDS OF THE FOREARM. 
 
 There are two principal arteries in the forearm. They are the end 
 
 l)ranches of the main artery of the arm, and are given off from that vessel 
 
 just below the bend of the elbow. They pass down the 
 Principal Arteries ^ ^ r ^t j^ ^^ x xi i.i 
 
 . ,, „ front ot the forearm, one on the outer, tlie otlier on 
 
 m the rorearm. _ '_ _ ' 
 
 the inner side of the liml). The pulsation of each can 
 l)e felt just above the wrist, about three quarters of an inch from the 
 outer and inner borders of the limb respectively. The outer one, the 
 radial artery, is commonly utilized for counting the pulse. 
 
WOUNDS OF THE FOREARM AND HAND. 579 
 
 ljleedin<J^ from these arteries may be fatal if uncontrolled. The means 
 of stopping such bleeding arc various. Pressure on the brachial artery 
 with fingers or tourniquet is usually efficient. Extreme 
 (Bmorriage. ^^^^ forcible bending of the elbow joint and fixation in 
 the bent position with a bandage may also be used. A pud in the bend 
 of the elbow renders this treatment more effective. Direct finger pres- 
 sure, or a tampon and a pad over the wound, will also accomplish the 
 same result. It should be borne in mind that a simple inelastic cord or 
 bandage tied about a limb above the bleeding point, without any pad to 
 make direct pressure upon the main artery of the limb, 
 is not a good means of controlling hsemori'hage. It is 
 not easy to shut off the arterial circulation by this means. The veins are 
 occluded while the blood is still passing through the arteries into the 
 hrab below the point of constriction. The limb becomes engorged with 
 blood at once. The blood can not get back to the trunk through the 
 veins, hence arterial bleeding continues, while bleeding from the veins is 
 increased. 
 
 Wounds of the forearm are often complicated by division of tendons 
 which transmit motion to the wrist, hand, and fingers. The upper ends 
 
 of the lower portions of the divided tendons can often 
 Division of Tendons , • ,i i mi ^ -i i t i • 
 
 •' be seen in the wound, ihey are white and fflistenine: 
 
 ana JServe Trunks. _ -^ & t? 
 
 cords. Some of the motions of the hand and fingers 
 are wanting or imperfectly performed. A surgeon should be seen in 
 such cases at any cost. Failure to sew together the divided tendons will 
 probably result in permanent disability. The large nerve trunks of the 
 forearm are sometimes cut. There are three of them : one accompanies 
 each artery, and the other lies alone along the middle of the front of the 
 limb. Their division is followed by some loss of motion or of sensation, 
 or both, in the hand and fingers. The cut ends should be sewed together, 
 if possible, lest permanent paralysis result. 
 
 WOUXDS OF THE PALM. 
 
 Wounds of the palm may bleed profuselj-. The bleeding may be 
 
 stopped by packing the wound with a tampon of gauze, and subsequent 
 
 firm closure of the hand over some hard substance, such 
 
 f-T .1 ^s a roller bandage, a stone or a piece of wood of suit- 
 
 able size. The fingers should be bandaged over the 
 hard body in order to maintain pressure upon the wound. A handker- 
 chief folded into a ribbon may be used for this purpose. 
 
 Division of tendons in the palm and back of the hand is followed by 
 loss or impairment of motion in some of the fingers. It is very im- 
 portant that the ends of such tendons should be sewed together. The 
 same is true of transverse wounds of both aspects of the fingers. 
 
580 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 Intlainod wounds of the palm of the haiul aw serious from the danger 
 of inflammation spreading to the sheaths of the tendons, and along these 
 sheaths into the forearm. Large, deep abscesses are 
 thus produced, and subsequent death of the tendons. 
 The dangers of septici^mia are considerable in such cases, and the separa- 
 tion of the dead tendons takes place only after tedious su]ipuration. The 
 functions of the hand are often greatly impaired. Such wounds should 
 be subjected to the most thorough disinfection, and early, long, deep cuts 
 should be made when necessary to provide for the escape of pus. The 
 cuts should be in the long axis of the limb, so that no tendons are 
 divided. Complete relief of all tension should be aimed at. When the 
 pus has spread into the forearm, the inflamed tendon sheaths should be 
 opened very freeh'. In severe cases it may be necessary to make an in- 
 cision which begins in the middle of the palm and extends to the middle 
 of the forearm, and such an incision will often save the patient the sub- 
 sequent use of his hand and prevent weeks of pain and suppuration or 
 death from septicaemia. In the writer's experience, a number of small 
 cuts and the insertion of drainage-tubes do not answer as well as very 
 free incisions in such cases. 
 
 TENOSYNOVITIS CREPITANS- 
 
 As the result of prolonged and violent use of the hand and wrist, the 
 tendon sheaths, most often on the back of the forearm, become inflamed. 
 The inflammation does not lead to suppuration, but to a dry and rough- 
 ened condition of the naturally smooth and moist sheaths in which the 
 tendons play. Slight swelling is noticeable along the back of the fore- 
 arm, and motion of the wrist and fingers is painful. If the palm of the 
 hand be applied to the back of the patient's forearm while he makes 
 active motions with his fingers, a peculiar creaking sensation is felt. 
 
 Recovery occurs in a few days under immobilization of the wrist and 
 fingers on a palmar splint, counter-irritation over the tendons with iodine 
 ointment, and pressure over the same with a firm pad and bandage. 
 
 GANGLION, VULGARLY "WEEPING SINEW." 
 
 A little elastic rounded lump appears suddenly or gradually, most 
 often on the back of the wrist on a line with the index finger, evidently 
 beneath the skin, to which it is not adherent. The disease is commonly 
 a sacculated dilatation of the lining membrane of the wrist joint. The 
 little swelling contains clear fluid. The communication with the joint 
 may or may not be obliterated. 
 
 Ganglion sometimes causes a good deal of pain on motion of the wrist 
 and considerable weakness of the hand. When this is the case it should 
 be removed entire through a small cut in the skin. The wound heals 
 
ACUTE SUPPURATIVE INFLAMMATION OF THE FINGERS. 581 
 
 rapidly and tlie operation results in cure. It can Ijc done painlessly witli 
 cocaine. Other forms of treatment are uncertain. 
 For fractures of the hand, see FractureH. 
 
 DISEASES OF THE HAND AND FINGERS. 
 
 Acute suppurative inflammation of the fln<):;ers may be^in in the soft 
 
 parts or in the bones. The l)acteria ordinarily enter through a wound in 
 
 the skin, often so minute as to escape observation. A 
 
 \,.' ' ' ;, ruptured blister, such as forms after unaccustomed 
 
 i< mgers : Cause. ^ . . 
 
 ■pressure and friction, or a little tear in the skin at the 
 side of the finger nail — a hangnail — are frequent ports of entry for the 
 germs of inflammation. Occasionally, though rarely, the inflammation 
 begins in the bone after a contusion, or in the course of multiple osteo- 
 myelitis. 
 
 A common site for these abscesses is the ball of a flnirer. Owinw to 
 the abundant nerve supply and the dense, firm character of the tissues, 
 
 the disease is very painful. The arrangement of tlie 
 
 f^f 00710813 t/ 1 O 
 
 connective-tissue bundles in the pulp of tlie fingers is 
 such that the pus tends rather to burrow deeply than to perforate the 
 skin, and there is great danger of the inflammation spreading to the 
 sheath of the flexor tendons of the finger, into the palm, and thence to 
 the forearm. Unless treated energetically, other tendon sheaths may 
 become involved, also the bones of the fingers. This is especially true 
 of the bone of the last joint of the finger, owing to its close anatomical 
 connection wuth the tendon which is attached to it. The tendons often 
 die and separate slowly by suppuration. Invasion of the bone neces- 
 sitates its removal or amputation. If the tendons are lost, the useful- 
 ness of the finger is, of course, greatly impaired. 
 
 The smallest wound or abrasion of the fingers should be disinfected 
 and covered with a film of cotton and flexible collodion, whenever this 
 
 ^ is practicable. When a superficial wound of a finsrer 
 
 becomes red and tender it should be dressed with a wet 
 antiseptic dressing of sugar-of-lead-and-alum solution or a solution of 
 ichthyol. AYlien the inflammation begins deeply and is attended by 
 swelling and throbbing pain in the finger, with a point of extreme tender- 
 ness, it is unwise to wait for more decided evidences of the presence of 
 pus. A small cut made at this time will save the patient from much suf- 
 fering and from a very much larger cut, or from several large cuts, which 
 would be necessary at a later period. Yery early incision of these ab- 
 scesses, followed by a w^et antiseptic dressing, is often attended by a rapid 
 disappearance of the inflammation and speedy healing of the wound with 
 a small scar. Delay is usually disastrous, from causes already mentioned. 
 
 Under no conditions is the use of poultices followed by worse results 
 
582 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 than in the treatment of these abscesses of the fingers. Extension of the 
 inflammation to the tenUon sheath is rendereil abnost certain, and the vi- 
 tabtv of the tissnes is so redneed that extensive slonghing or necrosis of 
 tlie soft parts of the linger is a regnlar eonsetjnenee. The writer lias seen 
 such a large number of fingers and even hands rendered almost useless by 
 this form of treatment that he can not condenm it too strongly. 
 
 Fish handlers, cooks, and occasionally others are subject to attacks of 
 inflammation of the skin of the fingers and hands, characterized by intense 
 redness, slight swelling, and moderate burning and itch- 
 Erysipeloid. .^^^ ^^ ^^^^ afiectcd skin. The borders of the iuflanuna- 
 tion are sharply marked, and the disease is peculiar in that it is apt to 
 spread slowly or rapidly from one finger to another and on to the back of 
 the hand. The parts h"rst affected may get well while the inflammation is 
 advancing elsewhere. The bactoria which produce the disease are found 
 on crabs and other shellfish. The disease is not dangerous, and treat- 
 ment with wet antiseptic dressings is followed by recovery in a few days. 
 
 Inflammation around the root of the finger nail— "runround," as it is 
 
 called— is caused by infection with pus microbes. The disease often 
 
 begins as a small abscess in the skin at one side of the 
 
 '^Runround." ^^^.^^ ,^^^;j ^^^^ infection is prone to travel slowly along 
 
 the base of the nail, causing it to become loose and act as a foreign body, 
 
 thus prolonging the inflammation. 
 
 In mild cases a little cut to let out any ]->us which forms, and a wet 
 antiseptic dressing, may suffice. In cases where the nail becomes loosened 
 from its bed it is best to remove the entire nail at once and to scrape and 
 disinfect the inflamed tissues thoroughly. Under less active treatment 
 the inflammation is sometimes prolonged for months. 
 
 A condensation and contraction of the subcutaneous fibrous tissue of 
 
 the palm and palmar surface of the ring and little fingers occurs, the 
 
 causes of which are not well understood. The disease 
 
 DxipniitrcH^s ^wn^ a very chronic course and show^s itself as a grad- 
 
 Coniacionuj e || increasing inability to straighten the fourth and 
 Palmar i anciu. ""■J » ./ ^ ^ 
 
 fifth fingers ; when of long duration, the fingers are 
 
 markedly and permanently bent toward the palm. The operative division 
 and removal of the contracted tissues is the only treatment. The results 
 of such operations are good. 
 
 Warts, which are true epithelial tumours of the skin, are common on 
 
 the hand and fingers. They may be removed by destroying them with a 
 
 drop of strong nitric acid. Care should be taken not to 
 
 \\arts. ^^^ ^^y ^^j^ ^^ ^l^g surrounding skin. When of large 
 
 size warts may be cut out bodily and the wound closed by a stitch. 
 
COMPRESSION OF THE FEMORAL ARTERY. 
 
 58;} 
 
 ciTArTp]R xn. 
 
 THE LOWER EXTREMITY. 
 
 For injuries of tlie joints and fractures, see chapters on these topics. 
 The main artei-y and vein of tlie lower extremity pass from tlie middle 
 of the front of the thigh at its junction with the trunk downward along 
 the inner side of the limb to the middle of the ham or 
 
 Wounds ; 
 Arterial Bleeding. 
 
 hollow at the back of the knee. Tlie artery can be con- 
 trolled temporarily by linger pressure as it passes over 
 
 the brim of the pelvis into the thigh in 
 
 the middle of the front of the limb. The 
 
 position of the artery can usually be de- 
 termined by its pulsation. Pressure must 
 
 be made backward, so as to compress the 
 
 vessel against the pelvic bone. Pretty 
 
 firm pressure is required, and it is diffi- 
 cult for one person to keep it up for more 
 
 than a few minutes uninterruptedly. The 
 
 wounded person must lie upon his back. 
 
 The one who controls the vessel stands 
 
 or kneels beside him. The best place to 
 
 apply a tourniquet to the thigh is at the 
 
 middle of the limb. The pad which is to 
 
 compress the vessel should be placed on 
 
 the inner surface of the limb about half 
 
 Avay between its anterior and posterior 
 
 borders. The course of the femoral ar- 
 
 ter}^ is indicated in Fig. 37. 
 
 The application of the elastic con- 
 
 FiG. 37. 
 
 Digital compressiox of the 
 femoral arteky. 
 
 strictor to the thigh has been described 
 
 under the treatment of hiemorrhage. Its application at a high point will 
 
 control arterial bleeding from the entire lower extremity. 
 
 Punctured wounds of the femoral artery are sometimes followed by 
 the formation of a traumatic aneurism. This very serious condition is 
 best relieved by ligature of the vessel above and below 
 the wound, and extirpation of the aneurismal sac. The 
 condition can be recognised by the formation of a pulsat- 
 ing tumour in the region of the wound. A whizzing sound can some- 
 times be heard, synchronous with the heart beat, by applying the ear to 
 the swelling. 
 
 The same general rules of treatment apply to wounds of this as of 
 other regions. 
 
 Traumatic 
 Aneurism. 
 
5S4 
 
 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 Tuberculosis of tlie hip joint (" hii>- joint disease"), beo-innin<; usually 
 
 iu the upper end of the thiuh bone, is common amoni;:; children. A 
 
 recognition of the early signs of the disease is impor- 
 
 Thtberenlosis of ^^^^.^ r^i^^ ^^.^^ svniptoin is slight pain and stilTness of 
 
 the Hip Joint ; , . . . . . , ^ t j. t i i. r 
 
 Sijmptom,'^. ^^^^ J*^^"^ ^" rising in the morning. Later a sliglit hmp 
 is noticed, and pain referred to the knee or hip. Grad- 
 ually deformity develops. The thigh is bent upon the pelvis and the 
 muscles become rigid and resist efforts to straighten the limb. 
 
 Fir.. 38. — Flexion ok tiik riiKiii ri-ox tiik i'elvis, in hip-joint diskask. 
 
 This condition is best recognised l)y laying the child on its back naked 
 upon a table, when it will be found that while the sound limb lies flat 
 ui)on the table the other remains a little bent at the knee and raised from 
 the surface upon which the body rests. If, now, the knee be pressed 
 downward so that the back of the limb rests upon the table, no motion 
 takes ])lace at the hip joint. The lower part of the spine bends forward 
 so that a hollow can be felt beneath the back, and the whole pelvis and 
 thigh move together as though no joint existed at the hip. (See Figs. 
 38 and 39.) 
 
 When the cliild stands erect the weight of the body is supported by 
 the sound limb ; the affected thigh is held a little bent. Viewed from be- 
 
 Fia. 39. — Lordosis, or b?;nl)Ing forward of the spinal column, in hip-joint disease. 
 
 hind, the furrow below the buttock is seen to be partly obliterated and to 
 droop on the affected side (see Fig. 40.) 
 
 As the disease progresses, the limb becomes more bent, rotated inward 
 and shortened. The further destructive changes in the 
 
 Ouflook an .^.^^ structures are similar to those already described 
 
 I TPdtllXPYht 
 
 under Tuljerculosis of Joints. The treatment is also 
 indicated in the same chapter. 
 
 The most important tuuKjurs which occur in the thigh are the malig- 
 
DISEASES OF THE LOWER EXTREMITY. 
 
 585 
 
 Bowlegs and 
 Knock-knee. 
 
 riant sarcomata of the tlii'f^li bone. Tlie disease often \>i','^]\\^ in the h^wer 
 
 part of the femur and leads to enlargement of the bone of a ratlier rapidly 
 
 progressive character. The treatment is amputation 
 Sarcomata of the , , , , ^ -, . ... rm i p 
 
 rnj ■ , J. through tlie Jnp joint, ina ciiances oi cure are not 
 
 good, but life may be considerably prolonged and ren- 
 dered more comfortable. A few cases are cured. 
 
 For injuries and inllammations of the knee 
 joint, see chapter on Joints. 
 
 Bowlegs and knock-knee are deformities the 
 appearances of wliicli are familiar to every one. 
 
 Both conditions are commonly 
 
 associated with rickets. When 
 
 present to a considerable degree 
 treatment is necessary. 
 
 In very young children treatment by apparatus 
 of various kinds may be successful. The opera- 
 tive treatment consists in breaking the crooked 
 bones with a mallet and chisel through a small cut 
 in the skin, setting the fracture in a good position, 
 and applying a fixed dressing of plaster of Paris. 
 In some cases it is necessary to remove a small 
 wedge of bone with its face directed toward the 
 convex side of the curvature. The bones may also 
 be broken without wounding the skin by means of 
 an instrument known as an osteoclast. The results 
 of all these operations are excellent. 
 
 Persons whose occupation obliges them to kneel 
 a good deal sometimes suffer from a chronic in- 
 flammation and enlargement of the little sac filled 
 
 M'ith watery fluid, which overlies and acts as a buffer 
 
 for the knee cap. The enlargement may become ex- 
 cessive, and attacks of acute inflammation, and even of suppuration, may 
 occur in and around the sac from time to time. 
 
 The treatment consists in the operative removal of the sac. The 
 operation is not dangerous, and results in cure. 
 
 Enlargement of the subcutaneous veins of the leg occurs usually in 
 persons who have to stand erect during much of the time. The enlarged 
 
 veins are increased in length as well as in diameter, and 
 
 . ems often form, when the individual stands erect, larsre, blue, 
 
 of the Leg : ' . i s ■> ■> 
 
 Symptoms. tortuous, cordlike masses, extending from the ankle to 
 
 the knee and sometimes to the groin. The subjective 
 
 symptoms are a sense of fulness and pain in the leg, and sometimes 
 
 severe cramps in the muscles. The changes produced in the nutrition of 
 
 Fig. 40. — Flexion of the 
 thigh and dkoopixg of 
 the furrow below the. 
 buttock on the affect- 
 ed side, in hip-joint dis- 
 EASE. 
 
 Housemaid's Knee. 
 
586 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 tlie skill of the leg and foot by the shiggi^^h circuhition of the blood in 
 tlie diseased veins are of more importance than the changes in the veins 
 themselves. Slight sources of mechanical and chemical irritation, which, 
 in a normal leg, would have merely a slight temporary effect, are not 
 recovered from, and ver}' commonly a chronic inliammation of the skin 
 is induced, which becomes acute from trifling causes. This chronic eczema 
 of the U(j^ as it is called, is one of the most troublesome conditions to 
 treat successfully which a surgeon meets. The itching and burning in 
 the skin of the leg which these patients suffer from is often intolerable. 
 
 Unless properly treated, a new and serious source of annoyance is 
 added after a time. A trifling bruise, an abrasion of the skin, or a slight 
 wound which iu a healthy individual would amount to nothing, fails to 
 heal, becomes inflamed, increases in size, and results in an intractable 
 ulcer, which heals only after the most painstaking care, extending often 
 over a period of many months. The ulceration is, of course, prone to 
 recur upon slight provocation. Occasionally perforation of the wall of 
 one of the dilated veins takes place, followed by violent bleeding, which 
 may be dangerous if not controlled. The chronic ulcers sometimes be- 
 come the seat of cancerous degeneration. 
 
 From infection with pus microbes attacks of inflammation may occur 
 around the dilated veins, sometimes resulting in abscess ; or the wall of 
 the vein itself may be involved, and obliteration of the vein may take 
 place as a consequence ; or the infected clot which forms within the vein 
 may soften and enter the general circulation, causing pyaemia. 
 
 The treatment of varicose veins of the leg is palliative and curative. 
 The palliative treatment consists of measures intended to improve the 
 circulation in the limb, and to prevent further increase 
 in the size and number of the dilated veins. To 
 this end the patient may wear a carefully applied roller bandage, ex- 
 tending from the bases of the toes to the knee. This should be worn 
 constantly during the day and removed at night. Or, better, an elastic 
 stocking, made to fit the limb of the individual, with a thin cotton stock- 
 ing beneath it, next the skin. Pure rubber bandages, applied like a 
 roller, are effective, but usually irritate the skin. The curative treatment 
 consists in the operative removal of the enlarged veins. It is only appli- 
 cable in a certain proportion of cases, and recurrences are not uncommon. 
 
 For the eczema a large number of local remedies are used in the form 
 of lotions and ointments. During acute attacks of moist eczema, in 
 which the skin is intensely red and covered with blisters M'hich burst 
 and discharge a large amount of watery fluid, rest in bed with the liuil) 
 elevated, and the application of cloths kept wet with a three-per-cent. 
 solution of ichthyol, is useful. When the acute symptoms subside some- 
 what, an ointment of zinc oxide (ten per cent.), containing salicylic acid 
 
ECZEMA OB' THE LEG. FLATFOOT. 587 
 
 (two per cent,), applied freely to the litnb and covered with ^auze and 
 a bandage, may be used. 
 
 Water shonld not be applied to the inflamed skin, nor should corro- 
 sive-sublimate solution be used to wash it. Before each dressing, the 
 crusts which form, composed of dried discharges and dead skin, should 
 be gently softened and removed with a cloth soaked in olive oil or liquid 
 vaseline. When the inflammation of the skin is chronic, various stimu- 
 lating ointments are used, such as diachylon ointment, or a ten-per-cent. 
 ichthyol ointment containing one or two per cent, of tar. 
 
 The chronic ulcers demand very careful treatment, which can usually 
 be carried out successfully only by a surgeon. They must be kept clean 
 and dressed frequently. Various stimulating applications are applied to 
 the raw surface, such as powdered naphthaline and Peruvian balsam. 
 When the new tissue on the surface of an ulcer which is healing grows 
 above the level of the surrounding skin, producing proud flesh, as it is 
 called, it may be touched lightly with a stick of nitrate of silver. A 
 flrmly applied bandage must be worn throughout the treatment. These 
 chronic ulcers sometimes become very large, and may completely sur- 
 round tbe limb. In these cases excision of the ulcer and the application 
 of skin grafts to the raw surface gives good results. Great care must be 
 taken in the treatment of chronic ulcers to get the raw surface and the 
 surrounding skin in an aseptic condition and to keep them so. To this 
 end the same precautions are taken which were described in the treat- 
 ment of wounds. Hands, dressings, and instruments must be scrupu- 
 lously clean ; the eczematous skin must, however, be protected as far as 
 possible from contact with irritating antiseptics. Rest in bed and eleva- 
 tion of the limb often render possible the healing of an ulcer which could 
 not otherwise be accomplished. 
 
 For injuries and diseases of the ankle joint, see chapter on Joints. 
 
 Flatfoot is a painful affection which depends upon a weakness of the 
 structures which support the arch of the foot. The arch sinks in conse- 
 quence, and the foot becomes flattened and displaced 
 outward. It occurs usually in persons whose occupa- 
 tion requires them to spend much of their time standing. 
 
 The treatment consists in the introduction of a suitably arched steel 
 spring into the sole of the shoe, thus furnishing an artificial support for 
 the stretched and weakened ligaments and muscles. In extreme cases, 
 associated with marked outward displacement of the whole foot, the de- 
 formity can sometimes be corrected by removing a wedge of bone from 
 the inner side of the foot. 
 
 Bunion is a deformity of the great toe produced by wearing narrow- 
 pointed shoes. The great toe is crowded outward ; an angular displace- 
 ment of the whole toe is gradually produced at the joint between the toe 
 
nSS SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 aud tlie foot proper. The tendons of the toe are di&placed to the outer 
 
 side, and the joint between the bone of the foot and the first bone of 
 
 the great toe is seriously altered. The ends of the 
 Bunion. , , i i ^ t i- ^ ■ • ^ 
 
 bones are enlarged and the ligaments oi the joint are 
 
 thickened. Over the projecting lower end of the bone of the foot there 
 
 is often formed a little sac of fluid — a bursa — beneath the skin. From 
 
 continued pressure, attacks of inflammation occur in the bur.-a Avhicli are 
 
 very painful. Occasionally infection and suppuration with the formation 
 
 of an abscess take place. 
 
 Prevention by the wearing of jiroper shoes is important. AVhen the 
 
 deformity is only slightly developed, a properly shaped slu»e will usually 
 
 be all the treatment necessary. Acute attacks of inflam- 
 I'reatment. . . , , / , . i i , i 
 
 mation m the bursa may be tivated by rest and wet 
 
 dressings. If an abscess forms it should be opened. AVlien the defor- 
 mity is marked, the only satisfactory treatment consists in removing the 
 enlarged lower end of the bone of the foot, followed by replacement of 
 the toe in a straight position. The results of this operation are good. 
 The various apparatus devised for the treatment of bunions are generally 
 ineffective. 
 
 Ingrowing toe nail is caused by wearing ill-fltting and tight shoes. 
 
 The skiu on one or both sides of the great toe nail is jjressed against the 
 
 sides of the nail until tenderness, inflammation, and ul- 
 
 7V' I //' , i ceration of the compressed fold of skin are produced. 
 
 The great toe nail should be trimmed straight across 
 
 the end of the toe and not cut too short. The shoes should be wide 
 
 enough to prevent the toes from being crowded together. When once 
 
 developed, the most effective treatment is the operative removal of the 
 
 skin at the side of the toe. This operation results in cure. 
 
 For chilblains, see Frosthite. 
 
 The deformities of the foot and ankle which have received the name 
 of clubfoot are of several types, in the most common of which, known 
 as equino varus^ the front part of the foot droops. The 
 sole of the foot looks iuM^ard, and the front part of the 
 foot is rotated inward about a vertical axis, Avhicli passes through the 
 smaller bones of the ankle. The patient walks upon the outer border of 
 the foot, and in neglected cases upon what should be the upper surface 
 of the foot, or instep. 
 
 Pes erpiinus^ or horse foot, may exist alone, in which case the front 
 part of the foot droops, the patient walks upon his toes, and in extreme 
 eases upon the upper surface of the foot. 
 
 The opposite of pes vav^s is called 2)en valgus. In this case the sole 
 of the foot looks outward and the patient walks upon the inner border of 
 the foot. 
 
DEFORMITIES OF THE FOOT AND ANKLE. 589 
 
 In tlie deformity known 'a.?, ])eH calcanettfi, tlie opposite oi pes equinuH, 
 the front part of tlie loot is drawn n[)ward aii<J the jmtient walkb upon 
 the heeh 
 
 There are several ways in whicli these different kinds of deformity 
 may be combined. A ]ar<^e number of cases of clubfoot are congenital — 
 i. e., the children are born with one or moi-e groups of muscles too short, 
 so tliat the foot can not be brought into the natural position for walking. 
 Otlier cases result from paralysis of certain grou])s of muscles due to dis- 
 ease of the spinal cord. Pes equinus, or drop foot, is often due to want 
 of care in cases of long illness in bed, in which the patient's feet are 
 allowed to fall downward from their own weight, as was mentioned in 
 the treatment of fractures. Fractures and unreduced dislocations in the 
 neighbourhood of the ankle joint may also result in one or other form of 
 clubfoot. 
 
 The sooner children born with clubfeet are put under treatment the 
 better. The treatment is mechanical and operative, usually a combina- 
 tion of both. The former method is suitable for cases 
 of slight and moderate deformity. The child's foot is 
 forcibly placed in better position and held there by some form of fixed 
 apparatus, such as plaster of Paris. The apparatus is frequently re- 
 moved, and active and passive movements are practised. A new appa- 
 ratus with the foot in still better position is applied from time to time, 
 until the deformity is completely ovei'come. In more severe cases this 
 treatment is combined with cutting of the shortened tendons and other 
 structures which maintain the malposition. ( 
 
 It is important that the deformity should be corrected before the child 
 begins to walk, because if walking is commenced with the foot in a bad 
 position the deformity will usually be increased thereby, and finally the 
 bones of the foot and ankle will develop in an imperfect and deformed 
 way, so that a cutting operation involving the removal of portions of the 
 ankle bones will be necessary before the patient can tread properly upon 
 the sole of the foot. The results of such operations, even in adults, are 
 good. 
 
51)0 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 CHAPTER XIII. 
 DEATH AND THE ST(^XS OF DEATH. 
 
 CoNTiNrANCE of life depends chiefly upon the maintenance of the 
 function of the lungs (breathing^ of the function of the heart (the circula- 
 tion of the blood), and of the functions of the brain. Cessation of breath- 
 iu^r or of the circulation of the blood are speedily followed by death. 
 When breathiiit:: is first affected, we speak of death from apnoea or from 
 
 asphyxia; when the heart gives out first, we sj)eak of 
 
 Immediate Causes j .1 r i \i i- j.- x ^.i 1 • 
 
 , ,, ,, death irom svncope : when tlie tunctions ot the brain 
 
 of Death. > r ' . 1 <• mi 
 
 are first paralyzed, we speak of death from coma. The 
 
 activity of the brain may, however, be to a great extent in abeyance, and 
 
 yet life may continue so long as those portions of the brain which control 
 
 breathing and the action of the heart perform their functions. 
 
 AVhen air is completely cut off" from the lungs, as in drowning, as- 
 ]ihvxia comes on in from one to two minutes, and the individual becomes 
 unconscious. The heart continues to beat for a short time after breath- 
 ins: has ceased, and death occurs in from three to five minutes from the 
 beginning of the process. There are some authentic cases in which, 
 under unusual circumstances, life has been prolonged for a greater period, 
 but such cases are exceptional. 
 
 The answer to the question. Is an individual really or only apparently 
 dead ? is rarely difficult. The more or less widespread dread of prema- 
 ture burial has little or no foundation in fact. The 
 Signs of Death. . j. i ,1 <■ n 
 
 Signs 01 death are as lollows : 
 
 First, cessation of breathing. The movements of the chest and 
 diaphragm during respiration are so evident that even a cursory examina- 
 tion could hardly fail to detect them. In any case, the application of tlie 
 ear to the chest wall will demonstrate the presence or absence of the soft, 
 blowing sound — the so-called respiratory invrmur- — which is produced by 
 the air entering and leaving the lungs. 
 
 Second, the beating of the heart, which ceases a few seconds or even 
 minutes after breathing has stopped, is not so evident to the untrained. In 
 tliis case the ai)sencc of pulsation in the large arteries of the neck and at 
 the wrist, and of the heart sounds, normally heard on applying tlie car to 
 the left side of the chest in front, are quite sufficient proof of death. 
 There are a few cases on record in which breathing and respiration were 
 carried on so faintly that an ordinary examination failed to detect their 
 presence, but these have been extremely rare, and the recognition of the 
 other signs of death which soon ensue would render the decision easy and 
 positive after a short time in any instance. 
 
THE HIGNS OF DEATH. 59I 
 
 Third, cooliiip^ of tlio body. After death tlif; t(!rnj)oratnro of the hody 
 gradually falls until it bocoiiies equal to that of the siii-i-oiiridiriL'' aii-. The 
 rapidity of tliis change is modified hy a nuiid)cr of circutnstanccs — tlio 
 touiperaturc of the air, the size of the body, and the presence or absence 
 of clothing or other covering. On the average, the tenriperature has been 
 foond by experiment to fall about 4° Fahr. for tlie first three hours after 
 death, '6° per hour for the next six hours, and more than ]° per liour 
 after that. In general, after ten or twelve hours the temperature of the 
 body will have fallen to that of the surrounding air. After certain forms 
 of death the cooling of the body is retarded. This is generally true of all 
 forms of sudden death except drowning. In cases of death from chronic 
 diseases cooling is rapid. The importance of this sign of death, however, 
 rests more upon a gradual and continuous cooling of the body than upon 
 any observed degree of temperature. 
 
 Immediately after death the eye loses its lustre. The cornea often 
 becomes a little milky in appearance, and the eyeball loses its firmness and 
 elasticity on pressure. There is also immediately after death an ashy pallor 
 of the surface of the body and a general relaxation of the muscular sys- 
 tem. The limbs can be moved in any direction easily. The lower jaw 
 falls. The muscles still retain their irritability for some time, and will 
 contract on the application of an electrical current. 
 
 Following the changes above described, and preceding decomposition, 
 are certain physical alterations in the soft parts of the body which are im- 
 portant signs of death. The soft parts lose their elasticity so tlvat they do 
 not regain their shape after being pressed upon ; thus the surface of the 
 body retains the impi-int of the irregularities of the surface upon which it 
 has been lying, or, if the surface was smooth, the portions of the body 
 which were resting upon it remain flattened. 
 
 Another still more characteristic sign is the so-called rigor mortis or 
 
 stiffness of death. This change comes on in from eight to thirty hours 
 
 after death — on the average, about twelve hours. Its 
 Rigor llortis. ,,. . n_c^j , n i. 
 
 duration is generally irom twenty-iour to thirty-six 
 
 hours. It is due to a general hardening of the muscles such that the 
 whole body becomes rigid. The joints can not be bent without consider- 
 able effort, but when once bent the limb remains flexible. The stiffness 
 does not return. This positive sign may serve to distinguish real death 
 from cases of so-called trance and catalepsy, in which latter condition the 
 limbs can be moved in any direction without difficulty, but remain mo- 
 tionless for an indefinite period in any position in which they may be 
 placed. 
 
 There are other signs of death of minor importance, but they are 
 hardly necessary in order to arrive at a decision. For them the reader is 
 referred to works on medical jurisprudence. 
 
592 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 After a varialtle period, de]>eiuling cliietly u}k>ii tlie relative degree of 
 heat and moisture to which the body is exposed, the last series of changes 
 occur, which, beginning with putrefaction, end in the 
 complete decomposition of the organic or carbon-con- 
 taining constituents of the organism. The end products consist chiefly of 
 water, carbonic-acid gas, and ammonia. Numerous other products are 
 formed during the process, some of which are gases possessing the 
 characteristic odours of putrefaction. 
 
 In general, putrefaction begins soon after rigor mortis has disappeared. 
 The signs are usually lirst seen on the lower part of the belly and groins, 
 as a greenish-yellow discoloration of the skin. The superficial veins are 
 often visible as brownish-red bands on the surface. The discoloration is 
 next observed upon the face and neck, lastly upon the arms and legs. In 
 cases of drowning, however, the discoloration usually first makes its ap- 
 pearance on the face and upper portion of the trunk. The formation of 
 gases beneath the skin accompanies the discoloration and causes a rapidly 
 increasing swelling which often reaches an extreme degree before the 
 gases find an outlet. After a time the yellow and red discoloration of 
 the surface changes to brown or black, and gi-adually all the soft tissues 
 are converted into a semifluid, black mass. 
 
 AVhen exposed to water or placed in a vei-y damp soil, dead bodies 
 
 occasionally become converted after some months into a fatty substance 
 
 combined with ammonia, adipocere — in fact, into soap. 
 
 * This substance is white or yellow in colour. The form 
 
 of the 1)ody is usually well preserved. 
 
 jMnmmification consists of a rapid evaporation of the w^ater contained 
 
 in the bod v. It occurs wdien a dead body is exposed to 
 Mummification. , • /' i • i . , mi i i i i • 
 
 dry air at a liign temperature. llie whole body is 
 
 shrivelled and of a brown or yellow colour. The odour of putrefaction 
 
 is absent. 
 
 CHAPTER XIV. 
 TRANSPORTATION OF THE INJURED. 
 
 "When an individual is injured the problem of moving him to a place 
 of safety comfortably, easily, speedily, and without further injury is often 
 a difficult one to solve, and yet of great consequence; The temporary 
 dressings and splints which may be applied to protect the injured part 
 have alreadv been described. 
 
TRANSPORTATION OF THP: INJURED. 
 
 rm 
 
 In the absence of an ambulance some f(^nn of sfrctcljcr upon which 
 
 the patient lies at full len<^th and is carri(;d by two or four men, stationed 
 
 one or two at either end of the apparatus, is the most 
 
 Tmprovismff a convenient means of accomplishin'r this. Doors, win- 
 
 Strdcher. , i -i i i 
 
 dow blinds, boards naded to,ii;ether, mattresses, benches, 
 
 tables, two saplings lield twenty to twenty-four inches apart by cross- 
 pieces at either end, upon which framework a blanket, a bedtick, or a 
 piece of carpet may be sewed, nailed, or tied, may all be used for tliis 
 purpose. During an Indian campaign it is said that General Jackson 
 carried the wounded on litters made of the skin of oxen strung between 
 two guns or poles. In the absence of a blanket or other cloth, withes 
 or cords may be used to form the floor of the stretcher. 
 
 If a horse can be procured, two long poles or saplings may be used to 
 form a travois or litter upon which the patient lies (see Fig. 41), 
 
 Fig. 41. — The travois. 
 
 Carrying the 
 Patient. 
 
 The bearers of a litter should walk with short sliding steps. Except 
 when the patient is in a condition of shock his head should be supported 
 by a pillow. In wounds of the abdomen the patient 
 should lie upon the injured side or upon his back with 
 the knees bent and a pillow placed behind them to 
 maintain this position. In injuries of the upper extremity the patient 
 should lie upon his back with the limb resting at his side or across his 
 body, or upon the sound side with the limb resting on the body. In 
 wounds of the lower extremity the patient should lie upon his back. The 
 litter should be kept horizontal in passing from one level to another. In 
 general, the patient should be cai-ried feet foremost, except when going 
 up hill. In fractures of the lower extremity, however, the patient should 
 be carried feet foremost when going up hill, head foremost when going 
 
 down. 
 
 40 
 
5S)4 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 Fjo. 43.— Patient aci:oss iiA.;K. 
 
 I'lU. 45. Twu-llA.\UJiD SEAT. 
 
GONORRHOEA, SYPHILIS, AND CHANCROID. 505 
 
 In placing a sevci'oly injured [)crson upon a litter, two, or Ijettor three, 
 persons should pass tiieir arms beneath him, lifting and supporting the 
 head and shoulders, trunk, and lower extremities, respectively. Figs. 42, 
 4y, 44, and 45 illustrate several modes in which an injured person can ha 
 carried without a litter. 
 
 CIl AFTER XY. 
 VENEREAL DISEASES. 
 
 There are three diseases which may be acquired through impure 
 sexual contact : they are gonorrhoea, syphilis, and chancroid. Gonorrhfjea 
 is usually acquired from sexual contact, but there are numerous undoubted 
 instances where individuals have taken the disease in other ways. 
 Syphilis is usually acquired by sexual contact, but the number of cases in 
 which the inoculation occurs in other ways is relatively very large. 
 Chancroid is rarely acquired except by sexual contact. 
 
 GONORRHCEA. 
 
 Gonorrhoea is a purulent contagious inflammation of the mucous 
 membrane of the genital tract, occasionally of the mucous membrane of 
 the eye, rarely of the rectum, caused by a special microbe, the " gonococ- 
 cus." The seat of the disease differs in the two sexes. In males, the in- 
 flammation affects the urethra primarily, but often extends later to other 
 regions, which will be spoken of under complications. 
 
 The symptoms and course of the disease are as follows : From two to 
 
 ten days after exposure the individual notices some swelling, redness, and 
 
 itching of the orifice of the urethra, followed in a few 
 Siimpioms and , i ,i ji •^^ j- ^ t^ • 
 
 tl k hours by the appearance of a milky discharge. L rma- 
 
 tion is decidedly painful. After a day or two the 
 discharge becomes abundant, thick, and creamy, and pain during uri- 
 nation intense. There may be fever and some prostration. The in- 
 flammation gradually travels backward, all the symptoms increasing in 
 severity, until it reaches that portion of the canal which separates the 
 front part of the urethra from the posterior part or neck of the blad- 
 der. This occurs usually after two weeks or more. In the minority of 
 cases the disease extends no further. In the majority of cases the pos- 
 terior portion of the canal (the neck of the bladder) also becomes involved. 
 When this occurs new symptoms are added. The patient is obliged to 
 urinate with great frequency, and the final closure of the neck of the 
 bladder as the last drops of urine are expelled is attended by severe pain, 
 sometimes by the passage of a few drops of blood. 
 
59G SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 AVhen tlie frout part of the eaiml alone is affected, the severity of the 
 symptoms begins to abate after two or three weeks or more. The dis- 
 charge becomes more watery, urination less painful, and after a very 
 variable period recovery may take place ; or, in many instances, all the 
 acute symptoms disappear, but the inflammation persists as a chronic 
 process in the deeper portion of the anterior tiirtlira, constituting the 
 disease known as chronic yoiarrhmi or yleef. 
 
 In this condition the oidy symptoms may be a single drop of white or 
 yellowish discharge which the patient notices in the orifice of the urethi-a 
 upon rising in the morning; or this may be absent, and the only evidence 
 of disease may be the presence of shreds of mucus and pus seen swim- 
 ming in rlio urine when the patient empties his bladder into a glass vessel. 
 The disease may persist in this form for months or for many years, and 
 remain contagious to the end. The recognition and treatment of the 
 chronic form of gonorrhea in men is of great consequence, because per- 
 sons so affected are the cause of untold suffering among many innocent 
 wives. 
 
 The occurrence of such a chronic inflammation is favoured by want 
 of treatment, by improper treatment, by indulgence in alcohol, by sexual 
 indulgence, by a narrowing of the calibre of the urethra. 
 
 When the inflammation involves the neck of the bladder, it is more 
 difficult to cure. It is very apt to become chronic, and to be attended by 
 serious complications. 
 
 The complications of gonorrhosa are very numerous. Among them 
 may be mentioned inflammation of the epididymis, a portion of the testis. 
 This condition, when it occurs in both testes, is often 
 followed by permanent sterility — i. «., inability to beget 
 offspring ; inflammation and sometimes abscess of the prostate gland 
 which surrounds the deep urethra ; inflammation of one or many joints 
 throughout the body of an intractable character ; inflammation of the 
 tubes which carry the urine from the kidneys to the bladder ; inflamma- 
 tion of the kidneys ; pytemia ; septicemia. Perhaps the most serious 
 and fatal result of gonorrh(ea in the male is the formation of scar tissue 
 surrounding the urethra, resulting in a progressive narrowing of the 
 calibre of the canal, producing what is known as stricture of tJie urethra. 
 This condition follows the large proportion of cases. 
 
 Stricture following gonorrlujea may be limited to a single short sec- 
 tion of the urethra, or there may be several narrowed portions, or the 
 
 whole canal may be converted into a hard, unyieldinc: 
 Stricture. "... . ' ./ (-• 
 
 tube of greatly diminished calibre. The symptoms pro- 
 duced by stricture are due to the obstacle which the narrowed portion of 
 the canal presents to the free flow of urine. The individual most often 
 presents himself for treatment on account of the persistence of a urethral 
 
STRICTURE, ACUTE AND CHRONIC GONORRHCEA. 597 
 
 discharge which resists onJiiiary curative measures, or on account of a 
 urethral discharge of a (;liroiiic character wliich lias made its appearance 
 years after tlie original infection, and lias follow(;d indiilgence in coitus or 
 alcohol. 
 
 If untreated, the strictured portion of the canal usually becomes 
 gradually narrower, until finally there exists a well-marked mechanical 
 obstacle to the flow of urine. The individual finds that it takes liim 
 longer to urinate than formerly, that the stream is not projected with the 
 same force, and that he must sti-ain somewhat to em])ty his bladder. At 
 this period excess of any kind may be followed by an attack of what is 
 known as retention of urine — i. e.^ the individual finds himself with a 
 full bladder and unable to empty it. Should he persist in his efforts, the 
 thinned and dilated urethra behind the stricture may burst ; the urine 
 then escapes into the loose tissues of the parts, decomposes, produces a 
 gangrenous inflammation and a rapidly fatal septicaemia, unless early re- 
 lief by operation is afforded. Serious changes are also pi'oduced in the 
 bladder by the mechanical obstruction to the flow of urine, and a narrow 
 stricture of the urethra which exists for years untreated inevitably results 
 in degenerative changes in the kidneys which not infrequently cause 
 death. 
 
 While the intelligent treatment of gonorrhoea in the male can be car- 
 ried out only by a physician, some of the methods used may be men- 
 tioned here. The object of the treatment in acute cases 
 
 Q -L ^s to destroy as soon as possible the microbes which are 
 
 producing the inflammation. This can be accomplished 
 in a fairly satisfactory manner in some cases by washing out the urethi-a 
 at frequent intervals with a weak antiseptic solution. The most effective 
 is, perhaps, a solution of cori'osive sublimate, one part to 20,000 to 30,000 
 parts of water, according to the tolerance of the individual. Large quan- 
 tities of a weak solution are better than smaller amounts of a stronger 
 one, which is apt to produce an intensely painful and sensitive condition 
 of the mucous membrane. Unfortunately, the gonoeocci soon multiplv 
 in the deeper layers of the mucous membrane, and we possess at present 
 no antiseptic which can be used in sufficient strength to I'each them in 
 this situation without producing untoward results. When seen very early, 
 gonorrhoea can sometimes be cured by the use of corrosive sublimate in 
 ten days or a fortnight. In the majority of cases the disease lasts, under 
 any form of treatment, for six weeks or more. Chronic gonorrhoea is 
 best treated by the division with a knife of narrowed points in the canal, 
 by the application of solutions of nitrate of silver to the inflamed por- 
 tions of mucous membrane, and by the introduction into the urethra of 
 steel instruments which dilate the canal. 
 
 (^f the treatment of the complications of gonorrhoea- we shall men- 
 
50S SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 tion only that of strictiii-o. In a lariic pi-oportion of cases this condition 
 can be cured permanently by a cutting ojieration. In some cases the 
 narrowed portions of the canal can be stretclied gradually to a normal 
 size by the introduction through them of smooth steel instruments known 
 as sounds. Oeca^iionally this treatment elYects a cure. Generally, liow- 
 ever, the sounds must be introduciHl from time to time throughout the 
 patient's life. 
 
 i\^() man ich.o has had (jojiorrJuea nJundd marry ludil he has heen^i 
 msured hy a competent surgeiyri that he is free from contayioit. 
 
 Gonorrhoea in the female affects the mucous membrane of the vulva, 
 
 the urethra, the ducts of the glands of I-]artholin — two glands as large as 
 
 peas, which lie on either side of the entrance to the 
 In the Female. . rni i r -i. j i. i.i 
 
 vagina. I he process may be limited to these regions, in 
 
 which ca>e it is quite readily cured. In a large proportion of cases, how- 
 ever, the mucous membrane of the uterus becomes involved, and later on 
 that of the Fallojipian tubes, and finally there occur from time to time 
 attacks of localized peritonitis. These serious conditions result generally 
 in chronic invalidism and sterility, and often necessitate the operative re- 
 moval of the diseased Falloppian tubes and of the ovaries as well, in order 
 to relieve the individual from her constant suffering. 
 
 Many cases of gonorrhoea in -women result from intercourse with 
 husbands previously infected and never cured. The contagion is trans- 
 mitted ignorantly doubtless, in most instances, but the results are none 
 the less deplorable. 
 
 SVPIIILIS. 
 
 Syphilis is a contagions constitutional disease, usually acquired by 
 sexual contact. Its cause has not been definitely determined, but syphilis 
 presents so many points of analogy v\dth tuberculosis, 
 and other diseases the causes of which are known to 
 be the presence and growth in the tissues of microbes, that we are justi- 
 fied in believing that syphilis also has a similar origin. Whatever the 
 cause may be, the blood of a person with active syphilis, as well as the 
 discharge from any sore existing during the active period of the disease, 
 is contagious. A solution of continuity of the skin or mucous membrane, 
 if only of microscopic size, is snfficient for the entrance of the poison 
 into the system. After the inoculation is made the wound heals promptly 
 and there is no evidence of any trouble for a ])criod which varies from 
 two to six weeks. 
 
 At the end of this period of incubation, as it is called, there forms at 
 the site of the inoculation a lump or nodule, the xyphdit'ic chancre. Its 
 character varies somewhat according to the site of inoculation. In some 
 situations the nodule is very hard, in others rather soft. In a majority 
 
SYMPTOMS AND OUTLOOK OF SYPHILIS. r/>9 
 
 of the cases ulceration of tlie KurfVutc of tli(; noiliik; takes place. The 
 
 ulcerated surface resembles raw liuin in colour, and discharges a little 
 
 watery fluid which is often blood-stained. The cliancre 
 Symptoms. . .', • ,• i , , i . . t . „ 
 
 is neitJier painful nor tender unless irritated or inllarned 
 
 by improper applications to its surface. Following the appearance of the 
 
 chancre the neighbouring lymphatic glands become enlarged and hard. 
 
 Such enlargements are usually painless, and but slightly tender. Two or 
 
 three months after the appearance of the chancre the poison lias reached 
 
 the general circulation and disseminated itself tliroughout the body. 
 
 Slight fever and malaise are not uncommon at this time. 
 
 There now follow a series of characteristic eruptions upon the skin 
 and mucous membrane of the mouth and throat. The skin eruptions 
 vary a good deal in their character and date of appearance. In many 
 cases the history of their occurrence is as follows: About six or eight 
 weeks after infection, pinkish spots, not elevated, which almost fade 
 when pressed upon with the finger, appear successively on the cliest, abdo- 
 men, back, extremities, and face. The spots disappear in a few days or 
 weeks and may give place to a general eruption of small, dull-red nodules, 
 which have a light-brown colour when pressed upon ; or, instead of these 
 nodules, numerous pustules appear upon the skin, each one of which 
 dries and becomes covered with a scab or crust. The spots, nodules, and 
 pustules vary in size from a pinhead to a dime. The nodules and pus- 
 tules usually last for several weeks or months and leave a light-brown 
 stain behind. N^one of these lesions itch markedly nor are they painful. 
 During the early months there may be falling out of the hair to a notice- 
 able degree. 
 
 The eruptions upon the mucous membrane of the mouth and throat 
 consist of shallow ulcers having a whitish centre and a red margin. 
 They vary in size from a millet seed to a dime, or larger, and are often 
 painful. The corners of the mouth and the tongue are a favourite site 
 for these mucous patches, as they are called. It is from such lesions that 
 syphilis may be communicated by kissing, and from the use of pipes, 
 drinking vessels, dental instruments, and the like. 
 
 Following these early eruptions there occur a great variety of skin 
 eruptions, for the character of which the reader is referred to works 
 upon syphilis. In general they do not occur over the entire surface of 
 the body, but are grouped together here and there. 
 
 After the first year of the disease the really serious and destructive 
 lesions of syphilis may make their appearance. They are all character- 
 ized by the production of poorly organized new tissue, 
 which resembles tubercle tissue in some respects, and, 
 like tubercle tissue, is prone to undergo a form of degeneration which 
 has received the special name " gummy," from the soft enmmv mate- 
 
(H)0 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 rial wl)ieli is the rc.-^ult of the prooes.'^. Tliis form of svphilitic in- 
 tlinnmatiou niav attack any orjj:an in the body, and when the brain and 
 spinal cord, or their covering, or any important ])art, become the seat of 
 the process the results may be disastrous. Consideral)le loss of substance 
 is son)etimes the result of the degeneration of these gummy masses, and 
 ugly deformities may be produced, of wliich the so-called syphilitic saddle 
 nose is a familiar example. 
 
 Syphilis remains contagious for a j)eriod of several years. After four 
 or five years a syphilitic indivitlual who has been free from symptoms for 
 two years or more may marry in safety, so far as the transmission of the 
 disease to wife or offspring is concerned, but he can never be sure that 
 the disease will not return in his own jierson, although these late mani- 
 festations are not contagious. 
 
 The essential part of the treatment of syphilis'duiiiig the first year or 
 eighteen months consists in the administration of one or other of the 
 preparations of mercury, according to one of several 
 ]ilans. A constitutional effect should be produced 
 which stops short of mercurial poisoning. During the later stages of 
 the disease, iodide of potassiuni alone, or combined with mercury, is 
 given in doses sufficient to relieve the synii>toms. 
 
 Syphilis is one of the diseases for which we possess remedies of real 
 value. Under suitable treatment the lesions of syphilis, in the majority 
 of instances, fade away in a manner at once gratifying to patient and 
 physician, although we do not know that the contagious stage is shortened 
 thereby, nor can we ever be sure that the disease will not show itself 
 again at a later period. 
 
 ('iiAxrru)ii). 
 
 ( 'hancroid is an acute contagious inflammatory disease acquired by 
 inoculation with the discharge from another chancroid, and characterized 
 l)y the formation of one or several pustules, which show a decided tend- 
 ency to spread locally and to cause more or less extensive necrosis of 
 tissue. 
 
 (chancroid is nearly always acquired during sexual intercourse. There 
 
 is no distinct period of incubation. Within a day or two after exposure 
 
 one or more red, tender, painful, elevated spots appear 
 
 IS ory an ^^ ^^^^ ^^^^ ^^ inoculation ; the centre of the elevation 
 
 Outlook, ' Ti 1 1 
 
 soon breaks down and leaves a craternke ulcer, the 
 
 base of which is covered with a yellow slough. The edges of the ulcer 
 are undermined, red, and soft ; the discharge of pus is abundant. If con- 
 fined beneath a tight foreskin, untreated, improperly treated, or when 
 occurring in individuals already broken down by dissipation and disease, 
 the ulceration may progress rapidly and lead to extensive loss of tissue. 
 
THE DIAGNOSIS OF SKIN DISEASES. 601 
 
 There are to be found in many liospitals ric!<rlccted cases of cliancroid 
 ■which have existed for nionths and years. In a coii.si<l(;i'al>l(; pi-oportion 
 of cases inflammation and suppuration of the lymphatic glands of tlio 
 ii^roin take place, leading to the formation of abscesses which sometimes 
 heal very slowlj^, or the wall of the abscess may ulcerate in a manner 
 similar to the original chancroid. 
 
 Early destruction of the base of the ulcer with strong nitric acid or 
 the actual cautery is the most certain treatment. If every portion of 
 diseased tissue is destroyed the slough seimrates, leav- 
 ing a healthy ulcer which heals rapidly under ordinary 
 antiseptic dressings. The inflamed glands may be extirpated, or if an 
 abscess has already formed it may be opened by a small puncture, washed 
 out, and its cavity filled with a sterilized ten-per-ceut. iodoform emulsion 
 in glycerin or oil. 
 
 CHAPTER XVI. 
 
 DISEASES OF THE SKIN. 
 
 There are a very large number of diseases affecting the skin. In a 
 considerable proportion of cases the nature of the affection is difficult to 
 determine, and a certain diagnosis can be made only by an expert on tliis 
 subject. There are a few skin diseases of common occurrence the recog- 
 nition of which is comparatively easy. These alone will be mentioned in 
 this chapter. 
 
 EXCESSIVE SWEATING. 
 
 Excessive sweating is a disorder of the sweat glands characterized by 
 a local or general increase of perspiration. The palms of the hands, the 
 soles of the feet, and the armpits are most apt to be affected in the local- 
 ized form. The affection is usually chronic, and often difficult to cure. 
 The general form is usually an accompaniment of debility. The localized 
 form is often of nervous origin. 
 
 For the general form of the affection, mineral acids, tonics, and bella- 
 donna taken internally are sometimes effective. In the localized form, 
 
 the application several times dailv of a wash containino; 
 Treatment. . . " . 
 
 sulphate of zinc, alum, and tannin, in the strength of ten 
 
 or fifteen grains of each to an ounce of water, is useful. Dusting powders 
 
 must do good. They should be used freely. The following is a good 
 
 formula : Salicylic acid, twenty grains ; boric acid, two drachms ; powdered 
 
 starch, six drachms. Mix. 
 
602 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 SEBORRIICEA. 
 
 Seborrluva is an affection of the sebaceous inlands characterized by 
 the production of an increased amount of oily matter in the skin. The 
 secretion of the glands may also be changed in cliaracter. The sealj) and 
 face are also usually affected. The skin is oily to an abnormal degree, or 
 is covered with greasy crusts and scales (dandruff). 
 
 Tonics when needed. Locally, in mild cases. Castile soap and hot 
 
 water are usefid. AVlien ci'usts and scales are abmulanr. tincture of green 
 
 soap may be substituted. The washing should be done 
 
 Treatment. .. i . i ^i ^ r j? ' i ^ 3 
 
 often enough to keep the parts free ti'om accumulated 
 
 secretion. The following formula may be used on alternate days with 
 
 the washing: Take of resorcin, one and a half drachm ; castor oil, twenty 
 
 drops ; alcohol, four ounces. Mix. Hub into the scalp at night with a 
 
 piece of ffannel. 
 
 C'OMR[)() (BLACKHEADS). 
 
 Comedo or blackheads, the appearance of which is familiar to every 
 one, is a disorder of the sebaceous glands in which the secretion is retained 
 and accumulated in the gland outlet. The accumulation of dirt gives the 
 mass of sebaceous matter a black colour. The disease is often associated 
 with constipation of the bowels and indigestion. 
 
 Prolonged steaming of the face, tincture of green soap rubbed into 
 
 the skin, and daily expression of the sebaceous plugs by pressure with 
 
 the iingers or the barrel of a watch key are useful. 
 Treatment. ^ 1 /• n • i • ^ " • ^ 1 
 
 J^ater the tolloM-mg lotion may he used to stimulate the 
 
 glands to a healthy action : Take of sulphate of zinc and sulphuret of 
 
 potassium, each one drachm ; rose water, four ounces. Mix. Lotion 
 
 for face. Should this apiilication cause irritation of the skin, its use 
 
 should be discontinued for a few days. 
 
 URTICARL\ (HIVES OR NETTLERASH). 
 
 Urticaria is an affection of the skin characterized by the formation of 
 white, pinkish, or reddish elevations or wheals, which vary greatly in 
 size and shajie. The lesions appear and disajipear quite suddenly, and 
 are as a rule attended by marked itching and burning. The disease is 
 usually acute, lasting a few hours or days ; rarely is it chronic. Distui-b- 
 ances of digestion from eating indigestible food or special kinds of food, 
 such as strawberries and shellfish, are common causes ; also certain drugs 
 taken internally, and continuous external irritations, such as repeated bites 
 of fleas and liedbugs. 
 
 AVhen due to disturbance of digestion, a saline {nirgative may be 
 given. Rhubarb and soda mixture may be given with advantage. Lo- 
 
SOME COMMON FORMS OF SKIN DISEASE. CO.'} 
 
 cally, a weak solution of carbolic; acid, one to two teaspoon fuLs to a pijit 
 
 of water, may be used ; also, batliing in a K(;liition of baking soda may bo 
 tri(Ml. The following lotion is usc^ful : Take of car- 
 b(Mic acid one dracinn ; bone acid, tour dracJims ; 
 
 glycerin, one drachm ; alcohol, two oiincef; ; water, one pint. Mix. 
 
 External use. 
 
 DERMATITIS (INFLAMMATION OK THE 8KIN). 
 
 Dermatitis, or inflammation of the skin, caused by poison ivy, is 
 characterized by redness and itching, sometimes by swelling and the for- 
 mation of blistei's. The eruption most often occurs on the hands and 
 face. The inflammation may last from a week to six weeks. 
 
 Among the local applications used are a strong solution of boric acid 
 
 (1 to 25), containing two drachms of carbolic acid to the pint ; a solution 
 
 of sulphate of zinc (one to four scrains to the ounce) ; 
 
 weak solutions of baking soda ; ten-per-cent. zinc-oxide 
 
 ointment ; cold cream. 
 
 HERPES. 
 
 Herpes is a disease characterized by the formation of small, rather 
 painful blisters on the skin. The blisters are situated on an inflamed 
 base and often occur in groups. Usually but one or two such groups are 
 present. The disease is often associated with fevers, and may occur as 
 the result of indigestion. In many cases it appears to be a nervous affec- 
 tion. The face and genitals are the usual seats of the disease. 
 
 "When situated upon the genitals, the application of camphorated cold 
 cream is useful. Cleanliness, a dusting pow'der of calomel, and the appli- 
 cation of the following lotion are good : Take of zinc 
 
 Treatment. ., ,1. ' ^ n •' j'l • i 
 
 oxide and calamine each nve grains ; of glycerin and 
 
 alcohol, each six drops ; water, one ounce. Mix. 
 
 HERPES ZOSTER (SHINGLES). 
 
 Herpes zoster, or shingles, is a nervous affection attended by pain and 
 the formation of herpes blisters along the course of a cutaneous nerve. 
 The nerves which run along the ribs are often affected. The pain usually 
 begins before the appearance of the eruption, and may be severe. 
 
 A mild galvanic current applied daily over the affected nerve usually 
 relieves the pain. The blisters may be covered with a fllm of collodion : 
 if already broken, a ten-per-cent. ichthyol ointment spread on gauze 
 and covered with a bandage is a good dressing. 
 
GUi SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 PSORIASIS. 
 
 Psoriasis is a cliroiiic inflainiiiatory atfectioii of the skin characterized 
 by the foniiation of dry, red, rounded, sliarply marked scaly patches npt)n 
 the skin, usually a little elevated aliovt' the surface. The exterior sur- 
 faces of the extremities, especially of the elbows and knees, are common 
 sites for the eruption. The scales are gray or silver}' white in colour, 
 and when scratched off leave a red, moist surface, which bleeds. The 
 disease may last for an indetinite period. It is usually better in the sum- 
 mer months. Itching is absent or slight save in rare cases. 
 
 The scales should be removed with hot water and soap. The follow- 
 ing solution, which forms a firm coating on the surface, may then be 
 painted on the lesions : Take of chrysarobin one 
 drachm ; salicylic acid, twenty grains ; ether, one 
 drachm; castor oil, ten drops; collodion, seven drachms. Mix. The 
 officinal tar ointment is also a useful a])j)li('ati(>n. 
 
 ECZKMA. 
 
 Eczema is an acute or chronic inflammation of the skin characterized 
 by redness and itching, and sometimes by the formation of little inflam- 
 matory nodules in the skin or by the formation of blisters or pustules. 
 In chronic cases the skin may be a good deal thickened. There are sev- 
 eral distinct types of the disease, a detailed description of which must be 
 sought for in works on diseases of the skin. In general, it may be said 
 that the inflamed skin is either dry and scaly or moist. The discharge 
 from the moist form dries upon the skin, forming crusts. All the forms 
 of eczema, if untreated, tend to become chronic. Eczema may occur 
 upon any portion of the body. Favourite sites are the scalp and face 
 and the flexor surfaces of the extremities. In some individuals there is a 
 constitutional predisposition to eczema, which is sometimes associated 
 with gout. Any source of external irritation may produce the disease. 
 
 In many cases a carefully regulated diet and mode of life must be fol- 
 lowed in order to obtain a cure. Tonics, alkalies, diuretics, laxatives, and 
 antirheumatic remedies are of use in certain cases. The 
 general treatment requires intelligent medical super- 
 vision. The local treatment has been mentioned under the treatment of 
 varicose veins of the leg. 
 
 ACNK. 
 
 Acne is an inflammatory disease of the sebaceous glands characterized 
 by the formation of little inflamed lumps on the skin, which sometimes 
 form minute abscesses. The face and back are favourite sites for the 
 eruption. The individual lesions last a few days and disappear, some- 
 
RINGWORM, AND THE ITCH. G05 
 
 times leaving a scar. The disease tends to continue indefinitely, one crop 
 of lesions being succeeded by others. The lesions may be few or many 
 in number. Tlie disease sometimes disappears spontaneously during the 
 third decade of life. 
 
 Tonics and laxatives should be given when needed. The local treat- 
 ment consists of incision of the individual acne pustules with a small 
 knife and the subsequent expi-ession of their contents, 
 and of the use of stimulating applications, among which 
 is the tincture of green soap, to be applied daily. Should this solution 
 prove too irritating, lead-and-opium wash may be substituted. The dis- 
 ease is essentially chronic, and treatment usually must be extended over 
 months or years. 
 
 RINGWORM OR TINEA. 
 
 Ringworm or tinea is caused by a fungus growing upon the skin 
 and characterized by round or oval, red or reddish-brown, slightly ele- 
 vated, scaly patches, and attended by moderate itching. The disease is 
 contagious, and may be communicated from one individual to another by 
 contact, or the lesions may multiply themselves upon the same individual. 
 The sharply marked border of the lesions, their rounded form, the fine 
 branny scales which cover them, and a tendency to heal in the centre 
 while advancing at the edges render the diagnosis easy. AVhen the dis- 
 ease occurs upon the scalp the roots of the hairs are affected and a small 
 bald spot may be produced. 
 
 One or more applications of strong tincture of iodine to the diseased 
 
 surface is usually sufficient to effect a cure. On the scalp and the bearded 
 
 portion of the face the hairs affected should be pulled 
 
 out, and an ointment composed of lard containing five 
 
 or ten per cent, of salicylic acid or one half of one per cent, of corrosive 
 
 sublimate may be rubbed into the affected area. 
 
 SCABIES (THE ITCH). 
 
 The itch is a contagious inflammatory disease of the skin caused by 
 an animal parasite, the itch mite, which burrows beneath the superficial 
 layers of the skin. The lesions produced vary somewhat during the dif- 
 ferent stages of the disease. The soft skin between the fingers is usually 
 first affected. As the itch mite advances his trail is marked by a minute, 
 elongated blister containing watery fluid, eggs, and the excrement of the 
 animal. The itch mite is situated at the further end of the blister. 
 Each little burrow lies upon an inflamed base. The burrows themselves 
 are easily recognised with the naked eye, the itch mite only with the aid 
 of a magnifying glass. The blisters are soon ruptured by scratching, and 
 the finger nails carry the eggs to the accessible portions of the body, 
 
006 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 where they liatch out ami in their turn proiliR-c now hurrows. The parts 
 seeoiidarilv affected are usually the inner surfaces of the thighs, the 
 genitals, the abdomen, armpits, the tiexor surfaces of the forearms, 
 and, in women, the lower surface of the breasts. As the result of con- 
 tinued scratching, the original character of the lesions is obscured. The 
 affected skin is covered by long abrasions produced by the linger nails, 
 and in manv cases a pustular eruption caused by infection with pus 
 microbes is added. Unless seen in its early stages, the disease must often 
 be recognised by these secondary characters. 
 
 The treatment consists of a bath of hot water and soap, followed by 
 the application of an ointment which destroys the parasites and their 
 eggs. Take of sulphur one ounce ; of balsam of Peru, 
 half an ounce; of /3 naphthol, two drachms; of 
 lard and of vaseline, ecpial ]iarts, as much as may be sufficient to make 
 four ounces of ointment. ]\Iix for external use. The application of the 
 ointment should be repeated on several successive days, and this treat- 
 ment followed by a hot soap-and-water bath. 
 
 HEAD LICE. 
 
 The presence of head lice may be recognised by itching of tlie scalp 
 and by the formation of various intlannnatory lesions upon the skin of 
 the head and neck, and by finding the lice themselves and their eggs. 
 The latter are minute gray or grayish-white, pear-shaped bodies, visible to 
 the naked eye, and fastened upon the shaft of the hairs with the small 
 end toward the root. The secondary inflammatory lesions produced by 
 scratching are often prominent symptoms for which tlie patients present 
 themselves for treatment. Swelling and even suppuration of the lym- 
 phatic glands of the neck sometimes occurs as the results of infected scratch 
 abrasions. Stiffness of the muscles of one or both sides of the neck, 
 simulating spasmodic wryneck or disease of cervical vertebrse respect- 
 ively, is not infrequently present. 
 
 The thorough application to the hair of a mixture composed of equal 
 parts of petroleum oil and olive oil, rejieated nightly for three nights, 
 followed by thorough scrubbing with soap and water, is 
 Treatment. ^gy^lly effective. The head of the individual should be 
 protected by a towel after the application. Ap]>roach to gas or other 
 flame should be carefully avoided. More rapidly effective is the applica- 
 tion to the hair of a mixture composed of equal parts of ether and tinc- 
 ture of larkspur. After this application approach to a flame should be 
 avoided with the greatest care, for the vapour given oft' by the ether may 
 catch fire even at a distance of several feet, and cause terrible burns. It 
 is best in many cases to cut the hair short. 
 
THE ELEMENT OF TIME IN SURGERY. GOT 
 
 BODY LICE. 
 
 Tlie body louse, larger than the head louse, inhabits the clothing, and 
 makes excursions upon the body for food. The bites occur especially 
 upon those regions where the clothing fits tightly — about the waist and 
 on the upper part of the chest. The bodies of those individuals long 
 atilicted with these parasites acquire a characteristic appeai-ance. The 
 continued scratching leads to the development of a deejj-brown pigmenta- 
 tion of the skin of the abdomen and thighs. The body is also covered 
 with recent scratch marks. A bath of hot water and soap, with disin- 
 fection of the clothing by boiling or baking, is all that is necessary. 
 
 CRAB LICE. 
 
 The smallest of the three varieties inhabits cliiefly the skin of the 
 genitals, occasionally the armpits, the eyebrows, and the margins of the 
 eyelids. The parasite, which resembles a crab somewhat in appearance, 
 clings closely to the skin by means of its powerful hooked claws. It is 
 found, upon close examination, at the roots of the hairs as a minute 
 brownish spot, scarcely elevated above the surrounding skin, and removed 
 only with difhculty, A variable amount of itching is produced, which 
 may be scarcely noticeable or severe. 
 
 The local application at night of half a teaspoonful of mercurial oint- 
 ment to the affected region, followed by a soap-and water bath in the 
 morning, the application to be repeated once or twice, if necessary, is 
 efficient. A watery lotion of corrosive sublimate, two or three grains to 
 the ounce, answers the same purpose. 
 
 CONCLUSION. 
 
 In concluding this article the writer wishes to emphasize the fact 
 that in the treatment of mcmy surgical diseases and injuries delay often 
 entails increased suffering, a graver risk, and, in many instances, loss 
 of life. He can think of no more fitting way in which to bring his 
 article to a close than by adding a few examples tending to show that his 
 admonitions on this head are necessary. 
 
 Many will doubtless be surprised to learn that a fresh wound, a 
 fracture, or a dislocation often demands relatively less haste in procur- 
 ing surgical aid than do abscesses and other purulent inflammations, 
 tumours, tubercular inflammations, and even certain deformities. Yet 
 such may fairly be stated to be the case. An open wound, if there be 
 no serious bleeding, is much more likely to heal without inflammation if 
 left alone, even for days, than if covered with an unclean dressing applied 
 simply for the sake of doing something. A broken bone can often be 
 
G08 SURGICAL INJURIES AND SURGICAL DISEASES. 
 
 jnit in plaeo as wi'll at the t'lul of tive ilavs or a week as immediately after 
 the accident. The niajorit}- of dislocations can he ivdueed as readily after 
 several days as innnediately after their occurrence. 
 
 On the other liand, every lunir of delay in opening an acute aljscess 
 causes increased suffering, destruction of tissue, and more marked consti- 
 tutional poisonini;. . Every week which elapses renders it more difficult 
 U) remove thoroui^hly a cancer of the hreast and diminishes the chances 
 of permanent cure. Every niontli duiang which a cliild with hip-joint 
 or spinal disease is allowi'd to ^o alumt untreated diminishes its chances 
 of recovery. 
 
 That these remarks are not unnecessary a visit to the wards of anv 
 hospital will furnish abundant proof. Only too often the surgeon must 
 undertake his operations M-ith misgivings or with only the hope of tcm])()- 
 rary benefit, sadly thinking to himself : " If this patient had but come for 
 treatment months ago how much better his chances would have been ! " 
 And sometimes he is forced to saj', when disease which might have been 
 cured at an earlier period has advanced beyond the reach of surgical aid : 
 '* No, I would not advise you to have any operation done. I will give 
 you some medicine which will diminish your pain and make you more 
 comfortable." 
 
VII. 
 DISEASES m GENERAL. 
 
 By J. WEST ROOSEVELT, M. D., and 
 WILLIAM P. NORTHRUP, M. D. 
 
 CHAPTER I. 
 
 THE CAUSES OF DISEASE. 
 
 Unhealthful surroundings are a frequent cause of disease. The danger 
 
 to health from bad air, bad water, and unsanitary dwelling houses is fully 
 
 set forth in the article on Hiiqiene. and needs only to be 
 
 Unhealthful Sur- ,• j . ^ ^^ ^ ^ ^ . 
 
 roiindinas mentioned now in order to call the reader s attention to 
 
 its reality. There are, however, certain causes of much 
 suffering and sickness which ought to be classed among these " unhealth- 
 ful surroundings," but which rarely are so classed, and indeed are rarely 
 mentioned by writers save in a very vague way. It is important to bear 
 in mind that perfectly healthy people, and people suffering from non- 
 contagious ailments, may be the cause of ill health among some with whom 
 they are thrown in close relations. The selfish, the ill-tempered, the quar- 
 relsome, the perverse, the whining, the nagging, the overbearing, be it 
 man or woman, always makes the lives about him or her more or less un- 
 happy, and unhappiness, if sufficiently great and sufficiently prolonged, 
 may make a weak body into a sick body. The fact that human pests 
 of the kinds mentioned usually contrive to worry their victims makes the 
 unhappiness produced by them particularly injurious to health. Worry 
 is probahly the most harmful mental strain to which human heings can 
 he sxibjected. It has been said that mental work never causes the health 
 to break down, but that worry often does, and that sickness which is said 
 to result from overwor'k is really due entirel}^ to overiaorry. This state- 
 ment is rather too sweeping, for it is hardly correct to deny the possibility 
 of injury from overwork ; but there is no doubt that woriy alone ruins 
 the health of many more people than does work alone, and that it does so 
 most frequently in cases of the weary or disheartened. Persons who by 
 their selfishness or inconsiderateness cause worry to others must not be 
 regarded merely as intensely disagreeable companions — they must be 
 41 609 
 
GIO DISEASES IN GENERAL. 
 
 looked upon as more or less dangerous to tlie liealrli of tlieir neig-hbours, 
 as part of the " unliealtliful surroundings," which, if possible, should bo 
 orot rid of. As one gets rid of bad plumbing cither by re})airing it, so as 
 to keep the noxious gases from escaping, or bv removing it entirely, so 
 ouo-bt these objectionalile people to be dealt Avith liy the sanitarian, either 
 in some wav \vherel)V they are stojiped from poisoning those around them, 
 or by removing them to some place where they can do no more harm. 
 Unfortunately, it is rarely possible to do either of these things, and so the 
 health of the worthier and better must often suffer. 
 
 The use of indigestible food, whether this be indigestible in its original 
 form or become so from bad cooking, is a well-recognised cause of dys- 
 pepsia of various sorts. In the matter of food we must 
 
 mpropcr ooi . YQ^Y\Qn\\)iiv that the adage is literally true — "What is 
 one man's meat is another man's poison." There is probably no single 
 article of diet, no matter how wholesome and digestible it is found to be 
 by the vast majority of mankind, which is not in some case extremely in- 
 digestible, or even poisonous. The following examples occur to my 
 mind in which I have personally observed in different cases more or less 
 poisonous qualities of a number of articles of food, which are for most 
 people very easy to digest : Roast mutton, roast veal, fresh shellfish and 
 other fish, strawberries, apples, peaches, bread, potatoes, eggs, milk. I 
 have seen people in whom half a wineglass of sherry or a few swallows 
 of beer gave rise to very severe indigestion. One man of my acquaint- 
 ance is prostrated with intense stomach ache and marked diarrha3a by a 
 teaspoonful of Tarragon vinegar, and in this same man five grains of 
 quinine causes violent colic. There are, on the other hand, some people 
 who find many things which are positively injurious to the majority of 
 mankind not only harmless to themselves, but even positively beneficial. 
 While there is no al:)solute rule, applicable in all cases, whereby we can 
 say what we may eat or drink without ascertaining by actual experiment, 
 there are certain facts ascertained by wide observation which enable us to 
 say what kinds of food are likely to be wholesome and what harmful for 
 a person living under given conditions. It is not to be supposed that a 
 proper diet can be selected for anyone if attention be directed only to the 
 human hemg xcithout regard to his occiq)ation and surroundmgs. A 
 diet which conduces to perfect health in a scholar of sedentary habits, 
 whose utmost physical effort is limited to a short daily walk, would prob- 
 ably reduce a blacksmith nearly to starvation, and the blacksmith's ordi- 
 nary dinner might be so great in quantity and so coarse in quality as 
 to meet the scholar's needs, if bulk alone be considered, for two days, 
 while its quality may be such as to make it not much more nourish- 
 ing than an equal bnlk of cobblestones. It is in general true that a 
 sedentary man requires and can dige>t less food than an active one, yet 
 
ON EATING AND DRINKING. 611 
 
 tliere are qnite inirncrons instances in which tlie converse is true. Some 
 
 professional men of sedentary habits have enormous appetites, and some 
 
 athletes eat very little. Moreover, the quantity of food taken seems to 
 
 have no relation to the stoutness or leanness of either sedentary or athlete ; 
 
 a man may eat but little, exercise a good deal, and yet be stout, and a 
 
 large eater, who takes little or no exercise, may be very thin, and yet l)oth 
 
 may be in good health. There are as great differences between human 
 
 engines in respect to their effective use of the food consumed as between 
 
 steam engines in respect to the power developed from a given weight of 
 
 coal burned ; some engines, liuman or steam, waste more, and others less, 
 
 of the energy contained in fuel. The same food, in the same amount, 
 
 which in one climate is found by experience to agree pei'feetly with a 
 
 man, may in another climate prove most injurious to health. The robust, 
 
 sturdy Englishman who tries in India to eat and drink as had been his 
 
 custom for years in England, finds that the attempt very frequently results 
 
 in ill health, or perhaps in death. 
 
 Quite as important as the sort of food is the quantity eaten. An old 
 
 friend of mine, who was a keen observer, used to say that "more people 
 
 die of overeatins:: than of overdrinking." There is some 
 Overeatifig. , ,^ • n ^ i tc i ic .• ^•, • 
 
 truth m the remark. It by overeating is meant not 
 
 only swallowing too great a quantity of food, but also swallowing im- 
 proper food, those who eat to excess far exceed in numbers those who 
 drink to excess. An overworked digestive system is always a menace to 
 health, and overeating may and often does cause disease of the stomach 
 and intestines, liver, kidneys, or heart. It is particularly apt to do mis- 
 chief in gouty people, either bringing on attacks of acute gout itself or 
 doing harm to some of the organs mentioned. 
 
 The injurious effects of alcohol have been too often and too fully dis- 
 cussed to make necessary more than a brief allusion to the use of this 
 
 powerful drug. It is sufficient to say that alcohol in 
 Stimulants and ^ • /^^, i , • r> ' , ^ t 
 
 Narcotics; Alcohol. <^ny form, -?/ taken to excess, ts a frequent cause of dis- 
 ease and death / that it is very doubtful if in the 
 United States it is ever really beneficial for young people to use habit- 
 ually any alcoholic drink of any sort; that while beer and light wines are 
 the least harmful alcoholic drinks to most persons, to others they are 
 very injurious ; and that there is no question that in hot weather alcohol 
 is more or less dangerous, no matter whether it be taken in beer, wine, or 
 distilled liquor. 
 
 Of course, no definition of the word " excess " can be framed which 
 indicates the precise amount of the stimulant which is injurious ; indi- 
 vidual susceptibility varies too greatly, and what is excess in one is ex- 
 treme moderation in another. It is as impossible to draw a line between 
 drunkenness and sobriety as it is to do so between sanity and insanity. 
 
012 DISEASES IN GENERAL. 
 
 ^[audlin drunkenness and raving mania are easy to recognise, but slight 
 intoxication and slight insanity are alike impossible to separate sharply 
 from perfectly normal mental states. Drunkenness is undoubtedly proof 
 of "excess." It is a matter to be decided by the individual whether or 
 nut he "feels'" the li(jUor. If he does he has had an excessive quantity; 
 but it must be remembered that one nuiy be unconscious of anything like 
 intoxicati(.»n and yet be decidedly drunk. If after a number of hours 
 headache or stomach sy mproms develop, these are proofs of excess. 
 
 Both tea and coffee are causes of nervous disorders and of various 
 
 sorts of diseases of the stomach and intestines — tea more often than 
 
 coffee, possiblv because it is more generally used in ex- 
 
 Tea and Coffee. . .' . , ^ i , i i '-.l • • •. i/- 
 
 cessive quantities, but probahly l)ecause it is in itselt 
 
 more injurious on account of the large amount of tannin contained in the 
 infusion when strong. 
 
 Tobacco may, like tea and coffee, cause nervous and digestive disor- 
 ders. It is also a cause of disease of the air-passages. It is said some- 
 times to cause absolute blindness; but there is some 
 (jucstion whether this last symptom lollows the use of 
 tobacco alone, or vvliether alcohol is not always necessary, in addition to it, 
 to affect the optic nerve. The blindness may be a result of alcohol rather 
 than tobacco poisoning. 
 
 Opium, morphine, chloral, ether, chloroform, co- 
 Ofher Stimulants . . . , , <■ ,i ,• i . 
 
 , Y . ,. came, antipyrine, and a number oi other stimulants 
 
 or narcotics are all, when habitually nsed, apt to de- 
 stroy the health. 
 
 It is a rule that human beings are better in health when regular in 
 their hours for sleep, eating, work, and play, than when this is not the 
 
 case. Perfect health usually demands a fixed amount 
 
 Injurious Ilalnts* , , , ^-_ " n i i / '77 
 
 ot sleep, and JNature can generally be trusted [provtaea 
 
 the hour for 7'etiring is fixed., and provided one does not learn to indulge 
 in the sensxnd enjoyment of droiosing after first awaMng) to indicate the 
 amount required by waking the sleeper in a refreshed condition. If one 
 watches a young, healthy child go to sleep and wake up, one sees that the 
 period of sleepiness is very suddenly followed by deep, quiet sleep, and 
 that the awakening, unless artificially induced, is quite sudden, although 
 the little one is apt to show some inclination to continue its unconscious- 
 ness. When, however, the child has once really become thoroughly awake, 
 it is evidently refreshed and cheerful, and a healthy adult after sufficient 
 sleep should have the same pleasant sensations as soon as the sleep is 
 
 *The word "habits" as here used is almost synonymous with "customs." I do not 
 intend it to be understood as meaning what it does in the terms "opium habit," "alcohol 
 habit," etc. I use it in the sense which it expresses in the phrases " neat in his habits," 
 " regular in his habits," " methodical habits." 
 
INJURIOUS HABITS AND LACK OV EXERCISE. 013 
 
 ended. It is true tliat alinost every one wlio is iincoDsfioiis, wlietlier 
 from sleep or disease, seems to have a decided desire to remain so, 
 and instinctively tries to put off the time when he niust I'eturn to active 
 life; therefore the first wish of the awakening sleeper is to sleep jnore, 
 but in heal'th this wish does not last long, and gives way to a sense of en- 
 ergetic content. The habit of overeating has been mentioned ; the habit 
 of eating too fast is another injurious to health. The habit of worrying 
 is dangerous, a fact already pointed out. In the matter of habits it may 
 be said that all are niore or less injurious which do not conform to the 
 general rule that the body tends to accommodate itself to a certain rhythm, 
 doubtless imposed upon it by its adaptation to the rhythmical sequence of 
 day and night, and that the body is pretty apt to indicate wdjat are in- 
 jurious if one carefully and fairly questions it. If a certain course of 
 action is repeated a number of times, and is always followed by discom- 
 fort, it means that such a course is harmful, provided the health before 
 adopting it was good. 
 
 Among the disease-causino- habits is to be reckoned lack of exercise. 
 If the body be not made to do a certain amount of physical work it is 
 
 apt to degenerate. The old adage, " If a man will not 
 Lack of Exercise. , ^ , i n i , 11 • , • 1 i • -,- 
 
 work, neither shall he eat, is true in other than its lit- 
 eral sense. If he does no physical work he often can not eat, having no 
 appetite. More often, although he can and does eat, he fails to digest 
 the food eaten, or, at least, fails to assimilate it properly. One of the 
 results of exercise is that by it the circulation is quickened and all the 
 organs get more nourishment than they previously had ; hence all the 
 functions are performed more perfectly. The more rapid circulation not 
 only carries nutritive materials in greater abundance to the entire bod}', 
 it also removes waste products more fully and more rapidly ; and these 
 waste products are always deleterious when present in large amounts. 
 (See Physiology : The Vital Processes in Health.) Moreover, the mere 
 using the body machinery, unless carried to the point of exhaustion, tends 
 to strengthen the parts used, while prolonged disuse weakens them. 
 
 The man who, without taking exercise, manages to eat largely is doing 
 much the same thing as would an engineer if he continued to keep the 
 lire under the boiler of an engine which is running at low speed as hot as 
 would be required to produce high speed. This would soon develop a 
 dangerous!}^ high pressure in the boiler and would endanger the ma- 
 chinery. So does too much food endanger the machinery of a sedentary 
 man, by accumulating too much energy in the organs, just as the ex- 
 cessive consumption of fuel accumulates too much energy in the boiler, 
 with resulting strain and injury. 
 
 There are a number of occupations which are causes of disease. For 
 the most part these are harmful because they involve contact with poison- 
 
OU DISEASES IN GENERAL. 
 
 ous substances (sufli as lead, arsenic. etc.V or tlie iiilialatiun of gaseous 
 fumes or gases (sueli as are produced in cei-taiii pi-ocesses of the manufac- 
 ture of various cheniical conipountls), or the exjiosure of 
 
 /y»r((H/.s ^j^^^ body to abnormal cttnditiims of temperature (stokers 
 
 Occupations. ^^ ... 
 
 in hot tire-rooms), or air j)ressure (thvers m armour, 
 
 and workmen in t^ie caissons or submarine sti'uctures, used in building the 
 piers of bridijes, etc.), or the inhalation of particles of dust (^knife grind- 
 ers, coal miners). In addition to such as are harmful because of the 
 nature of the materials used or oi the abnornud temperature or air 
 pressure involved in their ]iiirsiiit, some occupations cause ill health by 
 mere mental or bodilv wear and tear. The nervous system sometimes 
 gives out under long-continued strain (business anxieties and responsibili- 
 ties, etc.), or when certain muscles are employed in executing some deli- 
 cate task for a long time (writer's cramp, etc.), or when the occupation is 
 very monotonous and exacting and the worker is of a nervous tempera- 
 ment. 
 
 It is the fashion to lay great stress upon the influence of lieredity as 
 determining all sorts of phenomena observed in living organisms. It 
 
 is a little strange, therefore, to note the strong tendency 
 
 Heredity and . ,.j. i- i 4. i -j. • i. 
 
 n- ,., •^,,. amont; scientmc medical men to deny its importance as 
 
 Jiereditary Disease. ^ _ . 
 
 a cause of many diseases which a few yeai-s ago were 
 thought to depend largely upon its influence. That certain diseases may 
 be transmitted from generation to generation can not be doubted. In- 
 sanity and gout are examples of disorders which are often thus trans- 
 mitted. It is proven that certain forms of cancer also are apt to appear 
 among the descendants of people suffering fi'om these forms. Syphilis 
 uiKiuestionably is transmitted directly to many of the children of parents 
 suffering from this disease in an active stage. 
 
 In the cases last mentioned the parent infects the embryo, and the 
 child is born with the poison of syphilis actually present as such in its 
 body. In the other cases the descendants are not often born with the 
 real seeds (if I may so express it) within them. The syphilitic child is 
 born syphilitic, but neither gout, nor cancer, nor insanity are apt to be 
 manifested in very early life. What is inherited is a body susceptible 
 to the influences which cause rheumatism or gout, or perhaps certain 
 organs inherently weak, so that after a time they fail to do their work 
 properly, and, instead of producing sucli changes in the food as result in 
 the most perfect possible combustion of it, and removal of the ashes in 
 the form of waste, merely partially burn it and make poisonous sub- 
 stances, to the injury of the body. Thus, according to one theory, gout 
 is the result of an inherited weakness of the liver, which makes that 
 organ unable to complete the requisite changes in the nitrogenous sub- 
 stances derived from meat, eggs, etc., so that they finally are discharged 
 
HEEEDITY AND INFECTION. 615 
 
 from the body in tlie form of carljoiiic acid, water, and urea. (See 
 Physiology : The Vital ProceHnea in Health.) Urea is the ash of Huch 
 substances. Instead of oxi(Hzing tliem completely, the liver converts a 
 large part of them into uric acid, which is an injurious compound if 
 present in too large amounts, and which is deposited as urate of soda in 
 the joints during an acute attack of gout, and gives rise to many serious 
 symptoms and even leads to grave disease of various organs in some 
 people who never liave an acute outbreak. See Gout. 
 
 The question of heredity in tuberculosis will be more fully considered 
 under the various, sections which describe the local manifestations of tliat 
 disorder. (See Diseases of Digestive Organs, Heart, and Lungs.) For 
 the present it suffices to say that tubercle hacilli are not transmitted di- 
 rectly from parent to child, but it is possible that bodily peculiarities of 
 structure are transmitted which make the children of the tuberculous 
 unable to withstand the onset of the germs. They furnish a good soil 
 for the growth of the bacilli in organs which owe their weakness to 
 heredity, but they can not be said to inherit tuberculosis in the sense that 
 syphilis is inherited : they are not born with the disease germs already in 
 their bodies. 
 
 CHAPTER II. 
 INFECTION AND INFECTIOUS DISEASES. 
 
 Intection means the entrance into the body of some poison which 
 
 produces disease. The term is applied only to cases in which the poison 
 
 causes what we ordinarily understand by the word " dis- 
 Infection Defined. ,, /. ^ ' ^ , ^ !< c. • f ,• 
 
 ease ; for example, we do not speak of infection 
 
 with lead " or " infection with morphine " — we speak of lead or morphine 
 " poisoning." On the other hand, we speak of " infection with scarlet 
 fever," or tuberculosis, or malaria, etc., and we call diseases caused by 
 infection "infectious diseases." 
 
 Mucli misunderstanding exists as to the meaning of the terms infec- 
 tious and contdgious when applied to disease. It is therefore best to de- 
 fine them. The following definitions are taken from Foster's Encydo- 
 pcedic Medical Dictionary : 
 
 Infection. — The act or process by which disease is set up in an organism by 
 the implantation of morbific germs from vsatliout, or of a part of the organism 
 by the conveyance of such germs from another part. Infection differs from 
 contagion in the fact that the germs are not necessarily transferred from an- 
 other organism. . . . 
 
616 DISEASES IN GENERAL. 
 
 Contagious diseases, then, are necessarily infectious, since tlicy are 
 
 due to infections^ but infectious diseases are not neces- 
 Classification. ., ^ . nii • ^- i i ^ 
 
 sarilv contagious, lliere is some practical advantage 
 
 in making the following classitication : 
 
 TII1> IXFECTlors DISHASES INCLUDE— 
 
 i'lass I. NoN-coNTAGious DifiKASKs, sucli as malarial fever, cerebro- 
 spinal fever, etc. 
 
 Class II. Contagious Diseases, such as scarlet fever, smallpox, etc. 
 Class III. Communicable Diseases, such as syphilis, tuberculosis, ty- 
 phoid fever, etc. 
 
 Non contagious infections diseases can not be transmitted, directly or 
 indirectly, from the sick to the well. A patient with chills and fever is 
 not dangerous to his neighbours; they can not "catch" 
 jy the disease irom him. Malarial poisoning can only re- 
 
 sult from residence in a 'region of country in lohich the 
 malurial germs fnd cond lilons favourahle to their existence and propa- 
 gation. Human beings become infected from the germs growing in a 
 neighbourhood, not from those inhabiting the bodies of other human beings. 
 In contagious infectious diseases the infection takes place by poison 
 which is given off from the bodies of the sick in a form which in some 
 way is carried through tlie air, and, entering the bodies 
 jy- of healthy people who are near enough to tlie patient, 
 
 produces in susceptible subjects the disease from which 
 the patient suffers. Thus smallpox and scarlet fever spread, the sick 
 infecting the well through the air. In many diseases of this class 
 (and especially in scarlet fever, smallpox, and diphtheria *) the poison 
 
 * I prefer for practical reasons to class diphlheria as a contagious rather than a commu- 
 nicable disease. While it is true that could we be sure of destroying every particle of 
 the expectoration, nasal mucus, and all discharges of every sort from the body of a diph- 
 theritic patient, we should surely prevent the infection of others; we can not he sure of 
 doing this, and, moreover, the chances in the case of an unruly child or stupid adult of 
 accomplishing the feat of catching and destroying all the material coughed up are so 
 slight that common sense compels us to avoid exposing others to draiger from particles 
 which may have escaped our notice. Thporetirnllij it is right to cull diphtheria conimu- 
 iiicable and not rontngions, for we know that the poison does not spread as docs that of 
 smallpox, measles, or other true contagious disease, through the air directly from person 
 to person in an unknown way; it is carried by discharges which are liquid. Practically, 
 however, since the bacilli live after these discharges have become dry, and since excess- 
 ively minute quantities of the discharges are capable of producing malignant disease in 
 the healthy, and, moreover, since the violent coughing and struggling of the patients 
 make it very difficult, if not indeed impossible, to collect and disinfect all the expectora- 
 tion, we must look upon the disease as almost if not quite as dangerous as a true conta- 
 gious one, and act accordingly. Disinfect by all means, and disinfect thoroughly, for by 
 so doing we diminish the danger many times: but beware of trusting entirely to disinfec- 
 
INFECTIOUS DISExVSES. 617 
 
 may be indirectly cornrnniiicated tluv>ii<j^I) tlio iii(;diiiin of toys, clotliing, 
 furniture, books, or papers wliicli have been in tlie room witli tlie patient, 
 or have been used by liim while sick. Thus smallpox has been caught 
 from the clothing worn by smallpox patients, from carriages in which 
 they have been transported, from the furniture of their rooms, and from 
 the walls or floor of the rooms themselves. Scarlet fever has been spread 
 to uninfected places by clothing, books, and, in one instance at least, by a 
 ])icture which had hung in the room of a patient, and wliich was taken 
 down, rolled, and sent a considerable distance by mail, to cause an e|ji- 
 demic in the village where it was unrolled. The poison of diphtheria 
 clings tenaciously for a long time (months and perhaps even years) to 
 many inanimate objects. When not thoroughly disinfected the room 
 used by a diphtheritic becomes a hotbed of infection. Many and many 
 a case has arisen from keeping the favourite toy of some beloved child 
 who has died of the disease. Sentiment is a praiseworthy emotion in 
 general, but to preserve a death-dealing object for sentimental reasons, 
 while not criminal, is not criminal only because of the omission of law- 
 givers to make it so. It is as wicked as any conceivable act of criminal 
 negligence, and one who keeps such mementoes (and many are the people 
 who do) as toys, or clothing, or ornaments, or locks of hair which have 
 been exposed to contagion, unless these have heen siibmiited to a process 
 of disinfection of a sort which has heen beyond all shadow of doubt effec- 
 tual, is morally gnilty of manslaughter if a fatal case of disease results 
 from his sentimentality, and is morally responsible for all the suffering 
 which the illness he is a means of spreading may cause ! 
 
 Com,inunicdble infectious diseases are not contagious in the sense in 
 which that word is used in this classification. Infection takes place in 
 
 these cases in known and preventable ways. Thus ty- 
 Commumcable ^ • -, <• -i , , -n "^^i' i 
 
 r,. phoid lever is due to water, milk, or something swal- 
 
 JJiseases. ^ ... 
 
 lowed which is contaminated with bacteria of the spe- 
 cies known as the Bacillus tyjjhosus, or typhoid bacillus. The life his- 
 tory of the bacillus is this : It is able to live and multiply in water (espe- 
 cially when the latter contains filth derived from sewers, cesspools, etc.) 
 and in various sorts of soil, provided moisture be present. Taken into 
 the stomach, it passes downward until it reaches the small intestine. 
 There it finds conditions favourable to its growth, and it begins to grow 
 
 tion ! Isolate the patient as yon wonld a case of smallpox and " make assurance doubly 
 sure." It is not a matter for theoretical discussion, but for practical action. None but 
 a fool would take the risk involved in failing to adopt every precaution, destroying by 
 disinfectants every germ which can be captured, and preventing the wider distribution of 
 such as may have escaped capture when first expelled from the body by confining them 
 within the walls of the sick-room until such time as the room and every article in it can 
 be thoroughly and surely disinfected with corrosive-sublimate solution or heat. 
 
618 DISEASES IN GENERAL. 
 
 in certiiiii part^ oi tlie intestinal walls, causiiii:: ulcers to form. It also 
 passes into the blood, and is found in large numbers in the spleen. As 
 the disease progresses myriads of the germs are expelled with the dis- 
 charges from the rectum. If all the dejecta are thoroughly disinfected 
 the germs are, of course, killeti. and no haini comes to other people. If 
 not, and if the germs find their way into drinking water, they infect sus- 
 ceptible persons, who swallow them with the water. The fever does not 
 spread in any way save through tlie nuMJimn of water or other substances 
 contaminated with the excreta of patients. It is tlicyvfovi} )iot contar/iotts, 
 M-hile it is couinnniicahlc. In the case of sy jthilis the disease is connnu- 
 nicated only by dii'ect contact of the sick with the well, or bv the in- 
 troduction of the poison through an open wound by means, of the con- 
 tact of something contaminated with the jioisou of syjihilis derived from 
 the body of a syphilitic. The ordinary way in wliicli infection occurs is 
 well known. Indirect infection has been known to follow the use of a 
 tobacco ]>ipe belonging to a syphilitic, and to wounds intlicted by instru- 
 ments in the hands of a surgeon operating upon a syphilitic, and various 
 other accidents. 
 
 Tuberculosis is also a communicable disease. The bacilli are always 
 expelled from the body of a tuberculous patient in some fluid (usually ex- 
 pectoration), and infection takes place only when some of the germs are 
 swallowed with contaminated food or drink, or inhaled when the fluid 
 which contained them dries and becomes dust. The commonest source 
 of infection is the dry sputum of consumptives. Another very common 
 source is the milk of tuberculous cows. In the case of a Iniman being 
 there is no danger save from the expectoration or from some other dis- 
 charge containing the bacteria. It is always possible to destroy the dan- 
 gerous excretions. See TnhercnJosis. 
 
 CHAPTEE III. 
 THEORIES OF INFECTION AND IMMUNITY. 
 
 The theories of infection which from time to time have been ])ut 
 forth are very numerous. It is not worth while to concern ourselves with 
 those which have long been exploded. At the present day all scientists 
 accept one theory, and one alone, in explanation of the occurrence of 
 the vast majority of infectious diseases, and but few believe that any of 
 these diseases are caused by anything but a living poison. 
 
 The germ theory^ which has superseded all others, is that infectious 
 diseases are caused by the growth and multiplication within the body of 
 
THEORIES OF INFECTION AND IMMUNITY. 010 
 
 various species of micro-or^unlsnis or germs. In several diseases tliis 
 
 theory lias proved to be true. In others a germ origin is rendered proh- 
 
 ahle by the constant presence in each case of a par- 
 The Germ Theory , • i ' • x- • • i • i • , • 1 1 , i 
 
 of Infection ticvilar spccics 01 micro-organism, while ni still others 
 
 the course and history of the disorder makes its germ 
 origin a fair inference, although nothing has yet been discovered which 
 we can point to as a specific bacterium. For information about the; 
 probable ways in which germs produce symptoms and lesions, see Bac- 
 teria^ Tuherculosis, Malarial Diseases, and the article on tSargical In- 
 juries and Surgical Diseases. 
 
 All human beings are not susceptible in the same degree to infection ; 
 some are severely attacked after slight, others suffer lightly after pro- 
 longed, exposure ; some do not suffer at all. Immunity 
 
 T'ti) 771 1 17)i lit/ 
 
 from infection means the power of resisting the evil 
 effects of a disease jpoison. It is sometimes inherited and sometimes ac- 
 quired. 
 
 Inherited immunity is that which is transmitted through succeed- 
 ing generations. It is a peculiarity, like other hereditary peculiarities, 
 and is as inexplicable as are all others. It is subject, like the others, to 
 A^ariations in its degree, and it may be wanting in some members of a 
 family, while the others possess it in a marked way. 
 
 Acquired immunity results sometimes from prolonged exposure to the 
 infection of certain diseases in a not too virulent form. The sj'stem 
 seems to become accustomed to the unhealthful conditions, and from con- 
 stant battling with milder doses (if I may so express it) of the poison 
 learns to resist stronger ones. The inhabitants of malarial neighbour- 
 hoods do not succumb to malarial fever, as do new-comers. They have 
 acquired a certain immunity from the disease by reason of their long ex- 
 posure to its poison. From certain diseases immunity is acquired if the 
 body be brought up to and maintained in a perfect physical condition ; 
 when the general health falls below a certain point susceptibility follows. 
 The physical condition has no influence whatever upon immunity from 
 many diseases, however. Typhus fever, smallpox, and many others, are 
 just as likely to attack the strong as the weak. 
 
 There is a very extraordinary form of immunity which is acquired, as 
 in certain diseases ; one attack protects from subsequent ones for a longer 
 or shorter time. The possible reasons for this were discussed by the 
 writer in a paper printed in the Proceedings of the Xew Yorh Academy 
 of Medicine for 1893 and in the I^ew Yorh Medical Journal for ]\Iarch 
 18, 1893. It is here reprinted from the Medical Joiirnal : * 
 
 * The paper was entitled Acquired Immunify from Certniii Infectious Diseases, a JRe- 
 sult of Rereditij and Natural Selection, by J. West Roosevelt, M. D. 
 
♦520 DISEASES IN GENERAL. 
 
 The various theories wliieli have heon advauceil in explanation of the pro- 
 teciion attordeil hy one attack of certain infectious diseases from suhsequent 
 attacks may he sunnuarized as foHows : 
 
 1. The pathogenic micro-organism is assumed to exhaust the sui)ply of some 
 substance present in the botlies of unprotected people, which substance is neces- 
 sary for the nourishment of the pai'asite, aaid which, once removed by it, is not 
 rejjroduced by tlie body. This is called " the exhaustion theory." 
 
 2. Tlie mici-o-orgaiiism is thought to jmnluce within the body some sub- 
 stauce iuimical to its own existence, and tins antidotal sul>stance, once formed, 
 is not destroyed or excreted by the body. This is called " tlie antidote theory." 
 
 3. It is assumed that in a successful sti'uggle with the invading bacteria the 
 body cells acquire an increased sti-ength— become educated, one might say— 
 and thus are able to destroy the enemy. This new strength they transmit to 
 their descendants, so that the body is better able than before to repel subsequent 
 invadei's. Thus is established "tolerance "' to the jjoison, as it is maintained. 
 
 The first theory may be regarded as untenable for several reasons, among 
 which are the following, which seems to me to be fatal : If we accept it we 
 must believe that Nature has provided man with a number of different sub- 
 stances which can have no conceivable use other than that of providing food 
 and acconnnodation for pathogenic micro-organisms. These hypothetical sub- 
 stances are evidently not needed by the human body, since, ex hypothesi, bac- 
 teria remove them and they are not reproduced ; yet the patient recovers entirely 
 and is not at all the worse for his illness. It would be hard to believe that this 
 could be the case if provision were only made for the growth and nutrition of 
 some one species of germ ; but when we ai*e called upon to believe that the 
 majority of mankind come into the world with a separate and distinct " sub- 
 stance ■' suited to the needs of the micro-organisms of smallpox, measles, scar- 
 latina, chicken pox, vaccinia, yellow fever, and a number of other diseases, the 
 imagination is staggered and the reason revolts against such a preposterous 
 idea. In a sense which will be indicated in another part of this paper, and 
 which was not in the minds of its inventors, it may be said that there is some 
 truth in the theory. 
 
 A certain degree of plausibility is lent to the antidotal hypothesis by the 
 fact that, like all living things, bacteria produce by their own vital processes 
 substances which, if sufficiently concentrated, are fatal to the producers. The 
 great objection to it is that we know of no organic compound which is not ex- 
 creted or destroyed by the body within a short time after its inti'oduction into 
 the system. This makes it hard to conceive that any permanent protection can 
 be afforded by bacterial action. 
 
 Of the three explanations suggested, the third — that of acquired tolerance — 
 is nearer to the truth than the others, yet it docs not altogether satisfy the mind. 
 While it is free from the objections which apply to the others, it seems to me 
 weak in one important respect. It is perfectly logical to assume that the power 
 of resistance existing in a body cell should be transmitted to its descendants, in 
 accordance with the laws of heredity ; but it is an assumption hardly warranted 
 by experience or observation of other biological phenomena which ascribes to 
 cells the power of acquiring and transmitting peculiar resisting powers during 
 a period of .stress such as must exist under conditions which obtain in the in- 
 fectious disea.ses. It seems to be improbable tliat such should be the result of 
 thoir fight. 
 
ACQUIRED IMMUNITY. G21 
 
 To me it seems that the objections to the tlieory vanisli if we apply the 1ji,w 
 of the survival of the fittest to tlie problem as well as the law of lierfjdity. Let 
 it be supposed that the feebler cells concern(!d in the; strutcf^-le are for tiie most 
 part killed. When recovery takes place the body will resunu; its orif.niial func- 
 tional activity, but it will contain descendants of the cells originally strong 
 enough to destroy the poison of the particular disease through which it has 
 passed. Naturally the qualities of the parent cells are transmitted to their off- 
 spring. It is not so much by reason of new powers acquired by the stronger as 
 by reason of the destruction of the weaker cells that immunity is afforded- 
 This is much more in accord with Nature's methods as actually observ^ed in the 
 whole domain of biology. She seems to i^refer to slay the weak rather than to 
 leave them to transmit their weakness to others. The strong survive because 
 of their strength, and in the end this is a benefit, for it tends to perpetuate and 
 improve the species and elevate the type which composes the majority of such 
 species. In the long run it is far better that, relatively speaking, a few indi- 
 viduals should suffer and perish than that the whole number should do so at a 
 later day. The survival of the fittest cells in the human body preserves the 
 whole body from danger, if the theory of immunity set forth in this paper be 
 true. Living cells then form the " substance " assumed in the " exhaustion the- 
 ory " to be destroyed and never reproduced. 
 
 The evidence of its truth is largely derived from a consideration of the action 
 of certain laws of Nature upon living organisms of complex structure — viz.. 
 animals and plants. It is therefore not to be regarded as entirely trustworthy. 
 Reasoning by analogy is not true inductive reasoning ; it is not based ujDon ob- 
 served facts. Analogical evidence should be regarded by the scientist very 
 nearly as circumstantial evidence is regarded by the lawyer. The latter can 
 not be considered as approaching in value the testimony of trustworthy eye- 
 witnesses, but its importance increases with each additional demonstrated fact 
 which tends to show that a certain allegation is probably correct. When a 
 sufficient number of facts have been presented in court, which, although they 
 do not directly prove a case, make it extremely probable that certain events 
 have occurred (as the lawyers express it, " show its probability beyond reason- 
 able doubt "), circumstantial evidence amounts almost to proof, and has been 
 regarded by the courts as actually proof. This should be the position of the 
 scientist in respect to any theory which does not rest upon indisputable demon- 
 stration. The theory must explain all the known phenomena, and it must con- 
 flict with none of them. If based upon analogy, the closer and more evident 
 the analogy the more probable the theory. As time goes on and new observa- 
 tions are made in the light of more extended knowledge, each one which ac- 
 cords with the theory increases the probability of its truth. When all known 
 phenomena confirm it and no single one fails to agree icith it, it may be con- 
 sidered as proved. It matters not whether the hypothesis was based upon fact 
 or fancy. 
 
 It seems to me that this hypothesis is a rational explanation of the immunity 
 conferred by attacks of the diseases under discussion. The fact that attacks of 
 some acute infectious disorders do not diminish the susceptibility to infection 
 does not, as I think, confiict with it. The reasons which justify the last state- 
 ment will be given in another j)aper. For the present it is desired only to give 
 very briefly an outline of this theory in its relation to certain othei's. 
 
 If the doctrine of phagocytosis is correct — if the disease process is a direct 
 
022 DISEASES IN GENERAL. 
 
 conflict between the ])liagocytes ami the iiivadiiisr orovnis — then sui-cly llio 
 weaker cells must perisli, and, when the sti'uji:;:rle is over, the body nuist lind in 
 the descendants of the strtJiiyer a safeg-uard aj^ainst subsequent invasions.* If 
 it is by chemical substances produced within the body that the bacteria are 
 overcome, the theory is perfectly reasonable. The bactericide necessarily is a 
 product of cell activity ; it is the direct or indirect action of the living' tissue 
 elements which determines the con.stitution of all the .secretions and excretions. 
 The blood jjlasma is no exception. If the latter contains as one of its normal 
 constituents something' toxic to certjiin forms of bacteria when present in sutli- 
 cient amount, it is because some livino: cells produce it, as pai't of their life 
 work. If the presence of the germ determines the production of such a sub- 
 stance, not previously exi.sting in the j)la.sma, it is still by cell activity that it is 
 made. If recovery depends upon speedy elimination of the bacteria or some 
 product of their growth, or something- necessary for their nourishment, again it 
 must be accomplished by body cells. It might be that the micro-organisms of 
 some diseases can only flourish by killing certain cells, directly or indirectly. 
 "Whatever be the method of attack or defence, the struggle is between germ and 
 cell. The living tissue elements which are lea.st able to withstand the stress of 
 the conflict must succumb sooner than their stronger fellows ; it matters not 
 whether the weakness results from lack of suHicient destructive power as a 
 ])hagocyte, or of sulficient power to produce an unusual quantity of some bac- 
 tericide, or of adaptability to changed environment sutficient to manufacture 
 some offensive or defensive substance diff'erent from that previously produced, 
 or to withstand the deleterious efi^ects of some product of bacterial life, or to re- 
 move some sul)stance necessary for bacterial nourishment, or to do any work in 
 the fight of any sort. 
 
 It may be objected that there is no proof that cells inherit qualities possessed 
 by their ancestors. There is no direct proof ; but to deny the fact would be 
 equivalent to asserting that the whole is not equal to the sum of all its parts, for 
 the hereditary peculiarities of animals are admitted, and animals are composed 
 of multitudes of cells. If the latter do not inherit and transmit certain peculiar- 
 ities, how can the former ? If spermatozoon and ovum are able (as they un- 
 questionably are) to influence so powerfully the development of the entire body 
 as to cause physical or mental characteristics to recur generation after genera- 
 tion, it is impossible to conceive that this result can be produced unless every 
 generation of their descendants (the body cells) receives and transmits heredi- 
 tary traits. 
 
 It seems equally inconceivable that the law of the survival of the fittest, 
 which is of universal a])plication thi'oughout the whole animal and vegetable 
 world to each individual animal or vegetable of every species, should fail to 
 apply to every cell forming part of these individuals. No reasonable explana- 
 tion can be (or, at all events, has been) adduced of the existence of such an 
 anomaly in Nature. 
 
 It is a much more plausible supposition that qualities already possessed con- 
 genitally by the cells should be transmitted to descendants than that those ac- 
 quired in a short, fierce struggle .should be ti^ansmitted. Indeed, the possibility 
 
 * Phagocytosis is a term Jipplied by Motschiiikoff to the peculiar faculty possessed by 
 certain cells of taking into their own bodies — devouring, as it were — various minute ob- 
 jects, like some bacteria, and destroying them. 
 
CLASSIFICATION OF BACTERIA. 623 
 
 of the transmission of acquired traits is denied ])y soirui t)iolo;.fists. Of tlie eon- 
 genital traits there is no doul^t. 
 
 Of this theory it may he said, at least, tliat it is v^^ry faseiiiatin^^. Is it not 
 also suggestive and plausihle ? Is it not worthy of consideration as a working 
 hypothesis, if nothing more ? In. another pap(;r I sliall discuss in d(;tai] the 
 application of it to a number of diseases, and also to tlie protective effects of in- 
 oculations with attenuated virus and with vaccine. 
 
 CIIAPTEPw lY. 
 BACTERIA. 
 
 Bacteria (singular, bacterium) is a term applied to a large class of 
 living vegetable organisms of microscopic size, each consisting of a single 
 
 cell of very simple structure. The class includes a num- 
 Classification. ■, f i ^ • • , 
 
 ber 01 genera, each genus containing a great many spe- 
 cies. There are many difficulties in the way of making a satisfactory 
 classification of the various kinds of bacteria, and much doubt exists as to 
 many of the kinds observed, whether tliey can properly be considered as 
 separate species or mere varieties. Indeed, the whole system of nomen- 
 clature now in vogue must be regarded as nothing more than a convenient, 
 temporary means of expression, which will probably be extensively altered 
 as the knowledge of the subject becomes more precise. In spite of the 
 immense amount of work done by thousands of enthusiastic, patient, 
 skilled observers, who have devoted years of their lives to the study of 
 these organisms ; in spite of the brilliant intellectual abilities of many of 
 these investigators ; in spite of great advances in technique ; and in spite 
 of the enormous importance of some of the ascertained facts — the science 
 of bacteriology is still in its infancy, and our positive knowledge of bac- 
 teria is as yet very small. 
 
 Bacteria are of many shapes and (although all of them are so small as 
 to be visible only when liigbly magnified) of many sizes. Some of them 
 
 are shaped, roughly speaking, like rods ; others are spiral 
 Size Shape and .^ ^^ ^^^^ ^ corkscrew ; still others are spheroidal or 
 
 ovoidal, like a ball or an es,s:. The differences in shape 
 serve as one of the distinguishing marks of the various genera and 
 species. 
 
 Rod-shaped bacteria are called lacilli (singular, hacUhis). They are 
 sometimes long and thin, sometimes short and thick, and, although usually 
 almost straight, some of them are more or less curved. They are occa- 
 sionally thicker at one end than at the other. See Figs. 1 and 2. 
 
624 
 
 DISEASES IN GENERAL. 
 
 The spiral forms are called sjiiriUa (singular, sjiir'dluiii). Spheroidal 
 and ovoidal bacteria are i-alled cocci (singular, coccus). This term is 
 rarely used except as part of a compound word which 
 indicates the genus to which the particular coccus be- 
 lonors. Thus we speak of micrococcus^ a genus contain- 
 intja large number of species of spheroidal form ; st(fp/ii/- 
 lococcus, a genus characterized bv the peculiar groui)ing 
 of the germs in masses like a biiiicli of grapes; and 
 streptococcus, ;i gi'inis in which the cocci have a tendency 
 
 to grow in the form of 
 
 (^ \^ M r Hh M M Kod-sluiped and s])iral 
 
 bacteria fre(iuently have 
 the striking peculiarity 
 of moving about with 
 greater or less speed. 
 Some of them produce 
 this movement by means 
 of extremely delicate 
 hairlike processes {cilia) 
 which move rapidly in 
 much the same way as 
 an oar used in skulling 
 a boat, and thus propel 
 the body. In others the mechanism causing the movement is not known. 
 Cocci are always motionless. 
 
 Bacteria propagate in a very simple way. The parent cell divides 
 into two. It can not be said of the offspring that either is the descendant 
 of the other ; each contains one half of the ancestor, 
 ropaga ton. ^^^^^^ hath appear simultaneously with the disappearance 
 of that ancestor. There v^as one bacterium — there are two. That is all 
 that can be said about it. The rapidity with which reproduction occurs 
 in some species, under favourable conditions, is enormous; a single germ, 
 could the necessary favourable conditions be maintained, so that the ol)- 
 served birth-rate (if I may call it so) continued for twenty-four hours, 
 would produce between 16,000,000 and 17,000,000 descendants. Of 
 course such an enormous rate of increase can not be maintained, for if it 
 were, this earth would long ago have been devoid of all forms of life, 
 since the bacteria would, within a few days, have exhausted every chem- 
 ical compound necessary to life whicli the whole world contained, and 
 there being nothing left to feed upon, all living things would have ceased 
 to exist. 
 
 The conditions necessarv for the maintenance of bacterial life vary 
 
 Fio. 1. — The bacil- 
 lus ANTIIKAlIS. 
 
 (AltL-r DeBary.) 
 
 Fifi. 2. — The hacillus megaterium. 
 (.After De Bary.j 
 
PLATE III 
 
 4i^ 
 
 QqtOSo 
 
 
 
 
 ^*5 
 
 % 
 
 Pi-imai-y forms of" bacteria 
 ( spheroidal, rod-Iilce.and spiral 
 
 Spheroidal bacle7'ia ( ooc<;i ) 
 ill pairs f l.)ij>lococous ). 
 
 Cocci in cliains ( Strepto' 
 
 
 '?>.>? 
 
 
 
 Streptoeoccus pyogenes in pus . 
 
 Staphylococcus pyoqenes iii piis. 
 
 
 ^^' 
 
 
 Oi^v 
 
 V fi V 
 
 Bacillus tuLberculosis in spiitum. Bacillus antTu-acis iVom a culture. Spirilluin cholerae in seqments . 
 
 EXAMPLES OF MICRO-ORGANISMS 
 
 Dxaw.n from photographs magnified about 1,000 diameters 
 except figuifes4 and 6 m -which they are magnified about 500 diameters 
 
CONDITIONS OF BACTERIAL LIFE. f;25 
 
 somewhat amon<^ different species, but the vuriutions occur only witliin 
 
 pretty narrow Hiiiits. Like all living things, these tiny organisms can 
 
 not survive if exposed to too high temperature. Most 
 
 e^ rugg a jor ^^ ^j^^ known species are killed if exposed for a short 
 Existence. . . ^ '■ 
 
 time to boiling water, or to steam at a temperature equal 
 
 to that of boiling water. Some forms, however, when in the state known 
 as spores, are able to survive boiling for some hours. In general, bacteria 
 seem able to survive prolonged cold far below the freezing point of water, 
 for Prudden and other observers have repeatedly shown that ice obtained 
 from streams, lakes, and ponds always contains numerous germs which 
 actively propagate their kind when the ice is melted and the water raised 
 to a suitable temperature. It is important to note in this connection that 
 the bacteria which cause typhoid fever have been kept for weeks in ice 
 exposed to a temperature below zero, and have subsequently been found 
 capable of most active and vigorous growth. Drying bacteria, if the pro- 
 cess be conducted in a moderate heat, suspends temporarily the vital ac- 
 tivity of all known forms, and kills some species — e. g., the bacilli of 
 Asiatic cholera — but many species revive promptly when again exposed 
 to moisture, even though they have been kept a long while in the dry 
 state. The Bacillus tuberculosis survives many months in this condition, 
 and for this reason the dried expectoration of consumptives which is so 
 easily scattered into dust is a source of great danger to those who inhale 
 it. Curiously enough, many bacteria are killed in a rather short time if 
 exposed to bright sunlight, especially if they be dry when thus exposed. 
 Certain chemical substances prevent the active growth of bacteria and, if 
 strong enough, kill them. 
 
 It will be seen from the foregoing brief sketch that the germs are 
 pretty well fitted to maintain the struggle for existence, at least so far as 
 their ability to survive amid very different surrounding conditions is con- 
 cerned. They simply cease to exhibit active signs of life when the sur- 
 roundings are not favourable — remain in a latent state, as one might say 
 — and subsequently resume their activity when the surroundings again 
 become favourable, provided the unfavourable conditions are not con- 
 tinued too long and are not necessarily fatal. In order to make possible 
 the exhibition of the phenomena of active life, bacteria require a far nar- 
 rower range of variation in their environment than those mentioned as 
 compatible with their mere survival in the inactive state. Frozen bacteria 
 may not be dead, but while frozen do not show any sign of life. They 
 do not reproduce their kind, and, so far as can be shown, do not seem to 
 cause any of the chemical reactions which are produced by active living 
 things. A certain amount of heat is necessary before these can be brought 
 about under the influence of the mysterious something called life. Besides 
 warmth, some degree of moisture is necessary, and some substance to fur- 
 43 ' 
 
626 DISEASES IN GENERAL. 
 
 nisli food (that is to say, some chemical compound which the Hviiio; being 
 adapts to its use as fuel and as material wherewith to build uj) its own 
 body until it is able to propagate). Certain species require, besides warmth 
 and moisture, the presence of oxygen in large amounts, and only grow in 
 contact with the air ; others do not need more oxygen than they can ob- 
 tain beneath the surface of the fluid or semitluid in which they are placed. 
 The enormous potential rapidity of reproduction among these niicro- 
 organisms has been mentioned. We shall now consider what limits their 
 
 actual increase, so that they do not literally devastate 
 Causes Tending fo ^^ ^.i i j.i • i i" • i \ ^^ 
 
 . , r the eartli by tiieir overwhelming numbers. Among the 
 
 check Increase. •' " . ... 
 
 forces which tend to check the excessive niulti])lication 
 are the action of sunlight, which doubtless kills countless myriads, es- 
 pecially those which the wind has dried ; of the winds, which scatter them 
 far and wide, and often remove them from places where the surroundings 
 are favourable to places where they must die, because conditions obtain in 
 which they can not get the needed food ; rain and melting snow and ice, 
 like winds, must kill man}', as the ruiming water scatters them far and 
 wide. Some fall victims to organisms of higher and more complex types, 
 myriads are swallowed daily by man and all other animals, and vast num- 
 bers of these perish in the digestive tracts of their hosts, although some 
 are expelled unharmed ; and some, finding in the animal body conditions 
 favourable for their existence, remain and multiply rapidly. TZ/e most 
 destructive foes ofhacterla, hou'ever, are hacterla,, and the extreme rapid- 
 ity with which reproduction takes place is one of the most important 
 causes operating to prevent these organisms from becoming too numerous. 
 The last statement may seem paradoxical, but is not. Extremely rapid 
 multiplication implies an equally rapid increase in the consumption of 
 food, and therefore, unless the supply be inexhaustible, hastens the time 
 when none remains to support life. Even though there may be food 
 enough for all, it can not be obtained by the bacteria which happen to be 
 surrounded by hosts of others, which devour the food before it reaches 
 the former, and so these starve. Overcrowding causes death in a way 
 other than by starvation. All living things excrete substances which, when 
 sufticiently concentrated, arc poisonous to themselves and to others of their 
 species. When bacteria become so numerous that their own poisonous 
 excreta reach a certain degree of concentration they either die or, at least, 
 cease to multiply. There is yet another way in which bacterial increase 
 is kept in check — certain species seem to have the power to prevent cer- 
 tain others from multiplying side by side with themselves. In some in- 
 stances, doubtless, this is simply because the superior vigour of one species 
 enables it to deprive the other of needed food, but in others it appears 
 that the vital processes of the former result in the production of chemical 
 substances poisonous to the latter. 
 
I-IAEMLESS AND INJURIOUS BACTERIA. 627 
 
 (JlIArTEii V. 
 BACTERIA AND DISEASE. 
 
 It is a great mistake to suppose that all Ijaetcria are injurious to 
 
 health. Only a few species cause disease, and of the other species not only 
 
 are the great majority harmless — they are extremely use- 
 Not all Bacteria x i t i i ' • ^ l £ ^^ j.- -^ r xi .i 
 
 are Harmful Indeed, were it not tor the activity of the countless 
 
 billions which are silently at work changing dead animal 
 and vegetable matter into useful substances, life would be impossible upon 
 earth. They prepare food for all the rest of the world ; they make the 
 soil rich by decomposing all dead things and whatever has been cast away 
 by beings of higher orders when it has served their purposes. Dead 
 leaves, for example, can not possibly be of further use to the tree until 
 they have rotted. Bacteria attack the leaf and get from it what is needed 
 for their own life. In so doing they cause it to fall to pieces, and also 
 produce new compounds with gases absorbed from the air which are suit- 
 able for the use of growing plants and trees, and are taken up by them. 
 When the bacteria themselves die, their bodies, in a similar manner, are 
 decomposed, and what they had taken from the leaf is given back to the 
 soil in a useful form. It will be seen that all living things literally return 
 to the dust whence they came ; they merely borrow a few elementary 
 substances and arrange them in new combinations by means of a little 
 energy lent them by the sun, and after a while that which we call life is 
 gone, but leaves behind all that it had borrowed both of energy and of 
 matter. After death the body of the highest animal — man — becomes food 
 for lower forms of living things, and at last its constituents are prepared 
 by the bacteria for the support of higher vegetable life, to be further pre- 
 pared for supporting life in animals. Were all bacteria to be destroyed, 
 all life would soon end, for all the elements necessary to maintain it 
 would be shut up in the bodies of the dead. 
 
 Although most bacteria are harmless, some species are the cause of sick- 
 ness and death when they gain admittance under certain conditions to the 
 
 body. They cause suppuration (see the article Surgical 
 Injurious Bacteria 7-.". '70 ' i -r\' \ j iii n^i 
 
 dtl '^ Eif t Injiiries and ourgioaO JJtseases) 2i-u.a ^\'oha.b\\ 2l[V other 
 infectious diseases except malaria, which is caused by 
 a micro-organism which is not a bacterium. (See Malarial Fevers.) 
 The following is a brief sketch of the most widely accepted theories 
 concerning their relations to disease. The bacteria which cause disease 
 are called pathogenio (from two Greek words meaning sickness-causing), 
 and I shall use that term for convenience in this article. 
 
 Pathogenic bacteria differ from non-pathogenic in that they possess 
 
628 DISEASES IX GENERAL. 
 
 the power of surviving and multiplying under the conditions which exist 
 in the bodies of certain hunuin beings and other animals ; they are able 
 to obtain needed nourishment from the tissues of their hosts, and, for a 
 longer or shorter time, to withstand the efforts which the bodv cells make 
 to destroy or expel them. When they have once gained admittance to a 
 susceptible aniniars body they produce evil symptoms which vary greatly 
 in kind and in severity, according to circumstances. The symptoms de- 
 pend partly upon the species of germ, partly upon the virulence of the 
 particular individuals of species which happen to take part in the infec- 
 tion, partly upon their situation in relation to various organs and tissues 
 of the body, partly upon the degree of resisting power possessed by the 
 body cells, and partly upon the number of germs which find their way 
 into the body at any one time — /. e., upon the size of the dose of poison. 
 
 In using the word "'species" I do not wish to be understood to assert 
 that it is absolutely ]u-oved that clearly defined groups of bacteria exist 
 having characteristics so constant and striking as to justify the term in 
 the sense in which we apply it to groups of higher types ; I merely use it 
 for convenience. Bacteriologists speak of various "' genera " and " spe- 
 cies," but they do not regard any classification thus far suggested as any- 
 thing more than provisional. Thus they speak of bacteria which cause 
 tuberculosis {Bacillus tuherculosis) just as botanists speak of a definitely 
 recognised species of plant, like Papaver somniferum^ the opium popj)y ; 
 but the so-called genus Bacillus has only one characteristic — namely, its 
 shape like a rod — whereas the genus Palaver has a number of peculiarities 
 which distinguish it from other genera ; and the species tuhey^culosis is 
 recognised only by certain peculiarities of behaviour when dyed with cer- 
 tain aniline colours, and certain peculiarities in the conditions necessary 
 for its growth when cultivated outside of the animal body, and the fact 
 that it causes certain anatomical changes when it grows in the body, Avhile 
 the sjjecies soinniferum has many much more decided specific character- 
 istics. The PajKivcr somniferum produces, among other substances, 
 morphine, which, when administered in sufficient doses, gives rise to cer- 
 tain symptoms in man. The facts that a plant contains some substance 
 which resembles morphine in its effects upon the human body, that it 
 requires certain conditions of soil and climate for its growth, and that 
 some invariable chemical reaction occurs when certain tests are made, 
 are not sufficient to justify the assertion that it is the Papaver somnif- 
 erurn. The assertion that the Bacillus tuherculosis belongs to one spe- 
 cies is based upon hardly better evidence. This is, however, merely a 
 matter of theoretical interest, for the important fact is that certain rod- 
 shaped germs, having the peculiarities mentioned, are expectorated by 
 consumptives, and that these germs may cause consumption in any one 
 whose system they enter. "We do not know the ancestry of tubercle 
 
MODIFICATION OF DANGEROUS MICROBES. 629 
 
 bacilli. We do not know whether any harmless hacillus may, under cer- 
 tain conditions, become endowed wiih the terrible power of making 
 tubercles. We only know that the bacteria which grow in a certain way 
 upon certain culture media, and react in a certain way to dyes, cause 
 tuberculosis ; and because of their shape and their pathogenic power we 
 give them the name. 
 
 Pathogenic bacteria sometimes attack and destroy, or injure more or 
 less severely, some organ or group of organs or tissues, and produce 
 symptoms indicative mainly of the local mischief done. In the case, for 
 example, of a boil, the principal symptoms are due to the local lesion with 
 its painful swelling. Again, these germs may give rise to general symp- 
 toms only, as in typhus fever, where no one organ seems to be the par- 
 ticular seat of the trouble. Local diseases are, however, almost always 
 accompanied with symptoms of general disturbance. With the boil 
 <?omes fever and its discomforts, as well as the painful local inflammation. 
 
 I have said the species of germ has much to do with the kind of 
 symptoms produced, and I have also stated that the virulence of partic- 
 ular individuals of the same species differ. It is possible to cultivate cer- 
 tain pathogenic bacteria and, by modifying the culture media or the 
 other conditions under which they are grown, to intensifj^ or to lessen their 
 virulence. Pasteur asserted that he had done this so completely as to. 
 transform the most dangerous of microbes into entirely harmless organ- 
 isms — indeed, he believed that he had so modified some of them as to 
 make them useful in preventing the very diseases which, in their virulent 
 condition, they produce. Be this as it may, there is no doubt that germs 
 of the same species differ markedly in their poisonous properties, and 
 that the virulence of the latter can be greatly affected by artificial 
 means. Since it is shown to be possible to change a virulent into a 
 harmless microbe, there is reason to think that harmless species may 
 become changed into virulent ones, although proof that this takes place is 
 lacking. 
 
 The importance of the situation occupied by germs in determining 
 the symptoms produced by them is best shown in the case of the bacteria 
 of suppuration. When these invade a wound in some part of the body 
 where no important organs are involved, the wound becomes infiamed 
 and painful, pus forms in it, and the tissues in the immediate neighbour- 
 hood become more or less involved in the process. The general symp- 
 toms of fever appear, but the only result is the formation of an abscess 
 which finally discharges itself, and the symptoms subside. The case is 
 different when an important organ like the liver or brain is involved, for 
 now the patient not only suffers from the formation of pus, but also from 
 the injury to the affected organ. Here we have an example of difference 
 in effects due to difference in the situation in which the microbes are 
 
630 DISEASES IN GENERAL. 
 
 placed ; but there is another and move striking difference when the germs 
 tind their way into the general circulation and, instead of growing in solid 
 tissues, multiply in the blood itself. Violent general symptoms ensue, 
 abscesses (^large or smalH form rapidly in different places, and we have 
 what is called pyaemia, which usually ends in death. 
 
 In order to understand why there is such a great ditlerence between 
 bacteria lioating free in the blood and tlie same bacteria cuiitined in some 
 isolated locality, it is necessary to bear in niiml the fact that sujipuration 
 is a fight between the white cells and the bacteria. When the latter are 
 fastened in the tissues the former are able to gather in large numbers 
 and attack in the most effective manner. The wliite cells do not have 
 the power of pursuing their enemies in the tiuid blood, like lish in pur- 
 suit of their prey; all they can do is to attack those with which they 
 come in contact ; in the blood current the bacteria are at an advantage. 
 As a result of the bacterial activit}', or of that of the body cells, or of 
 both, fibrin begins to form and to entangle in its meshes numbers of the 
 enemy. The germ-laden masses of fibrin become large enough to plug 
 small arteries, and immediately the white cells attack the bacteria thus 
 arrested in their course. Cells and germs multiply, and an abscess forms 
 wherever one of the little plugs of infected fibrin lodge. 
 
 The general symptoms which accompany suppuration, as well as those 
 accompanying other infectious processes, seem to result from the action of 
 poisons which are formed by chemical changes produced by the growth 
 of the germs within the organism. In some instances it is possible, by 
 cultivating certain pathogenic microbes in suitable culture media in the 
 laboratory, and subsequently sterilizing the cultures by heat — thus making 
 it impossible that any effects produced can be due to the growth of the 
 bacteria when subsequently the fluid is introduced into the system — to 
 make compounds which, when injected in very minute quantities into the 
 circulation, produce the same symptoms as are observed when the same 
 organisms are in active growth during an attack of infectious disease. 
 Thus the bacteria of erysipelas (a disease in which there is intense local 
 inflamniation of the skin, due to the presence in it of the actively grow- 
 ing germs, and also marked general symptoms, such as chilliness, fever, 
 rapid and weak pulse, prostration, nausea and vomiting, and often diar- 
 rhcea), if cultivated in beef broth and peptones, cause chemical changes 
 in the broth of such a nature that a few drops of it, after steriliza- 
 tion, give rise to all the symptoms of severe erysipelas, except the in- 
 flammation of the shin, within a half hour after being injected hypo- 
 dermically. This shows that the general symptoms are due to the^?6»?'.S'0?i5- 
 generated in the infected skin, while the local ones are due in large part 
 to the presence of the living and multiplying germs themselves, which act 
 as irritants. 
 
ACTION OF GERMS IN ASIATIC CHOLERA. G31 
 
 Another example of the indirect action of germs is found in Asiatic 
 cholera. In this disease the bacilli do not enter the body tissues to any 
 extent; they simply decompose the contents of the digestive tube and 
 generate a virulent poison which is absorbed in the intestines in the same 
 way that a poison administered by the mouth is absorbed, and the symp- 
 toms result from the action of this poison. 
 
 When growing within the body, bacteria react toward the body fluids 
 just as they do toward any fluids in which they can grow — viz., they 
 produce new compounds by decomposing those ah-eady existing. The 
 souring of milk is caused by a microbe which produces, among other sub- 
 stances, lactic acid by decomposing the sugar of milk, and the microbes 
 of putrefaction give ample proof to the nose that they make of animal 
 substances new and most offensive compounds. I have already men- 
 tioned that the products of bacterial life are themselves poisonous to 
 the producers. In many diseases it is apparently for this reason that re- 
 covery ensues : the microbes poison themselves with their own excreta. 
 In the case of diphtheria, the fact that its bacilli make something which 
 helps the body to kill them has been utilized in the antitoxine treatment. 
 That method consists in increasing the amount of the antitoxic substance 
 in the blood of horses by infecting them with the concentrated poison 
 from cultures of the bacilli a number of times at certain intervals. After 
 a while the horses fail to show an}' symptoms after receiving the injec- 
 tions. The serum of those horses is used to inject into human beingsj 
 and it decidedly modifies and makes milder and shorter existing diph- 
 theria, and also prevents infection if injected in cases exposed to the con- 
 tagion but not yet sick. 
 
 CHAPTER YI. 
 ASIATIC CHOLERA. 
 
 Asiatic cholera is an acute infectious, non-contagious, but communi- 
 cable disease caused by a specific germ, the Bacillus cholercB asiaticce, 
 which is taken into the system with infected water or food, and in no 
 other way. 
 
 The cholera bacillus was discovered by Robert Koch in the course of 
 
 an investigation in Egypt undertaken by him when a severe epidemic of 
 
 the disease was raging in that country. His studies and 
 Cause : The Cholera . ^ ^ i i , , i , , i • i • , i 
 
 Bacillus experiments leave no doubt that the microbe is the cause 
 
 of the disorder, and that it is the only cause. This does 
 
 not mean that the bacillus, if swallowed by a perfectly healthy person, 
 
 necessarily produces cholera ; it means that unless the bacillus is intro- 
 
632 DISEASES IN GENERAL. 
 
 duoed into the digestive tube under conditions which permit of itsgrowtli 
 there, cholera is not possible. 
 
 The microbe is a minute ])acilhis, about one third the diameter of a 
 red blood-disk in length, which multij)lies raj)idly in fresh water, and 
 which is found in immense numbers in the dejecta of cholera patients. 
 It is sliglitly curved, and from its slmpe is often called the coiiuna bac'dlus. 
 It can not be recognisetl by its shape alone, or by any other peculiarity, 
 except the manner in which it grows on different nutrient culture media. 
 Comma siiaped bacilli are numerous, but the cholera bacillus forms cer- 
 tain peculiar colonies on potatoes, in gelatin peptone, and on agar pep- 
 tone, which, together with its shape, distinguish it from all other known 
 species. 
 
 It is very easily killed by drying, especially if exposed to direct sun- 
 light. It grows vigorously in fresh loater when the temperature of the 
 water is not too low, but it dies in a few hours in salt ivater, and never, 
 therefore, is a means of infecting tish, oysters, clams, lobsters, or crabs, in 
 the way certain ignorant people asserted that it might do. Weak acids 
 kill it immediatel}', and the normal acidity of the gastric juice is an effi- 
 cient protection against cholera in healthy people. This acidity is not 
 alwaj's maintained, however, especially in hot weather : slight attacks of 
 indigestion are frequent, in which the reaction of the stomach contents 
 become alkaline, and when this occurs the germs easily pass through it 
 into the intestines, the contents of which are normally alkaline. Here 
 they begin actively to multiply, and, save in a very few cases, the symp- 
 toms of cholera rapidly supervene. It should he home in mind during 
 an epidemic of cholera that there is not the least need of getting the dis- 
 ease. If a jyerson drinks only sterilized {J)oiled) water, which is kept in 
 sterilised vessels, and eats only properly cooked food, and keeps his hands 
 free from contact with cholera discharges {or, if obliged to handle these 
 discharges, or clothing soiled with them, carefully washes them imme- 
 diately in vKiter containing corrosive suhlimate or a small proportion of 
 acid), that person will not get cholera. 
 
 There are three stages in a typical case — the stage of invasion, the 
 stage of collapse, and the stage of reaction. Sometimes there is a short 
 stage of what is called the prodromal diarrhoea. 
 
 The invasion is usually very sudden. The patient while in perfect 
 liealth, or perhaps" after a few hours of slight intestinal disturbance, be- 
 gins to have a number of loose, painless, watery, diar- 
 rhceal movements. At the same time he begins to feel 
 weak and very ill. The movements soon change in character ; they be- 
 come more and more li(|uid and more and more colourless, until at length 
 they look precisely like rice water with a few white lumps or shreds float- 
 ing in it. ISTausea and vomiting are commonly early symptoms. 
 
SYMPTOMS AND TREATMENT OF CHOLERA. 633 
 
 Collapse follows in a few hours and the patient is completely pros- 
 trated, pale, or even bluish in colour ; the body, and especially the ex- 
 tremities, become very cold ; cramps occur in various 
 muscles, respiration is sighing and shallow, the pulse so 
 weak as to be imperceptible, the urine is suppressed, the rice-water dis- 
 charges may be almost continuous; consciousness is retained to within a 
 few minutes of the end in fatal cases. 
 
 If the jiatient survive this stage it is followed by the reaction. The 
 discharge diminishes in quantity, the pulse becomes perceptible at tlie 
 wrist, the cold extremities become warmer, and the tern- 
 perature in the rectum, which had fallen during the 
 stage of collapse to 97°, or even 96° to 95°, rises. Some urine may Ije 
 excreted, which is, however, loaded with albumin, and is usually bloody. 
 Soon fever sets in, and the temperature may reach 102° to 104°. With 
 the fever comes headache and delirium. Now follows either one of two 
 results : (1) The patient may go on, with diminution of all the symptoms, 
 to complete recovery, or (2) he may become comatose, the urine again 
 being suppressed, and death may occur within twenty-four to forty-eiglit 
 hours. 
 
 The treatment of cholera after the disease has fairly begun is unsatis- 
 factory. From fifty to seventy-five per cent, of the cases die. By far 
 ^ the most important treatment is that which prevents — 
 
 namely, avoiding infection. Nevertheless, the disease 
 is peculiar in this respect : the bacteria do not enter the blood, but pro- 
 duce their evil results by decomposing the contents of the intestinal 
 canal, and producing therein poisons which are absorbed by the system, 
 and in turn produce the dangerous symptoms. For this reason it is pos- 
 sible to hope that something will be discovered which will kill the bacilli 
 in the intestines without injuring the patient. 
 
 At present the best we can do is to give stimulants and remedies cal- 
 culated to combat the symptoms, but there is not much faith to be placed 
 upon any of them. 
 
 CHAPTEK YII. 
 MALARIAL FEVERS AND CHRONIC MALARIAL POISONING. 
 
 The cause of malarial diseases is infection with a micro-organism 
 which is not to be classed with the bacteria. It is called the Plasmodiiiin 
 TnalaricB, and it is found in the blood serum, the red blood-disks, the 
 white blood-cells, and in various organs. It varies considerably in shape 
 and size, and sometimes appears motionless, sometimes in active motion. 
 
C34 
 
 DISEASES IN GENERAL. 
 
 Fio. 3. — Young nattve parasite inside ked blood- 
 cell WITH NUCLEUS, NO PIGMENT. X 1,000. 
 
 Ehrlich dried specimen stained with methyl-blue. 
 Zeiss imuiers. -jV, projee. ocular 4. Calcium liglit. 
 
 The accompanying illustrations (Figs. 3, 4, and 5\ Mitli their descrip- 
 tions, will give a better idea of its appearance than can he conveyed 
 
 in words. It 
 The Cause of Mala- , r , 
 
 . , ,,. niav be lound 
 
 rtal Diseases. 
 
 in all cases of 
 malarial disease during an acute 
 o\\{\nx'\.ik^ provided qii'mhw has 
 not been administered in ejfi- 
 cieid doses. This drug prevents 
 its growth in the system, and 
 when a very weak solution of it 
 is brought in contact with ac- 
 tively moving plasmodia, while 
 they are being observed niidi-r 
 the microscope, it instantly ai-- 
 rests all motion and apparently 
 kills them. 
 
 "While we know a great deal 
 about the behaviour of the germ 
 within the body, we know prac- 
 tically nothing about its life his- 
 tory elsewhere. Xo attempts to cultivate it outside of the living animal 
 have been successful, and the conditions which it requires for existence 
 
 in malarial districts are no bet- 
 ter understood than before it 
 was discovered in the blood of 
 patients. We know that a con- 
 siderable elevation of tempera- 
 ture is one requisite for its de- 
 velopment, for malaria does not 
 exist in cold climates, nor does 
 infection occur in temperate cli- 
 mates when the weather is de- 
 cidedly cold, and the most viru- 
 lent forms of fevers occur only 
 in the tropics, or in regions with- 
 out long and severe winters. A 
 certain amount of dampness of 
 soil is also necessary, and low- 
 lying swamps and marshes and 
 the vicinity of stagnant ponds 
 are notoriously dangerous regions. If the swampy ground happens to be 
 in the tropics, fevers of the most malignant kind are apt to be bred in 
 
 iiG. 4. — Young paisasite inside swollen ueu blood- 
 cell, THE TIPS OF THE CRESCENT HOLDING THE 
 HYALINE NUCLEUS. X 1,000. 
 
 Same as above in stain and preiiuratiou. 
 
MALARIAL FEVERS-CHRONIC MALARIAL POISONING. 035 
 
 tliCMi. It is not iieco.s.sary that tlie wet ground slioiild he upou the .sui-- 
 face, for a swampy layer underlyirjf^ a pretty tliiek Htratum of Band and 
 gravel may be infected. 
 
 An elevation of four or five tliousand feet above the seadevel is 
 usually free from malaria, and it is said never to be met with above the 
 height of seven thousand feet. The boundaries of malarial and non- 
 malarial districts are often quite sharply defined. Sometimes a range of 
 hills or a belt of forest divides them ; but sometimes regions within a few 
 miles of markedly malarial districts, and having no apparent difference of 
 physical geography, and separated by no visible barrier from them, are 
 perfectly healthful. It is not safe, however, to assume that the uninfected 
 region will long remain so under the conditions last mentioned, for one of 
 the peculiarities of the poison 
 is that it slowly invades larger 
 and larger areas of territory, 
 provided soil and climate per- 
 mit. 
 
 There are certain facts about 
 the behaviour of malaria which 
 are of much practical impor- 
 tance. These should always be 
 remembered when one is in 
 malarious regions. It is well 
 known that in such regions any 
 extensive disturbance of the 
 ground (such as making exca- 
 vations for any purpose, build- 
 ing railway embankments, and 
 the like) increases greatly the 
 virulence of the poison, and is 
 followed by a marked increase 
 less of such work the better. 
 
 Fig. 5. — Fully developed parasite, rods of pig- 
 ment ARRANGED IN ROUND AREAS, NUCLEUS INDI- 
 CATED BY OPENING, ALSO VACUOLES. X 1,000. 
 
 Stain, preparation, and lens as above. 
 
 in the number of cases. Therefore the 
 Moreover, there is no better protection 
 than that afforded by thick sod, and where grass can be grown, dwelling- 
 houses should be surrounded by well-kept lawns, unbroken by flower beds, 
 free from shrubbery, and not too much shaded by trees. It is important, 
 of course, to drain marshes when this can be done ; but it must be borne 
 in mind that the first effect of drainage is usually to increase the un- 
 healthfulness of the region for a time, until the land previously covered 
 by water has become dry. 
 
 Susceptibility to malarial infection is greater in newcomers than in 
 residents of infected districts who have lived amid the germs for a 
 long time, and have also become used to the climate. Negroes are far 
 less susceptible than whites to tropical fevers, and natives of the tropics, 
 
636 DISEASES IN GENERAL. 
 
 of whatever race, less tlian visitors from the temperate zones. Ex- 
 posure to the hot sun, overexertion and fatigue, sudden chilling of the 
 body, and exposure to damp night air all add greatly to the risk of 
 infection. To this list of jiredisposing causes should be added feeble- 
 ness of body, no matter how brought about, and intemperance. 
 
 MALARIAL FEVERS. 
 
 The most striking characteristic of diseases due to malai-ial infection is 
 the regularity with which their symptoms tend to recur at lixed intervals. 
 This peculiarity gave rise to a name sometimes applied to them, periodiG 
 fevers. There are certain types in which the symptoms occur in parox- 
 ysms separated from one another by intervals of comparative or absolute 
 good health. These types are called intermittent fevers. Another type, 
 in which there is no period of complete absence of symptoms, but only a 
 decided improvement between the paroxysms, is called remittent fever. 
 
 The morbid changes found after death from malarial fevers are 
 
 essentially the same in all forms. The spleen is enlarged, hard, and 
 
 dark-coloured, with deposits in it and in other organs 
 
 of pigment derived from red blood-disks which have 
 
 been destroyed by the plasmodium. 
 
 INTERMITTENT FEVER. 
 
 An infectious, non-contagious, non-communicable disease, caused by 
 
 the Plasmodiinn malarice, and occurring in paroxysms which recur at 
 
 intervals of twenty-four, forty-eight, or seventy-two 
 Definition. , ,. j. ', -n i 
 
 hours, or sometimes oi seven days. iLacli jmroxysm, 
 
 in fully developed cases, is marked by a chill followed by high fever, 
 
 ■which subsides with profuse sweating. 
 
 Synonynis : Fever and ague; chills and fever; marsh or swamp fever. 
 
 The onset is sudden, although there may have been a few days of 
 slight discomfort before the first paroxysm. The patient is seized with 
 a severe chill. The skin becomes cold and rough, with 
 * "goose-flesh." The face is pale; the lips blue; the 
 
 nose looks shrunken ; the hands and feet shrivelled ; the teeth chatter 
 and there is severe shivering ; nausea and vomiting often occur ; there 
 is marked weakness ; the pulse is small and feeble. The chilly stage 
 may last from a few minutes to an hour or two. It is followed by the 
 stage of fever. 
 
 The shivering ceases and the sense of cold gives place to a feeling of 
 warmth, followed by a feeling of extreme heat. The skin flushes and be- 
 comes hot and dry ; the pulse grows strong and hard ; severe headache, 
 throbbing in character, sets in ; sometimes there is even delirium ; the 
 patient is restless and irritable. The stage of fever lasts several hours. 
 
INTERMITTENT AND REMITTENT FEVERS. f;37 
 
 Kext comes tlic sta<^e of sweatiiif^. 'I'lie internal toiriperature of tlio 
 body is elevated even during the cliill ; in the stage of fever not only is 
 the internal but also the surface temperature much above the normal, 
 frequently reaching 105° to 106° Fahr. With the commencement of the 
 sweating it falls rapidly. At the same time the other symptoms of fever 
 disappear, and soon the patient falls asleep, to awaken more or less weak 
 and languid, but otherwise little the worse for the attack. Either before 
 or during the sweating stage, diarrh(ca in the shape of one or two loose 
 passages may be observed. 
 
 The entire paroxysm may last from three to eiglit or ten liours. At 
 almost exactly the same hour, usually on the second day after the attack 
 (sometimes on the first day, the day immediately following it, and more 
 rarely on the third day), a similar paroxysm occurs; and the same thing 
 takes place at the same intervals for an indefinite time unless checked by 
 treatment. 
 
 Such is the history of a typical case of intermittent fever of average 
 severity. There are mild cases in which the chill is so slight as hardly to 
 be noticed ; or fever alone comes on, with or without subsequent sweat- 
 ing ; or instead of fever, chill, or sweat, the patient suffers from some of 
 the other symptoms — most frequently headache and general aching in 
 the bones and muscles — which come on at regular intervals. In warm 
 climates, and particularly in tropical and subtropical countries, very dan- 
 gerous forms are found. These are called 
 
 PERNICIOUS INTERMITTENT FEVERS. 
 
 After one or two attacks of simple intermittent type such as has been 
 described, the symptoms take on a new character. The chill, instead of 
 being followed by fever, may be prolonged, and the patient pass into 
 collapse and die. Or the fever may be accompanied by violent delirium 
 which merges into fatal coma. Or during profuse sweating heart failure 
 may take place. Sometimes diarrhoea and other symptoms resembling 
 cholera take the place of the usual ones, and death ensues ; and some- 
 times haemorrhages from the mouth, nose, bowels, or other mucous sur- 
 faces, or in the tissues of the body, show the pernicious character of the 
 attack. While simple intermittent fever is not dangerous to life, per- 
 nicious intermittent is extremely fatal. 
 
 REMITTENT FEVER. 
 
 A disease caused by the Plasmodium inalarice.^ characterized by fever 
 
 ^ ^ . . which is continuous throughout the attack, but which 
 
 has marked exacerbations and remissions occurring at 
 
 regular intervals. It is infectious, non-contagious, and non-communicable. 
 
 Synonyms: Malarial fever; typho-malarial fever; bilious remittent 
 
638 DISEASES IN GENERAL. 
 
 fever. Both remittent aiui intennitteiit fevers are often called by the 
 name of some place in which they are common, as l*aiiama fever, Clia- 
 gres fever, jungle fever, coast fever, African fever, etc. 
 
 Ilemittent fever is not connnon above the latitudes of mild winters. 
 In New York there can be no doubt that other diseases (particularly 
 typhoid") are often mistaken for it. 
 
 liemittent fever occasionally begins as a simjile intermittent with daily 
 paroxysms, each of longer duration in the fever stage, nntil tinally the 
 
 chill and sweat are absent, and the fever, with high tem- 
 Symploms. . . i i i • • • 
 
 perature at niglit and marked morning remission, re- 
 mains ; thus intermittent passes into remittent. More frequently there 
 is no intermittent beginning ; the disease is remittent from its onset. 
 Sometimes there are a few days of slight general discomfort, with aching 
 limbs, back, and head, restlessness at night, and loss of appetite, followed 
 by a chill or slighter chilly sensations. Sometimes the disease begins sud- 
 denly with a chill and without any preliminary symptoms. During the 
 first few days there is apt to be pain in the muscles and bones, prostra- 
 tion, headache, furred tongue, a temperature which is higher each evening 
 than it was the previous evening, while at some time of the day — usually 
 the early morning — it falls for a while nearly or quite to normal. After 
 from five to seven days the temperature tends to rise and fall daily through 
 nearly the same range — from 100° in the morning to 104:° to 105° in the 
 evening. This it continues to do for a variable period (from a few days 
 to a fortnight), and then the evening rise becomes daily less until at last 
 it ceases to occur, and convalescence is begun. Throughout the attack 
 there is disturbance of the nervous system — headache, restlessness or 
 delirium, and general pains. The tongue is at first coated white ; later 
 it often is brown and dry. The bowels are usually constipated ; the appe- 
 tite lost ; nausea and vomiting are common ; thirst is often intense. The 
 pulse is frequent and hard in the earlier stages ; later it is apt to become 
 weaker and more frequent. Sweating is often observed, particularly in 
 the later stages. Examination of the abdomen shows that the si^leen is 
 enlarged. This fact can be deuionstrated only b}^ a skilled observer. 
 There is often tenderness on pressure over both liver and spleen. In 
 severe eases a certain degree of jaundice may be present. Examination 
 of the blood, both in remittent and in the paroxysms of intermittent 
 fever, shows plasmodia, unless quinine has been given in large doses. 
 
 The most frequent complications are acute catarrhal inflammations of 
 the digestive organs and of the lungs. Some cases become pernicious in 
 character, and their symptoms then resemble those of pernicious inter- 
 mittent. The prognosis is, on the whole, good, provided efiicient treat- 
 ment is undertaken early. In the tropics, and in warm countries near 
 the tropics, remittent fever of a severe and dangerous type is quite com- 
 
GERM OF YELLOW FEVER NOT DISCOVERED. C39 
 
 mon, and the patient's clianees are better in proportion to the prevailing 
 severity of the poison in the neighbonrhood. The drug with which ma- 
 larial fevers should be treated is quinine. It sliould ]>e 
 Complications, given in doses of not less than twenty grains a day to 
 
 rogno.ni,, an adults for simple intermittent of ordinary severity. For 
 Ireatment. '^ _ . 
 
 some severe cases thirty to forty-five grains a day may 
 
 be required. Pernicious cases call for from sixty to one hundred and 
 twenty grains, and in such cases the drug should be given hypodermic- 
 ally and by the rectum, as well as by the mouth. In remittent fever the 
 dose should be given at the time when the temperature is lowest. The 
 efficacy of quinine is often increased if it be administered with some 
 purgative, like calomel, or, as it is in "Warbui-g's tincture, with several 
 aromatic and purgative vegetable substances. 
 
 CHRONIC MALARIAL POISONING. 
 
 In malarial regions some people seem to become accustomed to the 
 poison and live in comparatively good health. Others have a number of 
 acute attacks and then become weak, very pale, with a slightly yellowish 
 pallor, lose flesh and appetite, suffer from neuralgia and other pains, and, 
 in bad cases, become dropsical and die. They always have a spleen 
 greatly enlarged, and it may be so large as to occupy a good part of the 
 abdomen, forming an easily felt tumour — an " ague cake," as it is called. 
 Such patients are not much benefited by quinine, but sometimes arsenic 
 helps them. The greatest need for them is to leave the malarial district 
 as soon as possible. 
 
 Chronic malarial poisoning may appear in the form of long-continued 
 slight fever accompanied by great general discomfort and, it may be, by 
 periodic attacks of neuralgia or headache. Such should be treated by 
 a full dose of quinine and arsenic, and, if possible, should remove to a 
 more healthful region. 
 
 In chronic, as in acute cases, the plasmodium is present. 
 
 CHAPTER Till. 
 YELLOW FEVER. 
 
 Yellow fever is an acute, infectious, communicable, non-contagious 
 disease characterized by fever and prostration, and often accompanied by 
 jaundice. 
 
 The specific germ of yellow fever has not yet been discovered. That 
 it is a germ disease is hardly to be doubted, however. The following are 
 
640 DISEASES IN GENERAL. 
 
 important facts in regard to the spread of the poison and tlie })roduc- 
 tion of ei)ideiiiies like those ■wliich from time to time have caused such 
 terrible sutferiui^ and loss of life in the Southern States. 
 
 There is no question that the poison is j)(>rf((b/e ; that is to say, that it 
 mav be carried from infeeteil to uninfected regions by M-hatcver means 
 exist of transportation. The most freijuent cause of 
 epidemics in the Uuited States has been the entrance 
 iuto one of the Gulf ports of a vessel havinix the disease on board. Curi- 
 ously enough, it does not seem to be a directly cuniinrivu-able disorder. 
 It does not spread from person to person, but from place to place. In 
 the case of ships, it is the vessel or her cargo M-hich are the real carriers 
 of infection ; and this infection is transmitted to the soil or sometJiin<j 
 in the j)/ace w/iere a landing is made. In fact, yellow fever resembles 
 the malarial diseases in every respect far more tlian it does the contagious 
 diseases. In time of yellow-fever epidemic one is in no more danger if 
 in the closest kind of contact with a patient than one would be any- 
 where in an infected region. In this it resembles malarial fever, and 
 not at all scarlet fever, measles, smallpox, tj'phus fever, or other conta- 
 gious disease, for in such diseases the danger lies in coming into the im- 
 mediate neighbourhood of the sick person, or of something which has 
 been in close proximity to him. It resembles typhoid fever, cholera, or 
 other non-contagions, communicable disease in that these also infect indi- 
 rectly ; but these do not ever infect the «/;•, as do malaria and yellow 
 fever. It differs from malaria in that the latter is never transported by 
 human agencies. 
 
 The fever is endemic in a number of tropical countries, and is carried 
 from them, in the manner stated, to cooler regions. In no case does the 
 poison seem to survive long when the temperature falls l)elow the freez- 
 ing point of water, and a sharp frost checks an epidemic immediately. 
 Unlike malaria, one attack of this fever usually protects from subsequent 
 ones ; hut, as in the case of malaria, it is more likely to attack unaccli- 
 mated people than acclimated. The negro race is far less susceptible to 
 it than the white. 
 
 The onset of yellow fever is usually abrupt, with a chill, intense pain 
 
 in the back and loins, sharp rise of temperature (103° to 105°, or higher, 
 
 reaching occasionally 108° or 109° Fahr.), headache, 
 
 restlessness, great prostration, and often nausea and 
 
 vomiting. The pulse is more frequent than normal, and may he weak or 
 
 strong. 
 
 In a few hours, or perhaps not before two or three days have elapsed, 
 the temperature falls rapidly, and the patient improves in many ways, 
 but remains feeble. The pulse is now slower than normal and often 
 weak. The case may now go on steadily to recover}', or vomiting may 
 
ORIGIN AND HISTORY OF VACCINATION. C41 
 
 become a marked feature, and tlie vomited matters Ije like coffee f^rounds 
 in appearance. This is the so-caHed " black vomit," and is a symptom 
 of grave danger. The urine in these cases is usually diminished in quan- 
 tity, loaded with albumin, bloody, and contains bile pigment. Within 
 two or three days after the onset the patient usually becomes more or less 
 jaundiced— hence the name yellow fever. 
 
 Some cases occur in which the first symptom is the black vomit, and 
 death follows in a few hours. Death may occur at any stage in other cases. 
 
 The liver is found to be in a state of fatty degeneration. The kid- 
 neys are acutely inflamed. The spleen is not enlarged. 
 There is jaundice in cases that have lasted long enough, 
 HaBmorrhages in various parts of the body are common. 
 
 There is no specific treatment, and none that seems very satisfactory. 
 
 Most authorities seem to rely much on calomel, especially in tlie earliest 
 
 stag-e. Sedatives, stimulants, and various other classes 
 Treatment 
 
 of drugs may be required, according to the symptoms 
 
 arising in each particular case. 
 
 CHAPTEK IX. 
 VACCINATION. 
 
 Yaccination is the deliberate inducing of a specific infectious dis- 
 ease — vaccinia. The virus of this eruptive disease of the cow is inocu- 
 lated into man, producing a local pock ; this is fol- 
 lowed by constitutional disturbance — that is, by fever, 
 malaise, pains in the bones, general aching, etc. Inoculated subjects who 
 " take " — that is, develop a chai-acteristic pock and pass through the stages 
 of fever — are more or less permanently protected thereafter from small- 
 pox. A slight, acute, infectious disease (cowpox) is deliberately culti- 
 vated in the person to protect him from a severe one (smallpox). 
 
 Sir Edward Jenner, 1798, as the result of observation upon dairymen 
 
 and of experimentation, announced that persons accidentally inoculated 
 
 w^ith cowpox were thereafter insusceptible to smallpox. 
 
 In America, as the last step in this logical progression, 
 
 the law requires that, for the protection of the community, all persons be 
 
 vaccinated. The virus of cowpox used in human inoculation is obtained 
 
 directly from the pock (vesicle) produced upon the udder of a healthy 
 
 heifer by previous animal-to-animal inoculation. When the vesicle is 
 
 fullest of clear serum (watery in appearance) the chosen vehicle, either a 
 
 43 
 
♦U2 DISEASES IN GENERAL. 
 
 quill 01- an ivory point, is wot in the vesicle contents ami allowetl to dry, 
 
 and subsequently kept in a cool and dark place till reijuired for use. 
 
 The selected point of ujKM-ation is usually upon the outer asjieet of the 
 
 arm, just below the attachment of the muscle which caps the shoulder 
 
 joint — namely, at a point where several muscles meet in 
 
 Tr • ,' their attachment to the bone, but where there is least 
 
 Vaccuuttiun. 
 
 muscular movement beneath the skin, and consequently 
 least pain to the developing pock. At present it is thought better prac- 
 tice to vaccinate on the leg, either the inner or outer aspect, just below 
 the knee and near the shin bone. 
 
 The skin is first cleaned with soap and warm water, wiped dry with 
 perfectly clean (boiled) cotton cloth ; the outer scarf-skin is scraped away 
 with clean new needles or an aseptic (boiled) knife. By this process there 
 will be produced a moist, watery (serum) surface, with a little oozing of 
 blood. This should be sufficient to dissolve the dried virus from the end 
 of the quill during rubbing, prolonged for a minute. As the virus is 
 rather a thick, tenacious substance, it is well to let a drop of clear water 
 soften the virus while the preparations and operation are proceeding. 
 The best absorbent surface is thought to be a denuded skin surface 
 moistened with serum. A blister pi'oduces such a surface. Too much 
 blood, by coagulation, entangles the virus in the clot, if, by its free flow, 
 it has not already washed it away. 
 
 Successful inoculation begins to show, if the first vaccination (jiri- 
 mary), at the end of thirty-six to forty-eight hours, a slight redness, fol- 
 lowed by induration, burning and itching, fever, and aching of the bones. 
 About the fifth day the inoculation 'wound is surrounded with a raised, 
 ring-shaped vesicle (water blister). The fluid of this gradually changes 
 from clear serum to opaque white, then yellow (from the accumulation 
 of pus cells). Meantime the areola about the pock has spread to the size 
 of a silver dollar; the skin is liot, hard, and red ; little papillae — pinhead- 
 sized elevations — appear in the halo. 
 
 The fever, restlessness, aching of the bones, headache, and general 
 misery form the best possible example of the " constitutional disturbance " 
 or " febrile reaction " of a system struggling with the absorbed poison of 
 an acute infectious disease. Infants between three months and the age. 
 of the appearance of the teeth appear to suffer less than at other ages. 
 If the vaccination is npon the arm, the lymph nodes (glands) nnder the 
 arms are regularly enlarged and tender ; the arm feels heavy and painful. 
 If the pock is developed upon the leg, the nodes of the groin will be 
 enlarged and painful. 
 
 A revaccination does not run quite the typical course of a primary. 
 The period of incubation will be about three days ; the development of the 
 induration, vesicle, and pustule another three days ; drying and falling of 
 
VACCINATION AND REVACCINATION. 043 
 
 the crust a third throe days; and the scar left at last nmcli less deep and 
 pitted than the primary scar upon the same individual. 
 
 What constitutes a successful vaccination '^: Uow long does a success- 
 ful vaccination render an individual immune (insusceptible)? Upon this 
 hangs the further question, How often should persons be vaccinated ? 
 
 First, what constitutes a successful vaccination, or, more especially, a 
 revaccination ? The development of a characteristic pock with constitu- 
 tional reaction. The characteristic pock has successively these stages: 
 hardness (papule), vesicle, pustule, scab, and scar. A small, nodular, 
 warty, red mass, or any abortive blister, does not Hll out the requirements 
 of a successful pock. Quite as characteristic, also, are the constitutional 
 reaction fever and malaise. 
 
 The time for vaccination in infants is from the third to the sixth 
 month for the primary, from the tenth to the fifteenth year for revac- 
 cination. The infant may be vaccinated at any time 
 imejor accma- ^^^^ ^^ ^g -j^ perfect health. It is well to wait till the 
 lion in Injants. ^ . , , . . 
 
 third month, when its digestion is m good condition ; to 
 
 avoid the time of teething; to avoid any temporary depression from bron- 
 chitis or other ailment. It is thought by some that vaccinia in some way 
 determines a favourable course when induced in patients suffering from 
 whooping cough. 
 
 How often should persons be vaccinated ? A very good regulation is, 
 in all cases, to revaccinate every five years, and at any time that an epi- 
 demic prevails. Yaccinia affords a sure protection 
 Revaccination. . , ,, - . . rm j x* £ ±.\ • • 
 
 against smallpox lor a time, ihe duration oi this im- 
 munity differs in individuals, and can not be determined. It is well to 
 revaccinate several times, where persons are exposed to the contagion of 
 smallpox, if the first attempts fail. 
 
 Complications are seldom met where vaccination includes these factors : 
 good animal virus, a healthy person, ordinary cleanliness of skin and in- 
 struments, no injury to and consequently no chance 
 
 ompica.ions. q^^^^^q infection to the pock. There is now but little 
 arm-to-arm vaccination practised, and consequently little danger of trans- 
 mission of disease. There may be in severe vaccinia a certain amount 
 of diffuse redness of the skin, with heat and tenderness, especially in the 
 region of the pock. This may be a simple inflammation — dermatitis — and 
 have no relation to erysipelas. There frequently is a faint diffuse or 
 punctate eruption widely distributed over the body of a child with pri- 
 mary vaccination. This may resemble " scarlet rash," or may resemble 
 measles, and yet be without significance. 
 
 The pock should be protected from injury by any simple means. A 
 disk two inches in diameter, cut from a visiting card, may be shaped into 
 a shallow cone, like a watch crystal, by clipping out a V-shaped segment 
 
6U DISEASES IN GENERAL. 
 
 luid bringing the edges together with rubber adhesive plaster. The plas- 
 ter serves not only to lift the middle of the disk up into a cone, but the 
 long ends serve to bind the hollow cone to the arm. Wire screens are 
 sold in the stores for this purpose. 
 
 Practically there is nothing to be feared fi-om the effects of vaccina- 
 tion. There is no I'eason for withholding its protective intluence from an 
 infant that is ordinarily well, and there is great injustice in attributing 
 to vaccination any and all the ills that may overtake the patient, young 
 or old, in the next live years of life. 
 
 CHAPTER X. 
 SMALLPOX (VARIOLA). 
 
 Sala.llpox is an acute infectious disease, characterized by a skin erup- 
 tion which passes through successive phases of papules (small, indurated 
 nodules), vesicles (water blisters), pustules (pus blisters), 
 „, , ■ ,• crusts, scars (" pits "). It is one of the most contagious 
 of diseases — quite as much so as measles. The nature 
 of the infection is unknown. It is communicated by contact, by the 
 breath, by secretions carried by third persons, by fabrics, soiled linen, 
 utensils, etc. A corpse can communicate the infection. Crusts (scabs) 
 are believed to be very efficient carriers of the disease. 
 
 All ages are susceptible ; a child may be born with it. Other infec- 
 tious diseases seem temporarily to protect against smallpox, and one at- 
 tack of smallpox protects against further similar infection. Mexicans, 
 Indians, and negroes are especially susceptible to smallpox. 
 
 The incubation of smallpox is from ten to fourteen days. The onset 
 of the disease is abrupt, explosive. There is a chill with shivering, " chat- 
 tering " teeth in adults, convulsions in childi-en, high 
 
 ,,^ J'"'^*^ fever, headache, and, what is most characteristic, " split- 
 
 the Disease. ' ' ' . 
 
 ting," "breaking" pains in the back (loins). There is 
 high fever, dry tongue, stupor, or wakefulness and delirium. A peculiar 
 preliminary eruption, resembling scarlet fever or measles, often occurs 
 before the regular eruption. This is transient, but often temporarily mis- 
 leading. 
 
 On the third or fourth day the characteristic eruption begins — three 
 or four small pinhead-sized nodules, red and hard (papules). These are 
 characteristically hard, deep under the skin, feeling like birdshot, which 
 in a favouraV)le location, overlying a bone, as on the forehead, can be rolled 
 about under the finger. This is denominated a " shotty feel," and is 
 
SMALLPOX: SYMPTOMS AND OUTLOOK. G45 
 
 characteristic. The papular sta«jc lasts about tlirco <Ju_ys, dui-in^ which 
 time the eruption advances from the mouth, face, and scalp to the neck, 
 trunk, and extremities, appearing finally upon the palms and soles. 
 
 The lesion (injury, morbid change) in the skin will give one the im- 
 pression that it is deep; it is the true skin, beneath the outer scarf-skin, 
 that is affected. In chicken pox the scarf-skin rises up and forms a 
 blister-like pock ; it is obviously superficial, and is surrounded by the 
 faintest, most delicate pinkish halo. Smallpox attacks a deeper tissue, 
 gives a " shotty " nodule, and later develops a red halo about it, which is 
 manifestly a more serious inflammation. If the spots are close together, 
 they, later flow together, and form confluent smallpox^ with the worst 
 form of pitting. 
 
 The recognition of smallpox depends upon these points of history and 
 physical signs : an epidemic or exposure, sudden attack, chill, fever, 
 "tearing" pain in the back ; later, characteristic papular (nodular) erup- 
 tion, passing, in from twenty-four to forty-eight hours, into the vesicular 
 and later the pustular stage. 
 
 The outlook (prognosis) in a given case depends upon the severity of 
 the skin eruption, the sj^stemic poisoning, and the patient's strength to 
 resist. Confluent smallpox is of course a serious lesion, 
 and often fatal. This disease has the reputation which 
 it deserves. It is loathsome and defacing ; furthermore, it is a disease 
 which is a shameful disgrace to a family. It is a monument of negligence 
 on the part of some one. Smallpox is an avoidable disease. It is not, 
 however, an exceedingly fatal disease. The writer of this paper has 
 seen nurses and doctors caring for smallpox patients in rows in a big 
 ward, themselves perfectly protected by vaccination. It is the duty of 
 every parent to see that his children are vaccinated as babies, a few 
 years later, and every time there is an epidemic or chance exposure. A 
 recent successful vaccination is a sure preventive of smallpox. The 
 length of immunity conferred by a successful vaccination varies in indi- 
 viduals. Therefore the rule is a good one to revaccinate every five years 
 anyway, and whenever there is exposure or an epidemic. 
 
 A smallpox patient should not be allowed at large until the scars have 
 finished scaling — some three weeks or more. There exists for some time 
 a distinct stain upon the scars of the healed pocks 
 ' which remains some weeks, but gradually fades. This 
 stage does not threaten any danger to the public, provided the mucous 
 membranes and the skin are healed of the characteristic lesion. On re- 
 leasing a patient from the quarantine, the greatest care should be taken 
 that the skin and scalp are thoroughly cleansed with strong soap and hot 
 water, and that no scales or crusts remain. Of course, the patient should 
 put on fresh, new clothing. Often the palms will retain what the patients 
 
GiO DISEASES IN GENERAL. 
 
 call "seeds"' — small, ckep. hard crusts. Until all the characteristic mor- 
 bid processes are liealed, the patient should remain in strict quarantine. 
 The treatment of smallpox has been but little eucourag:inii:. Nothing 
 
 is known that can hinder the formation oi this deep- 
 Treatmint. i i i i • i • i 
 
 seared nodule and its suusecjuent going on to a destruc- 
 tion of the skin and CLUisecpient scar. 
 
 This name designates the moditied smallpox as it occurs in persons 
 who have been vaccinated. The fever is milder, the eruption scanty, the 
 
 course short, and rarelv scars remain. This modified 
 T (tnolotil. ,. ' . " . 1.1.11,1 
 
 disease may occur m persons vaccinated in childhood, 
 
 and not again. A recent successful vaccination protects absolutely. A 
 
 childhood vaccination allows in an adult a varioloid. An unvaccinated 
 
 person is susceptible to the one disease which shares with measles the 
 
 reputation of being the most contagious of the severer domestic diseases. 
 
 The result in smallpox is from twenty -five to thirty-five per cent, of 
 
 deaths. Those recovering have the mortification of knowing that their 
 
 defacement might have been prevented. 
 
 CHAPTER XI. 
 SCARLET FEVER (SCARLATINA). 
 
 Scarlet fever is an acute infectious disease (the nature of the infec- 
 tion unknown), self-limited, characterized by a diffuse or finely punctate 
 
 scarlet eruption upon the mucous membrane of the 
 Characteristics throat, upon the skin of the neck, trunk, limbs, and 
 
 extremities. There is a circumscribed briglit-red flush 
 of the cheeks, sometimes of a rather different red from the other skin sur- 
 faces, and pale areas along the nose and upper lip. 
 
 The poison finds expression early in an eruption u])on the mucous 
 membrane, seen best upon the soft palate and walls of the throat. This 
 is important in recognising the disease, because it is nearly always present 
 in well-marked cases, and is found early — often before any skin eruption. 
 The skin eruption is first seen upon the neck, cheeks, chest, abdomen, 
 and back, thence sju-eading upon the limbs and feet. The colour is scarlet. 
 The eruption is either a continuous red or, l)eginning as fine scarlet points, 
 becomes diffuse. The diffuse redness can be best recognised by pressing 
 the whole hand upon the skin and quickly removing it, when for an in- 
 stant the print of the hand will show white in contrast with the surround- 
 ing scarlet flush. The eyes are bright, not sensitive to light, not con- 
 gested, not tearful. There is not the cold-in-the-head look, nor the gen- 
 

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SYMPTOMS OF SCARLET FEVER. fj47 
 
 eral swollen, "boiled" l(X)k of measles. The tongue is coated early, later 
 clearing, and bright red on the edges and tip, with enlarged papilljje (less 
 than pinhead-sized). In typical cases it becomes the "strawberry" tongue 
 or "cat" tongue. The tongue may many times look decidedly straw- 
 berry-like. 
 
 Symptoms which patients complain of are headache, sore throat, 
 chilliness, or vomiting, followed by fever. In infants and young children 
 vomiting, sudden and unaccountable, is often the first 
 ■ symptom. A child may vomit at the table, or suddenly 
 vomit while playing quietly with its toys. The vomiting may ]>e but 
 once or several times. The poison seems to find expression in an explo- 
 sion or quick overwhelming of the system Avith fever reaction. 
 
 From the vomiting to the first eruption on the neck is usually about 
 one day ; to full eruption, reaching the extremities, about two more days ; 
 to fading and beginning disappearance, about three more. In a general 
 way, the history of the behaviour of the eruption of typical scarlet fever 
 conforms to the old rhyme — 
 
 " One to begin, two to show, 
 Three to make ready, and four to go." 
 
 The fading and disappearance of the eruption follows the order of its 
 appearance— throat, neck with the cheek flush, chest, abdomen, back, legs, 
 and, last of all, the feet and hands. 
 
 Peeling, or desquamation, is proportionate to the degree of the in- 
 tensity of the skin inflammation. In mild cases, in delicate skins, there 
 may be very little scaling. In severe skin inflammation the outer skin 
 may seem to be dead, parchment-like, and come off in sheets, especially 
 from the soles and palms. The nurse should sweep the plentiful scales 
 from the surface of the bed with a broom-brush, catching them in a dust- 
 pan. Again, the fingers may part with their dead skin, looking like a 
 glove-finger. The period of desquamation may begin early, and continue 
 till three weeks have elapsed from the fading of the eruption. 
 
 The fever of scarlet fever begins abruptly with the vomiting, increases 
 till the eruption is over the whole skin surface, then gradually declines in 
 four or five days to normal. 
 
 The kidneys are so commonly involved, to a greater or less extent in 
 scarlet fever, that some writers believe the eruption to be within them 
 quite as much as upon the throat or skin. Certain it is that albumin 
 appears (on boiling) in the urine during the early febrile stage, due 
 probably to the poison in the system and to the fever. This usually dis- 
 appears for a time in any case, and may reappear later about three weeks 
 from the beginning of the disease. This time it has more significance 
 and means a complicating inflammation of the kidneys. This may vary 
 
G4S DISEASES IN GENERAL. 
 
 from short, iiiikl kidney inflammation to any severe form of Briglit's 
 disease, so ealled. 
 
 The nature of the skin and mncons-memhrane lesion (injury or morbid 
 change) is mostly a congestion, a ]ocii\ dilatation of the snuillest blood- 
 vessels (capillaries) of the skin. This ini|ilios that there is little or no in- 
 tiltration, no hardness, thickness, and elevation of the surface. By gently 
 drawing the finger along the skin the blood is displaced temporarily, leav- 
 ing the skin ^vhite. Stretching the skin between two lingers blanches the 
 concested surface and constitutes a delicate test, although no better than 
 the imprint of the whole hand and its quick removal. The lesion, then — 
 the real morbid change, so far as it is understood — is the expression of 
 the general poison of scarlet fever upon the skin and membranes. An 
 example of an infiltration or induration would be a small so-called "blind 
 boil" or red, hard pimple. 
 
 The conduct of a case of scarlet fever is based on these facts : that it 
 is an acute fever which must run a course, is self-limited, tends to a 
 favourable ending, but is subject to certain complica- 
 tions which may leave certain after-results. First of 
 all, the patient should be placed on fluid diet, milk preferred. During 
 the first stage of high fever, with dry, burning skin, and great restless- 
 ness, there is no harm in sponging with tepid water — in fact, with any 
 comforting treatment which common sense may dictate. It is not neces- 
 sary to crowd on the bedclothing, to give hot drinks, to increase the body 
 heat in any way, with the idea of keeping the rash from "striking in." 
 A scarlatina patient in the first fever can scarcely catch cold in any 
 exposure. It is not perilous even to transport one from house to hos- 
 pital, as is frequently done in New York. The fever with dry skin pro- 
 tects the patient from the danger of catching cold so long as the fever is 
 at its height. Indeed, it is good modern practice, Avhere a child is hot, 
 restless, tending to delirium or convulsions, to cool it in a bath. The 
 irritation of a drj', burning skin causes nervousness, restlessness, and 
 sleeplessness, which tends to exhaustion. The indications are to relieve 
 this by simple means. Nothing is so simple, so rational, and successful 
 as bathing. Ev^ery form of bath does good. The first bath, which 
 should be given under the physician's directions and observation, may 
 range anywhere from a tepid sponging to a cold full-length bath, as 
 seems indicated. 
 
 It is our practice to cool the patient by baths — the method, the tem- 
 perature, and other details to be decided upon according to the require- 
 ments in the given case. 
 
 AVhen the fever begins to subside, the indications are to keep the 
 patient in bed, protected from currents of air, but not to exclude fresh 
 air. A patient does not catch cold from air that touches only the face 
 
TREATMENT OF SCARLET FEVER, 649 
 
 and enters tlie nose. The room sliould be large, airy, well li^^lited, with 
 sunny exposure. All hanf^ings and car])ets sliould be i-einoved and quar- 
 antine established. See regulations in J)ij)ldh.eria. 
 
 During the scaling period the skin should be sponged frequently to 
 remove the outer skin as it loosens ; vaseline, lanolin, mutton tallow, or 
 beef suet should be rubbed over the cleansed surfaces to limit the dis- 
 tribution of the scales snbsequently detaching themselves. 
 
 As the dangers of kidney complications and other sequelae of this dis- 
 ease are not all past before the end of three full weeks from tlie dis- 
 appearance of the eruption, the patient should be confined to the bed 
 during that time, especially in winter. This may seem rather arbitrary, 
 but a child once allowed to get down on the floor is beyond control, and 
 will certainly expose itself near a cold window or before an opened door. 
 If in summer, the temperature is everywhere the same, and this regulation 
 is less important. An active child may be fully dressed and allowed to 
 play upon the bed, not getting down to the floor. 
 
 When the fever is off and the depression of the system is on, the 
 child may easily catch cold and develop kidney trouble. 
 
 The complications of sore throat in the first week, of ear trouble, of 
 kidney inflammation, require careful daily attendance on the part of a 
 physician, and are not to be considered in this work. It is only to be 
 mentioned that all foul, discharging mucous surfaces are to be kept clean 
 and draining freely. 
 
 The outlook of a given scarlet-fever case depends mostly upon the 
 complications. In the first three or five daj's the general poison of the 
 disease may be a menace ; a serious form of sore throat, 
 pseudo-diphtheritic, may add itself to the characteristic 
 sore throat of scarlet fever, and at last the kidney inflammation may cause 
 serious alarm. However, the outlook is in general favourable, and most 
 cases give no occasion for serious apprehension. 
 
 CHAPTER XII. 
 CHICKEN POX (VARICELLA). 
 
 Chicken pox is an acute infectious, contagious disease of childhood, 
 
 characterized by an eruption of vesicles (water blisters) on the skin ; there 
 
 are a few spots of eruption, usually upon the mucous 
 Definition. , p -, \ r^^ ■ ^ 
 
 membrane of tiie mouth. Chicken pox may occur m 
 
 adults, notably upon those in close attendance upon a patient ; parents and 
 
 nurses, therefore, are often attacked. The nature of the contagion is un- 
 
050 DISEASES IN GENERAL. 
 
 known. The virus may be cuinmunicated diivotly, am] niav bo carried by 
 a third person. 
 
 The period from the time of exposure to the beg-inning of the first 
 symptoms (^incubation) is ten to fifteen days. The first symptoms may 
 attract no attention unless the attack is expected. The 
 ymp vnis. q\i[\^ may be a Httle feverish, possibly chilly, with pains 
 
 in the back and legs. Occasionally there is a slight transient rash, re- 
 sembling scarlet fever or measles. Usually the first recognised signs are 
 a few vesicles ajipearing n})on the trunk, face, and limbs, to the numl)er 
 of a hundred, more or less ; there may be a few in the mouth, seen best 
 on the soft palate. The typical well-formed vesicles are glassy, or opaipie 
 white, containing a clear, watery fluid (serum), hemispherical or flattened, 
 and surrounded by a narrow, delicate red halo, the rest of the skin being 
 of normal colour. After thirty-six to forty-eight hours the glassy hemi- 
 spheres become yellowish, begin to di-y in the centre, causing a central 
 depression, and at length become brown, dry crusts, which in a few days 
 detach themselves, leaving a red surface. A few in each case, especially 
 if irritated, extend deep enough to involve the true skin beneath the scarf 
 skin, and consequently leave, on healing, a permanent scar. Usually one 
 or more such irritated pocks occur upon the face. 
 
 "When examining a case of well-developed chicken pox, it will be ob- 
 served that there are present various forms of eruption or successive 
 stages of the same eruption ; upon the same back or chest there are small 
 piidiead, raised red spots (papules) ; while in the vicinity can be found 
 glassy vesicles, opaque vesicles drying in the centre, crusts, and possibly 
 traces of fallen crusts or scabs. In short, the pock of chicken pox may be 
 observed in every stage of its development within a hand's space. It is 
 seen that the eruption crnnes in successive crops. This is a characteristic, 
 which is of great aid in diagnosticating chicken pox from smallpox. 
 
 In adults the beginning of chicken pox is more severe than in chil- 
 dren. In the general course of the disease the patient is quite miserable, 
 but if the eruption can be found to exhibit all stages of the eruption at 
 the same time, the diagnosis is sure. 
 
 Chicken pox is to be quarantined, but requires little care beyond rest 
 in bed, milk diet, and time. 
 
INTENSELY CONTAGIOUS NATURE OF MEASLES. 651 
 
 CHAPTER XIII. 
 MEASLES {RUBEOLA). 
 
 Measles is a liiglily contagious disease ninniMg an acute, self-limited 
 course, characterized in an early stage by syniptotns of acute cold in the 
 
 head, and afterward by a rapidly spreading general 
 
 Nature and .. m - x- ^.i • ^ !• £ ^ ■ 
 
 ^, . ■ ,■ eruption. Ihe nature ot the intection oi measles is un- 
 (Jharaeterisncs. ^ 
 
 known. No germ has been isolated. The contagion is 
 communicated by the breath, by secretions of the nose and throat, and 
 may be carried by third persons. The intensely contagious nature of 
 measles, the fact that the early sneezing and coughing may communicate 
 the disease before it is recognised by the eruption, accounts in part for 
 the manner in which measles prevails in schools and communities. 
 
 Measles is a disease of childhood, but adults unprotected by previous 
 attack and brought into close contact with a patient suffering from the 
 measles are very liable to infection. Infants under six months are less 
 susceptible. Both sexes are equally susceptible to the disease. 
 
 Measles occurs in all seasons, rather more in cold weather ; it may 
 occur epidemically, and may be associated with an epidemic of whooijing 
 cough. One pi^onounced, unmistakable attack of measles is, however, sel- 
 dom followed by a similar attack of the disease, although cases of three 
 or four recurrent attacks have been recorded. 
 
 Measles may be considered an infectious disease which finds expression 
 in an eruption, and in symptoms associated with that eruption, the erup- 
 tion visiting first the nasal mucous membrane and eyes (sneezing and 
 weeping), and extending down into the throat or pharynx, where it can 
 easily be seen on the soft palate and side walls, thence into the vocal appa- 
 ratus, the larynx (coughing), and into the windpipe (coughing). There is 
 a tendency to pass still farther down into the bronchial tubes. After the 
 eruption (for such it really is, somewhat modified because it occurs now 
 upon a mucous membrane) has traversed the respiratory ways — nose, mouth, 
 and larynx — it begins to appear upon the forehead at the margins of the 
 hair, behind the ears, and upon the neck. Thence it spreads upon the 
 face, neck, trunk, limbs, and extremities, including palms and soles. 
 
 The mucous membrane of the nose is intensely red and swollen, and 
 
 shows what any one would naturally designate an irritated condition 
 
 (sneezing and sense of fulness). Upon the soft palate 
 AppearaMce of the .-, .. , p. . . j j 
 
 „ ,. • tlie eruption may be seen often as a spotted redness, or 
 
 Eruption. _ ^ -^ ^ . . • 
 
 " stippled " red. Upon the skin the characteristic erup- 
 tion first seen consists of delicate red spots, varying in size from a pinhead 
 to two or three pinheads, separated mostly by normal skin, though show- 
 
652 ' DISEASES IN GENERAL. 
 
 ing a toiuleney to group into patches Nvliii'h the fancy of the authors has 
 usually considered cresceutic. The colour uf the spots is delicate red 
 when first seen U])on the ])rotected skin behind tlie ear. There is a slight 
 tinge of purple in the thickly groujied ]mtches, and especially upon the 
 cheeks. The eruption is best observed u\)ou the trunk when the patient 
 is warm in bed. The eruption may be scattered, patchy, or dilYuse. 
 
 The characteristic symptoms of measles develop in the order of the 
 progression tif the eruption — namely, sneezing and weeping, bloodshot 
 eves, cough, and skin eruption on hair margins, face and 
 !/' P '»«• neck, trunk, limbs, and extremities. From the time of 
 
 the first eoltl in the head to the first eruption is usually three fall days. 
 From the first eruption on the face to the full eruption on the body and 
 extremities is usually twenty-four hours. The eruption is at its height in 
 about twenty -four to forty-eight hours longer. 
 
 The fever is now to be mentioned. It begins at the outbreak of the 
 disease with the nose and eye symptoms (cold in the head), continues 
 during the skin eruption on the face, and quickly mounts to a considei-able 
 height during the development of the eruption over the large skin sur- 
 face. In other words, the "breaking out" of the disease gives rise to a 
 local lesion (injury) which is attended witli a fever somewhat proportional 
 to the extent of the lesion, first upon the mucous membrane, then upon 
 more and more extended skin surface. The skin is inflamed, thickened 
 and congested. It is to a variable extent hot, itching, and burning. The 
 patient reacts with a fever projiortionately, atid when the acute "breaking- 
 out " stage is past, the fever quickly subsides. This is a favourable course. 
 
 Though measles is usually a mild disease and without complications, 
 
 vet in larfje institutions for children, or amono; soldiers in Ijarracks, or 
 
 inmates of workhouses — wherever people are crowded 
 Complications. , i 4.^ i i -i.! 1 
 
 — measles may he attended with more or less serious 
 
 after-effects. The eruption which has progressed from nose to larynx 
 may descend the windpipe into the bronchial tubes and produce bron- 
 chitis or broncho-pneumonia. The inflammation of the nasal mucous 
 membrane may mount through the little tube leading to the middle ear 
 and cause an inflammation, with pain and possible abscess, drum perfora- 
 tion, and discharge. This is not, however, frequent. The one compli- 
 cation to be feared is severe lung trouble tending to pneumonia. 
 
 Measles is an acute, self-limited disease. Mild, uncomplicated cases 
 require only protection, that Nature may have a fair fight; rest in bed, to 
 secure protection from exposure and fatigue ; fluid diet, 
 because it is more easily assimilated by a patient with 
 fever and without the usual exercise of health ; a mild purgative, to place 
 the organs in a condition of unembarrassed facility for elimination and 
 absorption. 
 
TREATMENT OF MEASLES. 053 
 
 No one but a skilled physician can assume the resporisildlity of saying 
 a case is typical, running a mild course, with no fear of complications. 
 If the child is under one year, measles is not a trifle ; the danger of pul- 
 monary complications requires the care of an expert. If over two years 
 old, the child may be said to be comparatively better able to bear the 
 attack. 
 
 Concerning the dark room in the stage of weeping — the initial stage — 
 it is not wise to overdo a good practice. The eyes should be directed away 
 from a bright light or bright reflection for the first four days. If the 
 light causes pain and irritation, protect them ; but do not depress the pa- 
 tient in prison darkness. As for keeping the patient warm, it seems use- 
 less to say anything. Most anxious friends satisfy a traditional demand 
 by swathing the child and keeping the skin macerated in perspiration. It 
 is a consolation to the friends, and the patient usually survives this excess. 
 It is not necessary to go heyond the hounds of comfort. If a child's skin 
 is warm, it shows redder ; if the air comes to it, the redness pales a little 
 from contraction of the capillary vessels in the skin. It is, however, 
 difficult to conceive of an acute infectious disease in a fevered patient re- 
 quiring this added heating and macerating of the skin. "When the cold 
 strikes the skin and the redness pales a little, let it be remembered the 
 effect is not necessarily a " striking in " of the eruption. This last condi- 
 tion, " striking in," having so much traditional value in the minds of the 
 laity, has really much the same physiological significance as the pallor 
 or the rattle in the throat of a dying patient. It is, in other words, akin 
 to collapse or fainting, coincident with failing heart and apj^roaching dis- 
 solution. It can not be brought about by temporary exposure ; therefore 
 do not add to a fever patient's misery by still further heating the tissues. 
 As a general precaution protect a moist, fevered skin from draughts ; a 
 dry one is less susceptible. 
 
 To recapitulate : Protect the measles patient, that Nature may make a 
 good fight. Protect the eyes while they are irritable from the irritation 
 of light. Protect the intestine from absorbing food that is not digested 
 because of high body temperature, or from its being of an improper qual- 
 ity. Protect from draughts ; protect from the effect of traditions which 
 lead to shutting out fresh air ; and protect from macerating the patient. 
 Finally, remember that the so-called " striking in " of an eruption is a 
 serious feature, because it is associated with grave internal changes, but it 
 does not arise from a'moraentary draught of air. 
 
 During the recovery of a patient there is a fine, branlike scaling of 
 the skin, varying in degree. Many times a measles cough persists for 
 weeks. It seems to be the local effect of the original eruption plus the 
 mechanical injury of severe, prolonged coughing. It is a hard, throaty 
 cough, and does not indicate bronchitis. 
 
654 ' DISEASES IN GENERAL. 
 
 How long should a patient be (]iiarantined after measles ? The period 
 of incubation for the infection of measles is from ten to twelve days — 
 from the eruptive stage of one case to the eruptive stage of a succeeding 
 case. It is not certain how late the contagion is active — how long after 
 the eruption begins to faile. It is certain that contagion is very active 
 from the beginning oi the initial cold-in-the-head symptoms. It is desir- 
 able, therefore, to wait till the eruption and all catarrhal sym])toms have 
 disappeared before the quarantine is broken and the child allowed to 
 mingle witli others. Before its reappearance in the community the 
 child's skin and hair should be thoroughly cleansed with warm water and 
 strong soap, and fresh boiled or new garments put upon it. The dis- 
 carded garments should be thoroughly beaten and aired, disinfected by 
 boiling, and washed in strong soap and water. The room should be 
 washed, the carpet and hangings beaten, and the whole aired thoroughly. 
 
 GERMAN MEASLES (ROTHELN, RUBEOLA). 
 
 This trifling disease, a transient imitation of measles at one time and 
 of scarlet fever at another, is so little understood by experts that it is 
 hardly worth while to discuss it here. It may resemble measles in re- 
 spect to the symptoms — eruptions upon the throat and skin — yet the con- 
 spicuous signs all fade in twenty-four or forty-eight hours, any trilling 
 fever wdiich it may have provoked being gone as well. Many such cases 
 have been observed in a patient who, before or after this attack, had un- 
 doubted measles. At another time the eruption may be very like scarlet 
 fever, transient, and unattended, with high or prolonged fever. 
 
 The diagnosis of German measles is usually made on its speedy disap- 
 pearance, the eruption coming and going in the space of forty-eight hours. 
 
 This disease is contagious, and occurs often in epidemics. 
 
 CHAPTER XIY. 
 TYPHOID FEVER. 
 
 Typhoid fever is an infectious disease, due to a specific bacillus, cliar- 
 
 aeterized by a fever of great irregularity in different cases, and with great 
 
 irregularity of symptoms. Indeed, typhoid fever may 
 
 ii^in UK ^^^ characterized as a disease without characteristics at 
 
 jyature. 
 
 least recognisable from bedside observation. In a thou- 
 sand cases, however, something may be learned which constitutes atypical 
 disease picture. 
 
TYPHOID FEVER. 655 
 
 Typhoid prevails in the United States and Canada, appearin^^ mostly 
 in August, September, and October, and has been called the autumnal 
 fever. Youth and young adult life are most susceptible to typhoid. The 
 disease is mildly contagious, the specific contagion being found in tlie 
 passages. In thinking of the contagion, let it be remembered that the 
 bacilli act practically like microscopic burrs. They may be carried, and 
 adhere to anything which they may touch. If these minute objects be 
 allowed to dry upon the skin, they may become dustlike and so carried. 
 Soiled clothing, bedding, and other fabrics serve as vehicles. The lesson 
 is, then, cleanliness and disinfeotion of stools. In hospitals, typhoid 
 patients are not separated from other patients, and neither nurses nor 
 other attendants acquire the disease. Typhoid bacilli maintain their vi- 
 tality after drying and freezing. Milk may become a favourable growing 
 medium if the cans become infected from water used either in washing 
 or otherwise. 
 
 Let it always be remembered that not all persons are susceptible to the 
 germ, and in perfect health a person may fairly feed upon and yet resist 
 the poison germ. 
 
 The characteristic morbid changes (lesion) of typhoid fever is swelling 
 of a group of glands in the lower portion of the small intestine. These 
 are denominated the patches of Peyer, or Beyer's jilaqiies. These 
 grouped nodules are about as wide as a finger and one to two inches long. 
 The whole symptomatic history of typhoid fever is centred upon the be- 
 haviour of these " patches." 
 
 Approximately, the stages of the fever are these : First week, swelling 
 of Peyer's patches ; second week, loss of vitality in the substance of the 
 gland, and death of the part (necrosis) ; third week, sloughing or separat- 
 ing of the dead tissue, forming open ulcers ; fourth week, healing. 
 
 The reasons for fluid diet, even in the fourth week, appear from the 
 above anatomical changes. 
 
 The earliest symptoms of typhoid fever are general indisposition, loss 
 of appetite, nose-bleeding. The onset of the disease is insidious ; the pa- 
 tient takes to bed without a suspicion of what is before 
 
 Symptoms. ^^.^^ ^^^^^ ^^^^^ ^ ^^^^ ^1^^^.^ appears upon the abdo- 
 
 men a rash — a few, seven, ten, or many delicate rose-coloured spots, pin- 
 head-sized. The characteristics of the spots are the delicate rose-colour, 
 the exceeding ease with which they become temporarily effaced, the slight- 
 est pressure or gentle traction sufiicing to efface them entirely, and 
 finally the fact that the spots come in crops. There is enlargement of 
 the spleen and liver. The general appearance of these patients is " ty- 
 phoid " — stupid, dull, apathetic. The tongue and lips are dry and brown- 
 ish. The passages of typical cases are " pea-soup " in appearance — fluid, 
 greenish, flaky. This characteristic passage is not present in a large per- 
 
656 DISEASES IN GENERAL. 
 
 centage of cases. Thoii^^h diarrluea is frequent and a feature of the 
 classical tyj^e in a thousand cases, yet it is not infrecjuent to lind constipa- 
 tion present tliroui::]iout the disease. 
 
 The outlook of a typhoid jiatient depends upon the previous habits of 
 the person, upon the general nutrition and health before the attack, and 
 
 upon the amount and virulence of the poison absorbed; 
 Outlvok. ^ ^ .^ . , /, • 1 • 1 
 
 or, to express it m anotlier M'ay, upon the way m Avhieli 
 
 the patient [in the cells making uj) his body) is able to combat the poison 
 in the system. As the lesion of diphtheria is practically limited to the 
 throat, so the lesion of typhoid fever regularly is found in the lower end 
 of the small intestine. In both cases there is a local lesion, necrosis, ab- 
 sorption, systemic poisoning, and febrile reaction. So the outlook may 
 be fairly estimated by the manner in which the patient bears the reaction. 
 Complications are not common, and for individuals living among 
 well-fed communities there are not those dangers that large metropolitan 
 hospitals report. Dependent upon the behaviour of 
 ■ the ulcers in the thin-walled intestine there may be 
 hremon-hage or perforations, with consequent peritonitis. These are rare 
 even in large hospitals. 
 
 In treatment the indications are fluid diet, to allow the grouped 
 glands (patches) to traverse the inevitable disease cycle uninjured, bath- 
 ing, to keep the high temperature from injuring the 
 heart's action and clouding the mental activity. Pro- 
 tect the patient from injury to the intestines due to hard food, from high 
 temperature — giving Nature an opportunity to fight the flood of poison — 
 and the outlook is good, even when the patient is apparently very low. 
 
 The passages should be caught in a bedpan containing carbolic-acid 
 solution (one part of strong carbolic to nineteen or twenty parts water) 
 or other disinfectant, allowed to stand an hour to fully destroy the germs, 
 then disposed of, that no surviving germs may drain into the supply of 
 drinking water. The parts of the patient should be cleansed; all soiled 
 linen should be boiled and otherwise disinfected, accordin": to the ideas of 
 the physician. Strong soap and hot water is a solution of unappreciated 
 value as a sure disinfectant. 
 
A CHARACTERISTIC WHOOP. 657 
 
 CHAPTER XV. 
 WHOOPING COUGH (PERTUSSIS). 
 
 Whooping cough is characterized by a spasmodic cough, ending with 
 a long-drawn, crowing inspiration, denominated a "whoop." It is a 
 liighly contagious affection, occurring in epidemics, the 
 nature of the infection being still unknown. It is con- 
 veyed by the breath, expectoration, atmosphere, and faljrics. Children 
 between the first and second teething are most susceptible, though parents 
 and nurses, and other adults in intimate relations with the patient, may 
 acquire the disease. 
 
 From the time of exposure to first symptoms (incubation) is seven to 
 ten days. The first symptoms are those of any ordinary cold — fever, cold 
 in the head, bronchial cough — the cough becoming spas- 
 modic. A prolonged bronchitis, with a cough tending 
 to come in paroxysms, is suspicious, especially if an epidemic is prevail- 
 ing. After ten days of the above symptoms a whoop is heard, unmis- 
 takable if well marked. The paroxysm usually can be anticipated by the 
 little patient. A look of anxiety comes over the face, the child ceases its 
 play, clings to its mother's skirts, and awaits the coming storm. The 
 paroxysm seizes the child, puts it to prolonged, urgent efforts at cough- 
 ing, till its breath is exhausted, its colour dusky, perspiration beads its 
 forehead, and it has expectorated a teaspoonful of thick, glairy mucus, or 
 has vomited. Then the spasm relaxes, the child draws a long inspiratory 
 " whoop," and sinks exhausted to rest. The intervals usually allow time 
 for rest, play, sleep, and food. These spasms may occur three or four 
 times a day or as often as every half hour. After a fortnight the attacks 
 appear less often and die away, the bronchitis lasting a little longer. 
 
 The outlook (prognosis) depends on the age of the . child, the amount 
 of impairment of nutrition from cough or vomiting, and the amount of 
 bronchitis. An infant under one year is in danger 
 00 c. ^^ ^^^^ complications resulting from the bronchitis — 
 
 namely, broncho-pneumonia. As to vomiting, it is seldom that it seriously 
 impedes the child's recovery. The stomach, not being primarily de- 
 rano-ed, manao-es to digest enough food to maintain the child's nutrition. 
 It certainly is a striking fact that, though a child seems to vomit every- 
 thing, it continues to keep its weight fairly well. 
 
 Whooping cough takes its name from the conspicuous symptoms. 
 
 The nature of the infection and the lesion are unknown. Treatment is 
 
 addressed to the bronchitis, to maintaining the nutrition, and to removing 
 
 all causes which induce the spasm. The spasm may be induced by 
 
 44 
 
05S DISEASES IN GENERAL. 
 
 irritation from a deraii«2:od stoniaoli, or from cxfitement, in>[)ired dust, 
 crying, etc. 
 
 Treatment should be carefully superintended l)y an expert. A large 
 room, well aired, with even temperature, is dictated by the condition of 
 the respiratory organs. The diet of the child should be 
 watched and regulated. There always remains the ques- 
 tion wherher to take the child into the open air, and what conditions of 
 atmosphere forbid it. Whatever course is pursued, everybody will prob- 
 ably be sorry another was not chosen. Our own preference is, in older 
 children, when the bronchitis is not deep in the tiner bronchial tul)es, to 
 take them if it be possible many hours a day into a moderate, dry, out- 
 door atmosphere. It seems to diminish the frecjuency of attacks of 
 cough, act favourably on the bronchitis, and assist in maintaining the nu- 
 trition. It requires a nice adjustment of case to seasons and to daily 
 weather conditions, and no fixed rule can apply to a series of cases. It 
 is possible to ''go out walking" in the liouse. Open wide the windows 
 of a large room, dress the child for the street, and promenade the aired 
 room for a time. The warm walls will temper the outdoor air and the 
 child will receive some good from the fresh-air promenade. 
 
 CHAPTER XVI. 
 MUMPS (PAROTITIS). 
 
 Mumps is an infectious disease, characterized by an acute inflammation 
 
 of the parotid glands. The parotid glands are irregular, sock-shaped 
 
 glands, lying in front of and below the ear (see The 
 
 Anatomy of the Human Body., Fig. 48). The nature 
 
 of the infection is unknown. The disease is contagious, spreading from 
 
 patient to patient, occurring more often in epidemics. Children and 
 
 youths are most susceptible, infants and adults least. 
 
 The time elapsing from exposure to the first symptoms of the disease 
 
 (incubation; is two or three weeks, usually in this time no intimation being 
 
 given of what is to develop. The first svmptoms are 
 Symptoms. ^, • , i ,, . , " i,. i • i 
 
 lever, pam below tlie ear on one side, swelling which 
 
 outlines the parotid gland, followed by a diffuse swelling of the neck and 
 cheek. After one or two days the opposite side begins the same cycle of 
 pain and swelling. "When tlie swelling is at its height the patient experi- 
 ences much pain and dilhculty in separating the jaws. Swallowing and 
 speech are painful. The time-honoured method of testing the oncoming 
 disease — tasting a pickle or other savoury food — depends upon the fact 
 
DIPHTHERIA AN ACUTE INFECTIOUS DISEASE. 659 
 
 that such ilavours stiimilate tlie gland to functicjiial activity, to pour out 
 
 its secretion. Besides pain on movement tliere may be a constant feeling 
 
 of tension, more or less earache, and tempoi-ary deafness. Drooling of 
 
 saliva may be a feature. 
 
 After a course lasting a week or thereabouts, the swelling subsides and 
 
 the patient recovers, with reasonable assurance of immunity from another 
 
 attack. There are rarely complications. In the male, 
 Complications and j.. , , . .• i <»^ ^i • i ^ i 
 
 ^g ,, , after puberty, one testicle, more often the right, may be- 
 
 come inflamed, painful, and swollen, much in the same 
 manner as the parotid gland. In the female the genitals and vagina may 
 have a catarrhal inflammation, with yellowish discharge ; tlie breast may 
 become enlarged and tender ; very rarely, one ovary. These are rare 
 complications, and are due more to the original infection, proljably, than 
 to catching cold. 
 
 The outlook of the original disease and any of the rare complications 
 is good. The patient usually recovers completely. 
 
 The identification of mumps in children is easy. The sock-shaped 
 
 swelling before and below one ear, with fever, pain on 
 Diamosis ajid ,. r ,t • ii'j_ ^ ^^i 
 
 rp , , motion of the jaw, and a history of exposure to tlie con- 
 
 tagion, makes the diagnosis clear, Karely the parotid 
 gland becomes inflamed in the course of infectious disease in adults, but 
 that is quite another afliair. 
 
 In treatment the main object is to make the patient comfortable. 
 The disease is self-limited and seldom gives rise to alarming symptoms. 
 
 CHAPTEE XYII. 
 DIPHTHERIA. 
 
 Diphtheria is an acute infectious disease, due to a specific germ, and 
 
 characterized by an inflammation of the mucous membrane of the nose, 
 
 mouth, or other air passages, the peculiar feature of the 
 Origin, Wature, and . ^ i- i • .i j ^- • j xi 
 
 .f, , ... inflammation bemff the production in and upon the mu- 
 Cnaractensncs. or i _ 
 
 cous membrane of a so-called " false membrane," This 
 constitutes the local diphtheria. The constitutional effect and symptoms 
 depend upon the absorption of poison. This characteristic false mem- 
 brane is of ash-gray colour, found at first more commonly upon the ton- 
 sils, from which it spreads to adjacent surfaces, notably the soft palate. 
 From this beginning it may spread upon continuous mucous surfaces to 
 the nose, or downward to the larynx and lungs. The false membrane 
 reminds one somewhat of the effect of a drop of water upon a fresh white 
 
660 DISEASES IN GENERAL. 
 
 blotting paper. There is a swelling of the tissue, eircuniseribed, sur- 
 rounded by the original tissue. The false membrane is not simply formed 
 upon the mucous membrane, but is a part of it, thickened, changed, and 
 circumscribed. The mucous membrane surrounding the patch of false 
 membrane is regularly inflamed. 
 
 The bacillus of diphtheria, named from the two investigators to wdiom 
 we are indebted for the discovery and completed study, is the Ivlebs- 
 Loetiier bacillus. It is a microscopic organism of one cell, rather larger 
 than the bacillus of consunijition, irregularly " clubbed " or rounded at the 
 ends. It multiplies by dividing itself in the middle, the two ends becom- 
 ing two mature forms, and dividing again into two, and so on. 
 
 Like many other disease-producing organisms, they are probably 
 present in abundance in crowded populations, and temporarily in the 
 throats of many healthy persons. So long as such a person remains 
 "insusceptible" the organism either continues to exist, doing no harm, or 
 dies out, not finding suitable soil in which to grow (see Bacteria). 
 
 If a child previously insusceptible has in its throat the bacillus of diph- 
 theria and by some accident, such as catching cold, the development of 
 scarlet fever, or by some other cause, becomes susceptible, what occurs ? 
 In other words, what is the history of a case of diphtheria in a general 
 way, so far as we know it? 
 
 The history is in general, this : A child whose throat for some reason 
 has the conditions favourable to the growth of the specific germ of diph- 
 theria — that is, becomes susceptible — acquires the micro- 
 organism. The tonsil is more often the seat of the first 
 lesion (injury or morbid condition). It would appear that crypts and 
 cavities of these bodies form a good culture medium. The germ, finding 
 a favourable soil, grows and multiplies. In some way connected with 
 its growth there is developed a soluble poison, a so-called toxin, which 
 causes circumscribed death (necrosis) of the cells making up the membrane 
 covering the tonsils. It is as though a tramp should build a fire upon a 
 lawn, killing the grass in a circumscribed area, charring the roots and sod. 
 The false membrane is then a circumscribed death of a mucous mem- 
 brane — a necrosis — the result of the peculiar inflammation set up in a 
 susceptible patient's throat by the presence and growth of the bacillus of 
 diphtheria. This dead membrane is augmented by coagulated fluid from 
 the blood and the white cells from the blood. The tendency of the false 
 membrane is first to cover the entire surface of both tonsils. There it 
 stops as at a natural barrier. It may, however, spread to the nose, involv- 
 ing all the mucous surfaces of the nose and throat, and halt again at a 
 seeming second barrier, the larynx. It may finally pass this point and 
 find free passage to the lungs. The laryngeal invasion constitutes the 
 worst variety of diphtheria, and is known as "membranous croup." 
 
SPECIFIC BACILLUS PRP^SENT IN DIPHTHERIA. 661 
 
 The bacilli of diphtheria arc practically foiiiid only in and aljoiit the 
 false membrane, not within the organs of the body. ''J'hc poison there 
 elaborated by the growth of the germs is absorbed into the general circu- 
 lation and gives rise to the systemic disturbance (fever). It is obvious, 
 then, that treatment must comprise local and constitutional remedies. 
 
 The general symptoms of diphtheria are frequently disproportionate 
 to the amount of false membrane seen in the throat. There may be but 
 little fever in diphtheria, beginning insidiously, and the 
 ymp oms. diilj not seem very sick. The throat may feel sore or 
 
 not. There may be headache or none. When it is remembered that the 
 poison is elaborated in the false membrane and the system absorbs it, and 
 " reacts " irregularly, it does not seem necessary to detail the fever fur- 
 ther. 
 
 It is believed by many of the medical profession that a throat severely 
 " sore " at the outset and accompanied by high fever is more likely to 
 prove non-diphtheritic. The constitutional symptoms of diphtheria are 
 exceedingly variable. 
 
 Heart weakness is one of the early signs of severe systemic poisoning. 
 It manifests itself in frequency and feebleness of beat. Of these quali- 
 ties the inexpert can form no trustworthy opinion. 
 Age, temporary excitement, and other factors come in 
 to produce varying results. Late in the disease there is a form of heart 
 weakness attended with some perils. Suffice it to say, diphtheria patients 
 with a manifest tendency to heart weakness should, as a rule, be kept lying 
 down, the head not unnecessarily raised from the pillow, and for some 
 time the heart should not be excited or put to unusual strain. Pneumonia 
 is not a frequent complication except there is false membrane in the 
 larynx. Different epidemics display different peculiarities. Many are 
 mild and attended with slight mortality. The kidneys are often tem- 
 porarily inflamed in severe cases. 
 
 It has been demonstrated that in all true diphtheria the specific bacillus 
 
 is present. The bacillus may be dried in the mucus expectorated from a 
 
 diphtheria patient, become pulverized by different means, 
 
 Cmtagionof ^^^ wafted on the air. For practical purposes it is bet- 
 ter to think of the germ as a burr which adheres to any- 
 thing it touches. A child in sneezing or coughing may spray the gar- 
 ment or face of an attendant with sputum containing germs. This may 
 adhere to the fingers, be caught under the finger nail, fasten to the hairs 
 of the beard, and thus be carried until it is caught upon another object. 
 It is endowed with great powers of vitality, capable of being awakened 
 to new growth and activity after months of existence in a dried state. 
 The indication is to destroy the germ in the mouth, in the expectorations, 
 upon whatever it may adhere to in the vicinity of the patient. Bacilli 
 
662 DISEASES IN GENERAL. 
 
 incased in dried mucus of sputum are especially well housed for a long 
 life. Strong soap and hot water readily dissolve this tenacious casing. 
 Xothing could bring greater dismay to the heart of a malignant bacillus 
 than to have its domicile destroyed, its armour stripjied away, and, half 
 flayed, to be flung into a corrosive disinfectant. 
 
 To this end the attendants should be guarded. They should keep 
 their throats healthy and free from mucus and pus by frequent gargles, 
 with nasal sprays, using bland fluids, such as salt or boric-acid solutions, 
 one or two teaspoonfuls to a pint of water. This mechanically irrigates 
 the surfaces and determines a healthy condition to the mucous membrane. 
 Cleanliiwss is nine and a half tenths of the treatment of all catarrhs. 
 
 To control the wanderings of the germs the patient should be quaran- 
 tined, cutting off all communication with those not necessarily attendants 
 upon the sick. With the patient the attendants must, 
 so far as possible, live in quarantine. On releasing 
 froni quarantine, the child should be washed thoroughly, ]>ut into clean, 
 fresh clothing, and the infected articles left behind in the old quarters. 
 
 The room should be large, airy, and have a sunny exposure. Air 
 should be allowed to change easily and freely without a])preciable draught. 
 All hangings, the carpet, all needless fabrics, valuable toys, and bi"ic-ji- 
 brac should be removed at the earliest moment. At the completion of 
 the case the walls should be stripped of paper and washed down with 
 disinfecting solutions, or, if this is impracticable, should be wuped (the 
 ceiling also) with fresh-bread masses, which entangle the dust and germs 
 and serve as a vehicle for removing them to the fire. 
 
 Let it be remembered that germs like dust settle upon irregularities 
 of wall, upon ledges, and upon the floor. To these special attention must 
 be given. First wipe with a damp cloth all up-facing surfaces, and when 
 the floor is cleaned it should be flooded with disinfectants in order to sat- 
 urate the accumulations of dust, lint, and germs in the cracks. Once 
 more, let it be remembered that cleanliness of the old-fashioned strong 
 soap-and-hot-water variety is very efficient. 
 
 The woodwork — this includes bedstead and furniture — should be 
 treated in this old-fashioned manner and thereafter washed with the dis- 
 infectant. The bedding, and all fabrics which can be so treated without 
 ruin, should be first washed thoroughly in hot water with strong soap and 
 afterward boiled hard for an hour or more. 
 
 Strict quarantine should be kept till the child has been pronounced 
 well of diphtheria — at least three weeks. 
 
TEUE MENINGITIS NOT COMMON. 663 
 
 CHAPTER XVIII. 
 MENINGITIS. 
 
 Meningitis is an inflammation of the membranes (meninges) covering 
 the brain and spinal cord. According to its distribution and character, it 
 is variously named cerebral or cerebro-spinal ; and according to its char- 
 acter, tubercular or simple. The most frequent location of meningitis is 
 upon the meninges enveloping the brain, and the more frequent variety 
 is, in children, tubercular ; in adults the variety is indeterminate. 
 
 Cerebral symptoms are common in children from nearly every ail- 
 ment — indigestion, anything causing high fever, pneumonia, and finally 
 from causes unexplainable. For the comfort of the 
 reader it may be remembered that if an excited parent 
 makes a diagnosis of meningitis, whatever else the child may have, in a 
 vast majority of cases it will not have meningitis. One of the most diffi- 
 cult diagnoses to be sure of early in the case is the disease under con- 
 sideration. Since it is the most difficult test of an expert, it need not 
 be discussed here except to mention some of the points which may help 
 to rule out meningitis. 
 
 First of all, an acute catarrh of the stomach and intestine, or an acute 
 indigestion, may give every symptom that a growth of tubercles or a 
 simple inflammation of the meninges can give — namely, vomiting, stupor, 
 convulsions, crossed eyes, cramped hands, stiff neck, retracted head, and 
 many more. 
 
 True meningitis is not commonly met. Among the symptoms in chil- 
 dren, these are perhaps the most suggestive : Prolonged obstinate vomit- 
 ing, which is sudden, projectile, or explosive, and not 
 Symptoms and -, . - n t- j . -.i iti 
 
 rp f f due to errors m feeding ; dense stupor, with a masklike, 
 
 expressionless, or deathlike countenance ; bulging fon- 
 tanelle — the anterior " opening '' of the skull (see The Anatomy of the 
 Ihivnan Body., Fig. T) ; automatically repeated motions of any limb or 
 of the eyes ; a peculiar disturbance of the rhythm of respiration, which 
 passes through this cycle, beginning with a deep sigh and followed sooner 
 or later with a suspension of respiration for a few seconds (called Cheyne- 
 Stokes respiration, from two writers on the subject). The bowels are 
 constipated and the abdomen is sunken. Castor oil cures most cerebral 
 symptoms. True meningitis is not common. 
 
064 DISEASES IN GENERAL. 
 
 CIIxYPTEK XIX. 
 RHEUMATISM. 
 
 A NUMBER of quite distinct diseases are included uiuk'r tlie title r/teu- 
 viatism. It is unimportant for the general reader to attempt to burden 
 the mind with too much technical detail, and a description of the differ- 
 ences between chronic rheunuitism proper and several other chronic joint 
 diseases which closely resemble it would be confusing and useless for our 
 present purpose — the more useless since the only possible hope of bene- 
 liting any of them lies in the employment of specially trained profes- 
 sional skill. We may classify rheumatism as acute and chronic, and in- 
 clude a number of joint affections under the latter head. 
 
 ACUTE ARTICULAR RHEUMATISM. 
 
 Synoi^yms : Acute rheumatism; inflammatory rheumatism; rheumatic 
 fever. 
 
 Acute articular rheumatism is an acute disease characterized by pain, 
 tenderness, and swelling, with or without redness, affecting one or more 
 joints and often affecting a number in rapid succession, and accompanied 
 by more or less fever. 
 
 Tlie real cause is unknown. The common idea that it is a direct re- 
 sult of what is called '" catching cold "" is only correct to a very slight 
 
 extent ; exposure in wet and cold weather, or to drauy-hts. 
 Causes. ' ^ ,. . , . , ^ .„ i , -, . . 
 
 or to any conditions which clnll the body surface, is 
 
 occasionally followed by an attack in j)<'(^pl<^ predisposed to rlienmatism ; 
 but while a history of exposure is obtained in a few cases, in many more 
 it is not. Moreover, among the cases ascribed to the results of exposure 
 and " taking cold," inquiry reveals that the great majority of them must 
 have been subjected to quite as much, if not more, exposure very many 
 times before without bad results, and that there is really little reason to 
 ascribe their sickness to it. People who are habitually exposed to cold 
 and wet are more prone to rheumatism than are others. The disease is 
 most common in the temperate zones. It is rare alike in very hot and 
 very cold climates. It is more frequent during the colder months than 
 the hotter. It is distinctly hereditable, frequently attacking several mem- 
 bers of a family. It occurs at all ages, but is most common in youth and 
 early adult life. A person who has had one attack is vei-y apt to suffer 
 from subsequent ones. In many cases it follows scarlet fever, and occa- 
 sionally other acute infectious diseases. 
 
 The invasion is usually aljrupt. Pain, rapidly becoming worse, is felt 
 
THE GREAT DANGER OF RHEUMATISM. 605 
 
 in one or more of tlic lai-gor joints (sornotirnoH the Kniullor are tii-,st in- 
 volved). Within a few hours tlie pain is intense, and tlie sli^i'lite.st move- 
 ment increases it terribly ; the affected joint or joints be- 
 
 ^ympom.. come swollen, the skin about them is tense and shiny, 
 
 and usually reddened ; fever is observed, the temperature being between 
 100° and 104° Fahr. ; the pulse is increased in frequency ; the appetite 
 lost; there is restlessness and nervousness, intensified by the dread which 
 the patient feels of moving ; the skin is often bathed in profuse sweat, 
 the odour of which is sour and offensive and the reaction very acid ; the 
 urine is diminished in amount, high-coloured, and intensely acid. The 
 inflammation may involve only one joint, or several may be simultaneously 
 attacked ; or it may be that the inflammatory symptoms will quickly leave 
 joints first affected to appear in others which had a few hours before been 
 free. 
 
 The sickness may last a few days or it may be prolonged several 
 months. It is impossible to tell how long it will continue in any case. 
 Sometimes the fever disappears, but the joints remain swollen, tender, 
 and painful, and the case becomes chronic. 
 
 The great danger of rheumatism is that the heart may be involved, 
 
 and endocarditis or pericarditis result. (See Diseases of Digestive Organs, 
 
 Heart, and Lungs.) Other complications are rare. 
 Complications. ^ . n , , i ii ^ . 
 
 Occasionally — but very, very rarely — the temperature 
 
 of an uncomplicated case rises rapidly to an extreme height — 106° to 109° 
 — and the patient, after being wildly delirious, becomes comatose and dies. 
 This is called rheumatic hyperpyrexia. 
 
 Complete rest in bed is imperatively demanded. The tender joints 
 may need to be protected from the weight of the bedclothes by suitable 
 bed racks. (See Surgical Injuries and Surgical Dis- 
 eases, Fig. 28.) Some cases do well on doses of sali- 
 cylic acid (ten grains in capsule every two hours) until there is ringing in 
 the head. Others do best on large doses of alkalies. Anaemic patients 
 require iron. Every case should be under the care of a physician who 
 can recognise disease of the heart and treat it, should it arise, promptly 
 
 and skilfully. 
 
 CHRONIC RHEUMATISM. 
 
 Chronic rheumatism may begin acutely, or it may never have had a 
 true acute stage. When it begins acutely, the cases usually consist of a 
 series of acute attacks following in such rapid succession that the patient 
 has not fully recovered from one before having another. 
 
 In such cases joint after joint is more and more injured, until finally 
 permanent changes of a destructive nature result. There is no fever ex- 
 cept during one of the acute attacks, but the joints remain swollen and 
 stiff, painful and tender. In time the ligaments, synovial membranes, 
 
006 DISEASES IN GENERAL. 
 
 and even the cartilages anU ends of the bones, thicken and grow rough, 
 and new fibrous tissue forms which obhterates more or less tiie cavity of 
 the joint and binds it and the surrounding structures rigidly together. 
 The limbs are thus variously deformed, and motion of them is interfered 
 with or rendered impossible. At the same time that the stiffening is tak- 
 ing place, changes in the cartilages are apt to occur which tend to dislo- 
 cate the bones and throw the limbs into hideously unnatural positions. 
 There is always more or less pain during the acuter outbreaks, and some 
 pain is constant in bad cases, especially when effort to move a diseased 
 limb is made. The general nutrition suffers ; the limbs waste, partly be- 
 cause of disuse of the muscles connected with the affected joints and 
 partly because the appetite fails and tlie digestion is not good. The dis- 
 ease may last ten to twenty-five years. 
 
 Some cases do not have the acute outbreaks ; one or more joints gradu- 
 ally l)ecome stiff and painful, and, as time goes on, these swell and become 
 disorganized. Among these cases are to l)e found a nunii)er which are 
 not truly rheumatic at all, but which, as I have said, it is needless to at- 
 tempt to describe separately in this book. 
 
 Chronic rheumatism is a disease usually met with after middle life. 
 Some of the cases with acute beginning are found to occur in the young, 
 and even in childhood. The prognosis is not good as to recovery, but 
 life may not be shortened, and, under good treatment, the process may 
 be arrested for a longer or shorter time, during which the patient enjoys 
 freedom from pain, if nothing more. 
 
 Baths, especially hot baths, alkalies, tonics, and regulated diet free 
 from starch and sugar, are the measures employed. 
 
 CHAPTER XX. 
 GOUT. 
 
 Gout is a disorder characterized by faulty metabolism, which results 
 in the formation of an excess of uric acid in the system, and by various in- 
 jurious effects produced by this substance. These are manifested some- 
 times in acute iiitlaniniation of joints, with a deposit about them of urate 
 of sodium ; sometimes in disease of the blood-vessels or some of the vis- 
 cera ; sometimes in both of these ways. 
 
 The direct cause of the lesions of gout is the presence of an abnormal 
 amount of uric acid in the blood and tissues of the body. The excess of 
 this acid is thought to be due to the faulty action of some of the organs 
 concerned in metabolism, whereby uric acid is produced instead of urea. 
 
GOUT A HEREDITABLE DISEASE. 007 
 
 (For description of rnetabolisiri and the formation of urea, see the arti- 
 cle on l*hysiolo(jij : The Vital VroceHneH in Jfealth.) Urea is tlie asli of 
 the nitroffenous food, and uric acid is t]i*>U£ij]it to repre- 
 sent one of the clianges which takes place in such food 
 during the process of combustion. It is not so rich in oxygen as is urea, 
 and may be looked upon as a partially burned ember. Whatever its 
 origin, it is present in excessive amount in gouty people, and it certainly 
 is poisonous in its effects. 
 
 Gout is a markedly hereditable disease. In a person predisposed by 
 heredity to it, it is almost sure to follow lack of exercise and high living, 
 if indulged for a sufticient time. It is one of Nature's rather grim prac- 
 tical jokes, that she makes many of those who inherit gouty tendencies 
 with a strong inherited liking for physical indolence and for the pleasures 
 of the table, thereby tempting them to their destruction ! Indolence, 
 overfeeding and overdrinking — and still more, excessive indulgence in 
 improper articles of diet — may cause gout even in those who have no 
 family taint. The precise opposite is true ; gout is sometimes caused by 
 starvation and privation of various sorts. 
 
 Gout may be classified as acute and chronic gout and as irregular ov 
 suppressed gout. 
 
 ACUTE GOUT. 
 
 Acute gout begins suddenly with an intense pain in one of the joints 
 
 — most frequently the metatarso-phalangeal of the great toe. The attack 
 
 usually begins at nia-lit. The joint is exquisitely tender 
 Symptoms. ^ -, . i , . ^"■, 
 
 and painful ; it soon swells, as does also the neighbouring 
 
 tissue ; the skin is tense, hot, and red ; there is some fever ; extreme irri- 
 tability of temper (partly due to the pain, but partly also to the disease 
 poison) ; scanty, high-coloured urine ; coated tongue ; quickened pulse. 
 The attack soon reaches its maximum, and remains violent for from one 
 to six or eight days. During this time there are remissions of pain ; but 
 sudden twinges, often produced by involuntary twitchings of the muscles 
 about the joint, occur at intervals, causing great agony. As the attack 
 subsides the pain lessens, the amount of urine secreted increases. On 
 cooling the urine deposits abundant urates ; sometimes there is diarrhoea. 
 The tenderness and swelling of the joint remain for some time after the 
 acuter symptoms have subsided. 
 
 It is a curious fact that people who are habitually cross and unpleasant 
 often exhibit a sweetness of disposition just after an attack of acute gout, 
 
 which makes their relatives hail the outbreak with joy. 
 
 The tissues about the joint are found to be acutely in- 
 flamed and to contain a quantity of urate of sodium deposited in their 
 substance. 
 
668 DISEASES IN GENERAL. 
 
 CHRONIC GOUT. 
 
 A succcssioji of acute attacks results in chrouic <routy inflainnintion of 
 the joints and the eoni])lcte destruction of them bv intiltration with the 
 urates and by bi-fakiiiix down tlie tissues about, lllliui:; tlicni witli thi- same 
 saUs. aiul fiiuilly ])roducin-; slu^-u-ish abscesses, whence the urates are ex- 
 |)elled from time to time. In chronic ijout ahuost every small joint in 
 the body nuiy be invaded and the patient become a hopeless invalid. 
 Death sometimes occurs from sudden ii^outy inflammation of some im- 
 portant organ. Thus the stomach or liver may fail, or the heart be 
 stopped. 
 
 rolchicum used during an acute attack almost always checks it within 
 
 twenty-four hours. It is (piestionable whether, in the long run, this drug 
 
 does not do more harm than c^ood. It is considered 
 
 Ireatment. . , , . . ^ 
 
 Wiser by maiiy good physicians to try rather to make 
 
 the patient comfortable by opiates, and let the attack run its course, than 
 
 to check it. The latter course seems to tend to cause internal disturbance 
 
 (luite often, and complete recovery does not seem to come so soon when 
 
 colchicum is used as when it is avoided. The patient should be put upon 
 
 a diet of slops during the attack and for some time afterward. Between 
 
 the attacks he should eat plain digestible food, avoiding all rich dishes 
 
 and all sweets ; and preferably should drink no alcoholic beverage of any 
 
 sort. If he lolll drink stimulants, let him avoid beer, ale, and all malt 
 
 liquors, Burgund}', heavy clarets, lihine wine, champagne, sherry, Madeira, 
 
 port, and all sweet wines — in fact, the best thing for him to take is whiskey 
 
 or brandy largely diluted and in small quantities. 
 
 Some do well on a diet composed almost entirely of meat, fish, and 
 
 green vegetables, and as free as possible from starch and sugar. Others 
 
 do best on starchy foods and fish, eschewing all red meats. Exercise, and 
 
 plenty of it, is imperative, and open-air exercise is especially beneficial. 
 
 The skin should be kept in order by frequent baths and daily friction. 
 
 IRREGULAR GOUT. 
 
 Gout manifests itself in the most varied forms in many people who 
 inherit it. Chronic and acute skin diseases, dyspepsia, asthma, bronchitis, 
 emphysema, Bright's disease, disease of the liver — these are some of the 
 shapes in M'hich it makes itself felt. They have been sufficiently described 
 under their appropriate heads. The gouty forms of these diseases do not 
 differ from those produced by other causes. In treating any of them it 
 is necessary to remember that it may be of gouty origin, and to treat the 
 gout by diet, etc., in order to benefit any manifestation of it in any par- 
 ticular organ. 
 
YIII. 
 DISEASES OF DIGESTIVE OKGANS, HEAET, AND LUNGS. 
 
 By frank W. JACKSON, M. D. 
 
 CPIAPTER I. 
 DISEASES OF THE PLEURA. 
 
 Pleueisy is an inflammation of the membrane which covers the lungs 
 and also lines the surface of the chest wall. This membrane is known as 
 the pleura. Its office is to cover and protect the lungs, 
 and to facilitate the movement of the lungs as they ex- 
 pand and contract during respiration. The surface of the pleura cover- 
 ing the lungs lies opposite, but unattached, to the surface of the pleura 
 lining the chest wall, and, as these two opposing surfaces are smooth and 
 glossy, the lungs move over the chest wall without friction. 
 
 This pleura is liable to various forms of inflammation, some of which 
 are only part of a general inflammation involving the tissue of the lung, 
 and some of which involve the pleura without disease of the lung. It is 
 the latter class which I am now describing. 
 
 Shnjple jpleurisy ^ or acute pleuritis, is an inflammation of a small por- 
 tion of the pleura lining the chest wall and of the corresponding pleura 
 upon the lung. The result of the inflammation is sim- 
 Simple Pleurisy : -y ^^ roughen the surface of the pleura by an exudation 
 ibymptoms and ^ m > t t i ■ t • 
 
 Treatment. ^^ nbrm. It may be caused by various conditions ; a 
 
 severe blow upon the chest will produce it, or a fracture 
 of a rib, or exposure to cold. Persons who are subject to rheumatism 
 may have it. It is sometimes found associated with Bright's disease of 
 the kidneys, and it is often found as one of the manifestations of la 
 grippe. 
 
 The symptoms of a simple pleurisy are a certain degree of fever and 
 general discomfort, a short dry cough, that is, without expectoration, 
 more or less pain over a small portion of the chest, with perhaps a little 
 shortness of breath. The pain is generally intensified on taking a long 
 
 669 
 
670 DISEASES OF DIGESTIVE ORGANS, HEART, AND LUNGS. 
 
 breath. The disease usually lasts about a week, and at no time does the 
 patient feel very sick. 
 
 A mustard j-ioultiee over the seat of pain is often all that is needed to 
 relieve the patient, but if the pain is very severe or long continued, it is 
 better to consult a physician, for the disease sometimes becomes chronic, 
 and is then known as phitristj with luJJwsions. This may be a serious 
 condition, reijuiring skilled treatment, for if at all extensive the lung be- 
 comes attached to the chest wall by little bands which interfere with its 
 expansion. 
 
 Suhacufc' j)h'i/r/,st/^ or j>/i'ur/\s// irith eftcslon {or icater on the cheat), is 
 
 a much more serious disease. Here a large portion of the pleura of one 
 
 lung becomes inflamed, and a large amount of scrum, or 
 
 Subacute Pleurisy: ^^.^j-gj.^ jg poured out into the space between the two 
 
 T t it pleurne, separating the lung from the chest wall and 
 
 compressing it more or less. This disease may persist 
 for months, and may even result fatally. 
 
 The patient may be taken sick suddenly with a high fever and all the 
 symptoms of a pneumonia, or he may become ill so gradually that he is 
 hardly aware that anything serious is the matter with him for a long 
 time. I once saw a gentleman who told me that he had had malaria and 
 an enlarged spleen for three months. An examination showed at once 
 that he had no enlarged spleen, but that his left chest was full of fluid. 
 This was his "malaria." AVhether the disease comes on suddenly or in- 
 sidiously, the patient has more or less fever, considerable or great prostra- 
 tion, shortness of breath, cough, with little or no expectoration, and usually 
 pain over the affected side. The degree of fever and shortness of breath 
 varies very much. Those in whom the disease comes on suddenly and 
 severely have a high fever, and often such severe breathlessness that 
 thev can not lie down in bed. Those in whom it comes on gradually 
 have usually only a moderate amount of fever, and are only conscious 
 of breathlessness when they attempt any exertion, as on walking or 
 working. 
 
 The treatment is always rest in bed — for a time, at least — and the 
 patient should invariably consult a physician, since the fluid must be re- 
 moved in various ways, as by diuretics or by aspiration. 
 
 Empyema, or pus in the chest, is a still more grave form of pleurisy. 
 In this disease an abscess forms in the pleural cavity (as the space be- 
 tween the pleura on the lungs and the pleura on the 
 Empyema: Symp- ^^^^^^ ^^,^^^ j^ called), and the lung is compressed by the 
 tain s and Ireatvieni. • ^ o • i i- 
 
 effusion of pus, instead of serum, as m subacute pleurisy. 
 
 The symptoms are similar to those of subacute pleurisy, only they are 
 much more severe, and the patient usually looks and feels much sicker. 
 His fever is high and irregular, and he is apt to sweat a great deal and to 
 
DISEASES OF THE PLEURA. 671 
 
 lose flesh rapidly. If he is not promptly and pi-opci-]y treated he becomes 
 emaciated and dies in the course of a few months. 
 
 The treatment is always to remove the pus. This may be effected by 
 aspirating the chest and thus removing the pus, or by making an incision 
 in the chest wall and introducing a rubber tube through which the pus 
 may gradually flow. It is often necessai-y to remove a portion of one or 
 more ribs. 
 
 Pneumothorax is a rare condition which results from the entrance of 
 
 air into the space between the pleura on the lung and the pleura on the 
 
 chest wall. This pneumothorax is caused either by a 
 Fneumoihorax and i i- ^i i . n i • i j^ ^ ^i ^ i 
 
 ., ., wound 01 tlie chest wall, which penetrates the costal 
 
 its Cause. _ ' _ ^ 
 
 pleura and thus permits the air to rush in through the 
 opening, or it is caused by the rupture of the lung and the pleura cover- 
 ing it. In this latter case, which is the most frequent cause of pneumo- 
 thorax, there is usually a tubercular nodule in the lung which softens and 
 breaks down, and through the opening thus made the air is pumped from 
 the lung into the pleural cavity. The effect of the air entering the pleural 
 cavity is to cause the lung to collapse and to become useless. 
 
 The symptoms of pneumothorax caused by a rupture of the lung are 
 at first those of pulmonary consumption, such as cough, night sweats, and 
 
 spitting of blood. Then, during some severe muscular 
 Symptoms, . i • r.^ <• ^ • ^^ 
 
 exertion, or even during a nt oi coughing, the rupture 
 
 suddenly takes place and the patient experiences a severe pain in the 
 
 chest, accompanied by intense breathlessness and a feeling of weakness or 
 
 faintness. He may even become completely unconscious, and he may die 
 
 without recovering consciousness. If he does not die at once, he rallies 
 
 from the shock of the rupture of the lung, but he is much sicker than he 
 
 was before. He has great and constant breathlessness, since he now has 
 
 only one lung to breathe with, and he is usually confined to his bed. He 
 
 may remain in this condition for two or three weeks and then die, or he 
 
 may grow stronger and be able to get out of bed and go about a little, 
 
 but he soon develops a purulent pleurisy in addition, and the disease is 
 
 then known as jpyopneum.oihorax^ or air and pus in the pleural cavity. 
 
 „ That is to say, he has part of the pleural cavitv filled 
 
 Pyopneumothorax. , , ', „ . „„ , . , . mi " • 
 
 With pus and the rest oi it filled with air. Ihe patient 
 
 under these circumstances can often feel the fluid splashing in his chest, 
 and he can sometimes even hear the splash. When a patient has pyo- 
 pneumothorax he is very much sicker than he was from the consumption 
 which caused the perforation of the lung. He loses flesh rapidly, has a 
 high fever at night, and perspires profusely. Afterward he expectorates 
 a great deal of foul-smelling material, which is the pus from the pleural 
 cavity. As a rule, little can be done for the unfortunate victim, because 
 an operation for the empyema does no good, since the disease of the lungs 
 
GT2 DISEASES OF DIGESTIVE ORGANS, HEART, AND LUNGS. 
 
 is the main cause uf the intiannnation of the pleura. All we can do is 
 to treat the consumption by cod-liver oil and tonics. In a few fortunate 
 cases tlie consumptive process is arrested, and then we treat the case as if 
 it were an empyema, and by opening the chest and removing a large por- 
 ti«-»n of one or more ribs we have a very fair chance of effecting a cure. 
 
 CIIAPTEK 11. 
 DISEASES OF THE BRONCHI. 
 
 LARYXGO-TRAcni:iTis is a mild inflammatit)n of the larynx and trachea 
 
 commonly known as a slight "cold." The larynx, or voice box, is the 
 
 cartilaginous organ situated in the neck and generally 
 
 /"'''I"?"' known as the "Adam's apple." (See The Anatomy of 
 
 tracheitis. ^^ )^ m • 
 
 the Human Body., Figs. 53, 54, and 55, and Physiology : 
 
 The Vital Processes in Health, Fig. 22.) This leads to and is continuous 
 with the " windpipe," or trachea, and contains the vocal cords or mech- 
 anism by which the voice is produced. The trachea is the large tube 
 that conducts the air into the lungs. (See Physiology : The Vital Pro- 
 cesses i)i Health., Fig. 9.) The trachea is made up of rings of cartilage, or 
 gristle, that can easily be felt in the neck below the larynx. The larynx 
 and trachea are lined with mucous membrane, a soft covering similar to 
 the velvety covering of the lips. When the larynx and trachea become 
 inflamed this mucous membrane becomes red and swollen and covered 
 with an increased amount of exudation or mucus. 
 
 This inflammation of the larynx and trachea is usually the result of 
 
 exposure to sudden changes of temperature, or to cold 
 
 and wet. It may be caused, however, by mechanical 
 iri-itation, as by the inhalation of smoke, or the fumes of ammonia, or 
 other irritating substances. 
 
 The disease often begins with a cold in the head and exteTids down to 
 the larynx. Then the patient has a dry, hard cough and a husky voice, 
 
 and feels a little feverish and generall^^ indisposed. 
 Jr- , After a day or two the coufjli becomes looser, but more 
 
 severe and paroxysmal, and there is an abundant ex- 
 pectoration of thick, tenacious material, which is " mucus " or " muco-pus." 
 The inflammation usually subsides by the end of ten days, and the pa- 
 tient is as well as before. 
 
 The treatment is simply to protect one's self from exposure to cold or 
 damp, and to quiet the cough by a few drops of paregoric, or by the use 
 of mild expectorants, as muriate of ammonia in five-grain doses, taken 
 
DISEASES OF THE BRONCHI. 6Y3 
 
 every hour. Irilialations of steam are often of service. Sometimes 
 
 the cold can be aborted by a Dover's powder, or ]>y five or ten 
 
 f^rains of quinine, or hot wliiskcy and water, or a hot 
 Treatment. , i , i , ^ ^,• 
 
 lemonade taken at bedtime. 
 
 Bronchitis is an inflammation of the raucous membrane of the Ijronchi. 
 
 The bronchi are the vast number of air tubes which are continuous with 
 
 the trachea and which spread throufi;h the lunL:;s, be- 
 Broncldtis. . ,, , ~, ■,■,..-, 
 
 commg smaller and more numerous as they subdivide, 
 
 just as we see the branches on a tree becoming smaller and more numer- 
 ous. (See Physiology : The Vital Processes in Health, Fig. 9.) 
 
 A bronchitis is a more severe " cold " than the form just described. 
 
 Like this, it is generally caused by exposure to cold and wet, but it may 
 
 be caused by irritating vapours, or by fferms, or in the 
 
 regular winter epidemic which is known as " la gri'pjjeP 
 
 It is also secondary to certain severe inflammations of the lungs, such as 
 
 pneumonia. 
 
 When an adult has an acute bronchitis he feels feverish and listless, 
 his appetite is poor, and he has a cough which is sometimes slight and 
 sometimes severe, and which is attended with a more or 
 Eistorv ^^^^ abundant expectoration of whitish material, "mu- 
 
 cus," or of- thick yellow material, " muco-pus." There 
 is soreness or pain under the breast bone, and there may be shortness of 
 breath, or even asthmatic attacks. The disease usually lasts from two to 
 three weeks, and then the patient recovers perfectly. 
 
 The mild cases require no further treatment than that recommended 
 for laryngo-tracheitis. The more severe cases require confinement to the 
 house, or even rest in bed. Ipecac is almost a specific 
 for acute bronchitis, and it may be given in small doses, 
 as ten drops of the syrup of ipecac, or one thirtieth of a grain of pow- 
 dered ipecac, every hour or two. If the cough is severe it may be quieted 
 by ten drops of paregoric every two or three hours. 
 
 If there be a high fever it is advisable to consult a physician. 
 Chronic hronchitis, or winter cough, is usually a part of some disease 
 of the lungs, as emphysema, or consumption ; or is due to heart disease. 
 It may occur by itself. It is worse in winter and better 
 Chronic Bronchi. -^ summer. There is but little fe^'er, but the patient is 
 its : Symptoms -, • -, .,., , „ ^ 
 
 and Treatment. ^P^ ^^ ^®®^ weak and sick with it and to lose flesh. 
 The treatment is mainly to be directed to the disease of 
 the lungs or heart, which is the primary cause. Muriate of ammonia, 
 paregoric, and cod-liver oil will aid in checking the cough, and change of 
 climate will often prove of benefit. 
 
G74 DISEASES OF DIGESTIVE ORGANS, HEART, AND LUNGS. 
 
 CHAPTER III. 
 DISEASES OF THE LUNGS. 
 
 Thk broncliiartnbes terminate in little bags or pockets which have 
 vei-v thill walls, and in these walls there are a great many little blood- 
 vessels. The oxygen from the inspired air passes through 
 
 iia omy oj these thin walls into the blood-vessels, and is then dis- 
 t/te Lungs. ' 
 
 tributed by the blood throughout the body. The main 
 
 object in respiration, then, is to draw air into the lungs in order that the 
 oxygen may jiass into tlie blood. The little bags are known as "air vesi- 
 cles." Each one is smaller than the head of a pin, and there are many 
 millions of them. These air vesicles are divided into groups which are 
 attached to a terminal bront-hus (just as in a bunch grapes are attached to 
 the central stem) by little "air passages,'' and the whole group makes up 
 what is known as a '* lobule," which may be said to resemble the M-liole 
 bunch of gra])es. (See Physiology : The Vital Pi'ocesses in Health, Fig. 
 8.) The lobules are closely united together to form " lobes," each " lobe " 
 making up about one half of the entire lung ; so that the lung as a whole 
 consists of bronchi, air vesicles, blood-vessels, and pleura. 
 
 Einphyseiua of the lungs is a very common disease. It is often called 
 
 "asthma," although asthma is only one of the symptoms of the disease. 
 
 Emphysema may be defined as a chronic disease of the 
 
 ., J air vesicles and of the bronchi. The air vesicles are 
 
 the JLiunys. 
 
 dilated, so that they become very much larger than nor- 
 mal. There are infiammatory changes in their Avails, and there is inter- 
 ference with the circulation of the blood through the capillary vessels 
 surrounding them. The changes in the bronchi are those of a chronic 
 bronchitis. 
 
 The result of these changes is that both luno;s become larger than 
 normal, and they contain too much permanent air, while too little fresh 
 air can get into the lungs. Emph^'sema is usualh' a disease of middle or 
 advanced age, but it may occur even in children. It is produced in 
 many ways. Itepeated attacks of bronchitis may cause it. Tuberculosis 
 may cause it, or it may come on by itself. It is often hereditary. 
 
 The chief symptoms are due to the broncliitis, which causes more or 
 less cough and expectoration. This cough is worse in winter and better 
 
 in summer, and persists year after year. It is therefore 
 '^"h'IT i"^^ sometimes called "winter cough." The patient is also 
 
 apt to feel weak and to lose flesh slowly, though this is 
 not always the ease. Shortness of breath on any exertion is very common, 
 as are also attacks of spasmodic asthma. These attacks of asthma may 
 
DISEASES OF THE LUNGS. 675 
 
 come on at any time, but tliey arc more frequent at night, 'i'liey arc so 
 severe that the patient is often obliged to get out of bed and sit upriglit, 
 with his head and arms upon the back of a chair, in order to get Ids 
 breath. Tliey will be described more in detail in the article upon AHth/iaa. 
 So the patient goes on for a great many years, having more or less cough 
 and expectoration and more or less shortness of breath, and feeling more 
 or less " poorly," until he finally dies of some entirely different disease. 
 The common belief that the subjects of "asthma" will be long-lived is 
 therefore not altogether ei'roneous. 
 
 In some cases of emphysema, however, the patients have few of the or- 
 dinary symptoms of this disease, but they act as if they had consumption. 
 They lose flesh and strength rapidly, and die in the course of a few years. 
 In considering the treatment it must be remembered that emphysema 
 can rarely be cured. The bronchitis can be controlled and the asthmatic 
 attacks much relieved, but the air vesicles never i^eturn 
 to their natural condition. Change of climate often 
 promises the greatest relief. A high, dry climate is the best, as Colorado, 
 or even southern California ; but the individual can often find by experi- 
 ence where he is most comfortable. The drugs nsed are those which help 
 the bronchitis and relieve the asthma. Iodide of potassium, in five- to 
 ten-grain doses three times a day, or muriate of ammonia, in ten-grain 
 doses, frequently repeated, or small and frequent doses of ipecac, will help 
 the bronchitis. The asthma may be relieved by teaspoonful doses of 
 Hoffman's anodyne, frequently repeated, or by the inhalation of the 
 fumes of burning stramonium, or saltpetre, or tobacco. In severe cases 
 inhalation of ether or chloroform may be tried, or morphine injected 
 hypodermically, but none of these last three remedies should be used 
 without the advice of a physician. General tonics, as iron and cod-liver 
 oil, are of service if the patient is weak and losing flesh. 
 
 PULMONARY CONSUMPTIOX. 
 
 Pulmonary consumption {or pulmonary phthisis^ or pulmonary tuljer- 
 culosis) is a form of lung disease which is very common and very fatal, 
 as is well known. It is a disease which is usually chronic — that is, which 
 progresses slowly and permits the patients to live several years, but which 
 is sometimes acute, or runs its course in a few weeks. 
 
 We now know that consumption is an infectious disease, by which we 
 
 mean a disease which is produced by infection, or the introduction into 
 
 the body of a material which causes the disease. The 
 
 « ere e infective material in this case is a minute living oro:an- 
 Bacillus. ,, -t • ^ ^ 
 
 ism, commonly called a " germ," which produces m the 
 
 lungs the characteristic morbid changes of tuberculosis. This germ, 
 
 which can only be seen by the aid of a very strong microscope, is shaped 
 
076 DISEASES OF DIGESTIVE ORGANS, HEART, AND LUNGS. 
 
 like a little stick of wood, or ** rod-shaped," and ir^incc it is rod-shaped, 
 the scientilic name "bacilhis" is given to it, for all rod-shaped germs are 
 called " bacilli." The particular bacillus M'hich produces consumption 
 never causes anv otlicr disease, and it is therefore known as the tuhu'vle 
 bacillus. 
 
 Consumption, then, is caused by the entrance into the lungs of tuber- 
 cle bacilli, which, by their rapid increase, cause a great many changes in 
 these organs, the most common of which is the produc- 
 
 , „ , tion of a irreat number ot httle grayish bodies oi about 
 
 and J^reaispuiiiiig. =^ i i ,i i T 7 mi 
 
 tlie size of a pinhead, called iuhercles. There may be 
 
 pneumonic consolidation, pleurisy and bronchitis also, and cavities may 
 
 form in the lungs. The tubercle l)acilli are carried into the lungs, along 
 
 with particles of dust, by the inspired air, but the}' are sometimes intro- 
 
 (.hiced into the stomach by milk from tuberculous cows, or by insufHciently 
 
 cooked meat from tuberculous animals, and, being taken up by the blood, 
 
 are carried to the lungs. 
 
 The bacilli which are inhaled are derived from the dried expectoration 
 of persons suffering from tuberculosis. Such persons expectorate freely, 
 and this expectoration is often swarming with the tubercle bacilli. Since 
 this is the case the question arises, Why are not more persons attacked 
 by this disease ? and the answer is found in the fact that something more 
 than the mere taking of the bacilli into the lungs is required to produce 
 consumption. In the iirst place, there must be a predisposition on the 
 part of the individual to acquire the disease — that is, a peculiar tendency 
 in the individual to favour the growth of the bacilli, just as certain soils 
 are favourable for the growth of certain seeds. In the second place, en- 
 vironment affects the growth of the bacilli, and the conditions may be 
 such that the bacilli can not increase. That is to say, an individual may 
 be kept under such line sanitary conditions that the tubercle bacilli will 
 not increase, even if taken into the lungs of one with the predisposition to 
 consumption. In other words, they can not grow in that soil under those 
 conditions. Finally, the bacilli are much more abundant in some localities 
 than in others, as in damp, low places and those unexposed to sunlight, 
 while at high altitudes and on the ocean the air contains none of these 
 germs. It follows, then, th-Atfor the j>ro(lnetio7i of cons^nnption we munt 
 have a constitutional ])redisposition to the disease, proper environment, 
 and, the growth of the tuhercle bacilli in the lungs. 
 
 Sex makes little difference in regard to the liability to consumption, 
 nor are there any limitations as to age ; the babe of a few months or the 
 old man may contract the disease, but it is most common under thirty 
 years of age, as there are more living people under than over this age. 
 It is well known that it is a disease which runs in families. It is more 
 prevalent among the poor than among the rich, but only because their 
 
PULMONARY CONSUMPTION. G77 
 
 environment is not so favourable. It is moi-e comuion in cities than in 
 the country for the same reason. 
 
 The cases of acute consumption act hke cases of pneumonia, or like 
 typhoid fever, and therefore need not be mentioned here. 
 
 In cases of clironic consumption tlie patients liave usually six definite 
 symptoms. They have cough ; they lose flesh and strength ; they have 
 a rapid pulse ; they have fever ; they have night sweats ; 
 ' and they have bleeding from the lungs. Every case 
 does not present all these symptoms, however, for spitting of blood, fever, 
 uight sweats, and cough may all be absent, either entirely or for a long 
 time. Bleeding from the lungs is so commonly found associated with 
 consumption that it is always regarded as a grave symptom. In fact, 
 many cases of consumption are first recognized by a sudden haemorrhage 
 occurring in a patient previously thought to be in perfect health. Bleed- 
 ing from the lungs may be so sliglit as to simply tinge the expectora- 
 tion, or it may be so extensive as to amount to half a pint of blood. A 
 haemorrhage from the lungs always frightens the patient, but it rarely 
 does harm, and often does good by relieving the congestion of the lung. 
 Death from hcemorrhage of the lungs is of the utmost rarity. Fever is 
 usually present during some part of the twenty-four hours. It usually 
 comes on about three or four in the afternoon, when the patient begins 
 to feel restless and " miserable," and he notices that his cheeks are flushed 
 and his lips dry. Then it lasts through the night. Sometimes it does 
 not come on until late in the evening. Sometimes it is only noticed dur- 
 ing the forenoon. In the more severe cases the fever is continuous and 
 the temperature is high, the thermometer registering 100° to 101° in the 
 morning and 102° to 104° in the afternoon. The night sweats are less 
 common than the other symptoms, but they are frequently present. They 
 .are usually cold sweats, and they weaken the patient so that he wakes up 
 in the morning unrefreshed. 
 
 The cough is a very constant symptom. It is at first only slight and 
 without much expectoration. After a time it becomes more severe, and 
 the expectoration becomes abundant, thick and heavy, and yellow in 
 colour. When the disease is well advanced the cough is very distressing, 
 and is often so severe as to cause the patient to vomit. The loss of flesh 
 and strength is very characteristic of the disease. In the course of a few 
 months the patient " looks consumptive." His face is thin, the cheek 
 bones are prominent, the ribs show through the skin, and his hair becomes 
 dry and thin or prematurely gray. The loss of strength is progressive, 
 but it is so gradual that the patient continues at his work for a long time. 
 
 The pulse-rate is increased often to one hundred a minute or more and 
 its frequency out of proportion to the fever or weakness.. It is one of 
 the most constant symptoms of consumption. 
 
(iTS DISEASES OF DIGESTIVE ORGANS, HEART, AND LUNGS. 
 
 There are a nunil)er of secoiularv syin])t(>ins wliicli may be ])resent. 
 The digestion is iin])aired aiul the jiatient is dysjieptie. Frecjueiilly tliere 
 is voiuitiiii; iiidej)en(lent of the coiiiiliiiiji;. In some cases this vomiting;; is 
 the prominent symptom, and, taken toy;ether ^A'ith tlie loss of llesh and 
 strength and the absence of spitting of blodd and niiiht sweats or coui^h, 
 may lead to the error of reu'arding the disease as cancer of the stomacli. 
 
 Sometimes the tubercle bacilli pass into the intestines, and, prodiicijig 
 inflammatoi-y changes there, give rise to a chronic diarrhcjea. Sometimes 
 there is tubercular inflammation of the larynx and the voice becomes 
 permanently husky. There may also be shortness of breath ; but many of 
 these patients, although obviously breathing rapidly, are conscious of but 
 little breathlessness. Some sulfer fi-oni ])ain in the chest and others 
 do not. 
 
 The duration of the disease is uncei'tain. Some patients go on with 
 moderate cough and occasional spitting of blood and moderate loss of fiesli 
 and strength for many years. Others die within two 
 or three years from the first symptoms of the disease. 
 A moderate number have a limited degree of tubercular inflammation of 
 one or both lungs and yet recover perfectly. Such patients may die years 
 afterward of some other disease, and a post-mortem examination of their 
 lungs will reveal only scars or chalky masses at the points where the tu- 
 bercular inflammation had formerly been recognised by the phj^sical 
 examination of the lungs. 
 
 The treatment of consumption is twofold. The first and most impor- 
 tant object is to prevent the spread of the disease to those as yet unaffected. 
 The second is the management of those already attacked. 
 To prevent the spread of tuberculosis it should be re- 
 membered that one tuberculous individual may infect many others. The 
 expectorations of a consumptive contain many bacilli, and if the expecto- 
 ration be I'ccklessly thrown upon the floor of the room or upon the street 
 it becomes dry, and mixing with other particles of dust, these bacilli may 
 be drawn into the lungs of a healthy person and tliere set up a tubercular 
 inflammation anew. The consumptive should therefore be careful not 
 to indulge in reckless s[)itting. The expectoration should be received into 
 bits of Japanese paper or rag, which must be burned while damp, or into 
 strong envelopes waterproofed, or little bottles or pasteboard boxes (see 
 Nursinrj the SicJc, Figs. 23 and 24) which the patient may carry round 
 with him and empty and clean frequently ; or if he be confined to the 
 house, the expectoration should be received in a cuspidor which is fre- 
 fjuentl}' cleaned. 
 
 The consumptive should, if ])ossible, always sleep in a room by him- 
 self. Certainly he should sleep in a bed by himself. The room should 
 be frequently aired and fi-equently cleaned, care being taken to dampen 
 
LOBAR PNEUMONIA. 070 
 
 the floor so that the dust shall not be spread about. iJairymeii and 
 butchers should be careful that their milk and meat are from healthy 
 animals. The cliildren of consumptive parents should ha carefully 
 watched and placed under the best possible hygienic conditions. The 
 same is true of delicate individuals who may come in constant contact 
 with consumptives. 
 
 The treatment of the patient who has contracted consumption consists 
 chiefly in building him up in every possible way, so that the system may 
 become strong enough to counteract the poison of the bacilli and to check 
 their growth. This is affected by freeing him from anxiety as much as 
 possible, by favouring an out-of-door life, by sufficient and nutritious 
 food, by proper ventilation of the sleeping room at night — for fresh air, 
 even if cold, never does any harm — and by selecting a sunny room. 
 
 If it can be arranged, change of climate is a verj^ im])ortant method of 
 treatment. Many improve wonderfully when sent to the Adirondack 
 Mountains or to Colorado. Some do better in a warm climate, as Florida, 
 or Georgia, or southern California, or Algeria. Some do better at sea or 
 on the seashore. Jjut, ivherever they go, they must live out of doors as 
 much as possible. Cod-liver oil, milk, and cream all help to improve the 
 patient's nutrition, and should be partaken of as freely as possible. The 
 daily cleansing of the skin of the whole body is also important. A bath 
 and a quick, brisk rubbing will help wonderful!}", and there is no danger 
 of " taking cold " in the process. 
 
 The most important of the drugs which may be employed is creosote, 
 which may be taken into the stomach or inhaled through an inhaling 
 apparatus. Iron, bitter tonics, and alcohol may be required, and various 
 sedatives may be used for the cough. 
 
 PNEUMONIA. 
 
 Pneumonia {ov pneumojiitis, or lung fever, or inflammation of the 
 lungs) is a disease which involves the air vesicles, the air passages, and the 
 smaller bronchi, and regularly has associated with it the inflammation of 
 the pulmonary pleura. There are several forms of such pneumonia, 
 which we designate by various names, such as lobar pneumonia, broncho- 
 pneumonia, secondary pneumonia, pneumonia of heart disease, chronic 
 interstitial pneumonia, and several others. The most important of these 
 are lobar pneumonia and broncho-pneumonia. 
 
 Lobar pneumonia is so called because it usuall}' involves at least one 
 lobe of a lung. It is an acute infectious disease attended with the growth 
 in the lung of certain " germs " or " bacteria." 
 
 These germs are found in the expectoration of patients who are sick 
 with pneumonia, and this expectoration when dried may be carried in the 
 form of dust into the lungs of healthy persons, and there set up a fresh 
 
GSO DISEASES OF DIGESTIVE ORGANS, HEART, AND LUNGS. 
 
 piitniiiioiiia, lint the presence of the iivrins alone (h)es not seem sufficient 
 to cause a pneumonia, for they are frequently found in the mouths, or in 
 the saliva, or in the nasal secretions of healthy persons. There must be 
 in addition an exposure to cold in order to ]>roducc the ])neunionia. 
 Persons who fall into the watt-r often iK'velo[) piu'Uinonia after the im- 
 mersion. It seems as if the sudden (.•hill eiialiles the germs to successfully 
 attack the hmg. 
 
 When a patient contracts pneumonia the germs multiply very rapidly, 
 and by their growth form poisonous chemical products (called "toxines") 
 which poison the whole system. The portion of the lung inflamed be- 
 comes solid by the filling up of the air vesicles by these germs, and by 
 exudation from the blood-vessels in the walls of the air vesicles. When 
 the patient recovers, this exudation disappears and the lung is left per- 
 fectly healthy. A lobar pneumonia may involve one lobe of one lung 
 or the whole lung, or parts of both lungs. In the latter case it is called 
 '' double pneumonia." 
 
 Pneumonia is found in almost every |)art of the world. It occurs at 
 all times of the year, but in countries in the temperate zone it is most fre- 
 quent from February to May. It may occur at any age from five years 
 up and in either sex. The feeble and weak are rather more liable to the 
 disease than the strong and robust. It is less common in the country than 
 in the city. 
 
 The symptoms of pneumonia usually conic on suddenly. The patient 
 after exposure has a sharp chill, followed by fever and great prostration, 
 and is usually obliged to take to his bed at once. With- 
 ■ in a few hours there is developed a short, dry, hard 
 
 cough, and sharji pleuritic pain on the affected side. This pain is usually 
 felt just below the nipple. There is soon added a thick, tenacious ex- 
 pectoration which is blood-stained, and which usually looks as if it had 
 l>een used to wash rust off old iron. Hence the name "rusty sputum." 
 This expectoration is characteristic of the disease. Sometimes there is 
 no blood in the sputum. Sometimes there is a great deal of bright-coloured 
 blood in it. This is especially the case in the pneumonias due to consump- 
 tion. Sometimes the sputum is very dark like prune juice; this betokens 
 a very grave case. 
 
 The patient goes on in tins way, with a high fever, the thermometer 
 indicating from 102° to 1(»5°, a rapid and full ])ulse, rapid respiration 
 (about forty to the minute), and a great sense of breathlessness, cough, pain 
 in the side, and perhaps delirium, for about a week ; then the fever sud- 
 denly leaves him and he rapidly returns to health. 
 
 The appearance of a patient suffering from pneumonia is very char- 
 acteristic. His face is anxious and there is a deep-red flush upon one or 
 both cheeks. His lu-eath is short and his sentences are broken by his 
 
BRONCHO-PNEUMONIA. 081 
 
 breatlilcssness. lie usnally lies upon liis Ijack, but lie may lie upon tlio 
 affected side so as to give full plaj to the healthy lung. 
 
 The disease may run its course in anywhere from two to eighteen 
 days. The seventh day is the most common day for the " crisis," as the 
 fall of temperature is called, to occur. If the disease is prolonged bej'ond 
 the eighteenth day we always fear that the pneumonia is due to consum]> 
 tion, although a pneumonia may last a month. 
 
 In the case of pneumonia which is due to la gr'qype the duration is 
 longer. Here the disease may last several weeks, and the temperature, 
 instead of falling suddenly, will rise and fall from time to time until it 
 iinally reaches the normal by slow degrees. 
 
 In the pneumonia due to la gripjje also there is less general disturb- 
 ance, and the patient, as a rule, is not so sick. 
 
 Pneumonia is not necessarily a fatal, disease. If properly taken care 
 of, the majority of the cases recover perfectly. 
 
 The treatment is always rest in bed, fluid food, chiefly milk, and such 
 
 medicine as is required to sustain the heart, to quiet the pain and restless- 
 
 ness, and to procure sleep. In very bad cases oxygen 
 
 may be inhaled. Such a serious disease as pneumonia 
 
 should be treated by a physician at the earliest possible moment. 
 
 Broncho-jpneuimonia (or lobular j^neitmonia, or capillary hronchitis, 
 
 or suffocative catarrli) is the form of pneumonia which is always found 
 
 in infants under five years of age, and occasionally in 
 
 adults. It may be due to exposure to cold or it may 
 pneumonia. . . 
 
 be due to germs, as in influenza. It may be secondary 
 to a general bronchitis, or to measles, or to whooping cough. 
 
 Small areas of consolidation are found in one or both lungs, and there 
 is generally an extensive bronchitis. 
 
 The symptoms in children depend somewhat upon the age. Infants 
 under one year may have nothing but fever, prostration and rapid breath- 
 ing. They usually die. Older children have cough 
 p-F-ij, without expectoration, because they swallow the latter, 
 
 fever, raj)id breathing, great prostration, and loss of 
 appetite. Sometimes they have convulsions. Sometimes they have 
 delirium, or alternate from delirium to stupor, with or without convul- 
 sions, and then they look very like cases of inflammation of the brain. 
 In cases of broncho-pneumonia and also in acute bronchitis in children 
 there may be so much mucus in the bronchial tubes that its vibration, 
 caused by the movements of the air in the bronchi, produces a thrill that 
 can be felt all over the chest similar to that felt when a cat " purrs." Ex- 
 perienced mothers recognise that a child has an extensive bronchitis in 
 this way. They " feel it in his chest," they say. It must be remembered 
 that this sign is not always pi'esent, nor is it an index of the severity of 
 
682 DISEASES OF DIGESTIVE ORGANS, HEART. AND LUNGS. 
 
 the broiR'ho-piioiunonia, and that it may ho (hie to l>rom-hitis alone. The 
 disease lasts from a few davs to four weeks. 'J'he fever does not break 
 suddenly, as in lobar pneumonia, hut subsides by de<i;rees. 
 
 The majority of cases in ehiUlren over one year old recover. 
 The treatment is to keep the cliild in l)ed if possible; if not. to hold it 
 quietly in the arms. The food >hould be milk or beef tea. lj)ecac, muri- 
 ate of ammonia, or belladonna may be i^iven for the 
 Treatment. , i • • » r i f • • ' • n 
 
 Itroncliitis. A tew drops oi paregoric given occasionally 
 
 Avill (piiet the cough. Poultices applied to the chest are valuable. If the 
 lieart becomes weak, live-drop doses of whiskey frecjuently repeated are 
 advisable. 
 
 When an adult has broncho-pneumonia, the disease sometimes resem- 
 bles a severe bronchitis, sometimes a lobar pneumonia, and sometimes con- 
 sum])tion. In the latter case the symptoms develop slowly and the disease 
 lasts a number of weeks. The fever, the cough, the night sweats, the loss 
 of flesh, and the signs in the lungs all resemble consumption, and the diag- 
 nosis can only be determined by examining the sputum with the micro- 
 scope and noting the presence or absence of the tubercle bacillus, which 
 is found in the sputum in consumption but not in broncho-pneumonia. 
 
 The various other forins of pneumonia are usually secondaiT to other 
 diseases, and their symptoms are those of the exciting disease. 
 
 CHAPTER IV. 
 INFLUENZA OR LA GRIPPE, OR THE GRIP. 
 
 Influenza is an epidemic disease due to a specitic germ. Epidemics 
 
 of influenza have occurred from time to time throughout the whole world 
 
 for several centuries. The last epidemic reached the 
 
 Dl'itributum I^'iited States in October, ISSl), and it has prevailed 
 
 every winter since, though in a more mild form than 
 
 during the first winter. 
 
 The germs attack the mucous membranes more commonly than other 
 parts of the body, although hardly any organ has escaped. 
 
 The symptoms are usually those of a severe cold, with an extraor- 
 dinary degree of prostration and great mental depression. Keuraigic 
 
 pains in various parts of the bod\^ are also very com- 
 
 Sympfoms mid rpi • n i • i _c ^ T £ 
 
 hist n mon. iiiere is usually a lugh fever, a temperature oi 
 
 103° or 104° being very frequently observed. The dis- 
 ease lasts for about a week, and then the cough, the pains, and the fever 
 subside, but tlic ])atient feels weak and languid for a long time. 
 
LA GRIPPE AND A8T11MA. 683 
 
 111 tlie more severe cases of influenza tliere may bo a very intense 
 bronchitis, or a pneumonia, or })leurisy with eil'usion, or empyema, or 
 pericarditis. 
 
 In even mild cases tliere may be inflammations of tlie ejes or a sup- 
 purative inflammation of the middle ear. 
 
 There is no specific \>y which we may treat tlie disease. All that is 
 necessary to do in an ordinary attack of influenza is to treat it as a sevei-e 
 cold. Stay in the house, if possible, or even in bed. 
 The diet should be light. If there is much pain oi- ]ii;_di 
 fever, phenacetine in five-grain doses, four or five times a day, will give 
 relief. For the depression and muscular weakness alcohcd or bitter 
 tonics may be used. If there he a severe hronchitis, or a imeumonia^ the 
 patient should he treated hij a physieian. 
 
 CHAPTER V. 
 ASTHMA. 
 
 By asthma we mean pai-oxysmal attacks of breatlilessness caused by 
 spasmodic contractions of the bronchial tubes. Asthma may be a symptom 
 of various diseases, as bronchitis, emphysema of the lungs, heart disease, 
 disease of the kidneys, or gout and rheumatism. It may be a purely 
 nervous phenomenon ; or due to climatic conditions ; to the odour of cer- 
 tain drugs, as rhubarb and ipecac ; to the pollen of vegetations, as in " rose 
 cold " and " hay fever " ; to the emanations from animals ; and to various 
 abnormal conditions of the nose. Bronchitis is the most frequent cause 
 of asthma. Asthma is frequently hereditary. 
 
 Asthmatic attacks usually come on suddenly at night. The patient 
 has a feeling of suffocation, his breathing becomes shallow and labonred, 
 with loud, crisp, or wheezing sounds, which hospital pa- 
 tients aptly describe as '* wfiistlmg m their pipes. Ihe 
 feeling of suffocation is so intense that the patient has to sit up in bed, or 
 get up and rest the elbows on a table, or sit by the open window. He 
 becomes pale, and the skin is often covered with perspiration. During 
 the most severe attacks it seems as if the patient miglit die at any minute, 
 but in simple asthma he never does. After a few hours the attack sub- 
 sides. Some patients have asthmatic attacks in the daytime, and others 
 have attacks which last both day and night for a long time. 
 
 The treatment is directed toward the exciting cause, if such there 
 be. The bronchitis must be treated, or the abnormal condition of the 
 nose corrected. In many cases change of climate or change of location 
 
0S4 DISEASES OF DIGESTIVE ORGANS, HEART, AND LUNGS. 
 
 is the only means of relief. !Some patients are comfortable in New York 
 city, and can hardly breathe ten miles outside of the city. Kuch in- 
 dividual has to learn by experience where he is most 
 comfortable. To cut short an attack of asthma we ma}' 
 use various medicinal agents. The patient may inhale the fumes of stra- 
 monium, or of burning saltpetre, or of tobacco, lie may burn any of the 
 asthma pastilles or powders which are sold by the druggists. The inha- 
 lation of ether or chloroform may be used, or morphiue may be adminis- 
 tered hypodermically. 
 
 CHAPTER VI. 
 HAEMOPTYSIS, OR SPITTING OF BLOOD. 
 
 Spitting of blood is regarded by the non-medical public as an almost 
 
 infallible sign of consumption. This is not really the case. Bleeding 
 
 from the lungs, indeed, constitutes .the chief source of 
 
 Causes. , . "- , X- • xi i. T 
 
 hjEmoptysis, and consumption is the most common dis- 
 ease which leads to the bleeding; but the blood may come from other 
 sources than the lungs, and it may come from lungs which are free from 
 consumption. Dr. Delatield describes eleven forms of haemoptysis which 
 occur without consumption : 
 
 1. A person has one attack of haemoptysis, only lasting a short time, 
 during which he raises a considerable quantity of blood. The bleeding 
 may follow severe muscular exertion, great mental excitement, or occur 
 without discoverable cause. 
 
 2. In women haemoptysis may take the place of menstruation. This 
 is, however, so rare that we always fear tuberculosis will develop. 
 
 3. Chronic nasal catarrh may be attended with occasional small losses 
 of blood. The blood trickles down the back of the nose and into the 
 mouth. 
 
 4. Poorly nourished and anaemic women may cough up a little blood 
 from time to time. 
 
 5. It is said that pregnant and nursing women sometimes have hse- 
 raoptysis. 
 
 6. Patients with heart disease may cough up blood from time to time in 
 considerable quantities. 
 
 7. Aneurisms of the branches of the pulmonary artery within the lungs, 
 when they rupture, cause fatal lupmorrhage, a large part of the blood be- 
 ing coughed up. Aneurisms of the arch of the aorta (or the great blood- 
 vessel leading from the heart), which ulcerate the trachea or main bronchi, 
 may rupture into these tubes by small or lai-ge openings. With the small 
 
HEMOPTYSIS, OR SPITTING OF BLOOD. C85 
 
 openings tlie patients congh np a little blood from time to time. "With 
 large openings tliey bleed to death in a few minutes. 
 
 8. Yery rarely elderly gouty jjer^wns have haemoptysis. 
 
 9. Yery rarely persons apparently well have blood in their expectora- 
 tion for a long time without assignable cause. 
 
 10. Injuries inilicted upon the wall of the chest, as from a fall from 
 a horse, may be followed by the expectoration of blood for hours or days. 
 
 11. Patients who suffer from emphysema and chronic bronchitis not 
 infrequently cough up small quantities of blood from time to time. 
 Much less of ten such patients have a large bleeding from the broncliial 
 tubes. 
 
 The treatment of haemoptysis is rest in bed, the administration of mor- 
 phine, or of gallic acid, or of dilute sulphuric acid, or of ergot. Salt 
 taken in large quantities — a teaspoonful or more upon 
 the tongue — will sometimes check the bleeding. Ice 
 may be applied to the front of the chest and kept there until the bleeding 
 stops. 
 
 CHAPTER YII. 
 DISEASES OF THE HEART. 
 
 The heart is a hollow muscular organ the function of which is to 
 
 force blood throughout the body. (See The Anatomy of the Human Body, 
 
 Figs. 25 and 27.) The heart may therefore be regarded 
 
 na omy oj le ^^ simply a pump. There are really two pumps placed 
 closely together, and known as the right heart and the 
 left heart. The function of the right heart is to pump the blood into 
 and through the lungs ; the function of the left heart is to pump the 
 blood which has passed through the lungs, and is now charged with 
 oxygen, throughout the body. Since the left heart has to drive the blood 
 much farther, it is stronger than the right heart — that is, it is more mus- 
 cular. It is also more liable to disease. The heart, as a whole, consists 
 of four cavities — a right auricle and ventricle and a left auricle and ven- 
 tricle. 
 
 The course of the blood is from the veins into the right auricle (which 
 is really a funnel for the collection of the blood) and through an open- 
 ing, which is guarded by a valve, into the right ventricle (or pump), then 
 through a large tube, the " pulmonary artery," the opening of which is also 
 guarded by a valve, to the lungs. (See Physiology : The Vital Processes 
 in Health, Fig. 5.) From the lungs the blood passes to the left auricle 
 and through the opening, guarded by a valve, into the left ventricle, and 
 
6SG DISEASES OF DIGESTIVE ORGANS, HEART, AND LUNGS. 
 
 tlien through the large distributini^ tube, or aorta, likewise guarded by a 
 valve, to the tissues of the body. From these tissues the blood is returned 
 by the veins to the right auricle. This is called the circulation of the 
 blood. The four valves, Avhieh are little, thin, membranous curtains, all 
 open in such a way that the blood can go forward l)ut can not go backward. 
 The heart and its blood-vessels might be compared to a Davidson syringe. 
 
 The interior of the heart is lined with a thin, smooth membrane, which 
 permits the blood to pass through the heart without friction. This is 
 scientitically known as the endocardiutn. Tlu; lu'iii-t is j^laccd within a 
 bag which is smooth and shiny on its inner side, so that the heart may 
 expand and contract easily, and is tough and fibrous on the outer side, so 
 that the heart may be protected. This bag is known as x\iq pericardium. 
 There are two layers of the pericardium, one covering tlie heart, the other 
 lying against the lungs. 
 
 In considering diseases of the heart we may speak conveniently uf 
 diseases of the endocardium ; of the heart muscle ; of the })ericardium ; 
 and of some nervous derangements of the heart. 
 
 Disease of the endocardium is the most frequent form of heart dis- 
 ease. It is commonly known as valvular disease of the lieart because 
 the valves are attacked by the intiammation and, becom- 
 
 f ., TT ^ , ing distorted, fail to perform their functions. The re- 
 of the Heart. » _ ' ^ 
 
 suit is often a very serious disturbance in the action of 
 the. heart, causing derangements in the circulation of the blood, with far- 
 reaching effects as regards the functions of various organs, as the brain, 
 the lungs, the stomach, the kidneys, etc. 
 
 The reason for all this disturbance is found in the failure of the heart 
 to properly perform its office as a pump. If in a water pump a valve be 
 deranged the pump will not work properly. If a valve be deranged in the 
 heart this pump will not work properly, and the result is that the blood 
 does not circulate regularly througli the body, but instead of that it moves 
 sluggishl}', or even stagnates in certain parts. Tliis we cull congestion ; 
 and since the tendency is for the blood to accumulate in the veins, we call 
 it venous congestion. This venous congestion of the brain causes head- 
 ache ; of the lungs, causes breath lessness, cough, or spitting of blood; of 
 the stomach, causes dyspepsia ; of the kidneys, causes scanty urine or 
 Bright's disease. The congestion of the veins of the legs causes the water 
 of the blood to exude through the walls of the veins into the loose tissue 
 beneath the skin and produces dropsy of the lower extremities. The 
 congestion of the veins of the upper part of the body makes the finger 
 tips and the cheeks and lips dusky in colour, or " blue." 
 
 The heart muscle is also affected by the derangement of the circula- 
 tion. In order to correct the faulty action of the valve, it works more 
 forcil)ly or more rapidly, and through the stimulating influence of in- 
 
DISEASES OF THE HEART. fjy7 
 
 creased exertion the tniiscle of the heart is enlarged. This is calhjjd kyjjer- 
 trophy of the heart. If by the increase of the muscular force of tlie 
 heart the bad effects of a slightly damaged valve are corrected, it is called 
 cmnjpensatory hypertropli.y. If, however, the derangement of the valve 
 is more extensive, the nutrition of the heart is soon aifected, and the lieart 
 muscle, instead of remaining thicker and stronger, as in hypertrophy, be- 
 comes thinner and weaker and less able to pump the blood onward. 
 This we call dilatation of the hearty because the cavities of the heart are 
 enlarged. This dilatation causes palpitation of the heart, a feeble and 
 irregular pulse, very great breathlessness on any exertion, attacks of faint- 
 ness, general loss of flesh and strength, and, finally, death. 
 
 Diseases of the endocardium, or endocarditis, may be divided into 
 three classes — viz., acute inflammation of the endocardium, chronic in- 
 flammation of the endocardium, and infectious or malignant endocarditis. 
 
 Acute endocarditis is caused in the great majority of cases by rheuma- 
 tism, less frequently by the infectious diseases, particularly scarlet fever, 
 
 and it is occasionally found as a complication of dis- 
 Acute Endocarditis. x- . i i • t m • • t i 
 
 ease oi the kidney. Sometimes it appears to develop 
 
 without any antecedent cause, but it is a question in these cases whether 
 it is not a primary rheumatic inflammation of the endocardium. In some 
 cases the primary rheumatic inflammation of the joints is so slight as to 
 be overlooked. This is particularly the case in children, where the slight 
 pains they complain of in their joints are ascribed to " growing pains." 
 
 Such an acute endocarditis usually causes a moderate swelling of one 
 or more of the valves of the heart, and shows itself by a inurmur, or soft 
 blowing sound, heard on listening to the heart ; or by 
 some little increase in the rapidity and force of the 
 heart's action. In the majority of cases this inflammation subsides as the 
 primary disease which caused it subsides, and the heart is left perfectly 
 healthy. Occasionally the inflammation is more severe and impairs the 
 function of one or more valves a little, and though the endocarditis sub- 
 sides, it leaves a slight permanent damage of the valve, or valves. This, 
 however, is so slight as to do little or no harm to the patient, who may 
 live a long life without ever being aware of this condition. In other 
 cases, however, the inflammation does not subside with the primary dis- 
 ease, but becomes chronic and leads to permanent and serious injury of 
 the valves. 
 
 The treatment of acute endocarditis is directed to the disease which 
 causes it. Since rheumatism is the principal cause, active treatment is 
 directed to the rheumatism to forestall the endocarditis, 
 if possible. The various preparations of salicylic acid, 
 salophen, and alkalies, such as bicarbonate of sodium, are the drugs era- 
 ployed. 
 
ess DISEASES OF DIGESTIVE ORGANS, HEART, AND LUNGS. 
 
 C/tfonic endocarditis may follow an acute endocarditis, or the intiani- 
 raation niav be chronic from the beginning. The causes of chronic endo- 
 carditis are the same as those of acute endocarditis. The disease goes on 
 for a long time, and the eli'ect is to damage the valves 
 „ , ,.,. of the heart verv considerably. The aortic and mitral 
 
 Lndocarditiii. " ^ ^ ^ 
 
 •valves are the ones commonly affected, either one or 
 both. The aortic valve is that which guards the opening of the aorta; 
 the mitral valve is that which guards the opening from the left auricle 
 into the left ventricle. The changes in the valves may be such that the 
 blood passes through the aortic or mitral oritice with ditiiculty, or that 
 the blood, having passed through the mitral or aortic oritice, leaks back 
 again. 
 
 The symptoms of chronic endocarditis depend upon the valve, or 
 valves, attacked, and upon the degree of damage to the valves. In some 
 
 cases the damage to the valves is only moderate, and 
 ' the inflammation is slow in its progress or ceases alto- 
 
 gether after a time. Here the heart hypertrophies enough to compensate 
 by its increased force for the imperfect action of the valve, and the nor- 
 mal circulation is consequently maintained. There are, therefore, no 
 symptoms of the disease. In other cases the disease is progressive and 
 the damage to the valves extensive, and we then find the serious symp- 
 toms of dilatation of the heart and disturbance of the circulation develop- 
 ing more or less rapidly. 
 
 The duration of valvular disease of the heart varies within very wide 
 limits. It was formerly believed that valvular disease of the heart and 
 
 speedy death were almost synonymous terms, but we 
 
 Prognosis. -, .^^^•^ 1 Tk^ . 1 T 
 
 now know that this is not the case. JN either speedy 
 death nor sudden death is probable. Many persons with very extensive 
 valvular disease of the heart live in comparative comfort for a great 
 many years, and die from some other disease. I^either is sudden death 
 to be expected in valvular diseases of the heart. It via>/ occur, but it is 
 the exception. 
 
 The treatment of chronic endocarditis depends upon the character of 
 the valvular derangement and the degree of compensating hypertrophy 
 
 ^ of the heart. In many cases no direct treatment of the 
 
 Treatment. ^ . • n^ . . -, 
 
 heart is necessary, sumcient exercise and a proper re- 
 gard for hygienic laws being all that is required. Because a person is 
 known to have heart disease is no reason why he should be doomed to 
 the life of an invalid. lie may indulge in all the ordinary out-of-door 
 sports, and he may attend to his business with the exercise of ordinary 
 prudence. Before the compensatory hypertrophy of the heart has been 
 establislied, or after it has begun to fail, M-e liave to guard the patient 
 more caretully. Exercise is to be taken, but with discretion, and business 
 
DISEASES OF THE HEART. 080 
 
 cares and anxiety are to be avoided as mucli as possible. The diet should 
 be carefully regulated. Then there are many drugs which will strengthen 
 the heart's action and favour hypertrophy. The principal of these is 
 digitalis. As accessories, strophanthus, coiivallaria, strychnine, and the 
 like may be used. Iodide of potassium, nitroglycerin, and morphine 
 dilate the blood-vessels and thus make the work of the heart more easy, 
 so they also help the weak heart. 
 
 In the most severe cases of dilated heart rest in led, together vrdh 
 some of the above drugs, is absolutely imperative. Such rest in bed often 
 enables the flagging heart to recover its tone after a while, and the patient 
 may then go back to work and remain in comfortaljle health for a long 
 time. 
 
 Infectious (or malignant, or ulcerative) endocarditis is a disease whicli 
 
 is usually acute and usually fatal. Its duration is about three weeks. The 
 
 disease is due to germs which, attacking the endocar- 
 
 Tj, J " ..',■ dium, cause ulcerations and " vegetations," or little soft 
 excrescences upon the valves, and by their growth pro- 
 duce a poisonous substance called " toxine," which infects the whole 
 system. The vegetations are very soft, and pieces of them containing the 
 germs are frequently broken off by the blood current and are carried in 
 it to distant parts of the body, wliei'e they lodge in small blood-vessels 
 and form abscesses. 
 
 Infectious endocarditis may occur as a primary disease ; more com- 
 monly it is secondary to some acute infectious disease, such as pneumonia 
 or childbed fever. 
 
 The symptoms are mainly a high fever, which may abate from time 
 to time, irreo'ular chills, and sweatinof. For this reason it is sometimes 
 
 mistaken for malarial fever. Sometimes it resembles 
 
 Symptoms and , i • i j- i i.- i i. x* o 
 
 •^^^ typhoid fever, and sometimes hasty consumption. Some- 
 
 times the germs are carried bv the blood into various 
 parts of the body and thus cause abscesses, or by blocking up little blood- 
 vessels in the skin they cause little haemorrhages, which give portions of 
 the skin the appearance of being covered with little " black-aud-blue 
 spots." 
 
 It is doubtful if any treatment is of avail, but large doses of quinine 
 may be tried, and whiskey or brandy administered. 
 
 The most important diseases of the heart muscle are acute dilatation 
 of the heart, fatty heart, and angina pectoris. Hypertrophy and dilatation 
 of the heart due to endocarditis have already been described. Simple 
 hypertrophy of the heart may also occur with Bright's disease, and chronic 
 dilatation of the heart may result from Bright's disease, emphysema of 
 the lungs, and other less common conditions. 
 
 Acute dilatation of the heart is a sudden weakening of the heart 
 4G 
 
GOO DISEASES OF DIGESTIVE ORGANS, HEART, AND LUNGS. 
 
 wliic'li results in a dilatation of its cavities and a thinning- of its muscular 
 
 wall. It occurs in individuals who have laborious occupations, and mostly 
 
 in those who indulo;e in excessive beer-drinking. The 
 
 Acute Dilatation ^ .i ' <• r m ji ^^ ^- i* ^i 
 
 ^,, jr t svmi>tonis are tliose 01 lailure 01 tlie pump action 01 tlie 
 of the Heart. • * r r 
 
 heart. There is sudden breathlessness, great weakness, 
 blueness of the lips and finger tips, palpitation of the heart and dropsy. 
 
 If not properly treated, the disease may end in death in a few weeks or 
 months. If properly treated, the ]>rospect of recovery is good. The pa- 
 tient must usually be put to bed, and digitalis, strychnine, alcohol, or other 
 cardiac stimulants administered. The diet niust be light or altogether 
 tiuid so as to relieve the digestive functions from all unnecessary effort. 
 
 Fatty heart is a disease of the heart muscle which consists in a de- 
 generation of the muscular fibres so that much of the muscular tissue is 
 
 replaced by fat. There are various causes which lead 
 Fatty Heart. ... mi " i • r • i .i . •.• 
 
 to it. ihere may l)e an iiiterterence with tlie nutrition 
 
 of the heart through disease of the arteries which supply the heart muscle 
 
 with blood. Alcoholic excess may ])roduce it ; or a sedentary life may be 
 
 the cause. It may be caused by typhoid fever ; diabetes ; or anaemia. A 
 
 less serious form of fatty heart occurs in corpulent persons. It consists 
 
 in a deposit of a thick layer of fat about the heart. 
 
 The symptoms are those of weak heart action, as breathlessness, pal- 
 ])itation, or fainting. There is always great danger of sudden death from 
 rupture of the heart. 
 
 The treatment is to improve the patient's general health by proper 
 food and proper hygienic conditions. 
 
 Angina pectoris is a very serious and often fatal disease which is 
 
 caused most commonly by disease of the arteries which 
 Angina Pectoris. , ,, , , , . , , ■, -, r^, 
 
 supply the heart muscle with blood. There may or 
 
 there may not be valvular disease of the heart also. 
 
 The symptoms are a sudden agonizing pain in the region of the heart 
 with a feeling of great anxiety and oppression, more or less breathlessness, 
 and pallor of the face. Very often the pain is also felt running down 
 the left arm or down both arms. The patient may die in the first attack 
 within a few minutes, or he may recover and have several such attacks in 
 the course of several years. Angina pectoris is exceedingly rare under 
 forty years of age. 
 
 The direct exciting cause of an anginal attack is a sudden contraction 
 of the diseased arteries so that the blood supply is shut off from the heart. 
 The treatment, therefore, is to dilate these arteries as 
 soon as possible. This is best effected by inhaling the 
 fumes of nitrite of amyl, which has a rapid and powerful action upon the 
 blood-vessels. A person who has had one attack of angina pectoris should 
 always carry about with him some " perles" or little glass capsules con- 
 
DISEASES OF THE HEART. 691 
 
 taining five drops of nitrite of amyl, and lie slionld crnsli one of these in 
 his handkerchief and inhale the fumes the moment the pain begins to be 
 felt. In this way an attack may be aborted. Sometimes the hypodermic 
 injection of morphine" is more effectual. Sometimes tlie inlialation of 
 ether or chloroform gives relief. To prevent the return of attacks the 
 strictest care should be exercised in regard to the habits of life. Tobacco, 
 and perhaps alcohol, should be absolutely prohibited and all undue excite- 
 ment or muscular exertion avoided. Iodide of potassium or nitroglycerin 
 may be given continuously in order to keep the blood-vessels dilated. 
 Angina pectoris is so serious a disease that it should be treated by a 
 physician at the earliest possible moment. 
 
 l^y pseudo-angina, oy neuralgia of the heart, we mean certain symp- 
 toms which resemble angina pectoris but which are not so severe and 
 
 which are not attended by the same danger of sudden 
 Nexiralqia of the i ,i mi • ^^ ^ • ,^ 
 
 „ ,' deatli. iiiere is usually paroxysmal pam over the re- 
 
 gion of the heart, but this pain is not as intense as in 
 angina pectoris and it does not run down the left arm. There is also more 
 or less palpitation of the heart and more or less breathlessness. It may 
 occur at any age. The causes of pseudo-angina are quite numerous. 
 Pseudo-angina may be one of the symptoms of disease of the aortic 
 valves. It may be due to the excessive use of tobacco or tea and coffee. 
 It sometimes occurs in hysterical individuals. 
 
 Unless it be caused by disease of the aortic valves it is not a danger- 
 ous condition, but if valvular disease is present death may occur in one 
 of the attacks. 
 
 The treatment is primarily to correct the conditions which give rise 
 
 to the attacks. The use of tobacco and tea and coffee must be restricted, 
 
 and proper food and exercise must be taken. In hvs- 
 
 terical patients appropriate measures must be employed. 
 
 They must be assured that there is no real heart disease, and valerian or 
 
 camphor and other sedatives may be administered. 
 
 The attacks of pseudo-angina do not usually require any direct treat- 
 ment, but if the pain is severe morphine may be given. Cases of severe 
 pain should always be treated by a physician. 
 
 Palpitation of the heart is the too forcible action of the heart, or 
 intermittent action of the heart, or irregularity in the force and frequency 
 
 of the beats. Such conditions may be associated with 
 Palvitation of the • -,• p ,^ ^ ^ t j_i 
 
 „ t severe oro-anic disease of the heart, in many cases there 
 
 Heart. _ '^ 
 
 is no disease of the heart whatever, but only a derange- 
 ment in the nervous mechanism of the heart. Palpitation may be caused 
 by nervousness, or excitement, or by indigestion, or by the excessive use 
 of tobacco, or alcohol, or tea. 
 
 The treatment of purely nervous palpitation is to remove the cause by 
 
G92 DISEASES OF DIGESTIVE ORGANS, HEART, AND LUNGS. 
 
 appropriate measures. If there is oriranic disease of the heart the various 
 cardiac drugs may be employetl. 
 
 TacJiijcarJla, or rapiil heart, is a ]>cculiar nervous disease of the lieart 
 in which the I'apidity of tlie lieart's action is very greatly increased. In- 
 stead of beating seventy times to the minute, the heart 
 may beat two hundretl times to the minute. AVith this 
 there may be breathlessness and faintness and bhieness of tlie skin. This 
 tachycardia frequently occurs iu parox^'sms, between w liii-h the })atient is 
 perfectly well. 
 
 Tachycardia may be c^iused by the same conditions which produce 
 palpitation ; or by pressure upon the sympathetic nerve; or disease of the 
 pneumogastric nerve ; or by either mental or muscular overwork. 
 
 The treatment is by digitalis or other drugs which slow the heart's 
 action. Electricity may be of service. 
 
 Exoj^hthahnic goUre^ or Graves's disease, is a nervous affection of the 
 
 lieart in which there is prominence of the eyeballs, en- 
 
 ■^^P''"""' largement of the thyroid gland (or goitre), and rapid 
 
 and forcible heart action. 
 The treatment is the same as that of tachycardia. 
 
 Pericairlitis, or water on the heart, is an inflammation of the pericar- 
 dium, or the membrane which surrounds the heart. As a result of this 
 inflammation, the adjacent surfaces of the pericardium 
 are roughened by a deposit of soft material called flbrin ; 
 or, if the disease does not stop here, there is also an exudation of serum 
 or of pus into the space between the two layers of the pericardium.- This 
 serum or pus compresses the heart. 
 
 The causes of pericarditis are the same as of endocarditis — viz., rheu- 
 matism, scarlet fever or other infectious fevers, pneumonia, consumption, 
 double pleurisy, and Bright's disease. 
 
 The symptoms depend upon the degree of the inflammation. If there 
 is exudation of li))rin only, there is rapid heart action, pain over the heart, 
 fever, and some breathlessness. When the physician 
 ' listens to the heart he may hear a characteristic "mur- 
 mur." If there is exudation of serum or pus into the cavity of the peri- 
 cardium, there will be the same symptoms and, in addition, great breath- 
 lessness, blue colour of the skin, feeble, rapid, and irregular pulse, and 
 attacks of faintness. 
 
 The treatment is, in the first place, to treat the disease which is the 
 primary cause. Blisters may also be applied over the heart, or ice may 
 be kept over the heart, or digitalis or strychnine may be 
 given. Of course the patient must be kept in bed, and 
 he should be attended by a physician, as there is often great danger of sud- 
 den death. 
 
DISEASES OF THE STOMACH. 693 
 
 Aiieurism of the arcli, of the aorta is a disease of the aorta wliicli re- 
 sults in weakening the wall of the aorta, and at some point a pouch or 
 
 bag is formed by a biilgiiig of its walL This is very 
 Aneurism of the ^^ y ^ , . ' i i .1 /• i i i- i 
 
 . , ^,L 'a j liable to rui)ture, and deatli ii'oni iiinmoi'i'liage lor 
 Arch of me Aorta. ' ' -^ 
 
 lows. 
 
 The symptoms are pain in the chest, often the presence of a tumour 
 in the upper portion of the chest which can be seen to pulsate, cough, 
 breathlessness, sometimes a husky voice, sometimes difKculty in swal- 
 lowing. 
 
 The disease may last for a nund)er of years, but there is always danger 
 of rupture of the aneurism and sudden death. 
 
 The treatment consists in a quiet life, the administration of iodide of 
 potassium for a long time, and of morphine if the pain is severe. In the 
 most serious cases the patient should be kept in bed. 
 
 CHAPTER VIII. 
 DISEASES AND DISORDERS OF THE DIGESTIVE SYSTEM. 
 
 Disorders of the digestion are very frequent in both adults and chil- 
 dren, especially the latter. In the large majority of cases such disorders 
 are ipur e\ j ftt notional, or produced by a temporai-y derangement of one 
 or more of the organs of digestion. In the lesser number of cases there 
 is the more serious condition of change in the tissues of the organs in- 
 volved, which usually results in prolonged and often in fatal disease. 
 
 DISEASES OF THE STOMACH. 
 
 The stomach is the large bag in which the food is mixed with the gas- 
 tric juice and thus liquefied and rendered fit for absorption by the blood. 
 It is situated just beneath the lower ribs on the left side and the lower 
 part of the breast bone. 
 
 Derangement of the stomach functions causes symptoms which are 
 known as " dyspepsia." These are a bad taste in the mouth, a coated 
 tongue, eructations of gas, the occasional rising into the 
 yspepsia. mouth of an intensely acid liquid, heartburn, nausea, 
 
 vondting, pain upon eating or after eating, a sense of weight or oppres- 
 sion just beneath and below the breast bone, loss of appetite, constipation 
 or an irregular action of the bowels, flatulence, palpitation of the heart, 
 hypochondriasis, and loss of flesh and strength. All of these symptoms 
 are not necessarily present in any one case. 
 
694 DISEASES OF DIGESTIVE ORGANS, HEART, AND LUNGS. 
 
 SiK'li a group of svmptonis may be ])ruduced l»y a variety of causes, 
 for it only means that the stomach is not doing its work properly. Thus 
 overwork, either muscular ur mental, will derange the 
 acriun of the stomach and cause dyspepsia; anxiety or 
 fright, hy interfering with the nervous mechanism of the stonuu-h, will do 
 tiie same thing. Imperfectly masticated food will cause it. In a like 
 manner improper food or too much food can not be digested and develops 
 these same symptoms. Then in many cases dyspepsia is caused by dis- 
 ease of other parts of the body than the stomach. For example, vomiting 
 in women is a common sign of pregnancy. In a like manner disease of 
 the uterus fretjuenfly causes vomiting. Diseases of the kidneys in either 
 sex is frcfjuently attended by dyspepsia. Finally, these same symptoms 
 may be caused by actual disease of the stomach itself, such as cancer of 
 the stomach, chronic gastritis, and the like. 
 
 It follows, then, that the treatment of " dyspepsia " should be directed 
 straight to the primary and exciting cause and not confined to the stomach 
 symptoms. The use of pepsin and acids and kindred 
 aids to digestion is in most cases to be avoided, or these 
 drugs are only to be taken with the idea of giving temporary relief, while 
 permanent cure will be found by correcting any errors in diet, or by re- 
 lief from overwork or anxiety, or by treating the disease which causes 
 the dyspepsia. 
 
 In those cases of temporary dyspepsia caused by overeating or by eat- 
 ing something which has Ijccn imperfectly digested — has "disagreed M^ith 
 one," as many people express it — often all that is required is to take a 
 gentle cathartic, as any of the laxative waters, and to refrain from all food 
 for twenty-four hours, or else to restrict the diet to milk or meat broths 
 for the same period. 
 
 Gastritis, or iniiammation of the stomach, or gastric catarrh, is an in- 
 flammation of the mucous membrane, which results in a diminution in 
 quantity and change in character of the gastric juice 
 and in a deposit of mucus upon the surface of the 
 mucous membrane. All the coats of the stomach may be simultaneously 
 in flamed j but this is rare. Gastritis may be acute or chronic. 
 
 Acute gastritis is a very connnon affection. It only lasts for a day or 
 
 two and is rarely dangerous. It is most frequently caused by errors in 
 
 diet. The food acts upon the stomach as a direct irri- 
 Acute Gastritis. , , mi • i> ^ i ^ • i- 
 
 tant. ine excessive use of alcohol is a frequent canse. 
 
 ]\Iilk which is partially decomposed often produces acute gastritis in 
 children during tlie heated term. It may be caused by exposui-e to cold. 
 Many of the symptoms of dyspepsia given above may be present, but 
 vomitivg is the most constant one. In some cases, jiarticularly in chil- 
 dren, y^?.'^^ is the most prominent symptom, iind the tcm])erature may be 
 
DISEASES OF THE STOMACH. 695 
 
 as liigh as 104° Falir. This often leads to the error of regarding tlie case 
 as one of scarlet fever or other specific fever. 
 
 The usual treatment is to refrain from solid food, as mentioned alcove. 
 If the attack be severe and vomiting has not occurred spontaneously, it 
 may be induced by drinking hot water with salt or mustard, or by an emetic 
 of ipecac. 
 
 Chronic gastritis, or chronic gastric catarrh, or chronic dyspejjsia, is 
 a serious and prolonged iniiauimation of the stomach, but one which can 
 
 usually be cured. It is most commonly caused by pro- 
 
 ChroniG Gastritis. -. \ • ^^ , • •> ^ . , , , , 
 
 longed errors in diet or overindulgence m alcohol, but 
 
 it may be secondary to various conditions, as disease of the heart, kidneys, 
 
 or liver. Exposure to cold and wet, and hardship, will also produce it. 
 
 The symptoms are those of dyspepsia extending over a period of 
 months or years. The most common are pain and vomiting, but both 
 may be absent. Blood may be vomited from time to time. The patient 
 gradually loses flesh and strength and looks seriously sick. 
 
 The treatment consists in a careful attention to the laws of hygiene — 
 that is, regular and sufficient meals ; relief from overwork and worry ; 
 proper exercise in the open air; and moderation in the 
 use of alcohol and tobacco, or complete abstinence from 
 the same. The diet must be simple, nutritious, and sufficient. There can 
 be no definite rule as to what to eat and what to avoid, for different indi- 
 viduals will find different articles of food agreeing or disagreeing with 
 them. Fried fat, hot bread, cakes, pies, and candies are to be avoided, as 
 well as rich gravies and fancy dishes. Many patients fall into the error 
 of eating too little at all times, or of restricting the articles of diet too 
 closely. In severe cases of chronic gastritis it may be necessary to con- 
 fine the diet entirely to milk for several weeks or months. From four to 
 eight pints of milk may be taken daily, and the patients, instead of grow- 
 ing weaker, as they usually fear they will, grow stronger and gain in 
 weight. By the use of a milk diet a perfect cure can very frequently be 
 effected. In the most severe forms of the disease the most effective treat- 
 ment is the Tegular washing out of the stomach each day •with icai^rn. loater. 
 This is done by introducing a large soft-rubber tube into the mouth and 
 pushing it down the gullet into the stomach. Then water is poured into 
 the stomach through a funnel elevated above the level of the head, and 
 after about a quart of water has been introduced the funnel is lowered 
 and the water, together with the contents of the stomach, are siphoned 
 out. (See Medicines and Treatment, Fig. 10.) This process is repeated 
 until the water returns perfectly clear. 
 
 This method of treatment seems at first very repulsive to the patient, 
 but he soon becomes accustomed to the introduction of the tube, and he 
 can then wash his own stomach out without discomfort. 
 
Ot)(3 DISEASES OF DIGESTIVE OHGANS, HEART, AND LUNGS. 
 
 Tliere are various drugs which may also be uiwii in the ti-eatiuent of 
 chronic gastritis, such as tincture of iiux vomica and the mineral acids, 
 but these should only be employed under the advice of a physician. 
 
 Ulcer of the stomach is a chronic disease, in which there is an '' ulcer," 
 
 or little round sore, situated in the mucous membrane 
 
 .^r , '^ of the stomach. This ulcer acts just as any other sore 
 btomacn. . . •' -i ^ • e 
 
 would do : it causes pain in the stomacli, and it fre- 
 
 (jwently bleeds. In addition, the ulcer causes a general gastritis. 
 
 Ulcer of the stomach occurs usually between the ages of eighteen and 
 forty, and it is more commonly found in women than in men. 
 
 The symptoms are those of dyspepsia, but j>ai7i, particularly upon 
 
 taking food, is usually experienced, and there may be tenderness on 
 
 pressure over the stomach. Vomiting of food may 
 
 ^7f /T^l"" occur at any time, and vomiting of blood may occur 
 
 from time to time. This blood is usually considerable 
 
 in amount. It may be bright-coloured and clotted, or it may be black, or 
 
 look like coffee grounds. 
 
 Ulcer of the stomach lasts for many months, but it may eventually be 
 cured. It is sometimes fatal, either through excessive haemorrhage or 
 from perforation of the ulcer — that is, the ulcer eats through the coats 
 of the stomach, and then the contents of the stomach escape from the 
 stonuieh into the peritoneal cavity and cause death at once from shock, or 
 more slowly by peritonitis. 
 
 The treatment should be under the direction of a physician. It is 
 customary to put the patient on a milk diet ; sometimes to feed exclu- 
 sively by rectal enemata. The druc; most commonly em- 
 Treatmeiit , 
 
 ployed is nitrate of silver, as this has a beneficial effect 
 
 upon the ulcer. For the relief of vomiting, bismuth, soda, and various 
 other drugs may be given. For the relief of pain, hot or cold applica- 
 tions to the pit of the stomach, or a mustard poultice, may suffice. If not, 
 various anodynes may be used ; but there is always grave danger in the use 
 of opium, for the opium habit is easily formed under these circumstances. 
 Cancer of the stomach is a fatal disease which attacks persons in mid- 
 dle or advanced age. It rarely attacks those under forty years old. It is 
 
 about equally common in men and women. Its cause 
 ,,, . is unknown. It is often hereditary. The disease con- 
 
 sists in the growth of a hard lump in some portion of 
 the stomach — usually at the " pyloric end " of the stomach, or that end 
 where the stomach joins the intestine. 
 
 The symptoms are for a long time those of dyspepsia, though pain in 
 the stomach may be a particularly prominent S3'mptom. Then the patient 
 begins to lose flesh and strength rapidly, and the skin assumes a peculiar 
 cancerous look — that is, it is very pale, with a light lemon-yellow shade 
 
DISEASES OF THE STOMACH. OOT 
 
 to it. Vomiting of food is now frequent, and there is commonly vomit- 
 ing of blood from time to time. Sometimes the patient, in placing liis 
 
 hand over the seat of his pain, will feel a hard liirrjp 
 Symptoms. i , ,i • /■ i . i i 
 
 about the size oi an Q^^^., but more commonly the tumour 
 
 is first felt by the physician. Sometimes the physician feels very certain 
 
 that there is cancer of the stomach, but he can not prove his diagnosis 
 
 because the tumour is situated at some point in the stomach where it can 
 
 not be felt. The patient usually dies in about two years from the time 
 
 when the tumour is first felt ; but as the tumour can not be felt until it is 
 
 of some size, the symptoms of cancer of the stomach last considerably 
 
 more than two years. 
 
 The treatment is usually only to relieve the patient and sustain his 
 
 strength. The diet should be light and nutritious ; often a purely milk 
 
 ^ diet is the best. Limewater, soda, bismuth, and other 
 
 drugs may be given for the vomiting or like dyspeptic 
 symptoms. For the pain, morphine must be given sooner or later, and 
 there is, of course, no objection to its use in this disease. The surgical 
 treatment of cancer of the stomach, either by removing the cancer or by 
 establishing an artificial connection between the stomach and bowels, gives 
 good results in a limited number of cases, but even under the most favour- 
 able conditions operation only prolongs life, for the cancerous disease will 
 return either in the stomach or elsewhere. 
 
 Dilatation of the stomach is a chronic disease which consists in a great 
 increase in the size of the stomach and an inflammation of its mucous 
 
 membrane. It may be caused in many ways — by a can- 
 
 Dilatation of the xi, i. i.- ^^ ^ • .^ \ • 
 
 cer or other tumour partially closing the pyloric opening 
 of the stomach, and so preventing the escape of the 
 food into the bowels ; by taking great quantities of food and drink into 
 the stomach, as among those employed in breweries, where they drink 
 excessive quantities of beer ; b}^ chronic gastritis ; by being simply run 
 down, and in various other ways. 
 
 The symptoms are those of dyspepsia, with considerable loss of flesh 
 and strength. The most characteristic symptom is the vomiting of very 
 large quantities of partially digested food once a day, or every day or two. 
 The stomach empties itself by this means. 
 
 The only satisfactory treatment is the regular washing out of the 
 stomach, combined with a plain and nutritious diet. When this treat- 
 ment is faithfully carried out all cases of uncomplicated dilatation of the 
 stomach recover completely. 
 
 DISEASES OF THE INTESTINE. 
 
 DiarrhcEa is the most common manifestation of disease or disorder of 
 the intestine. In the majority of eases this diarrhoea is due to an inflam- 
 
69S DISEASES OF DIGESTIVE ORGANS, HEART, AND LUNGS. 
 
 Illation of the niiicous incmbrane, but it iiuiy be produced by other causes 
 than inlianiniatiou. Thus, nervous excitement will cause diaiTha?a. Sol- 
 diers before going into battle are so affected ; students 
 Diarrhcea : Causes. , . ,. . ^. /v • .i 
 
 when coming up tor exannuation suner m tlie same 
 
 way; antl ewn slighter causes will bring on ;iii attack. Hot weather, or 
 more commonly t^udden changes from hot to cool weather, frequently 
 cause diarrhani. Certain articles of food, as green corn, or ini})roper or 
 decomposed food, may do the same thing. Drinking water, as the change 
 to the water at the seaside, may produce it. Impure water will do the 
 same. Inhalations of air contaminated by emanations from cesspools may 
 cause diarrluea. Diarrhcea is much more common among children than 
 among adults, and it is particularly prevalent in the summer months. 
 
 The treatment of a simple diarrhoea is, if possible, rest in bed and a 
 fluid diet — preferal)ly milk with a little limewater added — for twenty- 
 four hours. If due to too much or improper food, cas- 
 tor oil or a few one-tenth-of-a-grain doses of calomel 
 will carry off the offending substances and stop the diarrhcea. If due to 
 other causes, or if there have been a nuuiljer of movements, this is not 
 necessary, and the diarrhcea may be checked by live- or ten-drop doses of 
 paregoric for an infant, or teaspoonful doses for an adult, repeated every 
 two or three hours. 
 
 Acute enteritis, or acute inflammation of the intestine, or acute diar- 
 rhoea, is an inflammation of the mucous membrane of the intestine, and 
 
 it results from most of the causes already mentioned. 
 Acute Diarrhcea : mi x i j i.i i.- i; xi i i 
 
 a f -Lbe symptoms depend upon the portion ot the bowels 
 
 involved. If it be the upper portion of the bowels, 
 there is pain in the abdomen and fever, but there may be no diarrhoea; 
 if, as is frecpiently the case, the stomach is also inflamed, there is vomiting. 
 If the lower portions of the bowels are involved, there is diarrhoea and 
 pain, sometimes with and sometimes without fever. If the whole of the 
 digestive tract is acutely inflamed, there is fever, vomiting, pain in the 
 bowels, diarrhcea, and often great prostration. This latter form is known 
 as acute gastro-enteritis, or cholera morbus. In children it is known as 
 cholera infantum. Acute enteritis lasts several days; adults almost al- 
 ways recover, but it may be fatal in children. 
 
 The treatment depends upon the symptoms. If there be no diai-rhciea, 
 a milk diet and frequent small doses of calomel will suflice. If there be 
 diarrhoea, rest in bed, a milk diet, and small doses of 
 paregoric will often relieve. In other cases, bismuth 
 in ten- to twenty-grain doses may be added, or morphine may be substi- 
 tuted for paregoric in adults, but morphine must not be given to children 
 except under a physician's direction. If the pain is severe, hot poultices 
 applied to the abdomen, or a mustard plaster, will help to relieve the pa- 
 
DISEASES OF THE INTESTINE. (599 
 
 tient, In cholera infantum tlio fever is often very liii^li, and it is tlien 
 
 important to put tlie little patient into a tepid or cold batli in order to 
 
 reduce tlie temperature. If there he great prostration, whiskey should be 
 
 given in five- or ten-drop doses, frequently repeated. In all cases of 
 
 diarrhoja occurring in infants, change of air, especially to cooler air (as 
 
 at the seashore), is desirable. I send my hospital patients down to the 
 
 docks or out on the ferryboats during the heat of the day. Children 
 
 should be fed only on pasteurized or sterilized milk until the diarrhoea is 
 
 checked. Irrigation of the bowels by tepid water, or water containing 
 
 astringents or disinfectants, is often of service. 
 
 ChroniG enteritis, or chronic diarrhoia, may result from an acute 
 
 enteritis, or it may be due to a variety of other causes. It is very com- 
 
 . ^. , mon in prisons and among soldiers as the result of im- 
 Ulironic Diarr/iosa. . 
 
 proper hj'giene. It occurs among the delicate and 
 
 sickly. It may be caused by consumption, owing to the tubercular in- 
 Hammation of the bowels. It may result from chronic heart disease, or 
 disease of the liver or the kidneys. There may be only a catarrhal in- 
 flammation of the mucous membrane of the bowels, but very commonly 
 there are little ulcers all through tlie raucous membrane of the bowels. 
 The disease lasts a long time and is difficult to cure. 
 
 The symptoms are diarrhoja (from two to ten movements in the twenty- 
 four liours, alternating with constipation) ; there is pain in the bowels and 
 loss of flesh and strength. The treatment is strict attention to the laws 
 of health, a carefully selected diet, change of air, and various drugs for 
 the relief of the diarrhoia, such as bismuth, tannic acid, the mineral acids, 
 or nitrate of silver. 
 
 Dysentery, or hloody flux, is an inflammation of the lower bowel 
 
 wdiicli is characterized by frequent small passages con- 
 
 taining blood and mucus (or slime, as it is commonly 
 
 called), and attended by a straining pain in the rectum at the time of the 
 
 movement. 
 
 Dysentery may be either acute or chronic. In the acute form there 
 is usually only an inflammation of the mucous membrane of the rectum 
 or lower bowel. In the chronic form there are ulcers throughout the rec- 
 tum and colon. Dysentery may occur at any age, but it is rather more 
 common in adults. It is particularly a disease of hot countries, though it 
 may be found throughout the whole world. It is most prevalent in sum- 
 mer and autumn. Sudden changes of temperature are conducive to dys- 
 entery, and imperfect hygiene and improper food are also conducive to 
 the disease. It is very prevalent among soldiers in camp. It may be due 
 in certain cases to a specific germ called the Amoeha coll. Dj'sentery 
 may occur in isolated cases or it may occur in epidemics. 
 
 Both the duration and the severity of acute dysentery vary within 
 
700 DISEASES OF DIGESTIVE ORGANS, HEART, AND LUNGS. 
 
 considerable limits. It may last from two or three days to three weeks. 
 The patient may be so slightly sick that he does not go to bed, or the 
 attack may be so severe that he dies within forty-eiuht lumrs from the 
 initial symptoms. 
 
 C/tronic di/si'fih'/'i/ hxi^ts for months or years. The imticiit may be 
 finally worn ont by the disease and die, oi- he may die of some intercnr- 
 rent disease. 
 
 The treatment of acute dysentery is rest in bed. Ihiid (Hct, the nse of 
 bismuth or oi)ium to cheek the too fre(jut,'nt movements of the bowels, 
 or the combination of small doses of ojjium and small 
 doses of castor oil frequently re[)eated to produce regu- 
 lar and healthy movements of the bowels. 
 
 The treatment of chronic dysentery is practically the same, exce])t that 
 rest in bed is not reijuired. ]\[uch can be gained by fre(]uent irrigation 
 of the bowels by water containing astringents or disinfectants. A person 
 suffering from either acute or chronic dysentery should always be under 
 the care of a physician. 
 
 Constipation is a condition in which the fsecal matter is retained in 
 the bowels too long, or in which the expulsion of the faecal matter is at- 
 tended with difficulty. AVith most persons a natural 
 * movement of the bowels once a day is the regular thing. 
 Some have two natural movements a day — one in tbe morning and one at 
 night. A few individuals are accustomed to go two or more days without 
 any movement of the bowels and suffer no inconvenience from this pro- 
 longed retention of fsieces. 
 
 Constipation usually causes a good deal of discomfort. The abdomen 
 feels full, and it may be swollen ; there may be nausea ; the tongue is 
 coated and the appetite lost ; there is an unpleasant odour of the breath 
 there is headache, listlessness, and depression of the spirits. All these 
 symptoms are relieved when the bowels are moved. 
 
 Constipation may be present from infancy or it may come on at any 
 time. It is particularly common among women and among those engaged 
 in sedentary occupations. 
 
 The treatment of constipation is to avoid any form of medicine if pos- 
 sible. Tlie best way is to have a definite hour for going to stool and 
 
 to go regularly day bv day at that hour, and to sit 
 Treatment. . . -^ •- . ' 
 
 there quietly without straining until the bowels move 
 
 spontaneously, no matter how long it takes. Once the habit is formed, 
 there is usually no further trouble with the constipation. If this is not 
 the case, sufficient active muscular exercise Mill be of great value. Mas- 
 sage of the abdomen will also helj). The diet should not lie too concen- 
 trated, vegetables in particular being eaten freely. Fruit should also be 
 freely eaten. Stewed prunes are considered very eflTicacious. Two or 
 
DISEASES OF THE INTESTINE. YOl 
 
 three fi<i:;s at bedtime will often move the bowelH tljc next morning. A 
 glass of ice water before breakfast will often stimulate the bowels to move 
 immediately after breakfast. 
 
 If medicine must be nsed, any of the laxati\e Tnineral waters may be 
 taken before breakfast, or a laxative pill may Ijc taken at bedtime. The 
 drugs usually employed in laxative pills are cascara, nux vomica, ipecac, 
 and extract of colocynth. If the bowels move with difficulty, an injec- 
 tion of soap and water will soften the faeces and give a painless evacu- 
 ation. 
 
 The most common forms of intestinal ixiranitcH or worms are the 
 
 tapeworm and the roundworm. The former may be very long — many feet 
 
 — and usually only a few links or segments are discharged 
 
 Parasites ^^ ^ i\n\G, the head remaining attached to the mucous 
 
 membrane of the intestine and the segments growing 
 
 from it. The roundworm is about three inches long, and often several 
 
 are discharged at once. 
 
 The symptoms of the presence of worms are digestive disturbances, 
 nervousness and restlessness, picking of the nose and rolling the head, 
 and grinding the teeth at night. It must be remembered that these 
 symptoms may all be due to other causes than the presence of worms, and 
 that the only certainty of their presence is to see them in the faeces. 
 
 The treatment of tapeworm is to expel the head. To effect this the 
 intestine i? rendered as empty as possible by fasting for twentj-four 
 liours or by a light diet for two days. Then in the 
 morning a half teaspoonful of oleoresin of male fern is 
 administered, the patient continues to fast during the day, and in the even- 
 ing a full dose of castor oil or of calomel is administered. 
 
 The roundworm is dislodged by the administration of santonin. One 
 grain of santonin and one grain of calomel may be given in powder to a 
 child five years old every three or four hours until the bowels are moved. 
 
 Threadworms or seat worms are little thread-like worms which infest 
 the rectum. They are best removed by injections of limewater. 
 
 DISEASES OF THE LIVER. 
 
 Jaundice is a yellow discoloration of the skin and other tissues of 
 the body caused by some mechanical impediment to the discharge of the 
 bile into the bowels. The bile accumulates in the liver, 
 and is then absorbed by the blood, and is carried by the 
 blood to all the tissues of the body. In a few cases jaundice is caused by 
 changes in the system as a whole, and not by mechanical obstruction to 
 the flow of bile. This is seen in poisoning by phosphorus or by snake 
 bites. It is occasionally observed in connection with pneumonia and with 
 some forms of liver disease. 
 
702 DISEASES OF DIGESTIVE ORGANS, HEART, AND LUNGS. 
 
 By far the most eoininon form of jaundice is wliat is known as "ca- 
 tarrhal jaundice." Here the little opening of the common bile duct into 
 the small intestine is closed bv the swelling of the mu- 
 
 ^a arr a ^^^^^^ nu'mbrane of the small intestine due to the ea- 
 
 Jaundice. 
 
 tarrlial intlammation of the upper part of the intestine 
 
 and, usually, of the stomach also — <jastnhduo(h')i'(tls we call it. 
 
 The symptoms are a slight feeling of indisposition, some dyspeptic 
 symptoms, constipation, perhaps a little fever, and then the skin and the 
 mucous mcml)ranes become yellow, the urine also becomes yellow, and 
 the fivces dry and clay-coloured. Very often there is itching of the skin. 
 These symptoms last from two to three weeks and then the patient re- 
 covers perfectly. 
 
 The treatment is to be careful in the diet and keep the bowels open 
 by calomel or other gentle laxatives. Bicarbonate of sodium in modei-ate 
 doses frequently repeated is the best drug to diminish the jaundice. 
 Good results are also obtained by the daily injection of one or two pints 
 of ice water into the rectum. 
 
 Jaundice may also be caused by the lodgment of a " gallstone," or a 
 little solid biliary concretion, in the common bile duct, 
 
 ' '"'^ ■ thus preventing the escape of bile into the intestine. 
 Such a condition is commonly known as h'd'uiry coUe, or " the passage 
 of a gallstone." 
 
 The patient is suddenly taken with inteiise jiaiii in the right side just 
 below the ribs and on a line with the nipple. The ])ain usually runs up 
 to the right arm and there is frequent vomiting and considerable pros- 
 tration. The attacks of ]>ain come and go for a certain number of 
 hours and then intense jaundice appears. This jaundice lasts a variable 
 leuffth of time — that is, until the c^ihstone has worked its wav throuirh 
 the common duct and been discharged into the intestine. If the gall- 
 stone does not enter the common bile duct there will be the symptoms of 
 biliary colic for a long time but no jaundice, because the l)i!e is not pre- 
 vented from escaping. 
 
 The treatment of biliary colic is to put the patient at once into a hot 
 bath, administer morphine hypodermically, or give chloroform by inhala- 
 tion. The administration of large quantities of sweet oil — half a pint 
 or a pint — by the mouth M-ill often facilitate the passage of the gall- 
 stone. 
 
 Jaundice may also be caused by the pressure of a cancer or other 
 
 tumour upon the bile ducts. Here the jaundice is per- 
 Hardeninq of the . 
 
 r ■ manent. 
 
 Cirrhosis of the liver, hardening of the liver, or 
 
 gin drinJcer'^s liver is a chronic disease of the liver in which the liver 
 
 becomes incapable of properly performing its functions. The size of the 
 
DISEASES OF THE LIVER. T03 
 
 liver is usually considerably dirniuislicd, but sometimes it is so increased 
 that the patient himself can feel a distinct swelling in the abdomen. 
 
 The disease is most frequently caused by the slow poisoning of the 
 system by alcohol. Those who constantly indulge in several drinks of 
 spirits in any form each day, even though they are never intoxicated, are 
 liable to cirrhosis. The disease may be caused by other conditions than 
 the abuse of alcohol, such as syphilis, or from gallstones which have 
 been lodged in the bile ducts for a long time. 
 
 The symptoms are a slow and progressive loss of flesh and strength, 
 dyspepsia (especially morning vomiting or nausea), and fi-equently dropsy 
 of the abdomen. With the large form of cirrhosis of the liver there is 
 sometimes intense jaundice. This is a serious symptom. Often disease 
 of the kidneys is associated with cirrhosis of the liver. Sometimes pa- 
 tients die from the cirrhosis within two or three years ; others (especially 
 if they stop the use of alcohol) live many years. 
 
 The treatment is to stop the drinking of alcohol altogether, and to 
 
 regulate the diet and build up the system. If there is disturbance of the 
 
 stomach, appropriate druffs may be taken to correct 
 Treatment. , . . , 
 
 this condition. If there is dropsy of the abdomen the 
 
 fluid may be removed by increasing the action of the kidneys and bowels 
 by the proper drugs, or the fluid may be mechanically removed by tap- 
 ping the abdomen. 
 
 Cancer of the liver is usually secondary to a cancerous growth of 
 
 some other organ, as the intestine or stomach. Karely 
 Cancer of the Liver. ^, , p ,i t -.i . • i 
 
 there may be cancer of the liver without involvement 
 
 of other organs. 
 
 The symptoms are those common to cancerous disease, and in addition 
 there is pain and tenderness over the liver, and frequently enlargement 
 of the liver, so that the patient may feel the enlargement in the abdomen. 
 There may be intense and permanent jaundice. 
 
 The treatment is only palliative. It is a certainly fatal disease. 
 
 Abscess of the liver is a disease in which there is found one or more 
 
 collections of pus (or matter) in the substance of the liver. It is a disease 
 
 which if untreated lasts a long time, and finallv termi- 
 Abscess of the Liver. , . -, ,-, Tf t i i ^ x j • " x- 
 
 nates m death. It discovered and treated m time a 
 
 large proportion of the cases recover perfectly. 
 
 Abscess of the liver may occur in any part of the world, but it is most 
 prevalent in tropical countries. It is frequently found associated with or 
 following dysentery, in which case the abscess is caused by the same liv- 
 ing organism which caused the dysentery. This organism is called the 
 Amoeba coU. 
 
 The symptoms of abscess of the liver are often very indefinite. The 
 patient feels sick, he has fever, and he loses flesh. If there be no other 
 
Toi DISEASES OF DIGESTIVE ORGANS, HEART, AND LUNGS. 
 
 symptoms than those, and if tlicre be no enlargeuuMit of the liver \vhi('li 
 
 the physician ean discover, it may be impossible to make a diagnosis. In 
 
 other cases, in addition to these symptoms, there may 
 
 ^rn i , be a verv liiirli and intermittent temni'ratnre, with chilis 
 
 Ireatnttni. • , ^ ' ' 
 
 and sweatiiiii" ; tbei-c may bi' pain and tenderness over 
 the region of the liver, ami the enlaruenieiit may be so considerable as to 
 be readily recognised by the ]>hysician. 
 
 The treatment is to remove the ]>us by as|>irati(in. or by making a 
 gootl-sized opening throngh the chest or abdominal wall ami introducing 
 a drainage-tube into the abscess cavity. 
 
 DISEASES OF TIIK PAXCIREAS. 
 
 The pancreas lies very deep in the abdominal cavity — just below the 
 stomach. Its office is to assist in tlie process of digestion, particularly in 
 the digestion of fats. 
 
 Diseases of the pancreas are not common, and are always diilicult of 
 diagnosis. Disease may be suspected if there is pain in the npper part of 
 the abdomen, together with the presence of fat in the 
 stools and sugar in the urine. It must be remembered, 
 however, that fat may be present in the stools if taken into the stomach 
 in excess, and that diabetes may be due to other causes than disease of 
 the pancreas. Diseases of the pancreas are, however, often present with- 
 out any of these signs, and then the diagnosis can not be made with 
 any degree of certainty. 
 
 DISEASES OF THE SPLEEN. 
 
 The spleen is a solid organ about the size of a flattened orange. It is 
 situated on the left side of the abdomen and beneath the lower side, so 
 that in health it can not be felt. Its chief function is in connection with 
 the elaboration of the lilood. 
 
 The spleen is subject to a number of diseases which result in its en- 
 largement to such a degree that it can be felt l)y the patient, or which 
 
 may even cause great enlargement of the abdomen. 
 Enlarqement. ^^ i • i • • i . i • i • j-j 
 
 .Malarial poisoning causes an enlargement which is otten 
 
 very great and which may last a long time. This is commonly known as 
 an "ague cake." Leukaemia, or a disease of the blood which consists in 
 a very great increase in the white cor])uscles <jf the blood, is attended by 
 very great enlargement of the spleen. Diseases of the liver, especially 
 cirrhosis of the liver, cause a more moderate enlargement of the spleen. 
 Many infectious diseases — notably typhoid fever — are attended by en- 
 largement of the spleen. The s]:)]een may be dislocated or be displaced 
 from its proper position, and then it becomes congested and enlarged, 
 and remains so until it is replaced and maintained in its pi-oper position. 
 
PERITONITIS, ACUTE, CHRONIC, AND TUBERCULAR. 705 
 
 Tlie treatment of enlargement of tlie spleen is of tlie disease which 
 leads to the enlargement. 
 
 DISEASES OP THE PEIilTONiEUM. 
 
 The peritona3nm is the delicate membrane which lines the ahdominal 
 
 cavity and covers all the organs in the alKlomen. It is very sensitive and 
 
 very intolerant of any irritation, so that a very slight 
 Peritonitis. ' , '• •< i ^ £ . ^ • n ,• 
 
 cause may set up a widespread and latal innammation 
 of the peritonEeum. 
 
 Acute jperitonitis may be caused in many ways, but perhaps the most 
 common is by extension of the inflammation from tlie vermifi^rm appen- 
 dix, or by "appendicitis," as we call it. Inflammations 
 Acute Peritonitis. c. ,^ i ^ .i •. 
 
 of other organs may spread to the peritonaeum, or peri- 
 tonitis may be caused by a perforation of an ulcer in the stomach or in 
 the intestines, or by a blow upon the abdomen, or by surgical oj)erations 
 upon the abdominal cavity. 
 
 The symptoms are pain in the abdomen, vomiting, constipation, dis- 
 tention of the abdomen, great prostration, fever, and a rapid and feeble 
 pulse. There is commonly a peculiarly drawm and anxious expression of 
 the face. 
 
 The disease is always serious and frequently fatal. The treatment is 
 by rest in bed, the application of cold to the abdomen, and opium. A 
 physician should be called at the earliest possible moment. 
 
 Sometimes an acute peritonitis, instead of terminating in recovery, 
 passes into a chronic stage, which lasts for a long time ; in other cases the 
 
 inflammation of the peritonaeum is chronic from the 
 Chronic Peritonitis. ... t.t-t,, o i t,- 
 
 beginning. In this latter form we nave a condition 
 
 entirely different from acute peritonitis. It occurs most commonly in 
 
 children, and more frequently in girls than in boys. 
 
 The symptoms are pain in the abdomen, diarrhoea alternating with 
 constipation, emaciation, occasional fever, and a gradual distention of 
 the abdomen with fluid, so that the case resembles abdominal dropsy, or 
 an abdominal tumor, such as an ovarian cyst. Frequently there is but 
 little pain, emaciation, or fever — the enlargement of the abdomen is the 
 prominent feature. 
 
 Most of these patients recover, although months may ela]3se before the 
 abdominal swelling disappears. 
 
 The treatment is to build the patient up in every possible way. ISTow, 
 quinine and arsenic in small doses is of service. Frequently it is found 
 necessary to puncture the abdominal wall and draw off the fluid in that 
 way. 
 
 TuherciLlar jjeritonitis is a chronic inflammation of the peritonaeum, 
 which is caused by the tubercle bacillus. In tubercular peritonitis there 
 47 
 
706 DISEASES OF DIGESTIVE ORGANS, HEART. AND LUNGS. 
 
 is always some previous tulieiviilar iiifoL'tioii in some other ])art of tho 
 
 body, such as the hings or the genital organe, but the inflammation of the 
 
 peritomvum assumes sueh prominence that the i^rimarv 
 Tubercular I ^ ,• • r ,-,,i i • • r T 
 
 „ .. ., ^. intlammation is oi Jittle consecjuenee, and is, in fact, 
 
 often overlooked. The disease is most common be- 
 tween the ages of twenty and forty, and it attacks both sexes. 
 
 The ])rogress of the ilisease is slow, and, of course, in a large propor- 
 tion of the cases a fatal termiiiation is to be expected. 
 
 The symptoms are similar to those of chronic peritonitis, but more 
 marked. There is more pain in the abdomen, the emaciation is much 
 greater, and the fever more constant and more intense. But there may 
 be little or no fever. There is generally swelling of the abdomen, due in 
 j)art to distention of the intestines with gas, in part to fluid in the abdomi- 
 nal cavity. 
 
 The treatment is similar to that for chronic peritonitis. Laparotomy, 
 or opening the abdominal cavity by an incision of some size, has been 
 followed by complete recovery in a number of cases, but there is some 
 doubt as to whether these were cases of tubercular peritonitis or of chronic 
 non-tubercular peritonitis. 
 
IX. 
 
 DISEASES OF THE KIDT^EYS AND UPJNAKY 
 DERANGEMENTS. 
 
 By J. WEST ROOSEVELT, M. D. 
 
 INTRODUCTION. 
 
 The kidneys are subject to a large number of diseases Avhich nnore or 
 less endanger life. It is impossible within the limits of this article even 
 to mention the rarer affections of these organs, and I have made no effort 
 to do more than sketch in outline some of the most important and most 
 common. I have made no effort to describe the details of the morbid 
 changes which occur in the glands ; it would be impossible to do so in a 
 way which would be comprehensible to a layman. Moreover, so much 
 doubt and confusion exists in the minds of medical men in regard to the 
 causes of many of the symptoms of kidney disease that I have confined 
 myself principally to a simple account of what the main symptoms are 
 without trying to explain why they are. I hope that I may succeed in 
 giving a fairly complete and accurate practical account of kidney disease, 
 which can be understood without too much trouble. 
 
 BRIGHT S DISEASE. 
 
 A certain group of diseases characterized by lesions of the kidneys and 
 often associated lesions of other organs are commonly called Bright's dis- 
 ease. The terra is rather unfortunate ; but it can not 
 Characteristics. , ^ ^ -, i mi t ^ ,i • • 
 
 yet be abandoned. Ihese diseases have sometmng in 
 
 common, and it is as yet impossible entirely to separate them, clinically at 
 least, from one another. In all of them there is more or less destruction, 
 temporary or permanent, of the kidney structure. Almost invariably 
 both kidneys are affected. The lesions may affect only the secreting cells, 
 or all of the structures of the kidney. They seem all to be caused by 
 something which affects primarily the system at large, and secondarily 
 the kidneys. The poisons which may cause these lesions are probably 
 numerous and have not yet been discovered, nor has their mode of action 
 been entirely explained. 
 
 707 
 
70S KIDNEY DISEASES AND URINARY DERANGEMENTS. 
 
 It is needless to attempt to describe in detail the miinerous clnssi- 
 fications which liave been attempted, and I shall content myself with a 
 brief account of what I shall call acute Bri<i:ht's disease and chronic 
 Bright's disease. This classilieation is sufficiently accurate for the pur- 
 poses of this book. 
 
 GENERAL CAUSES OF BRIGHT'S DISEASE. 
 
 Bright's disease is mainly confined to temperate climates. It is not 
 
 common in the tropics or the arctic regions. In general it may be said 
 
 that the acute forms and the group of more chronic 
 
 Geographical ^.^^^^ which are characterized by a pretty rapid course, 
 
 Distribution and , i , ■■• j; i -i ii i j i 
 
 Historii ^y\u\ marked dro])sy, are diseases ot childliood and early 
 
 nianhot>d, while the cases with the atrophic kidney be- 
 l(')ng to more advanced life. 
 
 Exposure to cold and wet is thought to cause some acute cases if the 
 
 exposure is severe and sudden, as, for example, a night sjient in the cold 
 
 and wet. It is also thought by some authors that simi- 
 
 " lar but not so great exposure frequently repeated may 
 
 predispose to the chronic forms — a statement open to doubt. 
 
 Various infectious diseases, especially scarlatina, diphtheria, and yellow 
 
 fever, are apt to be followed by an acute form of Bright's disease. It is 
 
 stated by some authors that in scarlatina the lesion of 
 
 !!•■ the kidnevs is brousrht about by the skin lesion of that 
 
 Diseases. " . . 
 
 disease. The skin not being able to perform its func- 
 tions owing to the changes in it caused by the scarlatinal poison, the kid- 
 neys become diseased because of the extra work thrown upon them. This 
 is not the true explanation in all cases, however. The kidney disease 
 caused by other acute infectious diseases is usually considered to be an 
 effect upon the kidneys of the disease poison. Cholera produces a disease 
 of the kidneys of which patients often die. In this case it is thought 
 that the thick blood found in the stage of collapse in cholera can not trav- 
 erse the renal capillaries raj)idly enough ; that much the same condition 
 obtains as when a renal artery is partly compressed. When reaction oc- 
 curs and the blood again flows freely, the nutrition of the kidney having 
 suffered from the slowed current, acute Bright's disease ensues. 
 
 Various organic and inorganic substances may pro- 
 
 Orqanic and Inor- , . , • -r> • i 1.1 t 01 
 
 . o , , duce acute or chrome Bn£i;ht s disease, feucli are arsenic, 
 
 game Substances. . . '^ ' 
 
 phosphorus, carbolic acid, etc. 
 The effect of alcoliol in ju'oducing Bright's disease, either acute or 
 chronic, is not perfectl}' clear. Chronic druidcards, it is true, often have 
 chronic Bright's disease, but many also have it who have lived a temperate 
 life, and we do not find it in every drunkard. 
 
HEART AND KIDNEY DISEASE. Y09 
 
 Certain cases seem to be due to hereditary influence. It is not un- 
 common to find two or more of the same generation of a family affected 
 with chronic Bright's disease, and in some families it has 
 passed through several generations, one after another 
 dying of it. Gout seems to cause certain cases, and gout is certainly 
 hereditable. 
 
 THE RELATIONS OF HEART AND KIDNEY DISEASE. 
 
 Many cases of chronic Bright's disease are associated with hyper- 
 trophy of the heart. In some cases yve find with the hyj^ertrophy some 
 valvular lesion and sometimes dilatation. On the other hand, many cases 
 of valvular heart disease cause a peculiar lesion of the kidneys. We 
 have, then, two sets of cases — those in which the heart lesion is primary, 
 and those in which either the renal lesion precedes the cardiac or, at least, 
 the changes in the heart and kidneys occur at nearly the same time and 
 as a result of the action of the same poison. 
 
 HEART DISEASE COMPLICATING BRIGHT'S DISEASE. 
 
 Heart disease complicates certain forms of chronic Bright's disease. 
 Various explanations have been offered of this coexistence of cardiac hy- 
 pertrophy (enlargement of the heart) and Bright's disease. Perhaps the 
 most satisfactory is that which ascribes it to high arterial pressure. In 
 most, if not all, cases of chronic renal disease in which hypertrophy of 
 the heart occurs there is marked elevation of the blood pressure in the 
 arteries, showing itself by the long, slow, full, strong pulse. This rise of 
 pressure is thought to be caused by spasm of the arterioles or capillaries 
 throughout the body, due to some poison in the blood, which prevents 
 the free passage of the blood through these vessels. In order to force 
 the blood past this increased resistance the heart must do more work 
 than usual. Now, one of two things may occur : either the heart may 
 hypertrophy and, by becoming stronger, may overcome the resistance, or 
 it may not hypertrophy, but continue to try to do the increased work, 
 liable, however, to fail at any time when a little increased strain is thrown 
 upon it. This is the probable cause of heart disease in most cases. It is 
 needless to speak of others. 
 
 HEART DISEASE PRODUCING BRIGHT'S DISEASE. 
 
 Valvular disease of the heart causes a form of Bright's disease by in- 
 ducing a passive venous congestion of these organs. The other causes of 
 chronic congestion of the kidneys have been considered. In valvular car- 
 diac disease, no matter of what form, we have the veins too full and the 
 arteries too empty. The kidneys share in this congestion. 
 
710 KIDNEY DISEASES AND URINARY DERANGEMENTS. 
 
 APOPLEXY. 
 
 Apoplexy, or luviiiorrlingo into the brain, oeours in a number of eases 
 of chronic Bright's disease, especially in those with the atrophic kidney. 
 Tiie hsemorrhage may be large or small. Not infrequently it is the cause 
 of death. The frequency of cerebral hivmorrhage in Bright's disease is 
 not surprising when one remembers that in many cases we have high 
 blood pressure, a strong heart, and more or less diseased vessels — condi- 
 tions most favourable to cause rupture of a vessel and consequent haem- 
 orrhage. Disease of the cerebral vessels is often very pronounced in 
 Bright's disease. 
 
 ClKlillOSlS OF TIIE LIVER AND EMPHYSEMA OF TOE LUNGS, 
 with bronchitis, often occur with Bright's disease. 
 
 INFLAMMATORY COMPLICATIONS. 
 
 Cases of chronic Bright's disease are often complicated by inflamma- 
 tions of serous membranes. Pericarditis and peritonitis in an acute form 
 sometimes occur. Chronic meningitis occurs quite fre- 
 
 InHammations of .i -r> i -j.- • ^ ^ • x 
 
 o • n^ I quently. Bronchitis, pneumonia, and pleurisy are ire- 
 
 Sermis Membranes, i J . . 
 
 quent complications. 
 Patients with chronic Bright's disease, like those with diabetes, seem 
 often to ofi^er a suitable soil for the growth of the tubercle bacillus. 
 Phthisis is rather commonl}' found associated with renal 
 disease. In some cases i:>\\t]n&i& 2)>'oduces a form of dis- 
 ease of the liver, spleen, and kidneys, but it is not infrequently found 
 with the other forms of renal disease, and seems to follow them. 
 
 UR.EMIA. 
 
 Acute urcemia is a term applied to a group of dangerous symptoms 
 which may arise in the course of Bright's disease. The kidney disorder 
 causing acute urcemia may itself be either acute or 
 rp ' chronic. It is customary with many authors to speak 
 
 of chronic uraemia as distinct from the acute form. 
 This is for medical men a proper distinction, but for this book it is need- 
 less to make it. Whenever the term uraemia is used hereafter the acute 
 form is intended to be understood. 
 
 The following are the symptoms of acute uraemia : Headache, con- 
 fusion of mind, drowsiness, stu]5or (which may deepen into coma), con- 
 vulsions, dimness uf vision, nausea, vomiting, difficulty 
 in breathing, diminished or suppressed urine. The 
 headache may be mild, but is usually severe. It comes on suddenly in 
 many cases, and soon is followed by a certain amount of drowsiness or 
 
ACUTE UK^MIA. 711 
 
 stupor. When it first begins, liowever, tlie patient is nsually nervous and 
 restless, and acutely sensitive to noises, and is, moreover, apt to be cross 
 and irritable. Sometimes there is delirium instead of stupor. 
 
 Nausea and vomiting usually precede or follow the onset of the head- 
 ache. Vomiting, indeed, is frequently the first symptom observed. There 
 is sometimes, though rarely, diarrhoea. The skin is apt to be dry and the 
 bowels constipated. There is usually some fever. 
 
 After a few hours or days the patient either becomes comatose (com- 
 pletely insensible) and dies in this state ; or general severe convulsions 
 occur, in which the violent twitchings of the muscles toss the body about 
 in a hideous way. It is important for those whose fate it is to see such 
 convulsions to bear clearly in mind the fact that there is absolutely no 
 suffering connected with them so far as the patient is concerned. There 
 can be no doubt of the truth of this assertion, for patients who survive 
 these attacks invariably tell us that they have had no knowledge of their 
 occurrence. 
 
 Sometimes dimness of sight, or even complete blindness, ushers in an 
 attack of uremia, and it is seldom that some eye symptoms are absent. 
 
 When urgemia occurs the patient is in a state of immediate and great 
 danger. He may die in the first convulsion, or may survive a large num- 
 ber and finally recover, but it is imperatively necessary to call for com- 
 petent medical aid as soon as the first symptoms appear. 
 
 ACUTE BRIGHT S DISEASE. 
 
 Acute Bright's disease is caused by various diseases in which fever is 
 present. It occurs in some cases of pneumonia, typhoid and typhus 
 fevers, measles, smallpox, and various other acute dis- 
 eases. It is a frequent and dangerous complication of 
 scarlet fever and diphtheria. A form of it often follows the stage of col- 
 lapse in cholera, and is one of the causes of death in this disease, carrying 
 off the patient when he seems to be on the road to recovery. There are 
 a number of poisons which produce acute inflammation of the kidneys. 
 Among these may be mentioned arsenic, phosphorus, corrosive sublimate, 
 chlorate of potash (in large doses), carbolic acid, turpentine, preparations 
 made from the Spanish fly (cantharides), and certain other drugs which it 
 is unnecessary to enumerate in this connection. In some instances ex- 
 posure to cold and wet seems to bring on acute Bright's disease ; and 
 there are not a few cases the causes of which are en- 
 tirely unknown. The kidneys are found to be acutely 
 inflamed, and there is often more or less dropsy. The blood is pale and 
 thin. There may be acute inflammation of various organs besides the 
 kidneys. 
 
712 KIDNEY DISEASES AND URINARY DERANGEMENTS. 
 
 It is well to give a l>rief outline uf \vli:it may be ealled a typical case, 
 and then to consider the symptoms in a more detailed way. 
 
 A young adult, previously healthy, after having been exposed to cold 
 
 and wet for a number of hours, begins to feel weak and ill. He has 
 
 aching pains in his limbs, and perhaps some pain and 
 
 i/pua (u . tenderness in the loins. lie has slight headache and 
 his pulse is rai)id, his temperature above normal. His appetite is gone. 
 His urine is much diminished in amount, is of nearly normal specific 
 gravity, and contains a good deal of albumin, a little blood, and a few 
 hyaline and gramilar casts. In a short time the patient begins to suffer 
 from nau.sea and vomiting. Dropsy soon appears, and involves usually 
 first the feet or the face. In a few days it becomes general, the whole 
 of the subcutaneous tissue being involved. The skin becomes white 
 and waxy. Headache may now begin to be complained of a good deal. 
 Perliaps the vision becomes dim. Sleep may be poor, but the patient 
 feels drowsy. The nausea and vomiting may by this time have .become 
 very distressing symptoms. During all this time the quantity of the 
 urine has varied a good deal — sometimes it has been diminished, some- 
 times increased. At the end of two or three weeks it begins to increase 
 decidedly ; the patient passes two or three quarts a day. The dropsy now 
 begins to diminish ; sleep improves ; the headache passes off ; nausea and 
 vomiting disappear. At the end of another fortnight the patient is left 
 pale, thin, and weak, but with no other symptoms. The urine may be 
 albuminous for some months afterward. 
 
 Instead of this termination, the headache may become very severe and 
 the patient gradually become more and more drowsy, and finally die coma- 
 tose or in convulsions. On the other hand, it is not at all uncommon to 
 luive no uritmic symptoms at all ; the patient, except for the dropsy and 
 weakness, may feel perfectly well a few days after the onset. He may 
 have a good appetite and be free from any discomfort save that produced 
 by the general dropsy. 
 
 The urine is diminished in quantity and may be suppressed. Its 
 specific gravity is lowered and the amount of urea is lessened. There is 
 a large amount of albumin ; sometimes the urine becomes solid upon 
 boiling. Its colour is usually darker than normal, and it may be almost 
 black from the presence of blood. Granular matter, blood, ei)ithelium of 
 various types, pus cells, and granular, hyaline, epithelial, and blood casts 
 may be found in abundance. If the disease has lasted for some time, fatty 
 casts may be present. The amount of blood varies greatly in different 
 
 cases, and it may be al)sent. 
 
 Symptoms. ^i ^ • • ^•L■c j. t -j. • 
 
 ihe onset vanes in dirierent cases, in some it is 
 
 abrupt, with rigours, frequent and painful micturition, diminished amount 
 
 of urine, marked pain in the loins, and severe cerebral symptoms from 
 
ACUTE BRIGHT'S DISEASE. Yl3 
 
 tlie start. In others it is more gradual ; the patient only feels rather 
 out of health, becomes pale, and has some disturbance of the stomach. 
 Then dropsy sets in, with loss of flesh and strength. Such cases are not 
 apt to be so severe as the first. 
 
 Dropsy is present in a large number of cases. Anaimia soon be- 
 comes very marked. The pulse may be weak or strong. 
 CirM^ytj^tL ^t the onset it is _ often very hard and incompressible. 
 and Respiration. Some of these patients suddenly develop a rapid, weak 
 pulse with full vessels and dyspnoea, and die in a few 
 days or hours from acute dilatation of the heart (Goodhart). These pa- 
 tients may also die suddenly of syncope. Shortness of breath is often a 
 marked feature. It is sometimes due to dropsy of the chest and pressure 
 upon the lungs, sometimes to dropsy of the lungs, and sometimes its cause 
 is unknown. 
 
 In a majority of cases there is loss of appetite and severe nausea and 
 ^ . , , ^ ,, vomiting. The vomiting often occurs without any ap- 
 
 jDlSt%lT0Q/7lCQ Of thj& *y 1 
 
 Alimentary Canal. P^'^^°^ relation to the ingestion of food. It may, how- 
 ever, only occur after food has been taken. The tongue 
 is usually coated. If insensibility or great stupor occur, it becomes dry 
 and brown. 
 
 As has been said, some cases do not show marked nervous symptoms. 
 In many, however, these are severe. We have drowsiness, restlessness, 
 
 delirium, stupor, or even coma and convulsions. There 
 Disturbance of the -, -, ,. -, i . it i ^^ 
 
 Nervous System. ™^-^ ^^^ ^® partial or complete blmdness, usually 
 without change in the retina, and probably, therefore, 
 of cerebral origin. Some patients complain of dizziness. 
 
 The teinjperature is elevated in many cases at fii'st. After the onset 
 it may become normal, but if acute uraemia supervene it rises again. (See 
 JJrcemia.) 
 
 Loss of flesh and strength are apt to be marked after the disease has 
 lasted for some time. 
 
 Duration : Several weeks or months. 
 
 Terminations : Complete recovery ; apparent recovery, in which the 
 urine does not return to the normal and relapses occur, the disease be- 
 coming chronic ; death. 
 
 Causes of Death : Acute uraemia, syncope, or more gradual heart 
 failure. Some complication. 
 
 The prognosis varies much in different cases. In children the prog- 
 nosis is better than in adults. Suppression of urine for twenty-four hours 
 . is a very grave symptom. Convulsions may cause sud- 
 
 den death, although they may also pass away. Deep 
 coma is very grave, and well-nigh hopeless. 
 
 In the cases with an acute onset, where there is immediate danger to 
 
714 KIDNEY DISEASES AND URINARY DERANGEMENTS. 
 
 life, the treatment must be directed toward combating the nervous symp- 
 toms. For this purpose morphine is very vahial>lL'. It cahns the nerv- 
 ous centres and encourages the action of diaphoretics. 
 Chloroform or chloral are preferred by many authors. 
 It is customary to give liydragogue cathartics and to induce sweating. 
 Of course the patient will be put on a li(juid diet and kc{)t ([uiet in bed. 
 During the earlier stages it is often of use to give some form of purga- 
 tive, like calomel or Epsom salts (sulphate of magnesia) — not in larye 
 doses, however, but in small, repeated ones. The ap})lication of counter- 
 irritation (cups or mustard) over the loins may do good. Hot-air baths 
 (see 2[cdicincs and 'Tnatment) are useftd in some cases. The disease is 
 not one which can be treated with much prospect of success save by a 
 good physician. Various cases differ so much, one from another, that 
 the greatest skill (which can be obtained only from experience) is required 
 in order to deal with any but the mildest. It must be remembered that 
 while some cases are ahnost certain to recover without treatment, and 
 that some will die in spite of it, a large number remain which may be 
 killed by neglect or bad treatment, or cured by skilful, early attention. 
 
 CHRONIC BRIGHTS DISEASE. 
 
 Cases of chronic renal diseases, regarded from an anatomical stand- 
 point, may be divided into two classes : 1, those in which the most prom- 
 inent lesions are epithelial and the kidneys usually enlarged ; 2, those in 
 which the kidneys are small and the stroma (framework or interstitial 
 tissue) and vessels show the most marked changes. 
 
 Clinically, a sharp division of the different classes is impossible. In 
 some cases with large kidneys we have symptoms identical with those 
 usually produced by small kidneys, and vice versa. In the following 
 pages I shall attempt to describe the symptoms and course usually to be 
 expected with the different forms, but I admit that in many cases a differ- 
 ential diagnosis is impossible. There are, however, such great differences 
 in the symptoms usually produced by the two anatomical forms of kid- 
 ney disease that it is best to deal with them separately. 
 
 THE LARGE KIDNEY. 
 
 The large kidney is a form of chronic Bright's disease in which the 
 kidneys are increased in size and the course usually rapid. The disease is 
 more frequent before than after middle life. Males are 
 more frequently attacked than females. The disease is 
 said to be rarely seen save in temperate climates. Alcohol is thought to 
 be tlie exciting cause in some cases. Others occur as sequels to acute 
 outbreaks. Some authors are inclined to attribute to cold, or rather to 
 
CHRONIC BRIGHT'S DISEASE. 715 
 
 alternations of heat and cold, an important part in the aetiology. In 
 
 a large number of cases careful search fails to show any recognisable 
 
 cause. 
 
 A young adult observes that he is not feeling well. lie is pale, easily 
 
 tired, his stomach is easily upset, perhaps he has some breathlessness on 
 
 exertion. lie loses flesh a little. After a while dropsy 
 Symptoms observed i • <• i i i i tt' 
 
 . „, . , ^ appears, and in a tew weeks has become sreneral. lie 
 m a lypical Case. . . , 
 
 suffers from headache and sleeps badly. His appetite 
 goes almost completely. His bowels are sometimes confined; sometimes 
 he has diarrhoea. Anaemia becomes very pronounced. After a time his 
 eyesight grows dim ; he may even become blind. During ail this time his 
 urine is diminished. He may have attacks of dyspnoea. The pulse is 
 often one of high tension ; after a time hypertrophy of the heart may be 
 observed. After several months or a year, if the case continues to pro- 
 gress badly, as it usually does, the patient may pass into a typhoid state 
 and die ; or acute uraemia may set in, and he may die in coma or con- 
 vulsions. Sometimes the patients die suddenly ; sometimes they seem to 
 die from the mechanical effects of the drops}^ ; sometimes an acute inflam- 
 mation kills them. All the symptoms may undergo improvement for a 
 time and then again become worse. 
 
 Dropsy is usually developed early, and may be the first symptom. It 
 is sometimes slight and confined to the face and legs, but more often it is 
 
 general and severe. It is rare not to have any with 
 Disturbance of the .ii ^ -j t j: j.-i. j 
 
 ... , n 1 the larffe kidney. Loss oi appetite, nausea, and vomit- 
 Alimentary Canal. ^ '' . . . 
 
 ing are usually present at some time in the disease, and 
 may be the first symptoms. Diarrhoea is not unusual, and is sometimes 
 profuse and exhausting. 
 
 The pulse is usually long, slow, full, and strong. Hypertrophy of the 
 
 heart is found in a fair proportion of cases, but it is not 
 
 Disturbance of the ^^ fj-eqiient as with the atrophic kidney. Palpitation of 
 Circulatory and Re- '^ . „, 
 
 spiratory Systems. ^^^® heart and dyspnoea on exertion are Common. I he 
 
 patients may also suffer from true renal asthma, or from 
 
 dyspnoea due to the dropsy. Anaemia is pronounced. 
 
 The temperature often rises during uraemic attacks, but no rise of 
 temperature seems to accompany the disease except during these out- 
 breaks, or as a symptom of some complication. 
 
 Headache, slight or severe, is frequent. ]!S"euralgia, especially of the 
 
 fifth and sciatic nerves, occurs with some cases. Colic is quite common. 
 
 Blindness, partial or complete, occurs in some cases, 
 
 Disturbance of the . .-. •,! , i • j- ,^ ^- on • e, 
 
 -.J ry , With or witliout lesions oi the retina, feleep is often 
 
 JServous bystem. _ ^ 
 
 poor and interrupted by dreams. In advanced cases 
 there may be stupor, delirium, coma, or convulsions, or the condition 
 known as the typhoid state. 
 
71t; KIDNEY DISEASES AND UEINARY DERANGEMENTS. 
 
 The patients lose tiosh ami strengtli in a nuirked degree. The eases 
 
 frequently die within a year or two after the first symptoms are observed. 
 
 The symptoms may, however, intermit for a consider- 
 
 Course ami Dura- .^j^,^, ^\^^^^ ^^^^ ^j^^^j^ ^,^ ^^ ^j^.^^ -^ j^ possible for a 
 
 (ion: ( ousts ot . ^■ e i • i j i 
 
 Death ' j^atient to hve for ten years or more, liaviug had several 
 
 attacks, with intervals of pretty good health. Some 
 
 patients die very suddenly, apparently of synco})e ; some of ura?mic coma 
 
 or convulsions ; some of exhaustion ; some from the elfects of tiie dro])sy ; 
 
 some of phthisis, or other complicating disease. 
 
 The prognosis or outlook is serious. Some few of the cases seem to 
 
 recover entirely. Frecuiently, as has been said, the re- 
 Prognosis. . , ^ ^ ^ 
 
 covery is only apparent and relapses occur. 
 
 The plan of treatment to be pursued is calculated partly to relieve the 
 
 kidneys of part of their work, partly to remove troublesome or dangerous 
 
 symptoms, partly to build up the patient's strength. 
 
 At the beginning it is well to put the patient to bed and 
 enforce absolute bodily and mental rest. A milk diet should be tried. 
 If there are no urgent symptoms this is all that is needed for a while. If 
 dropsy is excessive, measures may be adopted for its relief. Catharsis 
 may be tried — a fairly large dose of some saline, for example, every day 
 or two for a time. The skin may be improved and sweating induced by 
 a bath of hot air, vapour, or water. Some patients improve under a 
 course of sweating, but some are exhausted by it, in which case it must 
 be abandoned. Diuretics — digitalis, squills, or other drugs, and especially 
 water — seem to be of service at times. If extensive ascites (dropsy of 
 the abdomen) or a dangerous amount of hydrothorax (dropsy of the 
 chest) be present, the patient may be tapped or aspirated. Sometimes 
 much good comes from draining off the fluid by means of a number of 
 punctures in the legs made with a clean sharp needle. If troublesome 
 vomiting occur, iced milk and limewater in small amounts, or carbonic- 
 acid water with milk, or bicarbonate of sodium, may relieve it. Diar- 
 rlujea, if it be not excessive, may be actually of service to the patient. 
 If it becomes profuse and exhausting, astringents, bismuth, and other 
 remedies may be tried. Patients with this form of diarrhoea do not usu- 
 ally bear morphine well. On the other hand, when acute urremia with 
 marked cerebral symptoms is present, morphine is often well borne and of 
 service. Headache with high arterial tension may be relieved with 
 chloral. Ursemic convulsions may be treated with morphine, chloi'al, or 
 chloroform. 
 
 General tonics are indicated. Iron is often very useful. After the 
 more severe symptoms have subsided, residence in a warm climate is 
 greatly to be desired. 
 
CHRONIC BRIGHT'S DISEASE. 717 
 
 Tim SMALL KIDNKY. 
 
 The small kidney is a form of chronic Bright's disease and differs from 
 the one which has been described in many M^ays. It is usually much more 
 chronic in its course. Its onset is insidious. It usually occurs after middle 
 life. In it the kidneys are reduced in size and there is great increase in 
 the fibrous tissue in them. Cardiac hypertrophy is more common with this 
 than with the large kidney. So also is apoplexy. The lesions of cirrhosis 
 of the liver and emphysema are present with it in a large number of cases. 
 
 It is a disease of temperate climates and affects ordinarily persons more 
 than forty years old. Cases are on record, however, in which it has been 
 found in children. Some cases seem to be hereditary. 
 For a certain number no cause can be assigned. The 
 subjects of this disease are often people who use alcohol to excess. Gout, 
 which is certainly hereditary, seems to produce some cases. Chronic lead 
 poisoning produces others. Occupations involving much exposure to se- 
 vere changes of temperature, such as iron-working, etc., seem to favour 
 the disease. 
 
 The urine in the earlier stages is usually increased in amount (two to 
 four). Its specific gravity is lowered (1005 to 1015), its colour pale. 
 Sometimes the passage of a large amount of urine alternates with the pas- 
 sage of a smaller quantity. Albumin at first is absent or present only in 
 small quantity. Casts also are not abundant and are hyaline or granular. 
 As the disease advances the amount of urine often diminishes. It may to- 
 ward the end be suppressed. The quantity of albumin usually increases 
 much as time goes on, and casts become more numerous and of greater 
 variety, and perhaps blood may be found. There are cases in which no 
 albumin is found at any time, and many cases in which several examina- 
 tions may be made before it is found. The specific gravity of the urine 
 in such cases becomes a useful help in the diagnosis. Even in cases with- 
 out albumin the microscope may show casts. In a case where this lesion 
 is suspected, a number of careful, thorough chemical and microscopic 
 examinations should always be made. 
 
 The onset is usually insidious. It is often impossible to say how long 
 
 the disease has lasted before the patient comes under observation. The 
 
 earlier symptoms vary much. Sometimes a patient com- 
 Symptoms. i«iii ' -i ^ • 
 
 plains that he has to get up at night several times to 
 
 pass water, and that he passes a great deal. At other times anaemia, with 
 
 loss of flesh and strength, first causes anxiety. Dyspepsia with perhaps 
 
 vomiting, or vomiting alone without dyspeptic symptoms, is occasionally 
 
 the first complaint. Some patients are troubled with constant headache. 
 
 Some first are troubled with sleeplessness. Some notice slight oedema of 
 
 the ankles in the evening. Others find their sight failing, and an ex- 
 
7 IS KIDNEY DISEASES AND URINARY DERANGEMENTS. 
 
 ainination shows advanced neuro-rotinitis (iiillaniinatioii of the optic 
 nerve). Occasionally severe neuraliria lir>t directs attention to the kid- 
 neys. An attack of spasmodic dyspmea occurriiiy; in a person not for- 
 merly the subject of asthma may be tlie tirst symptom noticed. l*alpita- 
 tion of the heart on exertion tirst troubles certain i)atients. Sometimes 
 renal svmi-)toms lirst appear after some more or less severe injury has 
 jirostrated the patient. In a few cases ura^mic coma and convulsions oc- 
 cur suddenlv in patients who were before thought to be well. Certain 
 peoj^le are stricken with apoj^lexy who have diseased kidneys, yet have 
 not shown symptoms before. In a certain number of cases no symptoms 
 are observed during life, and yet an autopsy shows marked renal lesions, 
 Sometimes the disease is lirst discovered during the course of an exami- 
 nation, undertiiken for some special reason, as, for example, life insur- 
 ance, where its existence has not been suspected. 
 
 Although the onset is usually insidious, certain cases seem to begin 
 acutely. In such cases there may have been no symptoms before the 
 acuter ones set in, or the symptoms may have been overlooked. It is not 
 infrequent to find hospital patients suffering from advanced atrophic 
 lesions, who aver that they were well, it may be, a week before their ad- 
 mission. Careful questioning may show that this statement is false. In 
 dealing with hospital patients, one must remember that they are not usu- 
 ally observant, and often overlook slight ailments. The habits of many 
 of the patients are such as to make them take certain symptoms as a mat- 
 ter of course, A man who gets drunk three times a week is not likely to 
 consider headache, nausea, and vomiting as unusual events. A man whose 
 life is spent in shovelling dirt and who never reads may easily overlook 
 slight dimness of vision. A person who habitually drinks a large amount 
 of beer will not be surprised at passing a great deal of urine. 
 
 Headache, more or less severe, occurs at some time in the course of 
 
 most cases. The pain is usually general and not limited to one part of 
 
 the head. It is sometimes severe, at others it scarcely 
 Disturbance of the , , ,, r t- r -<• £ i. /^\ 
 
 s. e ■/ amounts to more than a feelino: of discomfort. Chancres 
 
 JServous System. ... ° 
 
 of disposition and irritability of temper are often ob- 
 served. Some patients are much troubled with sleeplessness. A sense 
 of muscular fatigue and aching in the limbs is felt by many. Neuralgia 
 of various nerve trunks is sometimes a prominent symptom. It is well 
 to look to the state of the kidneys in an}' case of neuralgia. Certain pa- 
 tients suffer severely from attacks of spasmodic colic which come on from 
 time to time, and do not seem to depend upon the taking of indigestible 
 food. Disturbances of vision — such as amblyopia (dimness of vision) and 
 muscaj volitantes (floating spots), without visible retinal lesions — are not 
 infrequent. Inflammation of the optic nerve also may cause dimness of 
 sight. In advanced cases the symptoms of acute uraemia are often present. 
 
CHEONIC BRIGHT'S DISEASE. 719 
 
 The pulse is in most cases one of high tension — long, slow, full, and 
 strong. If patients at the end pass into a typhoid state the pulse may 
 
 become small and feeble, even dicrotic. The tension 
 Disturbance of the r^-t i n • ,i £ i. c x -i t 
 
 „. , , , „ lalls also during the progress or any acute febrile dis- 
 
 Ctrculatory and Re- . " . ^ , 
 
 spiratory Systems, tnrbance in these patients. Dropsy is not often severe. 
 It is frequently limited to trifling oedema about the 
 ankles, and it may be absent; nevertheless, certain cases have general 
 anasarca (dropsy). Toward the end it is not unusual to find some hydro- 
 thorax, hydropericardium, and ascites (dropsy). CEdema (dropsy) of the 
 lungs is frequent a little while before death. 
 
 Dyspn(Ba (breathlessness) is very often a source of complaint. It oc- 
 curs sometimes in attacks precisely like ordinary asthma (when it is called 
 renal asthma), but more often it is the result of dropsy and anaemia (poor 
 quality of blood), and is first noticed after exertion. Late in the disease 
 it may be almost constantly present for days or even weeks, and may 
 cause intense suffering. 
 
 Loss of appetite, or a very variable appetite, is quite frequent. Some 
 patients complain of thirst. Pain or discomfort in the epigastrium (up- 
 per part of the abdomen), pyrosis (heartburn), flatulence. 
 Disturbance of til e 
 
 Alimentary Canal. ^"^ ^^^^^ Symptoms of dyspepsia are present in a large 
 
 number of cases. Nausea, with or without vomiting, is 
 
 sometimes a troublesome symptom. In some cases the vomiting seems to 
 
 be caused by undigested food, in others not. Diarrhoea occurs and is 
 
 troublesome in some cases, but many are more or less constipated. 
 
 Anaemia, with marked loss of flesh and strength, is observed in very 
 many cases. As has been said, the last mentioned symptoms — loss of flesh 
 and strength • — may be the earliest ones noticed by the patient. 
 
 As it is possible to have cases with this lesion which present no symp- 
 toms, so is it the more possible to have a large number of the symptoms 
 described absent. 
 
 Patients rarely go on steadily from bad to worse. There may be 
 
 months and years when, save for urinary changes, they seem in good 
 
 health. After a while, however, they break down rapid- 
 
 Duration ^^ ^^^ ^^®* '^^^^ disease may last ten or fifteen years, 
 
 or longer, dying, perhaps, of some intercurrent affection 
 
 at the last. Its course is always slow. 
 
 Patients with this form of Bright's disease are very likely to die if 
 seized with an acute disorder, like pneumonia or some fever. A consid- 
 erable number of them die from some such intercurrent 
 Causes of Death. ,. -jii i ij-i; ^ 
 
 disease. A considerable number also die of apoplexy. 
 
 Some die apparently from a gradual failure of strength, passing into a 
 typhoid state before death. Others have the symptoms of acute uraemia 
 and die comatose or in convulsions. 
 
720 KIDNEY DISEASES AND URINARY DERANGEMENTS. 
 
 It is doubtful whetlicr patients ever recover from this form of Bright's 
 ilisease. It is usually stated that they do not. The disease is, however, 
 so chronic in its course that the prognosis as to length 
 of life is fair if the diagnosis be made early. The pa- 
 tients are liable, it is true, to die from some intercurrent disease, or from 
 the results of some imprudence, but thc}^ may live many years in com- 
 parative comfort. As a patient Avith valvular heart disease may live a 
 long time, with prudence and care in his mode of living, so may patients 
 with atrophic kidneys. In individual cases the prognosis varies with the 
 capability of the patient to carry out treatment, with the tendency of the 
 disease to advance or not in a given case, and with the time at which the 
 diagnosis is made. 
 
 If a patient is able to have bodily and mental rest, to obtain ])roper 
 food, and to reside in a warm climate, the prognosis is better than when 
 he is unable to do these things. In some cases the disease seems to have 
 a tendency to make more rapid progress than in others, in spite of all 
 treatment. If the diagnosis be not made and treatment instituted until 
 the lesion is already far advanced there is but little hope. A case in 
 which marked urivniic symptoms have appeared rarely survives long, yet 
 years may elapse between the lirst nriemic attack and death. Cases in 
 which haemorrhage into the retina has occurred are usually advanced and 
 of the gravest prognosis. Cases in which there is pretty rapid loss of 
 flesh and strength are also of grave prognosis. A pulse of very high 
 tension is indicative of danger. The occurrence of an acute complication 
 renders the patient's condition precarious. The prognosis in each case 
 must be made from the symptoms of that case, and can not be generally 
 indicated. 
 
 The indications are to build up the patient's strength, to relieve the 
 
 kidneys of some of their work, and to combat dangerous or unpleasant 
 
 _ symptoms as they arise. The food should be easily 
 
 Treatment. i • \ i j • , . . , , , , 
 
 digested and nourisJnng. Although contrary to theory, 
 
 many of these patients do well on a diet consisting almost entirely of al- 
 buminous food. In some cases a milk diet for several weeks is followed 
 by good results. Tonics are useful in many cases. The state of the skin 
 and bowels should be watched, but, unless dangerous symptoms call for 
 it, too much sweating and purging should be avoided. Massage and 
 daily baths, followed by friction with a coarse towel, are useful. Some 
 patients enjoy, and are benefited by, occasional Turkish or Kussian baths, 
 but in others these are debilitating. Residence in a warm climate, life in 
 the open air, moderate exercise, and complete freedom from worry are of 
 great value. The bowels should be kept free by gentle aperients. 
 
 Xausea and vomiting and dyspejitic symptoms must be treated as 
 these symptoms would be treated were there no kidney lesion. If the 
 
SACCHARINE DIABETES. 721 
 
 urine bccomos much diminished, diuretics maybe of service, Muny of 
 the most unpleasant symptoms arc relieved by drugs which reduce the 
 high tension, such as chloral. Nitroglycerin and the nitrites are being 
 extensively tried for this purpose at present and are worthy of further 
 trial. Nitroglycerin is effective in some cases where the tension is very 
 high, relieving the headache and other nervous symptoms in a remarkaijle 
 way. Attacks of renal asthma are not often relieved l>y this drug, but 
 usually are best treated by morphine. 
 
 DIABETES. 
 
 There are two entirely distinct diseases to which the name of diabetes 
 has been given. Both are characterized by a great increase in the amount 
 of urine passed. In one the urine is not only increased in quantity, 
 ])ut it also contains the form of sugar called glucose, a substance which is 
 one of the products of digestion and assimilation (see Physiology : Tlie 
 Yital Processes in Health), which, however, does not normally appear in 
 the urine, while in the other no glucose is found. The latter form of dia- 
 betes is comparatively rare, and is usually more annoying than dangerous, 
 but it will not be described in this book. The reader is referred to articles 
 upon Piabetes insipidus, or Polyuria, in the systematic treatises on med- 
 icine for information about it. The form here considered is what is 
 known technically as diabetes mellitus, or saccharine diabetes. 
 
 Diabetes mellitus is a disease characterized by an increased flow of 
 urine which contains glucose, and by increased appetite, thirst, and loss of 
 flesh and strength. The disease may prove fatal within 
 "" ' " ' a few months or may last for many years (fifteen to 
 
 twenty, or more) if properly treated, and give the patient but little in- 
 convenience. 
 
 Diabetes occurs in both sexes and at all ages after early childhood. 
 "What change in the organs of the body cause it to appear is unknown. 
 All that can be positively asserted is that it is not de- 
 pendent upon disease of the kidneys. The prominence 
 of the urinary symptoms makes it advisable to describe it among the 
 true kidney diseases, and for this reason I have done so. 
 
 It seems to be caused by severe nervous shock, such as intense sudden 
 grief or fright, in some cases. In others it follows prolonged mental 
 strain, the result of anxiety and mental overwork. Gouty people some- 
 times develop it, and it is occasionally inherited from diabetic or gouty 
 ancestors. It is asserted by some observers that the disease may be pro- 
 duced by excessive eating in persons of sedentary habits, but this is not 
 very probable. 
 
 The first symptoms noticed differ in different cases. Perhaps that 
 which is most commonly first noted by the patient is the increase in the 
 48 
 
KIDNEY DISEASES AND URINARY DERxVNGEMENTS. 
 
 Sytnpionu^ 
 
 ainuunt of Nvatcr j)assc(l. Jle may be ohliged to got u]> sovenil times at 
 night ill order to empty the hhulder. Excessive thirst lirst attracts the at- 
 tention of sunie, Avliile others observe tliat, in spite of 
 an appetite which is unnsnally good, or perhaj)s even 
 ravenons, tliey lose flesli and strengtli. Persons who have been accus- 
 tomed to liard work may iind themselves very easily fatigued, so that they 
 are unable to do what they luul looked nj)on previously as very light 
 tasks, and they Iind that their memory is not so good as it luul been, and 
 their temper worse. Occasionally the iuinous symptoms mentioned, to- 
 gether with intense mental depression, and perhaps also sleeplessness, 
 languor, and more or less headache, first lead to an examination of the 
 urine and the discovery in it of sugar. As the disease advances, in severe 
 cases {ichose course is not Diodijied htj treatment), the amount of urine 
 passed may reach as much as eight or ten quarts in twentj'-four hours, 
 and, as a necessary result of this loss of water, the patient is compelled to 
 drink a corresponding quantity. The urine is pale yellow in colour and 
 sometimes is observed to make any article of clothing with which it comes 
 in contact sticky or stiff to the touch. It is found to contain very variable 
 quantities of glucose.* 
 
 Cases are recorded in which mure than two pounds of sugar were ex- 
 creted daily ; but this is an enormous quantity, and even very severe cases 
 rarely exceeil eight to ten ounces. The quantity of food taken and di- 
 gested without apparent trouble by a diabetic is frequently astounding ; 
 it is not unusual for liim to grow thin on a diet which would literally 
 sustain five or six strong men in perfect health. 
 
 * The presence of this substance makes the specific gravity of the urine higher than 
 normal : it may be found to be 1050 or 1060. (Tlie specific gravity of water being 1000, 
 the specific gravity — i. e., comparative weight of an equal bulk — of normal urine is from 
 1015 to 1025, more or less.) The sugar ferments when a little yeast is 
 put into the urine, and becomes converted into carbonic-acid gas which 
 escapes in the form of bubbles, and alcohol. The simplest way of esti- 
 mating the amount of sugar present is to collect all the urine passed 
 in twenty-four hours in one clean vessel of sufiicient size. The entire 
 quantity is then measured, and from it a few ounces are taken and the 
 specific gravity is ascertained by means ul' ,iii uiiiMinictor (Fig. 1). A 
 small piece of compressed yeast is then added, and tlie specimen set 
 aside in a warm place for twenty-four hours, or until fermentation is com- 
 plete. The decomposition of the sugar causes the specific gravity to fall, 
 and the difference of that noted after fermentation and that previously 
 obtained measures with fair accuracy the proportional amount of glu- 
 cose. Each degree of loss in specific gravity indicates the presence of 
 one grain of sugar to the ounce of urine passed. Thus let us suppose 
 that a patient has passed 100 ounces of urine having a gravity of 1045, 
 and that, after fermentation, the gravity is found to be 1010, the difTerciice, being 35°, in- 
 dicates that each ounce of urine contained 35 grains of sugar, and that the total amount 
 of 100 ounces contained 100 x 35 = 3,500 grains, or -i lb. avoirdiniois. 
 
 Fig. 1. — An uri 
 
 N051ETEU. 
 
SACCHARINE DIABETES. 723 
 
 Unless clieckcd hy trcatrneiit, the diseuse <^i-o\v.s progressively worse; 
 emaciation becomes extreme ; the weakness eonliiies the patient to bed ; 
 the skin becomes dry and scaly ; tliere is u peculiar odonr of a sweetish, 
 sickening character to the breath ; finally death ensues either from coma, 
 which is called acetonsemia, or suddenly and without warning, or more 
 frequently from the effects of some complication. 
 
 Severe cases niay terminate fatally within a year from the time when 
 the first symptoms were observed ; the affection is, however, essentially 
 chronic in its course, and life is often prolonged for a number of years, 
 especially in cases which are properly and systematically treated. A con- 
 siderable number of these live ten years or more, provided they are care- 
 ful in their diet and in avoiding fatigue and exposure. The symptoms, 
 save the sugar in the urine, may pi-actically be absent for months at a 
 time, and then only reap|)ear in a mild foz-m. Kevertheless, the diabetic 
 lives with a sword suspended over him continually. 
 
 Consumption kills many and is very common. Acute pneumonia is 
 
 a quite frequent cause of death. Acute inflammations of the skin, in the 
 
 form of boils and carbuncles, are frequently met with, 
 Complications. , , , j-i t i ,- • t i i , 
 
 and are dangerous because the diabetic is very liable to 
 
 fatal blood poisoning from them. 
 
 The treatment consists in restricting the diet, so far as possible, to food 
 
 which does not yield sugar in the process of assimilation. In many cases 
 
 its results are very favourable ; but there is much difii- 
 
 culty in forcing the patient to avoid the harmful articles 
 
 of food. It is impossible for man to live entirely without starch or sugar 
 
 for a very long time ; these are the substances from which glucose is 
 
 made in the body. The more completely and continuously a diabetic 
 
 avoids them, the better are his chances of longer life and very fairly good 
 
 health. For details of the diet to be pursued, the special works on the 
 
 subject must be consulted. 
 
 THE EXAMINATION OF URINE. 
 
 Anything approaching a complete examination of urine can only be 
 made by one who has acquired tlie requisite skill by practice to enable 
 him to perform the necessary manipulations and observe accurately the 
 chemical reactions and microscopic findings. A brief description of the 
 methods employed may be of interest to readers of this book. 
 
 In examining a specimen of urine, the observer first notes its general 
 characters as to colour, odour, degree of transparency, and the presence 
 or absence of any precipitate visible to the naked eye. 
 
 The colour of the urine varies greatly in health, and can not by itself 
 be taken to indicate disease of the kidneys. In a great number of abnor- 
 mal conditions other than kidney disease urine deposits larger or smaller 
 
724 KIDNEY DISEASES AND URINARY DERANGEMENTS. 
 
 (|iuintities of jiivcipitates on staiidiiii;. These mav be composed of white 
 phosphates, or pink nrates, or hrii;ht-red crystals of niic acid (so-called 
 "brick dnst"), or of pus, mucus, blood disks, casts of the kidney tubes, 
 or epithelial cells deriveil from some part of the urinai-y tract. To 
 determine the nature of a j)recipitate the microscope is used as well as 
 certain chemical i-eaijents. 
 
 After noting the gross j)hytieal characters of the s])ecinicn its reac- 
 tion is taken by di])ping into it small pieces of paper coloured with lit- 
 mus. This dye has the peculiarity of changing its colour in fluids of 
 ditferent reactions. Tiie test papers are coloured, some blue and some 
 red. If the reaction be acid, the blue paper becomes red ; if alkaline, the 
 red paper becomes blue; while in neutral fluids no change is observed in 
 the colours. 
 
 The. specific gravity is next ascertained by means of an urinometer 
 (see note on page 722). After this has been done the specimen is sub- 
 mitted to tests having for their object the demonstration of the presence 
 or absence of certain substances which are not present in normal urine. 
 The more important of these are albumin and glucose. 
 
 Two tests are most commonly employed for detecting albumin : (1) 
 the application of heat, and (2) the careful addition of a small amount of 
 strong nitric acid. In making these tests the following precautions are 
 absolutely necessary : AVhen heat is used albumin is coagulated and forms 
 a white i;\oud, j)/'ori(h'd the urine is acid in reaction. If it is alkaline, 
 not only may all)umin fail to coagulate, but also a white cloud of phos- 
 ]>hates may be formed ; therefore if the reaction be not acid, it must be 
 made so by the addition of a drop of dilute acetic acid before boiling. 
 Nitric acid may give a precipitate of urates, but this dissolves readily upon 
 gently heating the specimen ; therefore a precipitate formed by nitric 
 acid should alwa^'s be heated to boiling before it is regarded as albumin. 
 
 Glucose is detected by means of a solution of a salt of copper which 
 yields a dense yellow precipitate of oxide of copper when boiled Mith 
 a fluid containing small amounts of that substance. This test is delicate, 
 but it requires much care in its application ; and the reader is referred 
 to the text-books upon urine analysis for the details. Sometimes a solu- 
 tion of a salt of bismuth, which yields a black precipitate when heated 
 with glucose, is used instead of the copper solution. 
 
 In some cases special tests are necessary to determine the presence or 
 absence of bile or of blood-colouring matter. These will be found de- 
 scribed in the text-book.s. 
 
 The microscope enables the observer to look for blood disks and 
 white blood cells, pus, epithelium, casts, mucus, etc., and to recognise the 
 physical appearance of various chemical precipitates. It also makes pos- 
 sible the demonstration of various bacteria occasionally found in urine. 
 
X. 
 
 DISEASES OF WOMEN AND MIDWIFERY. 
 
 By SA:\1UEL WALDRON LAMBERT, M. D. 
 
 INTRODUCTION. 
 
 Obstetrics, or midwifery, is that portion of medical science and art 
 which deals with pregnancy, with parturition, and with the puerperal 
 state in all their physiological and pathological relations. 
 Gynaecology is, in its best and broadest sense, a more 
 comprehensive term, and includes within its definition the science of ob- 
 stetrics and, in addition, all else which is peculiar to woman from the 
 various points of view of hygiene, physiology, and medicine. 
 
 The greater number of the following pages are devoted to a consid- 
 eration of the normal manifestations of the various functions of woman- 
 kind. Facts concerning the abnormal action of these 
 Functions of ,. ^ -\ p i t i - 
 
 W l-'id processes are discussed only as lar as they would be 
 
 likely to attract the attention of the non-professional 
 
 observer. These processes, peculiar to the female sex, are all connected 
 
 with the one great function of childbearing. At least thirty years of the 
 
 natural life of woman are given up to the monthly recurring preparation 
 
 for this function, or to the actual performance of it. 
 
 Three critical seasons occur in the life of evei'v woman as she lives 
 
 through this period of generative activity. The first marks its onset, and 
 
 is known as the ao-e of pul)ertv. The second critical 
 Three Critical ,. . ,, ^ . ' ^ j_ /> ^i' ^i ■ i • • ^ 
 
 Seaso7is ""^® ^* most miportant ot the three ; it begins with 
 
 pregnancy, includes parturition, and only ends with the 
 cessation of lactation. The final, least significant, crisis marks the end of 
 the childbearing period, and is called the menopause, or change of life. 
 
 All considerations of anatomy are omitted from this article, which 
 treats entirely of the physiological processes and of the principal mani- 
 festations of disease. The reader is referred to Fig. -iS in the article on 
 Physiology/ : The Vital Processes in Health, for a schematic drawing of 
 the anatomical relations of the special organs of the female. 
 
 725 
 
726 DISEASES OF WOMEN AND MIDNMFEKY. 
 
 CIIAPTKU I. 
 MENSTR UA TION. 
 
 The female orenniiial ei'll. tlu' ovum ^^\• " Oiri;/' is differentiated for its 
 special destiny from the i-emiiiniii*;- cells of the body of the luimaii female 
 
 even while this individual is sojourniuji; in the womb of 
 Ovulation. . ^, riM .1 ,1 r ^1 xi • J 
 
 Its mother, ilius tiie protoplasm ot tlie third gener- 
 ation lives in the body of the individual of the second generation before 
 the birth of the latter. These ova are developed in special organs called 
 ovaries. They are I'ipened at regular intervals, and are discharged from 
 the ovary when mature. They reach the uterine cavity and either die 
 and are discharged from the body of the woman, or they become fecun- 
 dated by combining with the generative cell of the male, and undergo 
 further growth. This periodic development and discharge of the ripe 
 ovules is known as the process of ovulation. The human e<^g is a micro- 
 scopic object, and if the process described constituted the whole series of 
 phenomena which took place at the time of the periodic discharge of 
 such small cells from the ovary, there would never be any tangible mani- 
 festation to mark the event. Such may be sometimes the case, and ovu- 
 lation without external signs may occur. 
 
 It is usual, however, that the lining membrane of the uterus gives 
 very decided evidence of its participation in the event. The uterus of 
 
 every healthy woman loses part of its lining membrane 
 
 ■M- , /. at certain rei^ular intervals. This interval is twenty- 
 
 Menstruatwn. .... 
 
 eight days in a majority of cases. This process of de- 
 generation lasts about five days, and causes a distinct congestion of the 
 uterus and the neighljouring organs, and a bleeding from the uterus ap])ears 
 from the vagina. This process is known as menstruation. Although 
 ovulation and menstruation are usually concurrent in time, either may 
 occur independently of the other. 
 
 This periodic discharge is a necessary preparation for pregnancy. The 
 fecundated ovule lodges in the renewed mucous membrane of the uterus. 
 and takes nourishment from it until more intimate relations of inter- 
 change can 1)0 established between the circulation of the mother and that 
 of her unborn child. If the ovum be not fecundated, the newly prepared 
 membrane of the uterus degenerates at the end of its allotted time — 
 twenty-eight days after the degeneration of its predecessor. 
 
 Menstruation is continued with great regularity after it is once estab- 
 lished. Its onset marks the beginning and its permanent cessation marks 
 the end of the possible childbearing period of every individual. 
 
 The transition period, during which a child ceases to be a child, is 
 
PHYSICAL MATURITY. Y27 
 
 known as the time of puberty, Tliis change is no sudden one, but the 
 characteristics of childhood gradually merge into those of adult woman- 
 hood or manhood. Until this metamorphosis bemns, 
 the physical development is practically the same in both 
 sexes. This process of change begins earlier in the female sex than it 
 does in the male, and is recognised before the law as completed in girls 
 at the age of thirteen, in boys at fourteen. Perfection of development 
 is not attained, however, by either sex until several more years have 
 elapsed. 
 
 In girls there are many signs of approaching maturity which are well 
 advanced before menstruation, the most characteristic of them all, appears. 
 The whole contonr of the body changes. The hips broaden by an actual 
 growth of the bony pelvis, causing the shoulders to appear relatively nar- 
 row. The breasts begin to enlarge, and the nipples to become more 
 prominent. The whole body becomes stouter (especially the thighs and 
 buttocks), in consequence of an increase in the subcutaneous fat. In addi- 
 tion to these more evident changes, there are others which are less promi- 
 nent. There is a marked growth and development of the special organs 
 of generation. The uterus and vagina enlarge, and the external parts 
 share in the same growth. 
 
 The first menstruation may occur without any disagreeable symptoms 
 at all. At other times it will be preceded by a varying number of attacks 
 
 of what seems to be an ineffectual effort on the part of 
 First Menstruation. ^.^ , ,.,.„,, „! i ^ 
 
 JNature to begin this function. Ihese attacks may be 
 
 accompanied by a more or less colicky pain in the lower part of the 
 abdomen, by distention of the bowels with gas, by aching pains in the 
 back and thighs, and by a certain amount of mucus discharge from the 
 vagina. At other times these attacks are of a nervous character and pre- 
 sent symptoms of an indelinite nature. The true significance of the at- 
 tacks may not be suspected until it is noticed that they disappear when 
 normal menstruation is regularly instituted. 
 
 Every child should receive at this period of life such care and advice 
 that she may be saved from the two extremes of excessive solicitude on 
 
 the one hand and of neglectful unconcern on the other. 
 Care of Young o i ^ i . . ^' . j- ,i • i 
 
 CI 't P h -t ^"f'h careful oversight is as necessary tor those girls 
 
 . M'ho pass through this transition period without special 
 symptoms as for those others who suffer from the various phases of phys- 
 ical and nervous disorders already referred to. No child is old enough 
 to menstruate who is too young to be told why she does so and what it 
 means. To instruct such a child in a right manner is perhaps the most 
 difficult task which is demanded of every mother. The child must be 
 made to feel that the event is not extraordinary, but that it is a quite 
 natural and normal function of the body. She must be instructed con- 
 
728 DISEASES OF WOMEN AND MIDWIFERY. 
 
 eerning tlie periodicity, the cliarat'ter, the auioimr. the duratien, and 
 the siguilieanee of the inenstnial tlow. Above all, she must be fore- 
 warned of tlie coming of the first menstruation. This much she must 
 know, but there are subjects in regard to wliich slie should not be in- 
 structed. It, is unwise for any child to get a preconceived idea that men- 
 struation is a jxiinful disease and much to be di-eaded. The widespread 
 mode of speech by which menstruation is designated a state of '' being 
 unwell"' is at best an unfortunate one. The child about to menstruate 
 should not be told that the e.\}>ected event may be painful, or that there 
 nuiy be any disagreeable accompaniment whatever. !She should never be 
 nagged at with questions as to her feelings, as to her head, and especially 
 not as to her nerves. Such anxious questioning will only increase any 
 natural tendency to nervousness or to hysterical symptoms that may be 
 present, and will bring about the condition it is intended to overcome. If 
 the particular individual is to be a sufferer from any of the disorders of 
 menstruation, the symptoms will appear of themselves only too soon, and 
 they can be treated best as they arise. To sum up, it may be stated that 
 girls at the age of approachmg iniherty slioxddhe instructed in the out- 
 lines of the j^hysiologij of their sexual fimctions, and shoidd he left to 
 learn hy experience^ if need he^ all pathological facts on the same siihject. 
 
 It is important that such a girl keep quiet for twenty-four or thirty-six 
 hours every time menstruation begins, at least during the first tvpo years 
 after its onset. It is really essential that the habit of regularity in this 
 function be established as early as possible, and nothing assists so much 
 to this end as careful rest and quiet during the first days of each monthly 
 jjeriod. After the periods have begun to recur with regularity and are 
 firmly established in their monthly hal)it, it is possible and right to allow 
 greater freedom to those girls who do not suifer pain ; but even they 
 should be more quiet than at other times. AVomen who must work may 
 continue to do so, but slionld curtail unnecessary physical exercise, and 
 not lose sleep and rest for mere recreation. 
 
 The fluid which is discharged from the genital tract in normal men- 
 struation is blood mixed with the mucous secretion of the vagina. At the 
 outset it is merely stained pink, but rapidly becomes 
 
 ,, , ,. dark blood-red, and finally, as it becomes less in amount, 
 
 3Ienstr nation. . 
 
 either grows paler or becomes dark and almost black. 
 This discharge has a peculiar odoui*, due to the presence of certain acids, 
 the products of a fermentative action. Menstrual blood remains fluid 
 and viscid, and does not clot as ordinary blood does, except it be retained 
 in the uterus for some length of time. The coagulation is hindered 
 normally by the admixture of the acid mucus of the vagina. The dura- 
 tion of the flow varies in diiferent women from one to eight days, and 
 the amount lost depends also in great measure upon the individual ; an 
 
NC>RMAL MENSTRUATION. Y29 
 
 average would 1)C three or four ounces for the whole period. The flow 
 begins, in most cases, rather suddenly, increases for one day, and after 
 remaining stationary at its height for two days it finally ceases gradually. 
 During these days tliere may be a slight swelling and itching of the ex- 
 ternal organs. The breasts also may become tender, hard, and swollen, 
 and may secrete a drop or two of fluid. The nipple may become dis- 
 tinctly darker in colour. Certain women never have any feelings of dis- 
 comfort whatever during their menstrual periods, but the majority of 
 individuals suffer during the first days of each epoch from a feeling of 
 weight and heat in the lower abdomen and of general aching in the back 
 and thighs. There is also a varying degree of nervous irritability and of 
 mental depression. The body temperature will be found elevated a frac- 
 tion of a degree during the menstrual flow, and the pulse is often quick- 
 ened. A number of nervous sym^Dtoms may present themselves, such as 
 headache, dizziness, chilly feelings, neuralgic jmins, palpitation, and fre- 
 quent desire to empty the bladder and rectum. Abdominal symptoms of 
 colic, of gaseous distention, of intestinal gurgling, of vomiting, and of 
 diarrhoea may occur. The presence of any combination of these various 
 symptoms is indicative of a general reflex irritability, and not of any 
 pathological process w^ith organic lesion. Such cases of slight degree 
 must still be classified as normal, although it is difficult to draw the line 
 where the diseased process begins. 
 
 These discomforts of menstruation are most marked in women who 
 have not borne children, although exceptionally they continue through 
 the whole period of menstrual activity. The manifestations of normal 
 menstruation may be altered to such a degree that the existing condition 
 may be considered as morbid or diseased. 
 
 The attendant symptoms referable to the nervous system may be 
 exaggerated, and each recurring period be associated with an attack of 
 true hysteria. Hysteria is a peculiar functional disease 
 of the higher brain centres, resulting in a lack of con- 
 trol of the mind and body, and accompanied by any of the possible de- 
 rangements of the physiological functions of the body. Hysteria is not 
 essentially connected with the generative organs, but is the resnlt of some 
 irritation either from within or from without the body acting on a weak- 
 ened nervous system. The hysteria of menstruation differs in no respect 
 from that induced by other kinds of irritation. Its manifestations are so 
 numerous that it is impossible to give any adequate idea of them within 
 the scope of this article. It should be remembered, however, that hys- 
 teria is a real disease, and that the sufferer is irresponsible and is not 
 feigning, however much certain symptoms may resemble an outbreak of 
 bad temper, or seem to be the results of a morbid desire for sympathj- or 
 of selfishness. 
 
730 DISEASES OF WOMEN AND MIDWIFERY. 
 
 Another disorder of menstruation is an increase in the pain, and this 
 is not uncommon in women who have been childless. The " normal " 
 pain of menstruation is usually of a neuralgic nature, 
 and precedes the establishment of the How or acectni- 
 panies its onset. The pain is due, in other cases, to an obstruction to tlie 
 escape of the menstrual discharge from the uterus. A cramplike, pain- 
 ful contraction of the uterus is induced by this anatomical condition. 
 The obstruction may be due to a congenital or acquired narrowing of the 
 canal in the neck of the womb, or to a clotted and solid condition in the 
 blood which has to pass through an otherwise sufficiently patulous open- 
 ing. This pain of obstruction may be very severe and continuous, but 
 usually recurs with exacerbations, and is at times uf the iiatui-e of labour 
 pains ; it is in reality due to the same cause. 
 
 The menstrual discharge may change its character as to amount, as to 
 its physical qualities, or as to its regular periodicity, and such change may 
 be sufficiently marked to constitute a diseased condition. The menstrual 
 blood may become clotted before it leaves tlie uterus, either because it is 
 retained in that organ too long or because there is too much of it. This 
 condition in itself is, as just mentioned, of most consequence as an ex- 
 citer of pain. 
 
 The mucous membrane of the uterus may be shed at these times in 
 
 large pieces instead of degenerating into microscopic debris. These more 
 
 or less perfect casts of the uterus are discharged with 
 
 ,r , svmptoms of fever, abdominal pain, hysterical attacks. 
 
 Dysmenorrhea. ^ ' _ ' _ . . 
 
 and, while the membrane itself is being discharged, of 
 severe expulsive pains. The accompanying How of blood is usually 
 slight, and the periods in these cases recur irregularly. 
 
 At times there will be a discharge of dark-brownish fluid instead of 
 the normal flow of blood. This change may be of no significance what- 
 ever, or it may be associated with some of the acute in- 
 Change of Colour, j. ,. j. . , , . . ,. tx . 
 
 tectious levers or With chronic wasting diseases. Vari- 
 ations in the periodicity and in the amount of discharge are related closely 
 to each other and in a direct ratio : the more frequent the flow, the 
 greater the amount. Those causes which act to diminish the amount of 
 discharge act also to make the same a less frequent occurrence. 
 
 Diminution or cessation of menstruation may be due to any general 
 disease which leads to an impoverished condition of the blood. Perhaps 
 
 the best example of such a disease is tuberculosis in any 
 
 Absmceof or Scanty j. . ^ • c ^ y c mi ,• i • i 'i 
 
 Menstruation ^"^ mamtold Tornis. ilie essential anaemias lead 
 
 to the same result; the most common form of antemia 
 
 is that which occurs in young women, and which leads particularly to 
 
 omissions and diminution of the menstrual flow. Exposure to wet and 
 
 cold and great mental excitement of any kind may cause a single omission 
 
MENSTRUAL DISORDERS. 731 
 
 of this function, but the diseases just mentioned cause prolonged cessation 
 or a much-diminished iiow at hing intervals. There is a popular belief 
 that tardy menstruation is a very serious condition, but as a rule it is easily 
 treated by general measures directed to the cause, and demands promj^t 
 attention, but is not a sufficient ground for the worry so often given to it. 
 The failure of this function to appear at the time of puberty may be due 
 to congenital malformation of the genital organs. Pregnancy and lacta- 
 tion act as a physiological check to the function of menstruation, which is 
 not re-established until after lactation has been continued for at least six 
 months. 
 
 Excessive increase in the amonnt of the menstrual flow is usually as- 
 sociated with too long duration of that flow, and often also with its too 
 frequent recurrence. These allied conditions may be 
 Me stri t' *^'^® ^^ local causes, or to diseases of other organs which 
 
 lead to pelvic congestion. Chronic disease of the 
 heart, liver, kidney, and intestinal tract may lead to such a series of 
 symptoms. 
 
 An unusual irregularity of menstruation is presented in a few women 
 
 who have a periodic bleeding from some part of the body other than 
 
 the uterus. Usually there is a simultaneous sliglit 
 
 ,^ , ,. "show" from the vagina and a larger haemorrhage 
 
 from the vicarious site. The nose and air passages are 
 
 the most frequent part of the body to be thus aifected. 
 
 All of the serious complications of menstruation demand medical care, 
 and it is beyond our present province to give minute details of such meas- 
 ures. I^one of these disorders should be allowed to 
 
 ^'!, ^ , continue indefinitely without some attempt beins: made 
 of 31enstrual -' i i . i 
 
 Disorders. ^^ correct them. Temporary delay in the onset, or 
 
 momentary excess, or diminution in the amount of the 
 flow, or a single attack of nervous symptoms, usually absent, can be the 
 result of temporary causes, and need not demand skilled advice. 
 
 Perhaps the cases which will permit the least delay are those of the 
 non-appearance of the flow in young girls in whom attacks of menstrual 
 pain and distress recur at more or less i-egular intervals and with steadily 
 increasing severity, and in whom there are no external signs of menstru- 
 ation. This usually means that there is some congenital deformity result- 
 ing in a retention of the discharges. It is fortunately a rare condition, but 
 it is one needing prompt surgical treatment. 
 
 It is wise for almost all women to remain quiet 
 Simple Rules for j_i i • . i i i . i t i i 
 
 all Wo every month durmg the hours when the discharge be- 
 
 gins. It is not necessary for all to go to bed, bnt a 
 certain degree of rest in the house, and possibly the application of con- 
 tinued heat to the abdomen, u-ill shorten the period of relaxation, and 
 
732 DISEASES OF WOMEN AND MIDWIFERY. 
 
 render them more able to g;o about during the latter part of the men- 
 strual time. It is unneeessarv for most women to restrict themselves to 
 a fluid diet at these times. Frii'd foiuls and highly spiced foods are dis- 
 tinctly ditficult of digestion at any time, and should be avoided now. 
 The use of wine or other forms of alcohol is in general to be discouraged. 
 
 Citv-bred ijirls are of a moi-e nervous temjierament than country-bred 
 girls, and are more a])t to ])resent the severe types of menstrual disturb- 
 ance. One reason for this is the dilference in their mode of life. Exer- 
 eise — and out-of-door exercise is the best — is an essential element in the 
 life of most women, and it is one that is neglected. The muscles of the 
 shoulders, arms, and upper part of the trunk seldom receive any attention 
 in this regard, wliereas the amount of walking and stair-climbing of the 
 regular routine of life exercises the legs sufficiently without special care 
 beiuff necessarv. Nowadays there are gymnasia and various classes for 
 the cultivation of grace and exercise enough, but it takes time and trouble 
 to follow them systematically. Every girl who makes her own bed and 
 who sweeps and dusts her own room is a healthier woman because of 
 this daily exercise than her sister who has no such habit. A good and 
 efficient substitute for sweeping, etc., will be furnished by the routine 
 use of a pair of wooden dumb-bells for five minutes each morning and 
 evening. Anything which improves the general health will lessen the 
 pains and discomforts of menstruation ; regular exercise is such a thing. 
 A further necessary requirement for continued good health and for nor- 
 mal menstrual function is a regular daily movement of the bowels. This 
 can be secured best by establishing a habit of attending to this need at a 
 definite hour each day. Once established, such a habit becomes a second 
 nature. 
 
 During the monthly periods all energetic exercises should cease ; this 
 applies especially to liorseback riding, long drives, tennis, bicycling, and 
 dancing. The same rule of abstinence applies to prolonged standing, as 
 in sight-seeing of all kinds, the inspection of picture galleries, the being 
 fitted at a dressmaker's, etc. Exposure to cold and wet, even of the feet 
 alone, is to be avoided at these ])eriods, when the whole system is relaxed, 
 and the slight catarrhal inflammations of the nose, bronchial tubes, and 
 throat are more likely to follow than they are at other times. A possible 
 result of such imprudence as already mentioned is the sudden cessation 
 of the monthly flow. If such a stoppage occurs, it may return after a 
 series of hot baths, hot mustard foot-baths, rest in bed, and hot applica- 
 tions to the abdomen. If it does not return within a few hours it proba- 
 bly will not do so until the next period is due. Even such a result is not 
 necessarily a matter for alarm or worry. 
 
 The regular treatment of those women who suffer each month from 
 the lesser degrees of menstrual disorder is to be carried out on the same 
 
THE CHANGE OF LIFE. 733 
 
 lines as already detailed — rest and ({uiet in bed, continuous dry heat to 
 
 the abdomen, plain, nourishing food, and at the time of onset hot- baths 
 
 to the whole body or to the feet alone. Further indications for treatment 
 
 may arise, but they will depend on the individual case and sliould be 
 
 referred to the family physician. 
 
 The childbearing period ends in the latter half of the fifth decade of 
 
 life — usually between the forty-fifth and fiftieth year. In general, the 
 
 earlier it begins the longer it lasts. Menstruation 
 Menopause. ,, t n 1 . i , 
 
 usually ceases gradually, the periods become shorter 
 
 and the flow less, then the intervals lengthen, and finally it stops, or it 
 may stop abruptly. This period of the climacteric, or change of life, 
 may be characterized by no other symptoms. In certain women, how- 
 ever, these last few periods will be attended by an excessive loss of blood. 
 This haemorrhage may be so large that the individual becomes anaemic 
 and may remain so for some time in spite of treatment. In other cases the 
 women grow fat ; tliey sweat a good deal ; they may have intestinal or gas- 
 tric indigestion, with water brash and formation of gaseous products, head- 
 aches, dizziness, and peculiar feelings of heat and cold in the upper part 
 of the body — the so-called " hot flashes." These symptoms are usually of 
 nervous origin and may require medical treatment. There is a widespread 
 and popular idea that this time of life is particularly dangerous to women, 
 whereas with care the distressing symptoms will regularly disappear. 
 
 The menopause occurs at an age when nearly every woman becomes 
 careless about daily exercise and about an active mode of life. If she 
 continues to eat she becomes fat and her liver becomes torpid. Many of 
 the symptoms of the climacteric are really due to so-called functional dis- 
 turbance of the liver. In the worst cases the arteries degenerate and gout 
 and chronic rheumatism develop. 
 
 Such cases must be treated by meeting the indications of special dis- 
 eases, and, in addition, by general measures directed to re-establish a 
 healthy manner of living. 
 
 A moderate, easily digestible diet, massage, and necessary exercise 
 will assist greatly. Above all, an overtaxing of the strength by excessive 
 social duties and mental work must be avoided. 
 
7;Ji DISEASES OF WOMEN AND MIDWIFERY. 
 
 CllArTKIi II. 
 
 PREGXAXCY. 
 
 WiiKNKVER anovum boeoiues iin[)iviiiiated it begins to grow and to 
 
 develop, in consequence of this development the special organs of the 
 
 female become modified so as to supply the necessary 
 
 . ' nourishment to tlie growing ovum, ilie i>rocess thus 
 
 ut an Ovum. ... . . ,. 
 
 begun can be divided into certain perioda : First, that 
 
 during which the ovum remains within the body of its mother and is 
 
 nourished directly from her blood ; second, that during whicli the fully 
 
 developed oil'spring is separated from its mother and begins to lead an 
 
 individual existence ; and third, that period during which the child, 
 
 though separated from its mother, is nevertheless dependent on her for 
 
 food in the form of milk. The first period is known as pregnancy, or 
 
 gestation, the second as parturition, or labour, and the third as the 
 
 period of lactation. 
 
 The changes which begin to develop in the body of a woman as soon 
 
 as pregnancy has commenced are at first slight and can not be detected. 
 
 Certain subjective feelings on the ])art of the woman 
 
 EL. ■ apj)ear more or less early and will lead to a })resumptioii 
 
 in favour of the presence of pregnancy. No one of these 
 
 subjective signs and no combination of them without the addition of some 
 
 of the objective signs to be described below can raise the question of even 
 
 a probability of the existence of pregnancy. All of these subjective 
 
 symptoms may be caused by other conditions. 
 
 The symptoms of this class may be referred to the digestive apparatus 
 and to the nervous system. The .most common deviation from normal 
 
 ,. . „. digestion is a diminution of functions characterized by 
 
 Subjective Signs. i p • i i . . . ' 
 
 a loss 01 appetite, and resulting in consequence in a cer- 
 tain amount of paleness and of loss of flesh. Added to this there may 
 be certain perverted desires for unusual food, also nausea and vomiting. 
 The less common change in digestion during the early months is an in- 
 creased appetite, improved circulation, heightened colour in the lips and 
 cheeks, and gain in flesh. As a rule, the bowels become constipated ; 
 rarely there is diarrhoea. The absence of any or all of these " symptoms " 
 is no contra-indication of the presence of pregnancy. 
 
 The nausea and vomiting of pregnancy are fairly characteristic. They 
 are most marked in the morning and are usually confined to that time of 
 day. These are symptoms of the early weeks of pregnancy and disappear 
 during the third or fourth month. Vomiting may become so constant and 
 severe that it will demand active treatment. The sliirhter cases will be 
 
SIGNS OF PREGNANCY. 735 
 
 controlled by careful dieting, ]>y avoiding richly seasoned, fatty, and 
 fried foods, and hot breads. It is wise also to eat something before ris- 
 ing, and to remain in bed for two hours later than the usual rising hour. 
 This early meal should be a very simple one — cocf;a, coffee, or milk, and 
 bread which is not freshly baked should suffice. The subsequent meals of 
 the day may usually be enjoyed without many restrictions. A multitude 
 of drugs have been suggested, and certain of them are of benefit, but they 
 should be selected to suit each individual only under professional advice. 
 
 The functional disturbances of the nervous system are due to an in- 
 creased irritability of the nervous centres. Feelings of heat referred to 
 the skin, of indefinite weakness, and of irresistible sleepiness, are not 
 uncommon. Fanciful likes and dislikes both for people and for inani- 
 mate objects are commonly known as the " longings " of pregnancy. The 
 character of a pregnant woman is often essentially changed. Sadness 
 rather than joy is apt to be the keynote of the thoughts of a prospective 
 mother. 
 
 The first objective sign that will attract the notice of the pregnant 
 
 woman will be the cessation of her monthly periods. This symptom, 
 
 following the recent development of any of the subjec- 
 
 Objective Signs of ^jyg gjgns just described, and occurring in a married 
 
 ,, ,. ^ ' woman who has been previously of a ree-ular menstrual 
 Cessation of , . ^ i . ^' . 
 
 Menstruation. habit, raises at once the probability of the existence of 
 
 pregnancy. In the case of women who have always 
 been irregular in this function a single omission, even with all the sub- 
 jective signs, is of no diagnostic value at all. It is also true that a preg- 
 nancy may exist and a monthly discharge be repeated for several regular 
 periods. This is a very exceptional occurrence, however. The cessation 
 of menstruation does not occur as a sign of pregnancy when pregnancy 
 begins while the woman is nursing a child,' because as a rule the men- 
 strual function is not re-established until after lactation is ended. During 
 the second month of gestation the evidences of its existence begin to mul- 
 tiply, and by the time the second menstrual period is skipped it would be 
 often possible for a skilled examiner to ascertain the probable presence 
 or absence of pregnancy. These early changes in the generative organs 
 would not be apparent to the ]fij observer, including the pregnant woman 
 herself. 
 
 The symptom next in order to attract the attention of the pregnant 
 woman is a series of changes in the breasts. The breasts begin to be 
 
 prepared for their functional activity as early as the 
 Chaiiqes in the , ,-, ^ iji-ji*^ .• 
 
 Breasts second month of pregnancy, and this development is 
 
 progressive up to the time of labour. The breasts in- 
 crease in size and become more or less tender to pressure. The swelling 
 mav stretch the skin to such an extent that certain markings occur, called 
 
736 DISEASES OF WOMEN AND MIDWIFERY. 
 
 striffi, similar to those on tlie aluloiuen, clescrilied hclow. Jn addition, tlie 
 subcutaneous veins etilari;e, and a few di\>i)s of a yellowish liquid, a partly 
 formed milk, may be expi-essed from the nipple. The nipj)le becomes 
 larger, more prominent, more sensitive, and darker in colour. The nipple 
 is one of the lirst places to show the dark pigmentation of the skin, here 
 called the areola, which is characteristic of the ju'cgnant condition. In ad- 
 dition to these signs certain small swellings, four to twelve in number, ap- 
 pear arranged around and near the nipple. Finally a coloration of the 
 skin is developed in a circle of varying extent about the nipple itself; the 
 ]iigment is arranged in a series of little circles about an eighth of an inch 
 in diameter around the openings of the sweat glaiids. The outer edge of 
 this secondary areola fades olf gradually into the normal skin. These 
 breast signs vary much in different women, are more niarked in a first 
 pregnancy than in subsequent ones, and the pigmentation is more marked 
 in brunettes than in blonde women. 
 
 The digestive disturbances of early pregnancy will cause a temporary 
 distention of the abdomen by gaseous dyspepsia, but a permanent in- 
 crease in the size of the abdomen does not occur until 
 ... al)ont the third month of pregnancy. From this period 
 
 on to the end of gestation the size of the abdomen in- 
 creases gradually in consequence of the growth of the uterus and its con- 
 tents. The g-rowins: uterus niav be felt as a hard, round swelliu"; in the 
 lower part of the abdomen, which follows a certain definite rate of pro- 
 gressive growth, and is thus one of the most imjiortant signs of preg- 
 nancy. Enlargements of the uterus from other causes will never follow 
 the same rate of increase. The landmarks by which this regular growth 
 may be controlled are indicated below in the table. 
 
 The stri.e on the abdomen due to the stretching of the skin appear as 
 slightly depressed lines of a reddish-brown colour. They may be limited 
 to the anterior abdominal wall below the navel, or they may be generally 
 distributed and very numerous. In consequence of their mode of origin, 
 they are most marked toward the close of pregnancy. These marks are 
 permanent, and remain after the birth of the child as white, scar-like lines. 
 New striae with the characteristic colour may develop during any preg- 
 nancy subsequent to the first. The navel or umbilicus undergoes certain 
 changes in consequence of the abdominal distention. The usual depres- 
 sion is gradually effaced, becomes level with the surrounding skin at the 
 seventh month of pregnancy, and finally projects to a greater or less ex- 
 tent above the surrounding surface of the abdomen. Finally, the skin of 
 the abdomen shares in the deposit of pigment, which has been described 
 above as occurring over the mammary glands. This pigmentation is 
 most marked along the central vertical line and over the u])per and inner 
 aspect of the thighs. 
 
QUICKENING AND FCETAL HEART-BEAT. 787 
 
 No one of the symptoms already described is in itself of any positive 
 
 value, although the simultaneous existence of many of these signs adds to 
 
 the importance of each. The only certain signs of 
 
 er am igns oj pj-yo-iiancy are referable to the faitus itself. And of 
 FregnancAj. i o ./ 
 
 these only two are absolutely free from the possibility 
 
 of error or mistake at the hands even of a skilled observer. 
 
 The recognition by the sense of touch of a portion of the body of an 
 unborn child and the hearing of the foetal heart-beat can occur only dur- 
 ing the examination of a pregnant woman. The heart-beat of the fcjetus 
 is heard usually just below and to the left of the umbilicus in the central 
 portion of the abdomen ; it resembles the regular tick, tick of a watch 
 in its rhythm and averages about 140 beats to the minute. 
 
 The body and limbs of a child still in the uterus of its mother can be 
 felt through the abdominal wall as soon as the uterus and its contents 
 have grown to a sufficient size ; this is usually the case during the sixth 
 month of pregnancy. The position of the child can be accurately mapped 
 out by an educated touch, but probably an untrained hand would discover 
 little more than the movements of the contained mass. These movements 
 of the foetus are perceptible to the mother some time before they can be 
 felt upon the abdomen. This phenomenon is known as " quickening," 
 and occurs during the latter part of the fifth month. 
 
 The growth of the uterus encroaches eventually upon the regions usu- 
 ally occupied by other organs. Certain symptoms referable to these 
 organs result from this mechanical interference with 
 
 Mechanical ^j^^-^, functions. The lower bowel and the bladder are 
 Interference with .,,,,, _,- i i 
 
 Various Organs. pi'Gssed upon, and there result an irritability of the latter 
 
 and frequent desire to pass water ; also a mechanical 
 obstruction to the filling of the rectum, and a distinctly greater degree of 
 constipation than characterized the earlier months of pregnancy. These 
 bowel and bladder symptoms are greatest during the last weeks of preg- 
 nancy. 
 
 The enlargement of the abdomen restricts secondarily the capacity of 
 the chest, and in consequence the breathing becomes more or less difficult 
 as the pregnancy draws to a close. Finally, the circulation of the blood is 
 interfered with. First, direct pressure on the veins returning from the 
 lower extremities causes swelling of the feet and legs and dilatation of the 
 veins, especially those of the pelvis. When the veins of the rectum are 
 involved they swell up and form piles. And, secondly, an increase in the 
 amount of tissue to be supplied with blood causes a compensatory en- 
 largement of the heart, which is of good import and gives no symptoms. 
 
 It may not be possible to determine the period of pregnancy at which 
 any particular woman is. It is important to do so as accurately as may 
 be because of its bearing on the date of probable confinement. Most 
 49 
 
rss 
 
 DISEASES OF WOMEN AND MIDWIFERY. 
 
 Ptriod of 
 Pregnancy. 
 
 rules for detorinining this future but important day are based on the 
 estimate that the average duration of pregnancy is between two hundred 
 and seventy and two hundred and eighty days. The 
 two tixed dates from which reckoning may l)e made are 
 the last menstrual period and the date of (piickening ; 
 of these, the first is the more trustworthy. The best rule is the follow- 
 \n<y : Add seven days to the date of the first day of the last menstruation 
 and count back three months. The date thus fixed is the probable date 
 of delivery. Reckoning from the date of quickening is a very uncertain 
 method, and only of value when taken into account with the other facts 
 which can be oi>tained by examination of the patient. The following 
 table presents the symptoms which have just been detailed arranged in 
 the order of their development. It may be of use in determining the 
 period of pregnane}' : 
 
 Month of gestation. 
 First and second. 
 Third and fourth. 
 
 Fifth and sixth. 
 
 Height of uterus. 
 
 Seventh and 
 
 ei'^hth. 
 
 First two weeks 
 of ninth. 
 
 Second two weeks 
 of ninth. 
 
 , At end of second month, 
 at level of pubic bone. 
 
 At end of third month, 
 easily palpable in low- 
 er abiloinen ; at end 
 of fourth, half way 
 between pubes and 
 navel. 
 
 At end of fifth month, 
 an inch below navel ; 
 at end of sixth, an 
 inch above navel. 
 
 At end of seventh 
 month, three fiiiijer- 
 breadths above navel ; 
 at end of eighth, five 
 fingers above navel 
 inclined to right. 
 
 Under false ribs of right 
 side and to end of 
 sternum. 
 
 Lower than last. 
 
 Maternal changes. 
 
 Signs of fcetal devel- 
 opment. 
 
 Suppression of menses, 
 swelling of breasts, nau- 
 sea, vomiting, sleepiness. 
 
 More marked swelling of 
 breasts, slight pigmenta- 
 tion and enlargement of 
 nipple. 
 
 Disappearance of func- 
 tional disturbances, 
 darker areola of breast, 
 secondary areola of 
 breast, enlarged tuber- 
 cles of breast, pigmenta- 
 tion of abdomen, level- 
 ling of navel. 
 
 Striae appear on abdomen 
 and on breasts, navel 
 level, secretion of colos- 
 trum in breast, swelling 
 of feet and legs in cer- 
 tain cases. 
 
 Embarrassment of respi- 
 ration ; vomiting may 
 reappear ; all others in- 
 crease. 
 
 More vomiting, piles, 
 swelling of veins of legs, 
 irritation of bladder, 
 trouble in walking, pain 
 in back. 
 
 None. 
 
 None. 
 
 Quickening before 
 end of fifth 
 month ; fcetal 
 heart heard dur- 
 ing sixth month. 
 
 Above continue and 
 increase, especial- 
 ly fcetal move- 
 ment. 
 
 Same as last. 
 
 Same as last. 
 
 The various receptive and eliminative apparatuses of a woman must 
 accomplish during pregnancy double physiological work : thus the diges- 
 tive system must continue to prepare enough nutriment for the future 
 mother, and in addition must furnish the proper sustenance for her 
 
HYGIENE DURING PREGNANCY. 731^ 
 
 offspring ; the lungs must absorb more oxygen and give off more carbonic 
 
 acid than before; tiie skin and kidneys must remove the waste products 
 
 resulting both from the energy of the mother and also 
 
 ,, ,, from that of the child ; and the blood must carry the 
 
 the Organs. _ ' -^ 
 
 increased supplies needed for growth, and also the in- 
 creased amount of refuse materials resulting from that growth. It is es- 
 sential, therefore, that the pregnant woman lead a healthful, quiet life, and 
 that she be more careful than ordinary about matters of general hygiene. 
 This general rule is of most particular application during the latter 
 months of pregnancy when the strain on the woman's organs is at its 
 height. 
 
 Such a woman should live in sunny, " well-ventilated apartments, 
 should not frequent crowded assemblies, or remain for any length of time 
 in air overloaded with carbonic-acid gas. If she is a 
 working woman she should avoid work which exposes 
 her to unhygienic surroundings. In general, she should live in sanitary 
 surroundings, and if she do not, the penalties in loss of health will increase 
 after she becomes pregnant. 
 
 The clothing should be of such a nature that it will not press upon 
 and displace the growing uterus or the enlarging breasts. The enlarge- 
 . 'ine7it of the ahdomen can not he prevented., and a con- 
 
 siderable aTROunt of harm can he done hy futile attempts 
 to disguise the facts of the case as long as may he. Whenever the waist- 
 bands of the skirts or the bust measure of any garment become tight and 
 cause distress, they must be loosened at once, and this process of gradual 
 enlargement must be continued to the end of the nine months. The 
 question of corsets is a much-disputed one, but is simply solved. The 
 same rule as already laid down for clothing in general applies also to the 
 corset. If any corset is uncomfortable or painful at any time it is doing 
 harm at that moment. If it sits easily and does not press upon the breasts 
 or uterus to check their growth, such a corset is not more harmful than a 
 similar pair in the non-pregnant condition. The final question as to 
 whether any particular garment is exerting harmful or painful pressure 
 at any time can not always be left for decision to the patient herself. 
 
 The clothing should protect against the weather, and be warm in win- 
 ter and cool in summer. As pregnancy advances, walking becomes 
 more and more a burden, so that shoes should be selected with low, broad 
 heels, which will lighten the task and will check a tendency to slip and 
 stumble. The stockings should be held up in place by strap garters at- 
 tached to the corsets above or to a shoulder brace. Elastic clasp garters 
 increase the obstruction to the circulation in the veins of the legs, and un- 
 doubtedly increase the tendency to varicose veins during the last months 
 of pregnancy. 
 
740 DISEASE!:? OF WOMEN AND MIDWIFERY. 
 
 The food of the proijfnant woman should be nuti-itioiis and, as a rule, 
 not excessive. In general, the i^artieular choice niav be left to the in- 
 dividual, and anything may be eaten which can be di- 
 gested Mithout discomfort. AVhatever may have been 
 the habit uf the non-jn'egnant woman as regards the use of wine, it is an 
 undoubted fact that alcohol in any form is. dui'ing the latter months of 
 pregnancy, an irritant to the kidneys, and distinctly contra-indicated, 
 whereas alcohol in the beginning of pregnancy is often an aid to the 
 treatment of the irritable condition of the stomach so connnon at that 
 time. 
 
 Exercise should l)e taken at regular daily intervals and out of doors. 
 
 The amount will vary according to the individual. The kind of exercise 
 
 will depend on the power of endurance of the woman 
 
 J"^ VB I'C I SP 
 
 in question. AYalking is undoubtedly the best and most 
 
 generally available form of out-of-door activity. Driving can be indulged 
 
 in, though long drives are very fatiguing. Bicycling, swimming, riding, 
 
 dancing, tennis, and similar violent exercises are not to be indulged in, not 
 
 always because dangerous in themselves for healthy pregnant women, 
 
 but because such exercises carry with them a liability to severe jarring 
 
 and jolting shocks from the many accidents which may occur. Similar 
 
 shocks and a consequent interruption of pregnancy can result from woi'k 
 
 of a too violent kind ; work on the sewins: machine is of this class and is 
 
 to be avoided. 
 
 Travelling by railway adds a risk from the frecpiently recurring shocks 
 
 of the vibrating motion of the train. This is of special moment if the 
 
 journey is prolonged or repeated at short intervals. 
 Journey.^. ;!-., , • i . . , 
 
 Ui course this danger is greater in the case of women 
 
 who have had premature interruption of the course of previous preg- 
 nancies. 
 
 In regard to the taking of baths it must be said that a very scrupulous 
 care of the skin is more necessary to the health of the pregnant woman 
 
 than to that of any other individual. Whatever may 
 
 Bafhing and Care , , ^^ -i ■,'•, r • ,i ■ i • r 
 
 of the Genitals '^ '^" habit of any woman m the taking of 
 
 baths, whether daily or less often, whether hot or cold, 
 
 this may be continued when she is pregnant unless some complication 
 
 arise to prevent. 
 
 The external genitals should be washed daily with clean water and a 
 clean wash cloth. The use of so-called antiseptic drugs and lotions can 
 do as much harm as good unless used for a positive indication and under 
 medical advice. Internal douches also are to be used with similar precau- 
 tions, and are neither necessary nor beneficial during the course of a nor- 
 mal pregnancy. 
 
 Much advice has been wasted in an effort to prevent trouble with the 
 
CHOICE OF PHYSICIAN AND NURSE. 741 
 
 breasts and nipples during nursing. JVfany of the proposed methods in- 
 crease the difficulty rather than diminish it. The simplest means are the 
 
 best. It is sufficient to rub the nipples gently with 
 Care of the Breasts. t , , , i i i • i ^^ r ^ ^ . • 
 
 dilute alcohol once daily alter a careiul but not vigor- 
 ous cleansing with clean water. If the nipples are retracted, the best 
 " instrument^' to draw them out is the clean fingers. In any case nothing 
 should be done until two weeks before the date of expected delivery. 
 
 There is a distinct tendency to decay of the teeth during pregnancy. 
 If any serious amount of trouble arises the teeth can be temporarily 
 
 , „ , treated with soft iillings. A thorough inspection by 
 
 Care of the Teeth, . . n i j 
 
 a dentist should be insisted upon when the patient has 
 
 regained her regular mode of life after the birth of her child. 
 
 The only drugs that might come under the head of household remedies 
 
 in the case of pregnant women are the cathartics. The milder forms of 
 
 „, , . , ,, laxatives alone should be used, and every effort should 
 
 lakmg of Drugs. . ,- ^ ■, ^ ^ -,. 
 
 be made to regulate the action oi the bowels by diet 
 
 and regimen and the cultivation of a regular habit. 
 
 CIIAPTEK III. 
 PREPARATION FOR LABOUR. 
 
 The question of employing a physician or a midwife is hardly to be 
 considered under the conditions prevailing in the United States. The 
 so-called raidwives of large cities in the United States are in great part an 
 immigration from Europe, whence also the custom has been derived. 
 There are practically no American trained midwives, and those who come 
 from Europe are not of the first class as compared with the midwives of 
 the Continental cities of Europe. 
 
 The choice of a nurse is of importance, and no final choice shoxilcl he 
 
 made without consitlting the physician to he hi charge. A good obstetric 
 
 ^ nurse must be a good nurse in the broadest sense, and 
 
 The JSiurse. ,,,. , -, ,. t • ^ c ^ • y 
 
 should devote herself to this class ot cases exclusively. 
 
 She should abstain, at all events, from the care of any case of contagious 
 disease for a considerable period before taking charge of a woman in or 
 after confinement. The nurse should be engaged for some time in ad- 
 vance to come to the patient at her expected lying-in. 
 
 The physician should be informed also at a considerable interval be- 
 forehand of his expected duty, in order that he may keep an oversight 
 of the last months of pregnancy. Three methods of examination and 
 
742 DISEASES OF WOMEN AND MIDWIFERY. 
 
 tlirce causes for watchfulness on tlie part of the physician arc indicated 
 during this period of pregnancy, and a woman shouki neither worry 
 about nor be shocked at such attention from her medi- 
 The Physician: ^ul adviser. 
 
 Jlei noils of , IT- 1 r 11 • 
 
 Kramiuation. Ihese proiiliyhictic measures are the following: 
 
 I. In order that a careful estimate of the develop- 
 ment and size of the bony jielvis may be arrived at, it is necessary that an 
 internal examination be made prior to the seventh month of pregnancy. 
 
 II. In order that labour may not begin while the foetus is presenting 
 in some abnormal position, it is necessary that frequent external abdomi- 
 nal examinations be made to ascertain the exact position of the fti^tus. 
 
 III. Finally, it is essential that the ui'ine of a pregnant woman be 
 analyzed at regular intervals during the last live months of this period. 
 These intervals may be fortnightly at first, and weekly during the last six 
 weeks. These analyses are demanded in order that inflammation of the 
 kidneys, which is the most insidious of all pathological complications, 
 may be detected as early as possible, and the proper precautions be 
 taken. 
 
 Every physician will have individual preferences as to the surgical 
 
 appliances of Mhicli his patient should lay in a stock before an expected 
 
 confinement. A number of dealers in surgical dressings 
 
 . ,". in New York prepare so-called labour boxes, which are 
 
 Appliances. ^ i _ ' _ 
 
 supposed to contain all that may be necessary during 
 labour and the lying-in period. The following list, taken from such a 
 box, will give a very good idea of them all : Two sterilized bed sheets 
 sanitary pads) ; four dozen sterilized vulva pads (sanitary napkins); one 
 four-quart douche bag, with glass nozzle; one zinc douche pan; two 
 sterilized mull binders, heavy ; five yards sterilized gauze ; one yard ten- 
 per-cent. iodoform gauze ; two three-inch heavy mull bandages, sterilized ; 
 one pound sterilized absorbent cotton ; one sterilized nailbrush ; two 
 twelve-inch papier-mache basins ; rubber sheeting, one and a quarter yard 
 by two yards ; rubber sheeting, one and a quarter yard square, rubber on 
 both sides ; safety pins ; two ounces carbolized vaseline ; one pint of satu- 
 rated solution of boric acid; four ounces starch powder; four ounces 
 fifty-per-cent. carbolic-acid solution ; two ounces green-soap solution ; two 
 one-hundred-gramme bottles chloroform ; one ounce fluid extract of 
 ergot; one small bottle of bichloride-of-mercnry tal)lets; one bottle steril- 
 ized tape. 
 
 The first two articles on this list may be homemade; the others must 
 be obtained at some shop. The bed sheet is a gauze or cheese cloth bag 
 and contains non-absorbent cotton batting; the finished pad is about one 
 yard square and two inches thick. The vulva pads are twelve inches 
 long, and are either made of sterilized gauze folded in six thicknesses, or 
 
THE LABOUR ROOM. 743 
 
 of absorbent cotton contained in a folded piece of such gauze. See Nurn- 
 iiKj the Sicl', Chapter XII. 
 
 This list may be modified, expanded, or contracted at the discretion of 
 any practitioner. In addition to tiiese obstetric appliances it is hardly 
 necessarj^ to remind a young mother that her infant will need clothes as 
 soon as born, and tliat they must be prepared beforehand. 
 
 A quiet, sunny, comfortable room should be selected as the lying-in 
 and labour room. This room should be of easy access to a bathroom and 
 water-closet. The labour room should be neither a dis- 
 mantled, barn-like apartment, nor should it resemble a 
 bric-a-brac shop. It is not necessary to disinfect an ordinary bedroom 
 and try to convert it into a hospital operating room. Surgical asepsis 
 and cleanliness are necessary, but they should be limited in their strictest 
 application to the body of the patient and what comes into contact with 
 her, and not foolishly applied to household articles, room, walls, and floors. 
 The lying-in room should be bright and cheerfully furnished, with few 
 enough pieces of furniture to be easily dusted and put to rights each day, 
 and not demand too much time of the nurse to the neglect of her patient. 
 
 The "labour bed" should stand with its head to the wall, both sides 
 should be accessible, and preferably with the right side of the patient 
 when lying on her back toward the light. A single 
 bed is to be chosen if possible, although a double bed 
 can be used without any very great inconvenience. A plain table for 
 easy access to bowls of antiseptic solutions and to the obstetric dressings 
 will complete the list of necessary pieces of furniture in the lying-in 
 chamber. 
 
 The labour bed should be prepared as follows : If the spring is very 
 yielding, a board like a cutting board should be placed between the spring 
 and the mattress. A piece of rubber sheeting should be spread over the 
 mattress and should be pinned in place with safety pins at the corners. 
 A sheet should then be spread, and then a sheet called a draw sheet 
 should be folded to reach across the bed and to stretch over the middle 
 third only of the length of the bed, and should be pinned in position. 
 On this draw sheet the protective bed pad of cotton batting and gauze 
 should be placed, and the pillow and bedding to cover the patient will 
 complete the bed-making. If these special bed pads are not at hand an 
 efficient substitute may be made by folding an old sheet which has been 
 boiled. 
 
 After the bed has been prepared the articles which will be especially 
 needed at the time of labour should be arranged on the table near the bed 
 and ready for use. The basins should be filled with a solution of corro- 
 sive sublimate (bichloride of mercury), in one of a strength of 1 to 2,000 
 for the hands, in the other of a strength of 1 to 5,000 for washing and 
 
7-t4 DISEASES OF WOMEN AND MIDWIFERY. 
 
 >j)onging the woman. The nailbrush should tloat in the first -named 
 
 basin, and small wads of absorbent cotton in the second. Cut pieces of 
 
 sterilized gauze about one foot square should be coRve- 
 
 .'?^y A7 'j J nientlv near for use about the woman, and the solution 
 Articles jyeeaed. . " . . . 
 
 of boric acid, the starch powder, the vaseline, the safety 
 
 pins, the tape for the cord, the ergot, and the binder and a vulva ])ad 
 should be laid out ready for use. Finally, the douche bag should be tilled 
 with warm water about half full, and enough hot water be kept con- 
 stantly on hand to iill the bag at short notice. Enough bichloride of 
 mercury should be dissolved in a tumbler ready to be added to the water 
 in the douche bag in order to make a iinal solution of 1 to 8,0U0. One 
 of the ordinary tablets which makes a solution of 1 to 1,000 in a pint of 
 water is the necessary amount to add to a full bag, or eight pints of water. 
 
 CHAPTER lY. 
 PARTURITION. 
 
 The mechanical expulsion of the foetus is the result of a muscular act 
 on the part of the mother alone. The child is passive, and has nothing to 
 do with the act of parturition. The muscles which act to expel the child 
 are primarily the uterus, and secondarily the muscles of the abdomen. 
 
 The term " mechanism of labour" refers particularly to the manner 
 
 in which the child adapts itself to the maternal structures as it passes 
 
 through the parturient canal. The regular mechanism 
 
 . T I is that bv which the child is born head first into the 
 
 of Labour. 
 
 world, and the unusual method is that in which the legs 
 and buttocks are born first and the head last. There is still a third possi- 
 ble position in which the child may lie Avhen labour begins — that is, trans- 
 verse, or with the shoulder in advance. In the first class of cases the 
 majority would l)e delivered without any assistance whatever, in the 
 second class only a very small minority can be delivered without help, 
 and in the third variety delivery is practically impossible till the child is 
 turned about and comes either feet or head first. 
 
 The act of labour is divided into three stages : the first, that of dilata- 
 tion of the cervical canal ; the second, that of expul- 
 sion of the child ; and the third, that of delivery of 
 the placenta or afterbirth. 
 
 It has been already pointed out that the uterus sinks lower into the 
 pelvis during the last two weeks of pregnancy. This is usually the first 
 
STAGES OF LABOUR. 745 
 
 precursor of bcgiimin<^ labour, and i.s foll<jwed Ijy an easier I'e^piration, a 
 better digestion, and a power to walk more coinfortal;ly. 'J'lie circulation 
 in the lower parts of the trunk and in the legs is, however, interfered 
 with to a greater extent than before, and these parts of tlie body become 
 swollen. At times, also, the bladder and rectum are irritated by the de- 
 scent of the presenting part of the fcjetus and give syrnptoins. A viscid 
 yellowish fluid comes from the vagina and the uterus begins to contract 
 regularly and rhythmically. These contractions may be painful, and 
 recur sufficiently often to lead to a suspicion that labour is beginning. 
 Such attacks are csdled false labour, and may last for an hour or two; 
 they may occur even three weeks before true labour sets in. 
 
 When true labour does begin it is characterized by an increasing 
 severity and an increasing frequency in the pains. During this first 
 stage of labour the lower part of the uterus is dilating under the inter- 
 mittent pressure upon its contained membranous bag, which, filled with 
 fluid, envelopes the child. The pains of this first stage occur every three 
 to ten minutes, are of a tearing character, and are caused by uterine con- 
 traction. The abdominal muscles take but little part in this process of 
 dilatation. When the neck of the womb is fully dilated the uterine 
 contractions cause the membranes to rupture, and the greater part of the 
 contained fluid escapes with more or less of a rush. 
 
 The second stage begins, and immediately the character of the pains 
 changes. The woman begins to use her abdominal muscles and to assist 
 the uterus to expel its contents by straining and bearing down. The final 
 phenomenon of the second stage is the stretching of the outlet of the par- 
 turient tract and the birth of the child. This final effort is the most 
 painful of all, and is alleviated in skilled hands by the use of an anaesthetic. 
 
 During this process of dilating and stretching, the child is at all times 
 passive, although used as a dilator in the second stage. "While the neck 
 
 of the uterus is being dilated by the pressure of its con- 
 Effect on the ^^-^^^ » |^ ^^ ^^^^^^ „ ^^^ j^^^^ ^f ^^^ ^|^.j j -^ ^^. 
 
 Child m Vertex ° ^ 
 
 Presentation. elongated and moulded by the pressure of the con- 
 tracting uterus into such a shape that it will conform 
 to the bony canal of the iTiother's pelvis. As soon as the waters break, 
 the further dilatation is accomplished by the advancing head of the child. 
 The advance of the head occurs during the contractions of the uterus, and 
 is therefore intermittent. In the intervals between pains the head recedes, 
 and at the next contraction advances again to a point beyond that reached 
 during the preceding pain. During its progress through the parturient 
 canal the head rotates in such a manner that when it has reached the out- 
 let the face of the child points to the back of the mother, and the back of 
 the head lies just under the pubic bone. During the final act in its birth 
 the head rotates around the pubic bone of the pelvis in such a manner 
 
746 DISEASES OF WOMEN AND MIDWIFERY. 
 
 that the child's occiput is statioiuirv while the face is rotated upward — 
 
 that is, extended until the external outlet of the genital canal is stretched 
 
 enough to permit the passage of the head. The shoulders follow with 
 
 the next contraction, one of them catching under the pubic bone as did 
 
 the occiput, and the other rotating over the posterior edge of the genital 
 
 opening as did the child's face. After the birth of the shoulders the hips 
 
 and legs give no trouble and the child is born. 
 
 When the child is born breech first the labour will go on more slowlv 
 
 than if the head is in atlvance; this is so because the softer breech is a 
 
 poorer dilating instrument than the round, smooth, hard 
 Effect on the j^^^^j rj.j^^ f.^^^. ^j^.^^ ^j^^ ^.j^jjj -^ ^^^j^^^^ ^^^^.^^ y^^ ^j^j^ ^^^^ 
 
 Presentation n^nal method may often be surmised before the breech 
 appears at the vulva l\y the slowness of the case and by 
 the discharore from the vajj-ina of meconium, which is the blackish-green 
 substance found in the bowels of the child at birth. In the case men- 
 tioned this meconium is squeezed out of the child hj the pressure incident 
 to its birth. When the buttocks finally reach the pelvic outlet, one hi]) 
 catches under the symphysis and the other sweeps over the perinasum. 
 From this point on the buttocks and legs, which soon follow, form a very 
 good handle to pull on in order to hasten the delivery. As soon as the 
 arms are born the head can be brought down by pulling on the legs until 
 the occiput has caught under the symphysis, and then the body of the 
 child must be carried up over the mother's abdomen till the face swec])s 
 over the perinreum and the baby is delivered. 
 
 The third stage of labour is one of very variable length. Most ob- 
 stetricians terminate it artificially by expressing the 
 ^ PlcJenia afterbirth, but there is no reason why it should not be 
 
 left to Nature at least for twelve hours, barring, of 
 course, the occurrence of haemorrhage or some other complication calling 
 for immediate interference. 
 
 The parturient woman can be assisted in many little ways, but most 
 of the real work must be done by herself. A skilled physician will be 
 
 able to determine the procjress of dilatation by means of 
 Care of tJie Par- . , • ^- i • .1 / r. 
 
 t ■ '4 ir .„„.. internal examinations, and in tlie same way to fix more 
 
 or less accurately upon the pro])able length of labour. 
 
 An attendant who is unskilled in the matter of internal examination can 
 
 do much harm and no good by atteni])ts at such manipulations. It is 
 
 better, therefore, to judge of the progress of the case by noting the 
 
 times of occurrence of such prominent events as the breaking of the 
 
 water bag, the change in the character of the pain from the tearing, 
 
 cramp-like pains of dilatation to the straining pains of expulsion, and the 
 
 visible stretching of the perinaium, with the appearance of the child's 
 
 head at the vulva. 
 
CARE OF THE PARTURIENT WOMAN. U7 
 
 During the first stage of labour the woman should walk aljout and 
 take fluid nourishment at intervals of three hours or so. She should 
 take an enema of soapsuds and water and evacuate tlie bowel as early as 
 possible, and should pass water frequently. She should be washed with 
 soap and water after her enema, especially about the lower part of tlu; 
 abdomen, the groins, the hips, and the buttocks. This stage of labour 
 should not last over twenty -four hours, and it may be much shorter. 
 
 During the second stage the patient should be in bed covered with a 
 light blanket. Most women will be more comfortable on their side than 
 on their back, and should get on their side in evei-y case as soon as the 
 head comes into sight ; the danger of lacerations will be thus reduced to a 
 minimum. This lateral position is such that the woman is on her left 
 side ; a pillow is placed between her knees, both of which are drawn upon 
 the abdomen. The attendant should stay beside the patient's bed, and as 
 the child is expressed should keep the parts thoroughly cleaned with a 
 piece of sterilized gauze and solution of corrosive sublimate (1 to 5,000). 
 During this critical time in the birth the attendant's hands should also be 
 kept wet in the same solution, after having been cleaned in the manner 
 described below. As soon as the head is born it should be supported in 
 the hands of the attendant, who must be careful, however, not to hinder 
 in any way the position that the head is forced to take. The shoulders 
 will be delivered at the next pain, and this delivery will be accelei*ated 
 materially by pressing the head against the perinseum until one shoulder 
 appears under the symphysis pubis; then, as the pain causes advance, the 
 head should be carried away from the perinaeum, and the child will be 
 easily delivered. 
 
 After the birth of the child one hand must be placed upon the fundus 
 of the uterus, as felt through the abdominal wall, and should be kept 
 there throughout the third stage of labour, or given to some assistant or 
 nurse. When the child has been attended to as described below, the 
 mother should turn on to her back, and the final procedure of delivery — 
 that of the placenta — must be considered. This third stage may last twelve 
 hours without harm, but usually it is over in an hour. During this stage 
 the uterus will be felt as a hard oval body, with its rounded end at the 
 level of the navel. It can be felt to grow harder at intervals of about 
 five minutes, and it will be at one of these periods of contraction that the 
 afterbirth is squeezed out. It is bad practice to attempt to deliver the 
 placenta by pulling on the cord. 
 
 The first two stages of labour should be accompanied by no apprecia- 
 ble loss of blood. The delivery of the placenta, on the other hand, is 
 always attended with some hgemorrhage. The amount of blood lost 
 should not be more than about the bulk of the placenta itself, and should 
 come away with the actual expulsion of the afterbirth. After the birth 
 
74S DISEASES OF WOMEN AND MIDWIFERY. 
 
 of tlie placenta tlicre should be no li;vniorrliai:;e other than a .slight oozing, 
 'I'he question of severe luvmorrliages will be discussed hereafter. 
 
 When tlie thii-d stage of labour is ended the mother should be washed 
 with a surgieally clean towel or piece of gauze, and a ])roperly prepared 
 pad should be applied to the vulva. The bed should be renewed by re- 
 moving the soiled protective bed jxid. and a fresh one ])ut under the 
 patient. If necessary, the draw sheet sliould also be rcj)laccd by a clean 
 one. After the uterus has been watched by the constant presence of the 
 hand upon the abdomen, and has been felt to remain as a hard round 
 ball with its upper limit at or below the navel for an hour, an abdominal 
 l)inder can be applied and the patient left to herself. (See Nursing the 
 Sick, Figs. 28, 20, 30, 31, and 32.) She should be on the back, with the 
 head low, and sleep if she can. She may receive some light nourishment 
 before settling down. 
 
 The main factor in the question of antisepsis and asepsis is cleanliness, 
 l)ur the kind of cleanliness meant is a peculiar one; it is a cleanness or 
 freedom from the special germs which have been proved 
 to be the cause of the most virulent complication of la- 
 bour — jpiierpcral fever. To avoid the risk of such infection all articles 
 that are to come in contact with the parturient canal of the woman must 
 be freed from these living germs or their spores. The articles to be so 
 treated are all the obstetric dressings, all gauze and absorbent cotton for 
 washing the patient, the bed pads which are to protect the bed from the 
 blood and other discharges, and all instruments and apparatus, llie most 
 Important of all the articles needing disinfection, or sterilization, as it 
 is called, are the hands of the accoucheur. In addition, the woman her- 
 self must be cleansed in all suspicious parts from which an infection may 
 arise. Finally, the navel wound of the baby must not be neglected, and 
 the same rules of surgery apply here. Sterilized tapes for tying the cord 
 and germicide washes for the mouth and eyes are necessary safeguards 
 against infection of these parts. 
 
 The method in which this sterilization is done is immaterial, so that it 
 is effective. The efficient germicides for sterilizing all instruments and 
 surgical dressings are heat applied as live steam or as boiling water, and 
 certain chemical antiseptics. The hot water or steam is the better of the 
 two. The heat is applied so liot that it is impossible to use it for living 
 tissues — the hand, for example. All dressings and gauze and all instru- 
 ments are to be exposed for one hour at least to tlie action of boiling 
 water and its escajnng steam. The protective bed pads, towels, gauze, 
 and similar stuffs are sterilized best by exposure to steam under pressure, 
 and all hospitals and dealers in surgical supplies have sjiecial apparatus 
 for the purpose. The sterilization of such cotton materials may be done 
 in an emergency by boiling them for an hour in a clothes boiler, or for 
 
ANTISEPSIS AND ASEPSIS. 749 
 
 smaller articles in a fish or aspai-ajjjus boiler. A very excellent and inex- 
 pensive sterilizer is made by the Arnold Steam Sterilizer Company, in 
 which the articles to be sterilized ai-e exposed to live steam. See N'wns- 
 ing the Sick, Fig, 14. 
 
 After being sterilized, the various articles should be wrapped in towels, 
 which have been treated to the same process, and the pa(;kages should Ijc 
 pinned and put one side except they be needed for immediate use. 
 
 The disinfection of the woman should consist simply of a thorough 
 cleansing with soap and warm water of the lower part of the abdomen, tlic 
 groins, the upper parts of the thighs, and especially the buttocks and the 
 external genitals. This washing should be done as soon as labour is fairly 
 begun, and should be repeated if the bowels move or if the patient passes 
 water. After labour is ended the same washing should be repeated, with 
 especial care to remove all clots and stains of blood, and the proper ol)- 
 stetric pad applied to the vulva. 
 
 Last and most important, the hands of the attendant must be rendered 
 surgically clean. To accomplish this the sleeves should be rolled up to 
 bare the arms to the elbow, all rings should be removed from the fingers, 
 and the hands should then be washed with soap, hot water, and a nailbrush. 
 After the hands have been washed once, the nails should be cleaned by 
 scraping under them with a blunt instrument, preferably one of wood 
 (ivory and bone nail cleaners are fair and metal knife blades are bad). 
 A second and more thorough washing should follow during which the 
 skin is scrubbed as high as the elbow, but the nails receive the greatest 
 attention. Such a final scrubbing should last at least three minutes and 
 should be followed by a rubbing Mdth alcohol and nailbrush, and finally, 
 and least important, by similar treatment with some chemical disin- 
 fectant. Cf. Surgical Injuries and Surgical Diseases, p. 444. 
 
 The chemical disinfectants may be powerful germicides, but they are 
 poisons, and they require an appreciable interval of time in which to act. 
 The benefit derived from their use has been magnified by their populari- 
 zation. They are an excellent aid to disinfection, but can not be used with 
 success to the exclusion of ordinary cleanliness. The best drug of this 
 class is the corrosive sublimate (mercury bichloride). It is to be used for 
 the hands in solution of a strength of 1 part to 2,000 parts of water. 
 After the hands are thus prepared they are to touch nothing except other 
 sterilized objects ; great care and a habit of avoiding such contamination 
 are necessary to guard absolutely against it. The common errors in this 
 regard are to dry the hands on a towel, to scratch the face or, worse, the 
 head, to handle the bedclothes of patients, or various pieces of furniture. 
 The hands should be wet in the corrosive-sublimate solution at all times 
 when in use, and should be washed in the same thorough manner when- 
 ever they become contaminated by contact with unsterilized objects. 
 
750 
 
 DISEASES OF WOMEN AND MIDWIFERY. 
 
 The methods of applying tliese same principles to the eyes, mouth, 
 and navel of the child are to use a saturated solution of boric acid to 
 wash out the mouth and eyes, and to powder bismuth or starch })owder 
 on the navel. 
 
 CHAPTER V. 
 CARE OF THE NEWBORN CHILD. 
 
 TuKRE is a widesjiread opinion among the laity that some serious legal 
 responsibility is assuiued by any one who separates a newborn child from 
 its mother by cutting the umbilical cord. Such is not the case ; any one 
 may care for these patients in this emergency, and the doing the right 
 thing at the right time will save the lives of certain children. 
 
 As soon as the child is born the mother may be temporarily left, or 
 some one else may hold the hand on the abdomen and top of the uterus 
 while the child is attended to. Tlie umbilical cord should be felt, and if 
 
 it is pulsating no great hurry 
 will be necessary. The child 
 should be picked up and held 
 in one hand with the back up 
 and the bellj down, until it 
 cries strongl3^ 
 
 Fl(i. 1.— ("iTTIXr. THE I'MBILIOAL COISD. 
 
 a, b, the line of division. 
 
 Fig. 2.— Keef knot ^AtU•r Wyeth.) 
 
 The child's eyes should be washed with the saturated solution of bo- 
 ric acid, and the mouth wiped out with the finger, on which is spread a 
 piece of linen wet in the same solution. As soon as the 
 r 'bT % r^-d ^^^**^ stops pulsating it should be tied in two places — one 
 about an inch and a half distant from the navel, and the 
 second at least two inches farther from the same point. The cord must 
 be cut between the ligatures and the portion attached to the child must be 
 carefully inspected to see that it does not bleed. 
 
 Fig. 1 represents a newborn child lying on its back with the coi'd 
 
CARE OF THE NEWBORN CHILD. ^51 
 
 and afterbirth attaclied. Two ligatures liavc been applied to the cord, 
 and the line of division is indicated by the line a h. This figure is in- 
 tended to illustrate how properly to divide the umbilical cord, and not 
 the proper position of the child before the cord has been cut. For the 
 sake of convenience, therefore, the child is represented as on its back and 
 not on its side, and the afterbirth as already delivered, although the 
 placenta is rarely born until an appreciable interval has elapsed after the 
 cutting of the umbilical cord. The cord should be tied with bobbin about 
 an eighth of an inch in width and which has been sterilized as described 
 above. The knot in this bobbin should be a regular square or sailor's 
 knot, and each part of the knot should be drawn tight enough to begin 
 to cut into the jelly-like substance of the cord. Fig. 2 represents the 
 making of a square knot. 
 
 As soon as born, and before the cord is tied, most children begin to 
 
 breathe and to cry more or less loudly. The first respiratory act is an 
 
 ^ . inspiration, and the method of holding the child iust 
 
 Respiration. described — i e., never on its back — must be continued 
 for some time, in order that the mucus and secretions 
 which are in the throat and mouth may not be sucked into the lungs. 
 
 RESUSCITATION OP APPARENTLY STILLBORN CHILDREN. 
 
 If respiration is delayed, or the crying is not vigorous even after the 
 cord is tied, the child must be stimulated to better efforts. This is done 
 by stimulating the skin of the child by spanking sharply with the hand, 
 by rubbing the back with whiskey or alcohol, or by alternate hot and cold 
 applications to the spinal cohimn and chest. The heat may be applied 
 with hot water, the cold with a piece of ice or cold water. In using fric- 
 tion with hot and cold water care must be taken not to depress too much 
 with cold applications, and it is wise to give the baby after such treat- 
 ment a hot mustard bath when it begins to breathe, and while still red 
 from this treatment to wrap it up in a hot blanket and place hot bottles 
 about it. Blowino; into the mouth and face of the child will tend also to 
 cause a reflex gasp. The mouth of the attendant can be placed directly 
 upon that of the child and the lungs partly inflated by blowing. AVhen 
 this is done the nose should not be held, in order to leave a safety valve 
 and not to exert too great a pressure on the lungs. On the other hand, the 
 abdomen should be gently compressed with one hand in order that the 
 air thus introduced may not go into the stomach but into the lungs. Such 
 active efforts should not be repeated too frequently ; about three times 
 per minute is often enough, while the rubbings and spankings are con- 
 tinued in the intervals. If the child does not begin to breathe after a 
 fair trial of two to three minutes' duration of the methods just detailed, 
 no further time should be lost, but artificial respiration (Sylvester's 
 
752 DISEASES OF WOMEN AND I^IIDWIFERY. 
 
 method) should he ho<^\m in the same manner as dctailod in tlie article in 
 
 tliis volume on Jfcdichics and Treatment. The child must be laid upon 
 
 the back and a renewed eft'ort to cleanse the pharynx 
 
 r ijicta ^^^ mucus must be uuide by insertini>; the lintrer covered 
 
 Bespinttiun. . , '' ^ • an 
 
 wirh ixauze wet m boric - acid solution. Ihe child 
 
 slionld be covered to its arnijiits -with a soft woollen blanket and sur- 
 rounded with hot bottles ; the head and sluiulders should be slightly ele- 
 vated. Tlie forearms are held just below the elbow and are brought 
 above the head as high as possible and pushed backward in this position. 
 (See 2ltdictnes and IWat/ntnt, Fig. 13.) In this manner air is drawn 
 into the lungs and an inspiration is the result. The arms are then low- 
 ered to lie beside the chest and are pressed against it, thus forcing air out 
 of the chest. (See 2[ediclnef> and Treatment., Fig. 14.) These movements 
 are made alternately ; the cycle should last four or live seconds. Tlie 
 tendency of a beginner is to hurry the rhythm of such a procedure, so that 
 it is wisest to control the performance of it by the constant observance of 
 the second hand of a watch. If success is to attend one's efforts the child 
 will usually show some sign of spontaneous breathing within ten minutes, 
 and the beating of the heart and the pulse will become regular and 
 stronger even before the respiratory act is established. The artificial res- 
 piration must be continued in unfavourable cases until the heart stops, and 
 in favoural)le cases during shorter periods with increasing intervals until 
 the child breathes regulai-ly and has cried strongly. 
 
 After the child's vital functions are fully established it should be 
 wrapped in wool, surrounded with hot-water bottles, and laid in its crib 
 or in a big chair. Before leaving the child the cord must be inspected, 
 to see that it does not bleed, and then the attention of the attendant 
 can be given again to the mother and the necessary care during the third 
 stage of labour, as has been detailed above. 
 
 When the mother has finally settled down for a sleep and the room has 
 been tidied, the further care of the child may be resumed. If this stage 
 of the case comes at an inconvenient hour in the middle of the night the 
 baby may be left till morning, except in two particulars : the skin should 
 be thoroughly smeared with an oily substance (vaseline or olive oil) in or- 
 der to soften the white sebaceous matter on the surface, and the cord 
 should be again inspected to see that the ligature is tight and that there is 
 no bleeding. If at any time the cord begins to bleed, a fresh ligature 
 must be applied. AVhile waiting for the ligature any serious haemorrhage 
 can be entirely controlled by squeezing the cord with the fingers. 
 
 The next thing in order for the infant is a bath. This should be given 
 before an open fire, except in midsummer, and in a portable tub long 
 enough for the baby to lie at full length. The water should be about 
 four inches deep and of a temperature of 100° Fahr. The infant should 
 
CAEE OF THE NEWBORN CHILD. 753 
 
 be sponged gently witli soap and water to soften and remove tlie seba- 
 ceous matter and the vaseline which has been rubbed on the skin ; it 
 . should then be placed in the water in such a manner 
 
 that one hand supports the head and neck hy putting 
 the back of the shoulders in the palm, with the fingers in one armpit and 
 the thumb in the other, while the free liand washes off the soap with a 
 small sponge. The bath should last about three minntes. The l)a?)y is 
 then dried and the skin is powdered with a starch powder. Especial care 
 must be given to the armpits, the groins, and the folds of the buttocks to 
 see that thej^ are dried and well powdered. The umbilical cord should be 
 dusted over with the starch powder and enveloped in absorbent cotton, 
 which should be held in position by means of a flannel band. The flannel 
 band should be about forty inches long and six inches wide, so that it will 
 surround the abdomen and lower part of the chest of the child. This band 
 
 ^, , . should be sewed on by a few stitches. The remainin<r 
 
 Clothing. , ^. .,, ,. 1 . -, » -, ^ 
 
 clothes will vary accordmg to the ideas of different 
 
 mothers. A common set of clothes for dressing infants consists of a light 
 woollen shirt worn over the band ; then, in order of application, a diaper 
 pinned with safety pins in triangular form ; a flannel petticoat or barrow- 
 coat wound around the abdomen and chest and pinned in place. The 
 barrow-coat reaches down a foot or more below the child's legs and is 
 turned back over the legs and pinned. A simple slip a yard and a quar- 
 ter long, extending well below the child's body, and woollen socks to pro- 
 tect the feet complete the outfit. 
 
 After the child is dressed it should be put to the mother's breast in 
 order that it may suck out the laxative secretion called colost)mm, which 
 . is usually to be found there. The child should then be 
 
 iiismg. yqIIq^ ^P jj^ f^ blanket of thin flannel or knitted wool, 
 which may come up over the neck and back part of the head, but 
 should leave the face free, and which should confine the arms bv bindinsr 
 them to the body. The child thus protected should be placed in a bed by 
 itself and on its side. Its legs should be further covered in cool weather 
 with a light woollen blanket. Usually the child will go promptly to sleep. 
 
 A separate bed, either cradle or crib, or an improvised affair made 
 
 from a clothes basket, must be provided for the infant, who should never 
 
 sleep in the bed of its mother or in that of anv other 
 Arrangements j i; mi • j. 1 j j. i • • ; i i" 
 
 ^ ;,, adult, ihis separate bed must be insisted on because 
 
 for Sleep. ^ 
 
 of the danger that the sleeping mother will push the 
 child out of bed, or roll on it and suffocate it, and principally because in 
 such a bed the child does not get a suflficient amount of fresh air, and lies 
 in the bottom of a tent formed by the grown person's shoulder and the 
 bedclothes. The child's crib should not be shut in with curtains either to 
 protect from draughts or to protect from the light. A child grows to 
 50 
 
754 DISEASES OF WOMEN AND MIDWIFERY. 
 
 liave tlie habits wliicli are taught it ; it is horn to k^ani, and it begins tlie 
 
 pi'ocess at once. If the sleeping eliikl is kej>t in a darkened room in 
 
 whieh no one si)eaks al)ove a whisper the child will sdon ae(piire the habit 
 
 of sleeping oidy under sueh conditions. If the ehikl is sung or rocked to 
 
 slce]>, or is allowed to suck its fingers when going to sleep, these habits 
 
 will be formed and will subse(piently be broken with ditKeulty or not at 
 
 all. The child should be taught by constant repetition to go to sleep 
 
 alone, lying in its bed, in the light by day and in the dark by night. 
 
 Ir is wise during the first week of life not to give a full bath until 
 
 after the dried uinl)ilical cord has separated from the navel. The baby 
 
 during this time should be sponged otf with warm water 
 Care of the Cord. j i i i ^.i ^ • rpi 
 
 and have clean clothes put on every morning, ilic 
 
 stump of the cord separates usually by the seventh day and leaves the 
 navel dry and healed, or the navel becomes so after a short period of 
 treatment with bismuth powder. The cord should be left to separate of 
 itself, being powdered each morning wdth starch to keep it dry and 
 wrapped in clean absorbent cotton. If any odour or any secretion of 
 ]>us develops about the cord, a drying powder of bismuth, or bismuth 
 mixed with iodoform, should be dusted on tlie navel. 
 
 During the first two months of life the baby should live in a per- 
 fectly routine manner. It should be fed at regular intervals, should 
 
 be awakened during the day for this purpose, and al- 
 
 Routine Life. , i , i . • i . i -i. -n t li • 
 
 lowed to sleep at night as long as it will. In tins way 
 
 it soon learns to wake at the regular times and to sleep at night for pe- 
 riods of six to ten hours. It is not cruel to the child to wake it for food, 
 nor will this sj-stematic feeding make the child " nervous." On the other 
 hand, nothing is more cruel to the mother than to bring her an infant to 
 nurse every two hours through the night as well as the day. 
 
 Another habit which must be taught the child as soon as possible is in 
 reference to the action of the bowels. During the first week the bowels 
 
 discharge the dark slimy meconium which fills them ; 
 
 as soon as the milk diet is begun the stools gradually 
 become yellow, soft, and smooth, and are repeated two to four times a 
 day. As soon as the child is three months old it should be made to sit 
 on a small commode chair at the same time each day, and will soon learn 
 to have regular passages. As often as the diaper is wet from urine it 
 must be changed and a fresh one applied, after thoroughly drying the 
 parts and powdering them freely. 
 
 A bath must be given each morning in the manner described, and the 
 
 face and hands should be sponged off every night before 
 
 the last nursing. The regular bath should be given when 
 the baby's stomach is empty and just before a regular feeding time. 
 After the baby is dressed and has had a meal it will usually go to sleep. 
 
CARE OF THE NEWBORN CHILD. Y55 
 
 The special cleansing of the eyes and the mouth with satiu-ated solution 
 
 of boracic acid should be a part of tiie niornin<j^ toilet. 
 
 There are two unusual symptoms seen at times during the first week 
 
 of life. One is a swelling of the breasts of the child and a secretion of 
 
 milky fluid ; the second is a mild hsemorrhagic discharge 
 Infantile Mammary j- ' ,■> ■ i; • i i i • n-n i 
 
 • -, ,. from tlie vagina oi girl babies, ine second requires 
 
 no treatment; the first may need surgical care, and in 
 any case such swollen breasts should be stuped with hot boracic-acid 
 solution. 
 
 The newborn baby can begin to go out of doors only when the weather 
 is fairly warm. The interval that should elapse be- 
 tween the birth of the child and the time for going out 
 naturally will be longer in winter and shorter in summer. 
 
 CHAPTER YI. 
 LYING-IN PERIOD. 
 
 After labour is finished and the woman has been washed and has set- 
 tled down for a rest nothing need disturb her for an hour or more. The 
 uterus will continue to contract rhythmically foranum- 
 " ber of hours — twelve to thirty-six in different cases. 
 These contractions may be severe enough to be painful, and thus cause 
 the so-called afterpains, Afterpains are less severe after the birth of 
 the first child than after subsequent labours. They are especially severe 
 if any blood clots collect in the uterus, and are increased by the taking of 
 cold drinks, by the act of nursing the baby, by any pressure over the 
 uterus, or by the filling up of the bladder or rectum. These painful con- 
 tractions of the uterus may be repeated as often as every half hour at 
 first, but the interval between the pains increases, and the severity of each 
 pain gradually decreases until they cease altogether on the second or third 
 day after labour. 
 
 At the time of labour there is a loss of considerable blood following 
 the birth of the child and accompanying the delivery of the placenta. 
 This flow of blood continues for a varying time after- 
 ward, and is at first bright red and quite profuse. Later 
 it becomes darker in colour and less in amount, and finally changes to a 
 colourless raucous discharge. It ceases as a continuous flow at the begin- 
 ning of the second week, but recurs at intervals for two weeks more, 
 especially after exercise, walking, etc. The lochia, as this flow is called, 
 
Toti DISEASES OF WOMEN AND MIDWIFERY. 
 
 liave an odour which is j)ec'nliar to thoinselves, ami shoiikl not bo fctnl ov 
 fcetid in any sense. 
 
 The uterus begins at once to retrograde and to diminish in size. Tlie 
 
 rate of diminution is of such a nature that the toj) of the organ descends 
 
 from the neighbourhood of tlie navel just after delivery 
 
 hwolntion of the ^jjj j^ ,.^3aches the level of the pubic bone about the four- 
 
 I'lerus. / . 1 . , , 
 
 teenth day. It has returned to its normal size by the 
 
 end of the second month. This shrinking or involution of the uterus is 
 the best guide as to when the patient should leave her bed and begin to 
 walk about. She should not do so until the lochia are absent most of the 
 time and the height of the uterus corresponds to the pubic bone. The 
 remaining characteristic feature of this period is the establishment of the 
 flow of milk. This is described in detail in the next chapter. 
 
 During the puerperal week the patient should have a normal temper- 
 ature, her pulse should be slow — even slower than normal — she should 
 
 feel well, and have a good appetite. She is apt to con- 
 Oeneral Health. . ^- ^ i <v 11 1 i. -n 
 
 tmue constipated after lal)our, but will pass more 
 
 urine than usnal. 
 
 During the first week after confinement the woman and the baby 
 
 should lead a very regular mode of life. The nursing should be regular, 
 
 and during the intervals the baby should sleep. If the 
 
 n "^^ ^i MT baby does not sleep at nio;ht it is well to keep it in an 
 
 Puerperal Wmnan. •' ^ . 
 
 adjoining room and take it to the mother only at nurs- 
 ing time. The mother should have a sponge bath every morning and 
 should be given a generous diet of solid food at all times. She should 
 not be kept on slops and fluids even for the first twenty-four hours. Milk 
 is a good food for these women ; it is a stimulant to the kidneys, easily 
 digested, and easily procured in a condition of purity, but a milk diet to 
 the exclusion of all else is not a desirable form of diet for a parturient 
 woman. Such a woman should eat three good meals a day, and should 
 take in addition some fluid nourishment between meals and during the 
 night. Milk, squeezed l)eef juice, and broths are good for these extra 
 feedings. 
 
 As often as the al)sorptive pads on the genitals l)ecome saturated with 
 the lochia they should be removed and replaced by fresh ones. The pro- 
 cess of changing these pads should be undei'taken only 
 ' with a strict observance of surgical cleanliness or asep- 
 
 sis ; the hands of the attendant should be cleansed as above described, and 
 the fresh dressing should be carefully handled so that it may not come in 
 contact with any object between the time it leaves its aseptic receptacle 
 and is placed on the woman. The genitals should be cleaned by washing 
 externally with mild antiseptic fluid (corrosive sublimate, 1 to 5.000). In- 
 ternal douching of the parturient canal should be done oidy for a very 
 
THE LYING-IN PERIOD. 757 
 
 positive indication and under tlie direct supervision of a physician, Tlie 
 
 doucliing of the vagina at regular intervals has been proved to do more 
 
 harm than good and should be omitted from routine practice. 
 
 The bowels should be moved artificially on the third day, preferaljly 
 
 by enema of soapsuds and water. If there is any febrile reaction at this 
 
 time a saline cathartic is indicated. The patient should 
 Bodily Fxmdions. , , ^ • r\ n , i i i^i i 
 
 use a bedpan during the nrst week both when moving 
 
 the bowels and when passing water. After that time she may use a com- 
 mode for the purpose. The bedpan is a disagreeable necessity to many 
 women, and some can not pass water at all in a dorsal position. If the 
 patient does not urinate during the first eight hours after confinement she 
 should be aided to do so by the application over the bladder of cloths 
 wrung out in hot water. If this fail it is well to allow her to try to 
 empty the bladder by sitting on the commode. This will usually be suc- 
 cessful unless the upright position causes her to feel faint. Of course 
 such a woman should not be left alone in the sitting posture, and should 
 be put back to bed immediately on the appearance of any untoward 
 symptom. The last resort is the passage of a catheter into the bladder. 
 (See Nursing the Sick, Fig. 15.) This little operation should be done by 
 sight alone, and with the most careful antiseptic precautions both for the 
 hands of the attendant, for the woman's genitals, and for the instrument 
 itself. The method is described in the article on Nursing the Sick. It 
 had better be left to skilled hands than be attempted by the inexperienced. 
 A routine record of the temperature of the patient should be taken 
 
 with a clinical thermometer in the mouth every morn- 
 
 Temperature and . , . ^, i , • x i i j i 
 
 ^ r> 1 mg and evening. I he pulse-rate per minute should be 
 
 recorded at the same time. 
 
 The patient should not receive many visitors during her stay in bed. 
 
 At first the list should be limited to the members of her immediate family ; 
 
 their social calls should be short, and should not be made by more than 
 
 one or two at a time. 
 
 The patient may move about the bed after forty-eight hours, and can 
 
 begin sitting up in bed at the end of a week. She may get out of bed 
 
 during the third week as soon as the uterus has invo- 
 
 i mgup Inted to such an extent that it is below the pubic bone. 
 
 Walking, etc. i i r 
 
 When she first gets up she should lie down on a sofa at 
 
 frequent intervals ; she may begin to take a few steps about the room and 
 can go downstairs about a month after labour, and may go out for a short 
 walk or drive as soon as downstairs. If the patient lives in an upper 
 story she should not attempt to climb a large number of steps for a num- 
 ber of days after she first goes downstairs. She should be carried up for 
 the first few times, and assisted up for a number of times more before 
 doing the average amount of stair-climbing incident to. life in a city 
 
V5S DISEASES OF WOMEN AND MIDWIFERY. 
 
 house. In getting abtnit again after eontinenient it is far wiser to do too 
 little than too nuieh. It is better to be up one hour twice with a suffi- 
 cient rest in between, than to be aliout for two hours once. The greatest 
 difficulty is to make women understand that thev are not the proper 
 judges of their own powers of endurance and of doing work. 
 
 CHAPTER VII. 
 LACTATION. 
 
 The condition and ajijiearance of the breasts during ]u-egnancy lias 
 been described already. At the time of labour they are in tlie same con- 
 dition as dni'ing the last months of pregnancy. No 
 
 gtnni g . marked chauije takes place in them until after the birth 
 
 Lactation. . 
 
 of the child. About the third day (forty to sixty hours) 
 
 after labour there is a sudden increase in the size of the breasts, which 
 
 become also more firm and somewhat tender. This swelling makes the 
 
 nipple relatively more flat and more difficult to be grasped by the infant's 
 
 mouth. 
 
 The general condition of these patients varies ; there may be uo 
 
 symptoms at all, or the patient may feel quite ill. In the severest cases 
 
 she will have a quickened pulse and a slight rise of tem- 
 M ilk Fever. ^ i , i i i i j- i 
 
 perature ; a headache develops ; her face becomes 
 
 flushed ; she feels hot and may perspire profusely ; at the same time a 
 
 distinct thirst increases her annoyances. Milk fever is an old term to 
 
 express this condition, but, as is shown below, the milk fever of thirty 
 
 years ago (and which still exists in the catalogue of diseases of tlie laity) 
 
 was more often a mild grade of puerperal fever than any special morbid 
 
 process connected with the beginning of lactation. 
 
 The question whether a woman should nurse or not is one which is, 
 
 theoretically, easily settled ; practically, however, many factors must be 
 
 considered l)oth from the point of view of the woman 
 
 /I II' ai^J from that of the child. Lactation is a distinct ad- 
 
 071 the Woman. 
 
 vantage to the mother during the first jiuerperal month. 
 The mammary irritation due to the sucking increases the contraction of 
 the uterus and accelerates its involution. The necessity for increased 
 food for a nursing woman will stimulate all her tissues to greater activity, 
 and especially to the ])utting on of fat. 
 
 As far as the child is concerned there can be no doubt but that good 
 breast milk is the best food for a newborn baby. Poor breast milk, how- 
 
LACTATION. 750 
 
 ever, is as bad a form of iiourislmieiit as any poor artificial loo'J. 'J'Ik; 
 
 best evidence that any particular child is receiving good and sufHcient 
 
 food is to be found in the child itself. As long as the 
 Result of Lactation , , • • • i i. -x • i i i i • n 
 
 j^ i'l m I J bal)y increases m weiiji-lit it is pi-cjbably domi; as we as 
 for the Child. •' . , " i ./ h 
 
 could be wished for. The child should Ije weiijiied 
 every week during the first twelve months of life to determine wheth(;i' 
 the food is agreeing with it or not. 
 
 The baby should be put to the bi-east every two hours for the first 
 week of life, except at night, and should be wakened in the daytime in 
 order that the proper routine be established. After the 
 yy ■ iirst week, and until the sixth week, the intervals may be 
 
 lengthened by counting tlie two hours' interim from the 
 end of one nursing to the beginning of the next. At six weeks the in- 
 tervals should be made three hours, including the time consumed in the 
 act of feeding, and should be kept at this point during the succeeding six 
 or seven months, or even to the end of the first year. 
 
 The amount of milk that a child should take at each feeding varies 
 with the age of the child. At birth the stomach of an infant will contain 
 
 one ounce ; the capacity of tlie stomach increases rap- 
 Amountof 3Iilk for . ■.-. ^ •,^ • . j ' . i • -u u. • j i i 
 
 .r ■ D 7 ■ idly, and witnin ten days this organ will contain double 
 
 JSursmg Babies. ... . , 
 
 this original quantity. At six weeks of age the stomach 
 will hold from three to four ounces, and this amount should be given at 
 each nursing. The increase is gradual after the second month, and the 
 amount given each time should be gradually increased until at six months 
 the child is taki-tig six ounces, and at nine months eight ounces of fluid at 
 each feeding. 
 
 It is a general rule that a baby of any age will get the proper amount 
 of milk from its mother's breast in a period of nursing of about fifteen 
 minutes' duration. The mammary glands will regulate and secrete the 
 amount which is necessary very accurately. When lactation begins the 
 breasts secrete less milk than they do at a later period, and the amount 
 is gradually increased to meet the changing demands of the infant upon 
 them. 
 
 If there be any deviation from the rule tliat the supply of milk equals 
 
 the demand, the first and most trustworthy witness thereof will be the 
 
 baby. If the baby gets too little food it will cry soon 
 
 nsujjicien an ^f^gj. beino; fed : it will try to put things into its mouth. 
 Excessive Feeding. . ./ i ... 
 
 especially its fingers, and it will not gain in weight at 
 
 the normal rate of five to nine ounces per week. If the baby is fed too 
 
 abundantly it will vomit the milk, not only directly after feeding, but at 
 
 the end of the period of fasting and just before the next feeding is due. 
 
 Many babies regurgitate a small amount of milk immediately after 
 
 nursing, especially if they are handled much and danced up and down ; 
 
7(50 DISEASES OF WOMEN AND MIDWIFERY. 
 
 rhe milk thus spat up is usually swei't-suK'lliug ami not cnrdlcd. Acidity 
 and sour-sinellini; curdled milk is cluiracteristie only of milk wliich lias 
 been in the stomach for some time. The natural process of digestion 
 causes such a curdling, and the occasional vomiting of sour milk is not 
 necessarily a sign of a deranged stomach. Hut when Vdiniting occurs 
 more or less regularly, and at the end of the interval between nursing, it 
 means tluit the stomach was not emj)tied as it should have been when the 
 next nursing began. 
 
 Further symptoms of overfeeding are hiccough, colic, and the appear- 
 ance of white lumps of undigested milk in the stools. Hiccough is rarely 
 a symptom of any special significance, but colic and lumpy stools may be 
 the precursors of serious diarrlnea. 
 
 The crying of an infant with the pains of intestinal colic is accom- 
 
 ])anied by tlie further symptoms that the legs will be drawn up on the 
 
 abdomen, that the child will squirm around and be rest- 
 
 ■,,,., , less, will bite at its fingers, and w'ill become pale even to 
 
 (f.s Ireatment. ' &> ? r ^ 
 
 blueness about the lips. These symptoms recur with 
 marked severity at intervals of two to five minutes, and tlie whole attack 
 may last for hours. Crying alone in babies is no evidence of colic ; they 
 always cry when hungry or when uncomfortable from wet or soiled diapers. 
 
 The treatment of the attacks of colic is to apply beat to the abdomen 
 by wrapping the child up on a hot-water bag, or, better, by giving a hot 
 mustard bath to the whole body. In addition, the child can be given hot 
 water to drink. As to drugs, they are best given only on the orders of 
 a physician. The teas made from plants containing essential oils, such 
 as peppermint, fennel, anise, or chamomile, have the best reputation. 
 Laudanum, and other opium preparations are very dangerous for cJiil- 
 dren, and even jjaregorlc is to he avoided. 
 
 The preventive treatment of colic consists in finding the direct cause — 
 whether overfeeding or underfeeding, or improper milk, or what not — 
 and of removing it. The amount of milk taken w'itli each nursing and 
 the intervals between feedings must be carefully investigated, and all er- 
 rors tending to overfeeding or to underfeeding must be corrected. This 
 can be easily regulated in babies who are on the bottle. But the amount 
 taken at each feeding by nursing babies can be decreased or increased 
 only by changing the duration of each nursing. 
 
 The nipples may be rubbed during the last two weeks of pregnancy 
 
 with dilute alcohol once a day in order to harden them. When the baby 
 
 is born it should be put to the breast to suck even be- 
 
 Breast ' ^^^'^ ^^'^ milk comes. This should be done about every 
 
 four hours, and will accomplish two things : first, it will 
 
 give to the baby the laxative colostrum which is in the breast, and, second, 
 
 it accustoms the nipples to use before the milk rushes in and distends the 
 
CARE OF THE BREASTS. YOl 
 
 breast, tluis renderiiif^ tlic first uttcrnpts at iiiir,siii<^ more difficult l»y inak- 
 iiig tlie nipples flatter tliari before. 
 
 Before eacb nursing tbe nipples must be softened ])y nibbin^^ witli a 
 small piece of absorbent cotton wet in boracic-acid solution ; tliis will 
 cleanse the nipple and will cause it to bear tlie j)ulling of tlui child with- 
 out cracking. The rubbing will stimulate the nipple to erect itself and 
 give the l)aby a better chance to take hold. Between the nursings the 
 nipples should be powdered with bismuth or starch powder and kept dry. 
 
 In the cases where the nipples prove to be tender and painful, and 
 especially wdien thej become actually cracked, the 
 use of a nipjple shield will be a great comfort and 
 allow the nursing to be done painlessly until the 
 nipples are tough enough to be nsed without 
 this aid. The best nipple shield is that devised 
 by Dr. Ware (Fig. 3) in that the side tube allows 
 the mother to assist the infant if it is weak, and 
 also to diminish the suction force by letting air 
 in behind the feeding nipple when the child is t^, „ . 
 
 c5 fi' ^ i<I(}. 3. A. NIPPLE SHIELD. 
 
 too strong. The instrument is of glass and soft 
 
 rubber and should be kept in the solution of boracic acid when not in 
 
 actual use. 
 
 At the time of the onset of the flow of milk into the breasts these 
 glands may become " caked," as it is called, and the condition known as 
 
 " milk fever " be set up, the symptoms of which have 
 Calced Breast and , -, -i i mi '. , , i- ^ • t 
 
 ., rn, f f been described, ine proper treatment of this condi- 
 tion is, first, to give a saline laxative, and, second, to ap- 
 ply to the breasts stupes of very hot water. Each stuping should last 
 about ten minutes and should consist of the application to the breasts of 
 flannel cloths wrung out in boiling water. These cloths are to be laid 
 dripping wet in a towel and wrung out by twisting the towel. About 
 ten such cloths should be used — that is, tw^o cloths used alternately five 
 times each. Such stuping should be repeated every two to four hours. 
 
 Between the stupings the breasts are to be bandaged or bound up. A 
 ' breast binder should be applied in such a manner that the breasts do not 
 drag by their weight from their attachments to the chest wall. A very 
 excellent binder for the purpose is the double Y (see J^^ursii'ig the SicA', 
 Fig. 33), which, wdien in position, causes the breasts to be approximated 
 to each other and pulled up tow^ard the middle line of the body, and also 
 toward the upper part of the chest. The breasts of a woman lying on 
 her back gravitate toward the abdomen, and more particularly toward the 
 armpits. The binder must overcome this tendency. When properly ap- 
 plied, the double Y-binder accomplishes this end without the necessity of 
 pads of cotton, and permits the child to nurse without its being removed. 
 
702 DISEASES OF WOMEN AND MIDWIFERY. 
 
 The diet of nursini; woineu must ho nutritious ami (.'usily digested. 
 Some women will tiud that certain articles of food must be avoided be- 
 cause tliev affect the milk and give the baby colic. Each 
 Diet of Nursing '. , . -, , ., ' • j. +• '-,. ir i 
 
 • •' case must be ludijed on tliese ixiints for itself, ancl no 
 
 \\ ontrlt. , 
 
 absolute rules can be formulated. In general, it is wise 
 to take ]>lenty of tluid,and tt) take some light nourishment between meals 
 and once during the night. A glass of milk or the juice of half a pound 
 of beef with a little bread are excellent forms of food for this purpose. 
 
 Every healthy woman should nurse her infant for one month, if pos- 
 sible, entirely for the benetit to be derived by herself. She should nurse 
 longer, and for as much of nine or ten months as she can for the benelit 
 of the infant. 
 
 A baby should be taken from the breast and put upon artificial food 
 bj tlie time it is ten months old. At this age it is able to digest cow\s 
 milk, also certain preparations of meat, and the various 
 cereals and prepared starchy foods. In changing from 
 one method to the other it is best to do so suddenly so far as stopping the 
 breast feeding is concerned, but gradually so far as trying the various kinds 
 of food just enumerated. This means that the child will be given during 
 its seventh, eiglith, or ninth month an occasional meal of barley water 
 and milk, of various gruels, or even some of the proprietary foods — 
 Mellin's Food or Imperial Granum, for example. A general rule should 
 be laid down that only one new article of diet shall be given during any 
 one period of forty-eight hours. In this way any difficulty of digestion 
 or any tendency to diarrluea will be very easily and correctly ascribed to 
 the proper cause — that is, to the innovation. 
 
 A child of six months should begin to learn to drink from a spoon 
 and from a cup, and should be taught thoroughly to do these things be- 
 fore weaning is attempted. Such children should drink water and also 
 the diluted cow's milk which it is proposed to give them when the final 
 break is made. If the child makes a great fuss and tights the new order 
 of things, it is wise for the mother to leave it temporarily, and it will 
 soon give up and eat. 
 
 The breasts should be made to dry np as soon as possible by binding 
 them tightly and then leaving them alone. Pumping them out and rub- 
 bing theni will relieve them for the moment, but tliej will harden and 
 swell up again in a short time. These uncomfortable feelings can be al- 
 leviated by hot stupes given as described on a preceding page of this 
 chapter. "Women about to wean a baby should take a mild laxative and 
 should diminish the amount of fluids in their diet. 
 
 Of the various foods for infants at the weaning period, the best to be- 
 gin with is cow's milk diluted with one fifth lime water and slightly sweet- 
 ened. If this temporary food is digested well, it is wise to keep it up for 
 
THE WET NURSE A LAST RESORT. 7C3 
 
 a few da^ys and tlieii to try tlic cow's milk pure. After a week rjr ten days 
 some one of tlie starch preparations slionid be given, and tlion after a 
 similar period another, and finally tlie juice of squeezed beef and soft- 
 boiled eggs. A child a year old can be fed three tiines a day on tliese fluid 
 and semisolid things until it has cut its teeth, or at least the first sixteen. 
 It can then receive bread, meat, potatoes, cooked fruits, in addition to 
 milk, gruels, beef juice, etc. 
 
 If a woman can not nurse her baby from any cause, the question of 
 putting the child on a wet nurse or of giving it artiticial food arises im- 
 mediately. The reasons why a woman can not nurse 
 
 Wet Mnrse . 
 
 may be either because her general liealth forbids or he- 
 cause something has happened to the milk supply. She may be suffering 
 from an organic disease of the heart, lungs, liver, or kidneys of so seri- 
 ous a nature that she can not endure the strain of nursing. Women who 
 are ill with tubercular disease, even of an incipient character, of any part 
 of the body, but more particularly of the lungs, should not nurse, both for 
 their own good and for the baby's. Certain women have no milk at all, 
 or the mother's milk may cease to agree with the child at any period of 
 lactation. After the sixth month most children will thrive on artificial 
 food if it is necessary to wean them from their mother. Before the sixth 
 month the necessity for a wet nurse will be raoi'e urgent in proportion to 
 the lack of vitality and to the growth of the baby. The artificial food 
 should be given a trial even if the crisis arises during the first week of 
 life. A wet nurse is indispensable in certain cases of weakly infants, but 
 should be held back as a last resort in all cases. In the case of sick chil- 
 dren the securing of a wet nui'se should not be postponed until it is too 
 late to save the life of a child. In the case of healthy, strong children, 
 the preference is given to artificial feeding because proper nutritious food 
 can be easily prepared by modifying cow's milk (because wet nurses are 
 the most difficult of servants), and because wet nurses are liable to the 
 same faults as regards their milk as are the mothers themselves, although 
 to a less degree. 
 
 A wet nurse should be chosen by a physician and only after a careful 
 physical medical examination, which should be of the same nature and 
 equally exacting as the regular examinations given by physicians to can- 
 didates for life insurance. In addition, the condition of 
 
 T.r the breasts and of the milk must be investio-ated, and, 
 
 Nurse. _ • • <• i 
 
 most important of all, the present condition of the 
 
 nurse's own infant must be thoroughly examined to determine evidences 
 
 of disease and retarded development. 
 
 The proper modification of cow's milk will solve the problem of the 
 
 correct food for any given baby. The milk of the ass and that of the 
 
 goat are expensive, and are not of practical importance in this country 
 
764 DISEASES OF WOMEN AND MIDWIFEKY. 
 
 at least, althou<;li both have been used and reeoimuemled highly in 
 
 France. 
 
 Cow's niilk differs from human milk in eontainiuij; a less quantity of 
 
 milk sugar and a greater (juantity of curd or easoin, Mhich is of a 
 
 more lumi)v consistence when coagulated. The lirst 
 Artificial Food. ^.^^ , -^.i xi • i " i i. i 
 
 ditticulty Mith the casein may be overcome completely 
 
 by dilution ; the second will be modified by the same process, and will be 
 
 nioditied further by the character of the diluent. If cow's milk be diluted 
 
 with alkaline fluids, such as lime-water, or with boiled starchy fluids, 
 
 such as barley water, its casein will precipitate in the process of digestion 
 
 in thinner curds than is usual. 
 
 Commercial cow's milk varies further from human milk as delivered 
 directly into the mouth of the child in having an acid instead of an alka- 
 line reaction, and in containing a greater or less number of bacteria, 
 whereas all milk is delivered from the secreting gland in a sterile condi- 
 tion. The acidity should be neutralized by the addition of an alkali, and 
 the limewater already spoken of as a diluent for the casein will accom- 
 ])lish this neutralization. 
 
 The removal of the bacteria is accomplished not by actually removing 
 them but by destroying them. The process of destruction may be by 
 heating the milk to the boiling point in a closed vessel, and is known as 
 sferilizafiofi, or by heating the milk in sealed vessels to a tempei-ature be- 
 low boiling, but which is high enough to destroy the germs and most of 
 their spores. This process is c&Wed pasteurizatioJi. Applied to milk, the 
 ]iasteurization is accomplished by heating to ir)8° Fahr. for a period of 
 thirty minutes. 
 
 Perhaps the best method of preparing artificial food for infants is 
 that detailed by Dr. Holt in his Cat/iechis?n on the Care and Feeding 
 of Children. To prepare twenty-four ounces of food he allows a quart 
 and half a pint (forty ounces) of milk to stand in a high milk bottle for 
 six hours, and removes the top eight ounces (half a pint) ; he secures in 
 this manner a cow's milk which contains an excess of cream or fat and 
 the amount of casein normal for cow's milk. He dilutes this top milk 
 with twice its volume of barley water, and secures thus a cow's milk con- 
 taining the amounts of casein and of cream which are normal for human 
 milk. He has in addition so modified the conditions that the casein will 
 coagulate in fine flocculi and not in large masses. 
 
 Barley water is made by boiling a quart of water and two tablespoon- 
 fuls of barley for six or eight hours, straining through a cloth, adding 
 salt, and replenishing the water as it boils away. A quicker method is to 
 cook two teaspoonfuls of Robinson's prepared barley flour in a pint of 
 water for twenty minutes. 
 
 It only remains to add sugar to the diluted cow's milk already de- 
 
ARTIFICIAL FOOD. 
 
 T65 
 
 Fig. 4. — Fkeeman pasteurizer arranged for heating the milk 
 befoee the pail is covered. 
 
 scribed, and in the case cited Dr. JJolt docs tliis in the proportion of six 
 
 heaping teaspoonfnls of milk sugar. In this manner a food is supplied 
 
 which is suitable for 
 most liealthy babies 
 for any age up to 
 eight months. 
 
 The total amount 
 needed will vary ac- 
 cording to the age of 
 the child and to the 
 amount necessary for 
 each feeding and to 
 the number of feed- 
 ings. The amount 
 necessary for each 
 twenty - four hours 
 should be prepared 
 at one time. It should 
 be put in the requi- 
 site number of bot- 
 tles, which should be 
 
 stoppered with a plug of cotton batting and put through the pasteurizing 
 
 process. 
 
 The bottles should be kept on 
 
 ice, and warmed by standing them 
 
 in hot water one 
 Care of the Bottles. , ^- -, 
 
 at a tnne when- 
 ever it is necessary to feed from 
 one. Each bottle should be thor- 
 oughly rinsed and cleaned imme- 
 diately after using, and all should 
 be boiled in a large pail together 
 before being used again. The rub- 
 ber nipples should be kept in a 
 solution of boracic acid and be 
 rinsed with clean water before 
 using. 
 
 The pasteurizing process is 
 done with a special pail and bottle 
 rack known as the Freeman pas- 
 teurizer. The method is as fol- 
 lows : The pail is filled to the 
 mark A with water and this is Fi«- s.-Freeman PAsxErRizER arranged for 
 
 cooling the milk. 
 
TOG DISEASES OF WOMEN AND MIDWIFERY. 
 
 brought to a boil; the bottles, tilled with milk at the teinperatiii-o of (he 
 
 room and each one surroiuukHl in its own i-ack by cold water, is jilnnged 
 
 into the boiliiiii; watei-. I'lie cover is closed ami the 
 Jlethoi] of ^ . " 1 ,. xi J? 1 11 1 , 
 
 „ . ... ai^paratus is removed Ironi the nre and allowed to 
 
 Pasteunzatton. ' ^ 
 
 Stand for half an hour on the floor (not on stone or 
 iron). The rack of bottles is tluMi i-aisrd. and. l)y running cold warer into 
 the ]>ail, the milk is rapidly coi>led and is ready for storing on the ice. 
 Fig. 4 shows the pasteurizer just after the bottles of milk have been 
 placed in the boiling water and before the pail is covered. Fig. 5 shows 
 the apparatus arranged for cooling the milk. 
 
 CHAPTER VIII. 
 PATHOLOGICAL CONDITIONS. 
 
 The diseases which are peculiar to the female sex are connected with 
 the functional activity of the female sexual organs. The origin of these 
 disorders is traceable most often to the act of childbearing, which may be 
 considered to include the condition of pregnancy and that of lactation. 
 The non-pregnant condition or period of menstrual activity is a secondary 
 factor as a cause of disease. 
 
 Many of the subjective signs of pregnancy may become developed to 
 such an excessive degree that they will become a truly abnormal condi- 
 tion and may then be classed as a " disease." The most 
 Bifteases of Freg- . ii.!ci.i' • ^ £ 
 
 y," ... important or these is an excessive amount ot vomitino;. 
 nancij : vomiting. ' ^ ^ 
 
 This may occur with so much persistency that the ])a- 
 tient loses flesh and strength, becomes pale, develops a low fever and an 
 extreme rapidity and feebleness of pulse, and may even grow so weak 
 that life itself is threatened. If fatal, the symptoms are those of starva- 
 tion^ — fainting attacks, muttering delirium, disturbances of sight and hear- 
 ing, and finally unconsciousness and death. Such cases should never be 
 allowed to go to the final stage, but radical measures should be adopted 
 as soon as the_y become febrile and the pulse grows rapid and feeble ; of 
 course medical care will liave been sought at an earlier period. The 
 measures already suggested for the relief of the vomiting of pregnancy 
 are as far as home treatment should be pushed ; further measures depend 
 on the peculiarities of individual cases, and, together with operative inter- 
 ference, are beyond the scope of this article. 
 
 The further derangements of the alimentary canal, constipation and 
 diarrhcea, may develop to an excessive degree and threaten the termina- 
 
PATHOLOGICAL CONDITIONS. YGT 
 
 tion of pregnancy. The diarrhwa of pref^nancy is a patliological state 
 
 in wliich the patient may grow thin and .starve to an excessive degree 
 
 similar to- that caused by vomiting. The constipation 
 
 onsipa ion am jm^j,|- \yQ counteracted Ijy the use of mild laxatives and 
 Diarr/ioea. ;' 
 
 of enemata. The various preparations of buckthorn 
 
 bark are good cathartics in these cases, but the enemata Avill give perhaps 
 the best results. The diarrhoeas must be controlled or the pregnancy be 
 terminated ; only careful medical treatment will accomplish either result. 
 The condition of poor nutrition which is so common in the first 
 months of pregnancy may persist without any causal relation to the dis- 
 turbances of alimentation just described. These pa- 
 
 . . tients become extremely pale and weak, surier irom 
 
 Ancerma. . . . 
 
 shortness of breath and palpitation of the heart, also 
 
 from attacks of fainting. They may have mild fever and the feet may 
 swell up moderately. They may bleed from the nose, stomach, and l)0wel8. 
 Although ill, they do not grow especially thin. This condition is very 
 serious and is often fatal. The only treatment is medical : to terminate 
 the pregnancy artificially. 
 
 There is a certain form of inflammation of the kidneys which is char- 
 acteristic of the pregnant condition, and which is a very serious complica- 
 tion when present. This disease is very insidious in 
 Kidney Disease. . . ^ , • t ^ ,••'•,! 
 
 its onset, but gives regularly certain signs in the urine 
 
 before the serious symptoms dev^elop. It is to anticipate such a com- 
 plication that the urine of pregnant women is examined at regular 
 intervals by their medical attendants. This precautio7i should never he 
 omitted., for the most dangerous eomplieation of "pregnancy may arise in 
 ajpjpearance suddenly., hut in reality after having given a neglected hint 
 in the urine., and perhaps nowhere else. As a rule, however, there are 
 other symptoms : persistent frontal headache ; pain in the upper part 
 of the abdomen, with or without nausea and vomiting ; double vision ; 
 dimness of vision ; spots before the eyes, even blindness ; swelling of the 
 face and hands ; also, but less characteristic, swelling of the feet and legs. 
 The patient becomes short of breath even when at rest, and her mental 
 condition changes — either to become irritable, or, on the contrary, somno- 
 lent. The most striking danger signs except the urine are the eye symp- 
 toms, the swelling of the face, and the condition of the nervous system. 
 These precede more or less directly the dangerous condition due to kidney 
 inflammation — the so-called eclampsia. 
 
 The symptoms of eclampsia are an alternating condition of nervous 
 
 irritability and nervous depression, a state of convul- 
 Eclampsia. . ^ , , c • mi ^ • 
 
 sion, and a state or unconsciousness, ine convulsions 
 
 of eclampsia are fairly characteristic ; the patient first stiffens all her 
 
 muscles and grows livid because of cessation of breathing, and then after 
 
768 DISEASES OF WOMEN AND MIDWIFERY. 
 
 a short half minute begins to work the arms and legs and jaw in repeated 
 jerks. This hists tive minutes or less, and the patient passes into an un- 
 conscious state which may last ten minutes or a number of hours. Even 
 when of short duration the loss of consciousness is replaced by a state of 
 stupor, which will be interrupted by fresh tits, by death, or by a gradual 
 return to normal conditions. 
 
 The treatment for the bystanders should consist of restraining the pa- 
 tient only so much as will ])revent her falling from the bed or otherwise 
 injuring herself, and especially to i)r()tect the tongue by inserting a towel, 
 cork, or jneee of soft wood between the teeth, so that the tongue will not 
 be bitten. The best treatment to shorten and control the tits is chloro- 
 form inhalation. This is, however, somewhat dangerous in unskilled 
 hands and should be kept as a last resort. Of course such a patient needs 
 immediate obstetric aid, and this is beyond the power of the nurse or 
 friends to give. 
 
 The best treatment is the preventive treatment, and all patients who 
 show any of the danger signals already mentioned should be put upon a 
 diet which will give the kidneys and other food-transposing organs as 
 little work as possible. Such a diet is an exclusive milk diet, and such 
 a patient should take in each twenty-four hours as much of two quarts of 
 milk as possible and should eat nothing else. Other measures should 
 be modified to suit the condition of each particular case, but only under 
 the direction of a physician. 
 
 Similar fits may occur from apoplexy or from epilepsy. If the former, 
 the outlook is no better than in eclampsia ; if the latter, there will be a 
 history of previous attacks and no repetition of the fit, and the patient 
 will return to her normal mental state Avitliin half an hour. Fits of very 
 deceptive nature may be caused by hysteria, but both in hysteria and in 
 epilepsy all the other signs, including those in the urine, are absent. 
 
 Infiammation of the parturient tract may occur during any pregnancy. 
 
 The inflammations of the vagina are the most common. The symptoms 
 
 are similar to those of inflammation at any time, and 
 Local Disease in Mir. • , , ^,,11 1 c • t ■ 
 
 „ will often require treatment at tlie hands or a specialist. 
 
 Jrregnancy. ^ ' _ 
 
 There are a number of abnormal conditions which are 
 connected more directly with the fuitus itself which niust be included 
 among the diseases of pregnancy. 
 
 The foetus may die at any period of pregnancy. When this occurs 
 the natural course of events is checked and the woman begins to feel 
 
 weak and sick ; she presents the signs of pregnancy, 
 .J 'p / and then these signs suddenly cease developing and 
 
 there is a partial attempt to begin lactation. These 
 signs of pregnancy in part disappear and the remainder remain station- 
 ary. When such an event occurs the foetus may remain indefinitely in 
 
DEATH OF THE FGSTUS. 709 
 
 the uterus. Tlie smaller the IVjotus, the longer the period of tiine that 
 
 must elapse before it is expelled. 
 
 In certain cases the membranes and afterbirth go on developing after 
 
 the death of the fcetns, and the result is a formation of 
 Molar Pre.cimmry. ,, , , ^m ■ •^■\ i n i • ■.. •, 
 
 a so-called mole. Ihis will be expelled in part as bttle 
 
 grape-like vesicles, and lead to a diagnosis being possible. 
 
 Another accident to the impregnated ovum is that it begins to develop 
 
 in the tube connecting the ovary with the uterus and not in the uterus 
 
 itself. Such a condition can persist for a certain length 
 Extra-uterine « , . • j_i i j_i ^ . <. 
 
 Preqiiancu. ^ ^^"^® '^ ^^^ ^^^ regular symptoms of pregnancy, 
 
 but after a varying period of six weeks to three months 
 the patient has attacks of pain and an irregular but fairly frequent Ijrown 
 discharge from the uterus. Such pains should attract and demand atten- 
 tion and lead to a careful examination by a physician. The treatment is 
 strictly surgical. 
 
 The foetus may be expelled before the natui-al end of pregnancy. 
 Such an event is styled an abortion in the early months, an immature 
 
 labour in the middle months, and a premature labour in 
 
 the latter months of pregnancy. The classical symp- 
 toms indicating that such an event is threatened are pain and hasmor- 
 rhage. The pain is similar to labour pain — intermittent, sharp, and referred 
 to the lower abdomen and back. The haemorrhage is more common in the 
 earlier months and may be quite profuse ; it is apt to be the earliest 
 symptom. The later the event occurs the more nearly it resembles normal 
 labour. 
 
 When a woman is threatened with an abortion she should keep per- 
 fectly quiet in bed and live on a restricted diet. She should avoid all 
 excitement of visitors, exercise, and amusement. If the miscarriage is 
 inevitable, the woman should take the same precautions about cleanliness 
 and surgical antisepsis as is necessary after labour. She should also be 
 content to keep quiet and in bed until the pelvic organs have regained 
 their normal condition. The medical treatment of abortion is compli- 
 cated and should be left to skilled hands. 
 
 Another error in development of the foetus is the formation of the 
 
 afterbirth in the lower and not the upper segment of the uterus. In 
 
 . consequence of this the afterbirth grows in front of and 
 
 not behind the foetus, and the child can not be born 
 until the placenta separates in whole or in part to make a passage for it. 
 The separation will cause a certain amount of bleeding, which may be of 
 alarming proportions. ITeemorrhage from the uterus during pregnancy 
 may occur, as already noted, during the first few months and have no 
 special significance. Such a flow of blood takes place at the regular in- 
 tervals at which a normal menstruation would have occurred if pregnancy 
 51 
 
770 DISEASES OF WOMEN AND MIDWIFERY. 
 
 liad not supervened. It is of less amount and less duration than that of a 
 regular period and gives no other symptoms than the loss of blood. 
 Haemorrhage in the earl}' months of pregnancy is one of the principal 
 symptoms of threattMied abortion ; in such cases the amount of blood is 
 greati'r, it is of brighr-reil colour, and there is usually a discharge of clots. 
 The llow may begin after some fall, and the time has no necessary rela- 
 tion to the interruj)ted monthly tiow. The second pi-incipal symptom of 
 abortion (pain) is soon added, and the ease develops the characteristics of a 
 true abortion ; or the symptoms subside and abortion does not take place. 
 After the third month of ]:)regnancy there should be no haemorrhage until 
 after the birth of the child, except for a slight show when true labour 
 begins. The condition known as placenta praevia, however, will cause a 
 loss of blood, and in considerable and dangerous quantity, not only when 
 labour begins but even before that period. 
 
 The usual course of these cases is that there will be a number of at- 
 tacks of loss of blood occurring at irregular intervals between the fifth 
 and eighth months of pregnancy. These attacks come on suddenly with- 
 out previous warning and cease as quickly as they began. The amount 
 of blood lost is usually small at first, but the final attack is apt to threaten 
 life itself, because the amount of blood is so considerable and it is shed 
 so rapidly. 
 
 The complication of placenta praevia is one of the most serious that 
 can arise in the course of a pregnancy, and its treatment demands prompt 
 action and accurate kiu)wledge on the part of any practitioner. The 
 lesson to be learned by the laity is to appreciate the importance of the 
 seemingly inconsequential loss of blood of the early attack, and to summon 
 professional aid before the serious accident occurs and the patient is be- 
 yond relief. 
 
 It remains to speak of pregnancy occurring in women who are sufiEer- 
 
 ing from chronic diseases. The chronic diseases of the specially vital 
 
 organs — the heart and lungs — are the ones of real 
 
 Pregnancy in . , . „ ^, 'j, 
 
 ^, . r>- mi])ort. All the organs ot a prei^nant woman are 
 
 Chronic Diseases. '■ & i t? 
 
 placed under an extra strain by the mere fact of preg- 
 nancy itself. If any organ is diseased to a degree to interfere with its 
 functional activity it will do poorer work during pregnancy than before. 
 AVomen who have an active tubercular process in any organ, especially 
 if it be in the lungs, undergo a distinct increase of risk by becoming 
 
 pregnant. Tubercular disease will become active after 
 Tubercular and ^ ■[ -^ ^ ^ • ^ j^ ^ 
 
 n , n- a pre^fuancv, even when it lias been quiescent lor a long 
 
 I'almonary Disease. , ^ " , . -, . . . 
 
 time. The period just after confinement is the critical 
 
 one, and prolonged lactation is a very serious menace to the life of tlie 
 tubercular woman. The children of tubercular mothers inherit a weak- 
 ened constitution and diminished power of resistance to the tubercular 
 
COMPLICATIONS OF LABOUR. 771 
 
 germs; tliey may even be the subjects of tubercular disease at tljo tiino 
 
 of their birth. 
 
 Organic lieart disease results in a mechanical interference witli the 
 
 heart's action. Pregnancy, by tlirowing more work on this pump, will 
 
 cause increased symptoms of mechanical interference, 
 Heart Disease. i n ^i ^' j- . i i , i . 
 
 and all the symptoms oi an uncompensated heart lesion 
 
 will arise. The result to the woman will vary in proportion to the amount 
 of disease present in the particular case. The milder cases will not be 
 seriously disturbed ; the serious ones may prove fatal. Each case must be 
 judged for itself ; but one can state the general rule that repeated preg- 
 nancies are to be avoided in women with organic disease of the heart. 
 There is no bad result to the child born at term of such a mother, but 
 pregnancy in such women is apt to end prematurely in abortion. 
 
 Pregnancy occurring in a woman who has Bright's disease of the 
 
 ^^., ^. kidneys will cause an increase of the existino; disease. 
 
 Kidney Disease. „, . "^ c i i . i i i ^ 
 
 Inis condition ot tlie kidneys has also a tendency to 
 
 terminate the pregnancy. 
 
 Pre-existing disease of the nterus, whether inflammatory or of the 
 „, . ^ . nature of a displacement, has a very marked effect upon 
 
 the normal termination of pregnancy. Repeated abor- 
 tions, or the delivery of stillborn children, constitute the regular obstetric 
 history of such patients. 
 
 The various complications of labour and of the lying-in period demand 
 
 prompt interference and skilful attention. It is beyond the scope of this 
 
 article to detail all of these diseases and their operative 
 
 r , treatment. It will suffice to point out the prominent 
 
 Labour. ... . , 
 
 symptoms, and to assist in this manner to a recognition 
 
 of the conditions which demand absolutely a physician's aid. 
 
 The average duration of labour is for first labours, twenty-four hours; 
 
 for subsequent labours, twelve hours. The greater part of this time is 
 
 taken up by the period of dilatation. Delay may occur 
 Prolonged Labour. , • i i , • p • , i • ' , " i , i 
 
 at any period, but is oi more vital importance both 
 
 to, mother and to child when it occurs during the stage of expulsion. 
 Besides the evidence of some obstruction given by the mere lapse of time, 
 the woman will present certain symptoms : she will become weak and 
 feverish, her pulse will grow rapid and feeble, her tongue dry, the pains 
 change character, after a period of increased activity the uterus becomes 
 tired, and the pains occur at long intervals and are weak. There are 
 many causes for such delay, but they are beyond relief so far as an ordi- 
 nary nurse is concerned. 
 
 If there is delay in the third stage and the placenta is not expelled 
 within a reasonable time, no special harm can come to the woman, and 
 she should be washed and put to bed to rest quietly. If the afterbirth is 
 
772 DISEASES OF WOMEN AND .^IIDWIFERY. 
 
 not delivered at tlie end of twenty-four hours help should be secured. 
 
 During the waiting period the uterus should he watehed l)y j^lacing a 
 
 luind on the al)donuMi, and auv tendenev of this organ 
 Retained Placenta. , ^ ,. , , ,', ^ 'w ^ \ £ ■ !• 
 
 to eidarge or to sotteii snoukl be controlled by irietion 
 
 and by pressure. The immediate ilanger of such relaxation is post- 
 partum hfeniorrluige. 
 
 If the outlet of the genital canal has been torn it will heal under best 
 conditions if it is sewed together by a surgeon. If the tear is small, or if 
 no surgeon can be secured, it will reijuire no special 
 treatment otlier than extreme cleanhness and as little 
 movement of the injured parts as nuiy be. It may be wise to tie the pa- 
 tient's knees together for a week excej)t when necessary to change her 
 dressings. Such patients should be longer in getting up and about after 
 conlinenjent. 
 
 Haemorrhage before labour is finished is a rare com])lication. It oc- 
 curs more especially in the cases of placenta previa already described. 
 
 „ , Ilaemorrhaoje after labour, however, is more frequent, 
 
 Mivmorrnaqe. , . .,, n tj- 1 
 
 but IS stul an infrequent occurrence. It present, such 
 
 a hfpmorrhage may be a very serious and even fatal event. 
 
 The signs of threatened lia^morrhage are a relaxed condition of the 
 uterus and a rapid pulse. The blood may collect in the dilating uterus 
 or it may appear externally at once. The amount lost may be consider- 
 able — four, five, or more double handfuls of clots may be expelled in half 
 as many minutes. A large double handful of clots is not an infrequent 
 accompaniment of normal labour, but more than this will mean an exces- 
 sive flow. If a woman is l)leeding she will present the general signs of 
 loss of blood. She becomes pale ; she feels faint ; she has thirst for water 
 and for air; her pulse is rapid, weak, and in-egular. In the worst cases 
 she becomes restless and thrashes about her bed. With the first shock 
 the body temperature falls, and subsequently rises again to a point above 
 the normal. 
 
 The treatment is first to stop the flow, and second to support the 
 woman's general strength. If haimorrhage occurs, the uterus must be 
 sought for and pressed upon through tlie abdominal wall. It must be 
 held continuously in its contracted condition for at least an hour after 
 the bleeding ceases, and must be closely watched for two hours longer. 
 As soon as the uterus is found and held, hard pressure must be made to 
 squeeze out the contained clots and the afterbirth, if it is not yet expelled. 
 This pressure must be hard enough to be distinctly painful, and should 
 be directed in such a way that the top of the uterus is pushed back and 
 down. A piece of ice on the abdomen will he]j> temporarily. Allowing 
 the baV)y to nurse on the mother's breasts w'ill induce uterine contraction. 
 As to drugs, two will be of value — one dose of twenty drops of laudanum, 
 
COMPLICATIONS OF THE LYING-IN PERIOD. 
 
 « 1-5 
 
 or an opium pill of one grain, or a morphine pill of one sixth of a grain, 
 sliould be given to quiet tlie nervousness and restlessness and to steady the 
 lieart, and a teaspoonful of the fluid extract of ergot will help to cause a 
 contraction of the uterus. A third drug which will not only not helj>, but 
 which will be of a distinct disadvantage, is wine or whiskey or other form 
 of alcohol. After the first flurry is over and the uterus is held firirily, 
 a final local measure may be taken in the shape of a hot vaginal douche. 
 This douche should be given only with strictest antiseptic precautions 
 and with the douche bag and previously sterilized nozzle. The douclie 
 should be at least four quarts of boiled water, to each quart of which a 
 tablespoonful of vinegar has been added, and should have a temperature 
 of 110° Fahr. After the douche a fresh sheet may be spread doubled up 
 under the patient's hips, but no special care should be taken for sesthetic 
 cleanliness' sake. The patient needs quiet and rest above all else, and 
 must be disturbed as little as possible. Finally, the foot of the bed may 
 be raised and the patient's legs bandaged tightly from the toes up, to 
 squeeze the blood out of the limbs into the body, where it will reach the 
 brain and the heart and do the most good. The patient's thirst may be 
 alleviated by water, cracked ice, and small amounts of milk, and other 
 fluid food should be given at frequent intervals. After twelve hours she 
 may have solid food if she can digest it without distress, and a plan of 
 general tonic treatment and diet must be followed. 
 
 The conditions already described as diseases of pregnancy may com- 
 plicate labour as well as pregnancy. They may not de- 
 
 Other Complications , .-i i i t, • " i-i "^ Ci. i i 
 
 J, T , velop until labour beffins, or even until alter labour is 
 
 of Labour. ' . 
 
 ended. 'The most serious of these are eclampsia and 
 placenta praevia ; they need no further notice here. 
 
 The whole list of complications of the h'ing-in period, except for those 
 
 which, beginning before labour, continue in an active state afterward, 
 
 may be summed up in the one ^^ordi— fever. It has 
 
 Complications of ^^^^ ^^^^^^ already that the normal condition of a 
 
 the Lying-tn Period. '\ e • i • i i n i 
 
 woman after labour is an afebrile one, and it should be 
 
 a routine practice to take the patient's temperature every morning and 
 evening. The thermometer will find here a veiy important use, for no 
 other one symptom is a better indication that some trouble has arisen or 
 is threatening. At the same time the degree of temperature is a very poor 
 criterion of the severity of the illness in general or of the critical nature 
 of the woman's present state. Care must be taken, therefore, to look for 
 other signs of trouble, and not to infer a fatal issue because a woman's 
 temperature rises suddenly to 104° or more. ^Neither must one go from 
 the depths of despair to the ecstasy of hope with every rise and fall of 
 the clinical thermometer. There is no worse habit than the constant 
 taking of a patient'' s temperature j it teases the patient and it icorries the 
 
774 DISEASES OF WOMEN AND MIDWIFERY. 
 
 friend^', (uul dots no (jood tv/mttCt r. The toiuprraturo i^lioulJ be taken 
 at regular intervals, Nvliieh should be every twelve hours in these 
 patients. 
 
 Puerpei'al fever is a general ti'i-iii, and means that lorni of " blood 
 poisoning" wliieh arises from an infeetion of the parturient wounds, 
 more espceially of the wounded blood-vessels and tissue 
 spaces at the site of the separated placenta. There are 
 other causers of fever in the puerperal state, but this wound infection is 
 the most serious, and in its severe forms one of tlie most dangerous, of 
 all diseases. 
 
 It is the fate of most women to begin labour in a constipated condi- 
 tion, and this may have no special influence on the course of events 
 to follow. In certain cases, however, a very marked 
 
 ^, ,. /. febrile reaction will arise, due entirely to the constipa- 
 
 Constipntion. ' *' ^ 
 
 tion present. The fever of constipation usually is mani- 
 fested by the third day, and is characterized by a more or less sudden rise 
 of temperature, even by a chill ; the pulse also becomes quickened, but 
 not excessively so ; thus, with a temperature of 103° Fahr., the pulse \k\\\ 
 often be below 90. 
 
 Besides the constipation there may be slight tenderness on the left side 
 of tlie abdomen just above the groin, and a frontal headache, loss of ap- 
 petite, and general feeling of illness will complete the clinical picture. 
 The treatment is simple and consists of cathartics. Of these, perhaps 
 the salines are the best. A simple enema of soapsuds and water may be 
 necessary to start the action of the bowels. 
 
 Another common cause of fever is found 'in the mammary glands. 
 
 When regular nursing is begun the nipples are very apt to become bruised 
 
 and even cracked, and an infection of the gland may 
 Fever from the m ^ i i ^i i ^i • i mi i i 
 
 D , easily take place through this wound. ihe glands, 
 
 "caking" under the influence of beginning activity, 
 become engorged with blood, swollen, painful, and tender. If an infec- 
 tion through such a nipple invades such a gland, a more or less intense 
 inflammation will result. Inflammatory disease of the breasts may occur 
 at any period of lactation, but it is most fi-equent during the first two 
 weeks. 
 
 The symptoms of such an attack are a rather rapid rise of tempera- 
 ture and a quickened pulse-rate, a headache, and general body pains, 
 especially in the back ; there may be vomiting at the outset, the bowels 
 may be constipated or normal, and the appetite is capricious. 
 
 The local signs are a hard, tender, painful, reddened swelling of one 
 or both breasts. These signs may be diffused or localized in a certain 
 part of the gland. The affected area is apt to be more or less triangular 
 in shape, starting from the fissured nipple as an apex and spreading over 
 
PUERPERAL BLOOD POISONING. YY5 
 
 a widening surface to the periphery. Tliis area is reddened in proportion 
 to the amount of iiivolvetnent of. the sl<iri itself. 
 
 If an abscess is to form tliere will be a limited area of inflammation, 
 which finally becomes soft, and, if left alone, the skin bi-eaks tlirough in 
 one or more places and there is a discharge of pus. 
 
 The course of these inflammations is either short, ending in resolution 
 after forty-eight hours or so, or an abscess forms, and they run a tedious 
 and long course to a cure. The short cases do not interfere with nursing ; 
 the longer and more severe ones check the flow of milk entirely, so far 
 at least as the infected breast is concerned. 
 
 The treatment of the early stages is the same as already outlined for 
 simple caking of the breasts, and consists of liot stupings repeated every 
 three hours and continued for periods of ten minutes each time. In 
 the intervals the breasts should be supported by a binder. The bowels 
 should be freely evacuated by saline cathartics, and the patient should be 
 put on a restricted diet for forty-eight hours. Nursing should be con- 
 tinued regularly, and any abrasion of the nipple should be cauterized 
 once with a solution of nitrate of silver or with the solid drug (lunar 
 caustic). Many incipient cases of inflammation can be checked by such 
 treatment. If not so aborted, the treatment must be radically changed ; 
 and when pus is formed, surgical treatment, as for any abscess, is indi- 
 cated. Nursing must then be stopped on the affected breast and the 
 patient must be put on a generous diet. 
 
 One form of treatment should be mentioned only to be condemned : 
 
 the ordinary flaxseed poultice is a poor means of applying moist heat. 
 
 As usually renewed, at intervals of two hours, the poul- 
 Other Cases ,. ■, ., . r . i j? xi • • 
 
 . „ tice soon loses its extra heat, and tor tlie remaining 
 
 of Fever. _ _ ' , _ ^ 
 
 time the patient keeps the poultice hot instead of the 
 reverse being the fact. Any puerperal woman may be attacked by some 
 intercurrent disease having no special reference to her condition. Bron- 
 chitis and tonsillitis are among the commoner kinds of inflammation which 
 may arise. They need no special mention here. 
 
 The general symptoms of puerperal blood poisoning or septicEeraia are 
 those of any acute infectious disease, although the individual symptoms 
 
 are fairly characteristic. The temperature runs a very 
 Puerperal Sepsis. • , i " , , . t • i i , ,- i i ■ 
 
 variable course, at times high and at times low, reaching 
 
 even the normal or below. These variations occur at irregular intervals 
 
 and have no reference to the real course of the disease. The pulse is 
 
 rapid and in severe cases weak and irregular. The pulse is the best guide 
 
 to the patient's actual condition ; a low temperature and weak pulse is a 
 
 more critical state than the reverse condition of high temperature and 
 
 strong pulse. The pulse is more rapid than the mere rise of temperature 
 
 will suggest, and if the patient dies it is from failure of the heart's action. 
 
7TG DISEASES OP WOMEN AND MIDWIFERY. 
 
 The rapid elevations of teiniieniruro are verv apt to be aecoinpanied by 
 chills, and the sndiien falls in temperature by severe anil exhaustinjj^ 
 sweatin<^s. The onset of the disease is apt to be aeeoiupanied by nausea 
 and vomitinir, as are also the chills. iVt other times the patients will eat 
 and digest solid food, although the appetite must often be tempted. The 
 tongue becomes dry and coated. There is considerable headache and the 
 patient is restless and t;leepless. !She is delirious, esj)ecially when asleep, 
 but when awake is usually conscious even to the very end in fatal cases. 
 The bowels are regularly constipated, but there may be diarrhoea. The 
 urine is the dark-coloured and scanty urine characteristic of fever. 
 
 The local symptoms are also quite characteristic : the uterus, as felt 
 through the abdomen, becomes soft and tender to pressure, the abdomen 
 becomes swollen, and there may be general tenderness and abdominal pain. 
 The lochia become at first scanty, even absent, but after a day are re-estab- 
 lished and may present a foul odour. The secretion of milk is at first 
 unchanged, but if the disease lasts any length of time the milk will be 
 diminished often to a very marked amount. The patients lose flesh and 
 strength and colour, and feel ill even from the very beginning. 
 
 The cases vary much in regard to the severity of the attack. They 
 
 usually begin on the third day after lal)our, and may be a mere rise of 
 
 temperature lasting twelve hours, or a fatal attack may 
 
 Milk Fever. i & > ./ 
 
 result from the infection. The coincident occurrence 
 
 of the onset of fever and the beginning of the secretion of milk led early 
 observers to connect the two as cause and effect. This led to the naming 
 of this condition " milk fever." No necessary connection exists between 
 the two, and milk fever as such has disappeared from the lying-in cham- 
 ber. Mild cases, and severe ones, too, of puerperal infection still occur, 
 but the latter especially are much less common than formerly. 
 
 One especial form of puerperal infection must be mentioned apart ; it 
 is that form in wliidi the inflammation attacks the large veins and extends 
 
 „.„ ^ from those of the pelvis to the veins of the leof. As a 
 
 Milk Leg. j- ^ • ^ • , ^ , , 
 
 consequence oi tins the vems become plugged up by a 
 
 blood clot and the blood can not return from the extremity. The leg, 
 
 therefore, swells and remains large for some time. This is usually a 
 
 severe form of the disease, and as a consequence the secretion of milk is 
 
 diminished. The old idea M-as that the milk left the breast and settled in 
 
 the leg, hence the old name " milk leg." 
 
 The treatment of puerperal infection should be started early. The 
 
 first indications are to eliminate other possible causes of temperature. 
 
 The bowels should be freely moved by saline cathartics; 
 Treatment for . e ^ r t^ i\ i " ^ • i 
 
 Puerperal Infection. ^ teaspoonful of Epsom salts every hour for six doses is 
 
 usually efficient. The breasts should be treated as de- 
 scribed above if there be the slifjhtest evidence of trouble there. If after 
 
DISEASES OF THE NON-PREGNANT WOMAN. Y7T 
 
 thirty-six hours of this troatrncnt tl)(3 torr)[)('i'atiirG is not normal or does 
 
 not remain normal, there is probably an ini'octive process at work, and 
 
 skilful medical care is to be songlit as early as possil)le. 
 
 A word as to tlie diet of patients witli this fever may be added. \V(t 
 
 are very apt to take our views on this subject from tlie essential treatment 
 
 of our ffreat endemic fever — typhoid fever. These 
 Diet. . . 
 
 cases are really very different. There are in septicaemia 
 
 no ulcers in the intestine, which never fail in typhoid. The absolute rule 
 for fluid diet does not apply in this case, and in fact these patients do 
 best when taking all the solid food possible. They digest it readily and 
 they need the strength. Alcohol is very beneficial to them. Whiskey is 
 perhaps the best form for use in the United States. 
 
 The diseases of women may be classified as inflammations, displace- 
 ments, deformities from injury, and tumours. These various forms of 
 
 disease will be manifested by many similar symptoms, 
 Diseases of the Non- ■, .^ , . • •, , , i ' ' , i . . . . 
 
 pregnmii Woman. ^"^^ *^^^ diagnosis between the many subdivisions is not 
 
 always easy. It will suflSce for the present purpose to 
 detail the prominent symptoms of each group of cases and leave the dif- 
 ferentiation of the special case to experts. 
 
 Disease of the female pelvic organs may cause any of the symptoms 
 of disease in general. These signs of pathological process are called 
 
 general because they aft'ect the healthy action of the 
 Symptomatology , , t , ; , . ^ . ■ i i r- ,i 
 
 in Gener I body as a whole, and are distinguished from tlie symp- 
 
 toms called local, which are referred particularly to the 
 diseased portion of the body. These general symptoms present the pic- 
 ture either of an acute and more or less severe illness with all the mani- 
 festations of fever, or of a chronic cachexia with the loss of flesh and of 
 strength, with annemia and disturbance of the alimentary tract, and a 
 condition of complete or incomplete invalidism. The local symptoms are 
 manifested by varying amounts of pain and discomfort, by the develop- 
 ment of unusual discharges from the genital tract, and by disturbances of 
 the normal functions of these organs. 
 
 The chronic forms of disease are supposed to induce in these patients 
 a special set of symptoms which can be classified neither as local nor as gen- 
 eral in the usual acceptation of those terms. Of these peculiar or special 
 symptoms mention may be made of certain kinds of pain of a reflex na- 
 ture. The " left hj^pochondriac stitch" is a pain in the left side just below 
 the breast ; the " clavus " is a feeling as if a nail were being driven into 
 the head ; the mammary glands often ache and ai'e the seat of reflex 
 pains ; and finally there is a headache in the posterior part of the head 
 and neck which occurs frequently in these diseases. A feeling in the 
 whole pelvis akin to pain — the so-called "bearing-down pain" — is a 
 symptom of frequent occurrence in all pelvic disease. It is further pe- 
 
778 DISEASES OF WOMEN A>;D MIDWIFERY. 
 
 cnliar to these patients when the general niitiition suffers and they grow 
 pale and aiuvniie that they develop nervous symptoms of an liysterical 
 nature ; they become seltish and exacting and morbidly dispirited ; they 
 may even become hypochondriacal. Acute inflammation of the external 
 organs will present the symptoms of pain, swelling, redness, and local heat. 
 There will be an increased discharge, purulent in character, and there may 
 be painful and frequent efforts to pass water. Chronic disease of an in- 
 Hammatory nature of the external tissues, and inflammation of the deeper 
 organs, whether acute or chronic, will give similar but less pronounced 
 symptoms. AVhen the uterus is involved there may be a continuous dull 
 ])ain, tenderness to ])ressure, local swelling, and a feeling of heat referred 
 to the lower part of the abdomen in the middle line of the body. The 
 menstrual function will be deranged and may be too fi-equent and too 
 jirofuse. The patient may further develop, if married, a habit of abort- 
 ing, or she may become sterile. Displacements of the uterus by which 
 this organ is commonly tilted backward, or is pressed downward even to 
 appear externally at the vulva, lead to a similar train of symptoms. In 
 fact, both displacement and inflammation are frequently present in the 
 same organ. The pain in these cases of malposition varies somewhat, and 
 may be referred to the lateral part of the abdomen or low down on the 
 side and above the groin. Such pain is constant, dull in character, and is 
 increased by motion and exercise. It is commonest on the left side, but 
 may be bilateral and of a dragging nature. The pain may be referred to 
 the back, and then is situated over the lower part of the spine, usually 
 over the pelvic spine or sacrum. The neighbouring organs will be func- 
 tionally disturbed, and there will be frequent desire to empty the bladder 
 and a difliculty in moving the bowels. 
 
 Lacerations of the genital tract which cause symptoms are due to 
 severe injuries at the time of labour. The symptoms are due to the sub- 
 sequent displacement of the pelvic organs, or to more serious injury re- 
 sulting in the formation of communicating passages between the alimen- 
 tary canal or the urinary tract and the genital passages. 
 
 The tumours of the female organs are either alidominal or pelvic. 
 
 The symptoms of the former may be nothing more than an enlargement 
 
 of the abdomen. The symptoms of pelvic tumours are 
 Ttimours. . , , ' \ ^ t ■, 
 
 pain caused by pressure on the nerves descending to tlie 
 
 legs, which is therefore referred to the legs and not to the real seat of the 
 disease, severe and persistent constipation, and finally a watery, sanious^ 
 and offensive discharire characteristic of the more dangerous forms. All 
 tumours may cause a severe and prolonged flow of blood from the uterus. 
 Tumours of these organs may be small and of no consequence — the so-called 
 benign growths — or they may take on the must malignant character, prov- 
 ing in the end fatal, with every indication of a severe and wasting disease. 
 
XI. 
 NERVOUS AND MENTAL DISEASES. 
 
 By FREDERICK PETERSON, M. D., Ph. D. 
 GENERAL CONSIDERATIONS. 
 
 The nervous system is so closely connected with every organ and 
 tissue of the body, subserves so completely every function of the organ- 
 ism and of the mind as well, that care of and attention to it are of para- 
 mount importance. Undoubtedly, too, it is a nervous mechanism which 
 lies at the basis of heredity. Hence the great tendency of nervous dis- 
 eases in parents to entail upon the children shattered or unstable nervous 
 systems. 
 
 Nervous disorders are more likely to affect the progeny than any 
 
 other species of malady. It is therefore especially needful to guard the 
 
 nervous system of the growing child against not only 
 Nervous System of ,, n j? i tj. -l ^ • j^ ^i - '^- j? 
 
 pi -ij. the evils of heredity., out against the acquisition of any 
 
 nervous disorder that may prove disastrous in after- 
 life. The brain and spinal cord and nerves of a child are more impres- 
 sionable than any other portion of the organism. Upon them depends 
 the storing up of all the impressions received from without and which 
 constitute experience and all the higher functions which have to do with 
 experience, such as memory, judgment, reason, will, and the emotions. 
 A child may be looked upon as a bundle of nerves, easily stimulated by 
 every external impression ; easily overstimulated, too, so that its nervous 
 system reacts quickly to overwork of body or brain and to any illness 
 which may occur in it. It is remarkable how slight a bodily ailment or 
 irritation is needed to induce delirium or convulsions in a child, or bad 
 dreams and night terrors. 
 
 A nervous child, one predisposed by heredity or by a delicate organi- 
 zation to manifest nervous symptoms on the slightest provocation, should 
 be taken in hand early and the family pliysician or a specialist be asked 
 to regulate its daily life, lay out its hours of study and recreation and 
 sleep, and prescribe the kind of diet best adapted to its needs. Only by 
 such means can the evils incident to such a constitution be warded off. 
 
 779 
 
780 NERVOCS AND MENTAL DISEASES. 
 
 The c'liief causes of mental disease, and of a great variety of nervous 
 disorders also, are heredity and stress or strain of some kind. AVe shall 
 turn our attention more [)arrii'ularly to the (jiiestion of heredity. 
 
 IIEREDITV. 
 
 Let US suppose that we can trace our lineag-e huek to the time of 
 "William the Conqueror. The ])eriod of time consideretl is about twenty- 
 tive generations. As a person has two parents, four grandparents, eight 
 great-grandparents, sixteen great-great-grandparents, and so on, one can 
 readily estimate that at the time of "William the Conqueror there were 
 33,554,432 ancestors actually taking part at that time in the formation of 
 the descendant in existence at the present day. Adding to these, how- 
 ever, the intermediate forefathers between that date and to-day, the 
 figures prove to be in round numbers about 67,000,000. 
 
 Now, as blood, while not really ranking as a heredity carrier among 
 physiologists, has from time immemorial expressed that idea, as evidenced 
 by the common phrases " blue-blood," "blood will tell," 
 etc., I carry my arithmetical process a little further by 
 estimating that the descendant has 76,800 drops of blood in his body, so 
 that had each ancestor contributed an equal share to its composition, that 
 of his forbear in the time of "William the Conqueror w'ould have been a 
 little over yoVir ^^ ^ drop. 
 
 But the truth is that our ancestors do not so divide their bequests that 
 each has an equal representation in our physical and mental personality. 
 Galton, for instance, assigns one quarter of the heritage of a child to each 
 parent and one sixteenth to each of its grandparents, leaving one quarter 
 to be divided in a constantly diminishing fractional ratio among his re- 
 moter ancestors. I have attempted to solve the mathematical problem of 
 what intinitesimal fraction of heritage was left this descendant by one 
 who fell in the battle of Ilastings^about y.TTir.TrDT.imr.Tnro.Tnro'- 
 
 I have been assuming that the question of heredity is taken for 
 
 granted, though I have often been asked if I believed in heredity ; so I 
 
 infer there may be some who have not a very detinite 
 Heredity Defined. . , <• i ..,.,., . t -n 
 
 idea 01 wJiat is implied in the premises, i wul say, 
 
 therefore, that while the word is really a new one, and not to be found in 
 
 some of the dictionaries, the fact of our inheriting attributes from our 
 
 forefathers has been a matter of common belief in all ages. It is shown 
 
 in such expressions as "like father, like son," "a chip of the old block," 
 
 "good breeding," and so on. In Jeremiah it is said : "The fathers have 
 
 eaten sour grapes, and the children's teeth are set on edge." Heredity is 
 
 the theme of a number of Shakespeare's sonnets : 
 
 " Thou art thy mother's glass, and she in thee 
 
 Calls back the lovely April of her prime." 
 
HEREDITY DEFINED. T81 
 
 Heredity is one of tliosc trntlis so ti'ari.sf)Hrciit and ho otririi])i'(;.sorit tliut 
 we accept it without tl)oiii!;lit of it and its far-i-c^acliin^ cojiseqiicnces. 
 
 Like begets lii<;e. In the acorn lies iatent tlie ancesti-al oak, and as it 
 bursts from the ground it i^rows to be the exact counterpart of its parent 
 — bark and bole and branch and leaf. 
 
 From the willow springs the willow, and not the spruce. Man is not 
 born a shapeless mass of protoplasm, develoj)ing by cii-cumstance into 
 some fantastic creature ; but from his birth lie has in him the elements 
 which evolve the same muscles, bones, limbs, brain, eyes, hair — nay, the 
 very features of his ancestors. To be sure we are more startled by the 
 appearance of six fingers in the children of a six-fingered parent, because 
 of its uncommonness ; but is it not quite as marvellous and just as con- 
 vincing an argument for heredity that they have any fingers at all, and 
 especially that they have five, exactly the same number as their fore- 
 fathers had ? What I wish to express is, that it is not necessary to look 
 for the presence of unusual inherited traits, though these undoubtedly 
 serve to emphasize and call our attention to a fact so common that it 
 otherwise might escape notice. It is a truth so constant and so plain that 
 the word reproduction, when we stop to think of it, implies heredity — 
 for what is reproduced is something that has been already produced. We 
 start, then, on the self-evident principle that man, animal, and vegetable 
 are reproduced each after its kind. Not oidy are the same physical 
 characteristics inherited which give them their likeness to their ancestors, 
 but those more ethereal qualities and characteristics, such as the spiritual 
 and mental attributes of men and animals, the colours, taste, and perfume 
 of trees and flowers. 
 
 The discussion going on in the scientific world between Darwin. 
 Galton, Weissmann, and their followers is not so much as to the truth of 
 heredity as it is concerning the theories of heredity, as to what are 
 heredity-carriers, as to how and in what proportion ancestral qualities are 
 bequeathed to us, as to how we have been modified and improved through 
 the lapse of ages, as to whether acquired traits are inherited in great de- 
 gree or not. 
 
 Each man is made up of certain numbers of bones, muscles, nerves, 
 
 blood-vessels and organs, arranged in a certain form, which belong to him 
 
 as a man and distinguish his race from others. These 
 
 Racial and ^^.^ j.^^j^] characteristics which we all possess. Besides 
 Characteristics. ^^^^^® physical qualities we have other attributes, sucli 
 as instincts, emotions, perceptions, intellect, will, ethical 
 qualities, which may be summed up in the general term "human nature." 
 These are also racial characteristics, and are possessed by every ordinary 
 man. Our anatomies, then, and our human nature are the qualities given 
 us by the race, possessed in common by us all, and upon this racial 
 
782 NERVOUS AND MENTAL DISEASES. 
 
 foundation are built tlie (jualitios wliich distin^ui>li us from others — our 
 individual characteristics — as a rule comparatively slight variations in 
 physical structure and mental (pu\lities, for few are distinguished by any 
 extraordinary physical or mental atti-ibutes; when we are, it is expressed 
 by excess of one kind or another, and we become Samsons, monstros- 
 ities, geniuses, or idiots. 
 
 In going carefully over the human structure, however, we iind among 
 
 our racial characteristics certain eccentricities, so to speak, which are 
 
 shared by us all ; unnecessary appendages that certainly 
 
 ' ' » "'y ^^ ^^^ beloiiij to us, for we have no use for them, and 
 
 Organs. o ' ' 
 
 yet for countless ages we have been passing them down 
 by inheritance from one to the other. I allude to rudimentary organs, 
 such as, for instance, the three muscles which are attached to our ears, the 
 numnnary glands in the male, and the apjwndix vermifornns connected 
 with the large intestine, which gives us so much trouble by being the site 
 of appendicitis. Of what possible use are they ^ Innumerable other 
 animals and many plants possess similarly curious heritages. The ostrich 
 has no need for wings, nor the unborn whale for teeth, nor the mountain 
 tadpoles, which are never near the water, for gills {Salanmndra atra). 
 All these rudimentary organs are doubtless records of ancient states when 
 they were of service. They are reminiscent of conditions in the infancy 
 of the race. I cite them here because of their having been retained solely 
 through the wonderful force of heredity. They probably had no utility 
 even as recently as a hundred thousand years ago. Think of the virility 
 of those ancestors who have left this lasting impress upon us, and of the 
 extraordinary power of the heredity carriers which, in giving ns our 
 bodies and our human nature, have not forgotten these little testimonials 
 of kinship bequeathed us by our antique relatives. 
 
 Doubtless there are vestiges in our minds, too, of immemorial instincts 
 
 and aspirations which the complexity of our mental processes makes it 
 
 . difficult to discover ; for as the growth and develop- 
 
 Impulses "lent of our bodies as well as our minds depends upon 
 
 the brain and spinal cord and all the delicate filaments 
 whicli radiate from them to every tissue, so the nervous system plays the 
 most important part in the influences which have to do with heredity. 
 The nervous co-ordinations must be rearranged by strong stimuli in order 
 to be reproduced by the heredity impulse. This is why traits acquired 
 by US' in our individual lifetimes are not apt to be inherited by our de- 
 scendants. If a person loses an arm, his children are not deprived of that 
 useful member, for the nervous mechanism of development which has for 
 ages produced arms in their proper places and Mdiich is fixed in the pow- 
 erful hereditary impulse of the I'ace has not been changed. So in the 
 breed of dogs whose tails have been cut off for countless ijenerations, not 
 
EFFECTS OF ALCOHOLIC INDULGENCE. Y83 
 
 one is born witliout a tail, becaii.so the; nervous co-ordinations governing 
 the evolution of the tail bear down with all the hereditary force of the 
 race since its first beginning when the tail existed, thongli the animal was 
 legless, to keep it in existence. Probably if we could in some way reach 
 this nervous mechanism which is responsible for the evolution of the tail 
 we might prevent, or at least modify its development. Just as the physical 
 organization depends upon the nervous system, so too does the whole men- 
 tal organization. Both mental and bodily characteristics are hereditary. 
 
 Wherever the nervous system is profoundly disarranged — as, for in- 
 stance, in a number of nervous diseases — there may be a change in the na- 
 ture of the heredity impulse. Such profound derange- 
 Alcohol ment of the nervous system may be produced, for in- 
 
 stance, by poisons. As a striking and common instance 
 let us take alcohoL This poison, when taken to excess, vitiates the blood 
 and causes organic diseases of many viscera, but is particularly noteworthy 
 for its terrible effects upon the brain. "We have all heard of or met with 
 cases of alcoholic gout and the drink craze and alcoholic insanity, and 
 these conditions are well known to be hereditary. But there are other 
 hereditary states, not perhaps so familiar, induced by alcoholic indul- 
 gence. The children of an inehriate parent are not only apt to hefeeljle 
 physically and mentally^ hut, worse than this, idiocy and epilepsy are 
 frequently due to this ancestral vice. In a report on idiocy in the State 
 of Massachusetts one half of the idiots in an institution were the progeny 
 of habitual drunkards. I have under my charge in Xew York city some 
 five hundred idiots, on Randall's Island, and while it is difficult to obtain 
 accurate histories in the majority of cases, I am convinced that the pro- 
 portion due to drink in the parents is very large. Dr. Howe, of Massa- 
 chusetts, tells of a drunkard who was the parent of seven idiots. Dr. 
 Kerr mentions a. family of six children. The two oldest were perfectly 
 healthy ; after their birth the father became a habitual drunkard, and the 
 remaining four children were born during this period. One was feeble- 
 minded and the other three were idiots. 
 
 While alcoholic indulgence frequently causes epilepsy in its victims, 
 
 and this epilepsy may become hereditary, it is rather common to find 
 
 epilepsy in the children of drunkards who may not 
 
 CO ic n ug- themselves have been epileptic. It is one of the fre- 
 ence and ±jpilepsy. r i 
 
 quent legacies left by the inebriate to his children. If 
 
 not idiotic, or epileptic, or inebriate, the children of drunkards frequently 
 
 inherit shattered and unstable nervous systems, rendering them hysterical, 
 
 neurasthenic, possibly criminal, and an easy prey to insanity or other 
 
 nervous disorders. ISTor is it the first generation only that may suffer for 
 
 the parents' excesses. Such vicious heredity has been known to manifest 
 
 itself for at least three o;enerations. 
 
784 NERVOUS AND MENTAL DISEASES. 
 
 In passing to another form of profound (.li&arrani>:oniC'nt of nervous co- 
 ordinations sufficient to aflEect the hereditary impulse, let us look at in- 
 sanity. The two qreat factors in tlte production of all 
 cdHCis oj insanity are liereaity ami strain. iMnee most 
 peoi)le do noi hecome insane, it is evident that their iiei'vous systems are 
 sutticiently stable to withstand the oi-dinary incidents in the struggle for 
 existence. There are of course stresses of such severity that any ner- 
 vous organization, no matter how great its stability, may be upset ; but 
 the individual of average stability is not apt to be aU'ected by any of the 
 ordinary vicissitudes of human life. AVe may be sure, therefore, that 
 when insanity develops it is due to some hereditary weakness in the 
 nervous organization. It is not necessarily a direct legacy from insane 
 parents ; what is left to the child is a fragile nervous constitution, and 
 this may have descended from ancestors back of the immediate genera- 
 tion. The evidence of this inherited fragility of the nervous mech- 
 anism may present itself as insanity, or it may be epilepsy, or it may be 
 feeble-mindedness, or it may be criminal tendencies, or it may be sim- 
 ply nervousness, hj-steria, or certain kinds of headaches, or possibly only 
 eccentricity. All of these disorders are more or less interchangeable, 
 and are merely proofs of an unstable nervous organization. Thus hys- 
 terical or eccentric parents may have insane children, and e])ik'j)ti(' parents 
 criminal descemlants, and so on. Epilepsy and insanity are closely re- 
 lated, and their interchange is perhaps more frequently observed than 
 that of the other conditions mentioned. The tendency to an unstable 
 nervous structure may lie dormant for a generation or two, appearing in 
 the grandchildren or great-grandchildren. This phenomenon is called 
 latency, or reversion, also atavism, and is frequently observed in connec- 
 tion with various kinds of heritage in animals of all kinds. In human 
 beings it is noted in the nervous diseases already mentioned, and other dis- 
 orders, such as the hsemorrhagic diathesis, multiple fingers, and the like. 
 Xow as to the nature of criminal heredity. You have probably all heard 
 of the Jukes family. A Dutchman born about 173u gave origin to a pro- 
 geny numberino: in all perhaps twelve hundred members. 
 Criminal Ilcreditii. \ . ' r ^, . ' , T,r t-x i 1 11,11 r 1 
 
 Out 01 tins number Mr. Dugdale calculated by careful 
 
 study that there were two hundred and eighty adult paupers, one hundred 
 and forty criminals, sixty habitual thieves, seven murderers, and fifty 
 courtesans, and he calculated the loss they caused to the State in seventy- 
 five years to be one and a quarter million dollars, without " taking into 
 account the entailment of pauperism and crime of the survivors in suc- 
 ceeding generations, and the incurable diseases, idiocy, and insanity grow- 
 ing out of their debauchery and reaching further than we can calculate." 
 In certain researches among criminals in prisons it has been found that 
 so close a relationship exists between hereditary nervous disorders and 
 
THE LAWS OF HEREDITY. T85 
 
 crime that more than forty per cent, of tlie prisoners liad a history of 
 insanity, epilepsy, idiocy, and other nervous diseases existing in their 
 families. 
 
 In England it has been determined that " the ratio of insane criminals 
 to sane criminals is thirty-four times as great as the ratio of lunatics to 
 the whole population of England." 
 
 Fortunately for ns, there is a dominance of the racial hereditary- im- 
 pulse, a force bearing down upon us from antiquity and tending to bring 
 us back to the normal type, from which the weakness or sins of our im- 
 mediate forefathers may have tended to deflect us. So there is a natural 
 inclination for the unstable nervous system to disappear. Otherwise we 
 might all of us in time become insane. 
 
 A very interesting feature of heredity is what is known as prepotency. 
 
 The attributes of our ancestors, bequeathed to us, if unlike, struggle for 
 
 supremacy : if alike, they are emphasized. Sometimes 
 Prevotencv. . . 
 
 there is a blending of qualities — as, for example, in the 
 
 colour of the skin. The child of a black and a white parent is half white 
 
 and half black, a mulatto ; of a mulatto and a white, a quadroon ; of a 
 
 quadroon and a white, an octaroon. Sometimes a strong characteristic 
 
 has preponderance or prepotency, like the Bourbon nose, which persisted 
 
 for at least four generations. So too with mental attributes ; some may 
 
 assume the mastery over others, and conditions like insanity may become 
 
 prepotent in a family, in which cases marriages should naturally be so 
 
 regulated that the racial hereditary impulse may come to the rescue. 
 
 The chief points in the laws of heredity that may be summed up 
 here are as follows : 
 
 Offspring tend to inherit every attribute of both parents, and since 
 
 the parents have inherited from the grandparents ad ivfirdhim^ there 
 
 are innumerable faint or latent attributes from re- 
 Laws of Reredihi. i • i , i , • .i n- • 
 
 mote ancestors which tend to appear m the oiispring. 
 
 When circumstances are favourable, these latent attributes may become 
 
 more strongly marked, may become prepotent, so to speak, and the child 
 
 may show a reversion to the type of a great grandfather or some other 
 
 ancestor. A child is a new combination of two lines of ancestral traits, 
 
 and in him there is a struggle for survival among these different traits. 
 
 Still another law is, that characteristics which have appeared in a 
 
 parent at a certain time of life tend to appear in the child at the same 
 
 period. This is shown in the epochs of normal growth, the periods of 
 
 puberty, adolescence, change of life, and senility. It is also shown in the 
 
 frequent tendency of offspring with insane inheritance to break down at 
 
 the same period of life as did the parent or grandparent. A particularly 
 
 interesting example is the form of insanity known as paranoia, a strongly 
 
 marked hereditary form, in which there is a regular cycle or sequence of 
 
 52 
 
7S6 NERVOUS AND MENTAL DISEASES. 
 
 events. First there is eeeentricity aiul nu)rl)itl sliyness during childhood ; 
 ii melancholy and hypochondriacal condition up to the age of thirty ; then 
 a development of delusions of persecution ; and following this, indeed 
 growing from this, delusions of grandeur, of being a prophet, king, re- 
 former, or saviour of mankind. N\'e lia\ e examples in the cases of Joan 
 of Are, John l>i"0\vn, ]\[ohainnu'(l, John of Leyden, and others too nu- 
 merous to mention here. 
 
 Another very interesting law is that a certain degree of dissimilarity 
 between parents seems to be necessary for the production of healthy off- 
 spring, and that when parents have a very similar constitution, or an 
 exceedingly dissimilar constitution, the effect is deteriorating. As an 
 example of similarity of constitution, take the case of cousins. It fre- 
 (piently occurs that consins inherit characteristics that resemble each other 
 remarkably, traits prepotent in the family, and in case of their marriage 
 the children will be degenerate, feeble-minded, idiotic, or insane. This 
 has been noted so often that it is a matter of popular knowledge. At the 
 same time there are countless examples of the marriage of cousins without 
 such unfortunate results, for the simple reason that it is more common 
 for cousins to be dissimilar in their constitutions than similar. The mar- 
 riage of cousins is only disastrous where some such attribute as instability 
 of nervous organization is prepotent in the family. 
 
 The question whether a trait is acquired or congenital is sometimes 
 
 dilKcult to solve. For example, a drunken mother bears children who 
 
 also become drunkards, imbeciles, epileptics, or lunatics. 
 
 ri' -t I There is no denial of the fact of heredity here, nor can 
 or Congenital. _ •' ' 
 
 there be a denial of the fact that this is an acquired 
 tniit on the part of the mother. At the same time we must remember 
 that the mother, saturated with alcohol, saturates her children before they 
 are born with this poison, thus shattering their nervous system before 
 they have yet seen the light. The nervous diseases of her grandchildren 
 are not inherited disorders acquired by their parents, but the inheritance 
 of their congenital defects. After all, the important point to keep in 
 mind is that such traits or modifications of character in our ancestors are 
 inherited by us, and we need not quibble over the minor question as to 
 whether they are acquired or not. 
 
 In an earlier part of this argument I stated that not only physical, 
 
 but also mental and moral attributes are among the legacies bequeathed 
 
 , . ^^ ,. to us by our forefathers. It may not be amiss here to 
 
 dwell a little upon some of the features of psychic 
 heredity — as, for instance, upon hereditary genius. Galton has written a 
 volume upon this subject which is a mine of interesting information, 
 dealing, as it does, with three hundred families, containing among them 
 one thousand eminent men, of whom f(jnr hundred and fifteen were illus- 
 
PSYCHIC HEREDITY. 787 
 
 trious examples of <]jciiiu.s. They consist of judges, statcsineii, coinniarid- 
 ers, literary men, scientitic men, poets, artists, and divines. Jle finds that 
 exactly one half of illustrious men have one or more eminent relatives. 
 The large number of eminent descendants is due to the marriage of illus- 
 trious men with women who were alxjve mediocrity; for while it is a 
 })opular opinion that men of genius marry women below mediocrity, sucli 
 proves by examination not to be the case. Another popular idea — that 
 great men have remarkable mothers — proves also not to be a fact, though 
 such men are undoubtedly greatly indebted to maternal influence as well 
 as to paternal. The sons of gifted men are much more precocious than 
 their parents, and are apt to be ruined in health by overwork, while the 
 daughters are apt not to marry, either because accustomed to a higher 
 moral and intellectual tone in the family circle, or because of cold, shy, 
 odd, or blue-stocking manners that render them often unattractive to 
 men. For such reasons illustrious men do not leave as many gifted de- 
 scendants as they otherwise would. Galton proves that it would be pos- 
 sible to produce a highly gifted race of men by judicious marriages in 
 consecutive generations. A prevalent opinion that men of genius are 
 physically feeble, puny, and stunted in growth is found not to be true. 
 On the contrary, in strength and stature and massiveness they rank high- 
 est, though there are and have been a few exceptions. In this volume of 
 Galton the illustrious men selected are chiefly English, or such as are well 
 known to Englishmen. He avoided foreigners through fear of errors; 
 but he advises any reader to select a dozen names of eminent men in any 
 profession and of any nationality, and to study the characteristics of their 
 kindred. He will be astonished at the results. 
 
 From all that I have stated concerning the inheritance of physical or- 
 ganization, of mental characteristics, of moral and criminal attributes, of 
 
 disease and defects, and of genius, it would almost seem 
 Individuality. , „ , , ^, . . . , . .j. 
 
 as II we had nothing ongmal m us, as it we were mere 
 
 compounds of attributes bequeathed to us and for which we are not re- 
 sponsible, and which we, in our turn, pass on to our descendants. Our 
 only individuality lies in the fact that the mixture and development of 
 attributes given us varies in each person. Some blend and are empha- 
 sized, become prepotent; others, dissimilar in nature, struggle with each 
 other for mastery. The two packets of physical and mental quahties 
 handed down to us by our father and mother, and containing, besides the 
 individuality of our parents, all the characteristics of the race, might be 
 roughly compared to two complex chemical substances mixed together, 
 which unite chemically to form a new substance. The new compound 
 has qualities peculiar to itself, and yet in it are attributes of the ingredi- 
 ents which entered into its composition. Or we might compare heredity 
 to a kaleidoscope which contains a number of bits of coloured glass repre- 
 
7SS NERVOUS AND MENTAL DISEASES. 
 
 senting ancestral bequests. Each turn or shake of tlie kaleidoscope gives 
 us a new individuality, wonderful and beautiful in its details, some more 
 so than others, and yet the niatiTials of which the marvel is composed are 
 always the same. 
 
 STRESS OR STRAIN. 
 
 "While a hereditary instability of the nervous sj'stem is undoubtedly 
 
 the chief factor in the causation of insanity, and also in the ii'tiology of 
 
 many nervt)us diseases, such as hysteria, neurasthenia, 
 
 Causation of epilepsv, and the Hke, vet another important factor is 
 
 Jyervonsand Jiintai , , . i ' i n i • ^• • ^ ^ 
 
 Diseases stress of one kind oranotiier. lerJiaps every individual 
 
 has a certain amount of instability of his nervous system, 
 so that some strain, if sulliciently severe and prolonged, may upset the 
 normal balance, and it is evident that the degree of stress necessary to 
 disarrange the normal mental or nervous equilibrium must vary with the 
 resistance of the individual subjected to the stress. Fortunately, the ma- 
 jority of people have nervous systems of fair stability, and do not readily 
 give in to the vicissitudes of life. The stresses or strains which are well 
 known to often excite nervous or mental diseases are briefly as follows: 
 Blows upon the head ; organic brain diseases such as meningitis ; apo- 
 plexy ; tumours ; various acute or chronic diseases in any part of the body 
 affecting the general health and nutrition ; changes in the circulation of 
 the blood (congestion or aniemia), and particularly the vitiating of the 
 blood by toxic diseases or by poisons (specific disease, specific fevers, such 
 as smallpox, diphtheria, scarlet fever, typhoid, etc., and in the line of 
 poisons may be mentioned opium, alcohol, cocaine, coal gas, carbonic-acid 
 gas, carbon bisulphide, hasheesh, tobacco, coffee, tea, etc.) ; finally, the so- 
 called moral strains, such as worry, anxiety, grief, fear, and so on. 
 
 There are .physiological conditions of the organism, too, which in a 
 certain way render the individual liable to be more easily affected by the 
 
 combined or separate action of heredity and strain ; con- 
 
 r c isp .Hu g )/s (]if ions of great activity or change at the different periods 
 ological Lo7idtfiuiis. _ o ./ t> r ^ 
 
 of life, which put the system into a state to be readily 
 
 iiilluenced by adverse circumstances. To this category belong the active 
 
 changes incident to the growth of a child — the period of puberty and the 
 
 era of adolescence. Here also belong the so-called internal "commotions" 
 
 brought about by pregnancy, childbirth, and lactation, and l)y the change 
 
 of life. The period of degeneration or senility, when retrogressive 
 
 changes in the tissues are active, is furthermore a condition in which 
 
 hereditary taint and stress, more or less severe, may induce nervous or 
 
 mental disease. 
 
 We shall now give in alphabetical order the names and definitions of 
 
 the more common diseases of the nervous system and of the mind, Avith 
 
 some brief account of their symptoms and their treatment. 
 
TREATMENT OF ALCOHOLIC INEBRIETY. 789 
 
 NER VO US VISE A SES. 
 
 Abscess of the Bkain. — A colloctio]! of pus may take place in tlie 
 brain at any age of life. The cause is nearly always some septic material 
 that finds its way into the brain. Usually the poison comes from disease 
 of the ear, but injuries to the scalp or skull, and diseases of the nose or 
 orbit of the eye, may lead to the. formation of abscess in the brain. Some- 
 times it is from general specific poisons in the blood, such as those of 
 scarlet fever, typhoid fever, and the like. Injuries to the skull are more 
 common as a cause in childhood than any other. Sometimes a month, or 
 even a year or two, elapses after an injury to the head before the de- 
 velopment of the abscess. 
 
 The symptoms are very different in different cases, owing to the vary- 
 ing position of the formation in the brain. Headache, chilliness or fever, 
 sleepiness, vomiting, delirium, stupor, convulsions, dizziness, or paralysis, 
 and so on, are among the manifestations met vpith in varying degree and 
 frequency. The diagnosis of its presence and position must be made by 
 an expert in such disorders, and the treatment in suitable cases is alto- 
 gether surgical. An operation is made for the removal of the collected 
 pus if the specialist and surgeon consider it advisable. Prevention is, as 
 in all diseases, the chief point to bear in mind. Early and strict attention 
 to injuries to the head and to diseases of the ear, orbit of the eye, and 
 nose is of paramount importance. 
 
 Alcoholic Inebriety. — There is no class of eases that comes under the 
 care of the physician that presents greater difhculties in the way of treat- 
 ment than that of sufferers from alcoholic inebriety. To the practitioner 
 are brought such as are in the stage of alcoholic neurasthenia, such as 
 present symptoms of acuter alcoholic conditions, such as have delirium 
 tremens, such as are insane from the abuse of this poison, and such as 
 exhibit actual organic lesions of the nervous system, like alcoholic neuritis 
 and alcoholic pseudo-ataxia. Patients may come under his observation 
 in any of these states, or in the intervals between paroxysmal outbreaks of 
 the drink habit, when they may present no particular symptoms. He may 
 be required to treat the nervous conditions of alcoholic excess, and there 
 may be lesions of other than nervous viscera demanding his attention, 
 like gastric disorder and cirrhosis, and their sequelae. Thus there are 
 states for immediate attention, and there is the habit itself exacting his 
 best judgment and skill in the way of eradication and prophylaxis. There 
 is therefore a wide field for therapeutic apjjlications of great variety. 
 Leaving out the treatment of the chronic organic conditions, such as 
 lesions of the peripheral nervous system and viscera, our advice is gener- 
 ally sought to relieve the excitement or nervous exhaustion of a recent 
 
790 NERVOUS AND MENTAL DISEASES. 
 
 (lebaiieh. and to fonnulate ^otue plan for combating the tendency to re- 
 currence. 
 
 The best treatment of acute alcoliolism of any form may be briefly 
 summarized, l)ut no treatment .-should be undertaken without the physi- 
 cian's advice and supervision : 
 
 1. Cut off all alcohol, and confine to bed. 
 
 2. Ulue pill at night, followed by saline cathartic. 
 
 3. Hot wet pack for sleei)lessness. 
 
 4. Hypodermic injectinn of nitrate of strychnine, gr. -^^ to -jV- 
 
 5. "Water, milk, koumiss, broths, soup, meat juice, raw eggs, arrowroot, 
 juicy fruits, and the like, when there is gastric disturbance. 
 
 This is the outline, in short, of a kind of treatment adapted to all, cases 
 of acute alcoholism, though bromide and chloral, or duboisine, are indi- 
 cated in a certain number of instances. 
 
 In chronic alcoholism, which manifests itself most commonly as a 
 form of neurasthenia, the following should be the ordinary routine treat- 
 ment : 
 
 1. Cut off alcohol. 
 
 2. Hot wet pack for insomnia. 
 
 3. Disturbances of the alimentary canal to be met by aperients and 
 dyspeptic remedies (rhubarb and soda, hydrochloric acid, and the like). 
 The diet should be milk, eggs, and vegetable foods, meats rarely. 
 
 4. Strychnine again the main agent to restore nerve tone; best given 
 hypodermatically, but may be given by mouth in combination with qui- 
 nine, or in thiid extract of cinchona (gr. ^\ to dr. j), or in infusion of 
 gentian. 
 
 Having now briefly gone over what I consider to be the best methods 
 of meeting immediate conditions apparent in any case of inebriety brought 
 to the physician for advice and treatment, the more important question 
 arises how to rid the patient of the habit — how to cure the disease of 
 inebriety. This is a most complex question, and one that has for many 
 decades commanded the attention of all men — laymen, lawyers, physicians, 
 and charlatans. Either the desire for alcohol must be got rid of, or the 
 alcohol itself must be made unattainable. To eradicate the desire, appeal 
 has been made to the enfeebled will of the victim by lectures, pledges, hyp- 
 notic suggestion, religious influences, and the like, sometimes with success; 
 and drugs have been lauded by physicians, and secret nostrums by quacks, 
 to accomplish the same end, sometimes also with success, though not so 
 much through the merit of being an antidote to the desire for drink as 
 by virtue of the support by faith or suggestion given the weak will of 
 the patient. 
 
 On the other hand, to make alcohol unattainal)le, the law has been in- 
 voked to regulate liquor-selling in general, to prevent its sale to drunk- 
 
TREATMENT OF ALCOHOLIC INEBRIETY. 
 
 791 
 
 ards, to imprison hahitues, or to commit them to inebriate institutions for 
 a definite length of time. All of these' means have been successful in 
 individual instances. But no drug has been found that is always equal to 
 destroying the desire, and the laws are inadequate as regards regulation 
 of the liquor traffic and the isolation of the drunkard from his ruling 
 demon. Sequestration in a penitentiary is limited by the law, and the 
 writ of habeas corpus has been the evil genius of special institutions for 
 inebriates. Many are committed to insane asylums, but after a few weeks 
 of rest and treatment the debauch is recovered from, and, not being in- 
 sane, the asylum has no longer the power to detain them. So they come 
 and go several times in the year with the regularity of the seasons. The 
 rich try the inebriates' homes and the poor are condemned to the peni- 
 tentiaries. They are " repeaters." Think of being brought up for the 
 two hundred and forty-sixth time before a police court for drunkenness — 
 yet this has happened, and the defendant was a woman ! 
 
 In the cases that generally present themselves to us, commitment is as 
 a rule the last resort. We try moral suasion, occasionally hypnotism, and 
 we make usually half-hearted attempts at treatment by drugs. We send 
 them on long sea voyages on sailing vessels containing no liquor ; "we try 
 the watchful care of a companion or nurse. Sometimes these means are 
 effectual, generally not. The despairing friends after a time resort to the 
 advertising quacks. Their remedies are no more efficient than those 
 already in our hand, but it must be confessed that they often take more 
 pains with each individual case than we do. Some of the advertised in- 
 ebriety cures seem to be not only swindles, but cruel and criminal swin- 
 dles. Several years ago the chemist of the Massachusetts State Board of 
 Health analyzed some of these so-called cures for inebriety, in order to 
 ascertain how much alcohol they contained. The analyses published were 
 as follows : * 
 
 Scotch oats essence 
 The " best '" tonic .... 
 Carter's physical extract 
 Hoofland's German tonic . 
 
 Hop tonic 
 
 Howe's Arabian tonic . 
 Jackson's golden seal tonic. 
 Liebig Company's cocoa beef tonic 
 Mensman's peptonized beef tonic 
 Parker's tonic .... 
 Schenck's seaweed tonic 
 
 contained 35 per 
 
 cent, alcohol 
 
 
 7-65 " 
 
 " 
 
 -" 
 
 22 " 
 29-3 " 
 
 " <t 
 
 
 7 " 
 
 " 
 
 
 13-2 " 
 
 « 
 
 
 19-6 " 
 
 " 
 
 
 23-2 " 
 
 " " 
 
 
 16-5 " 
 
 « 
 
 
 41-6 " 
 
 n ti 
 
 
 19-5 " 
 
 " 
 
 The so-called gold cure of Keeley, upon analysis, was found to con- 
 tain no gold at all, but in each teaspoonful about one thirty-second of a 
 grain of muriate of ammonia, one sixteenth of a grain of aloin, and forty- 
 
 ■ Medical Register, July, 1888. 
 
792 NERVOUS AND MENTAL DISEASES. 
 
 five ininiuis of compound tincture of cinchona. His livjioderniic injec- 
 tion was ascertained to be composed of sulphate of strychnine, atropine, 
 and boracic acid. The Keelev cure, while it has been doubtless effectual 
 in curini>: many cases of inebriety, has not made use of any drug not long 
 ago tried ]»v plivsicians all over the world. ( )ne of the advantages of this 
 much-lauded method is undoubtedly the etVects of repeated suggestion. 
 AVe have not been in the habit of paying that particular attention to in- 
 ebriates that is necessary ; we are too prone to dismiss such a case with a 
 mere prescription and some good advice. I may be pardoned for citing 
 an instance of the value of continuous attention. A young man of wealth 
 was apparently a contirmed inebriate. Everything had been done for 
 him on ordinary lines that could be done — drugs, moral influxMices, change 
 of scene and occupation, the dismissal of liis boon companions. I found 
 a teetotal sailing vessel and sent him to the South Seas and China, a 
 nine months' voyage without a drink. lie came back robust, hopeful, 
 took to drink at once, and had incipient delirium tremens in a few 
 days at a hotel. Before sending him to an inebriate institution, for 
 which I had made arrangements, I decided to give him one more trial. 
 An occupation was found for him in a down-town office, and he was put 
 upon the strychnine treatment, but was made to report daily at my office 
 at a certain hour. This he did for a year. lie has not tasted a drop 
 for three years, and is married, prosperous, and happy. I believe the 
 continued attention and suggestion of the daily visits to my office were 
 the remedial agents in his case, the strychnine merely acting as a prop 
 to his nervous system as he was passing through the ordeal of deprivation 
 of his wonted stimulant. Since then I have had several other cases. Hyp- 
 notism I have tried once or twice with considerable success. The treat- 
 ment I should outline for the removal of the habit, and which I have 
 found often very efficacious, is briefly as follows : 
 
 1. The hypodermic injection of nitrate of strychnine in the doses al- 
 ready given, at least twice daily, more frecpiently if possible, and always 
 by the physician himself. The moral influence and personality of the 
 physician are of the greatest importance. By this frequent contact of 
 physician and patient the effort and attention of the inebriate are kept 
 continually at their highest pitch. 
 
 2. A diet of milk, eggs, and vegetable foods should be enforced, meats 
 being allowed but once daily. 
 
 3. Kegular occupation, regular hours, and the avoidance of the society 
 of fast companions must be insisted upon. 
 
 4. There is a certain class of patients to whom a substitute for a dram 
 of lifpior is at times imperative ; when the desire comes on it must be satis- 
 fied. The substitute must be immediately at hand. With some of these 
 a combination of strychnine and fluid extract of cinchona (gr. -^Jy- to dr. j) 
 
TREATMENT OF ALCOHOLIC INEBRIETY. 793 
 
 taken with a glass of water works very well. It is not always convenient, 
 however, to carry a bottle in the pocket, so I am at times in the habit of 
 prescribing powders composed of from twenty to forty grains of red cin- 
 chona bark, half a grain of capsicum, and three grains of powdered nux 
 vomica, to be taken with a glass of water when required. 
 
 As I have already stated, the Keeley cure depends largely upon sug- 
 gestion for its results. It has had many successes, but, of course, also 
 many failures, which latter are seldom published to the world. I have 
 had four Keeley failures under observation. One is now insane with 
 complications of hepatic cirrhosis and chronic gastric catarrh, and their 
 sequelae. He will not live long. The second is also insane. The third 
 is under treatment with me. The fourth has been apparently cured in a 
 sanatorium for inebriates, and has had no liquor for over a year. 
 
 There is a multitude of cases in which no treatment yet devised avails 
 to check the alcoholic propensity, and in these the only alternative is to 
 put them out of the reach of alcohoh How difficult this is to accomplish 
 is well known to us all. Commitment for three to six months, which is 
 the longest period permissible in all the institutions I know of in this 
 country, is merely temporizing. It should be commitment for one to two 
 years, or even more. It is a fact that the nervous system and the heart 
 and other organs do not recover their normal equilibrium in less than two 
 years after prolonged alcoholism, and sometimes even four to six years 
 are needed to re-establish healthy functions. Recently a step in the right 
 direction has been taken by an institution in this city. For some five 
 years I have been the attending physician of the House of Mercy, which 
 is in charge of the Sisters of St. Mary, of the Episcopal Church. AVhen 
 they removed from the foot of West Eighty-sixth Street to new buildings 
 at In wood I induced them to form a department for inebriate women in 
 the new quarters. The Sisters became interested in the project, and the 
 trustees have had a bill passed by the ]S^ew York Legislature which is quite 
 unique in this country. This department in the House of Mercy is called 
 the St. Saviour's Sanatorium. It is empowered to receive women inebri- 
 ates either by voluntary or legal commitment. In the latter case two 
 physicians are required to make out certificates, and upon these a judge 
 commits the patient for a year. Before the expiration of the year she 
 may be recommitted, if it is deemed expedient, for another year. Hence 
 patients may be detained here for two years. This feature of extended 
 commitment for a long period marks a ne-w epoch in the history of such 
 establishments, St. Saviour's Sanatorium is beautifully situated on the 
 Hudson River in the upper part of New York city. The rooms and 
 parlors are cheerful, pleasant, and inviting. Out-of-door exercise and 
 drives, as well as indoor employment, and the companionship of the Sis- 
 ters and ladv visitors, are features of the treatment. Thus far there are 
 
794 NERVOUS AND MENTAL DISEASES. 
 
 accoinmodatiuns for but sixtoeu ])atients, and these are selected from tlie 
 refined and cultured classes, the institution being too small for the accom- 
 modation of all classes of female inebriates, even if it were possible or 
 desirable to mingle peo})le occupying ditferent moral and intellectual sta- 
 tions in life. 
 
 There is also in this city a somewhat similar institution for male ine- 
 briates, the New York Christian Home, where religious influence is the 
 chief remedial agent. I am convinced of the great usefulness of such in- 
 fluence in many cases. 
 
 One of the great drawbacks to all homes of this kind is the tedium 
 vihi' from which patients are apt to suffer ; there is not sufiicient employ- 
 ment or recreation ; the routine and monotony become irksome. 
 
 If I were to suggest an ideal means of dealing with inebriates, it would 
 be the establishment of a little world in which alcohol had no place, but 
 in which life with its various occupations, domestic arrangements, and 
 amusements M'ent on exactly the same. It would in fact be a colonization 
 scheme, such as has proved so valuable in the case of epileptics and of the 
 insane, only much more extensive and much more feasible. The problem 
 involved is merely the exclusion of alcohol from all part in the colony's 
 affairs. It is true that this could not be accomplished in any region open 
 to ordinary traffic, travel, and comnmnication ; even a Chinese wall built 
 around such a colony would not protect it from the invasion of its enemy ; 
 it would find some means to j^ercolate through. But I can imagine some 
 Temperance Island so far removed from the mainland as not to be ac- 
 cessible to small boats, with only one harbor, five to ten or more miles in 
 diameter, amenable to the laws of the United States, the property of a 
 corporation of practical philanthropists, where all boats and baggage and 
 merchandise would be thoroughly tpiarantined against the introduction of 
 alcohol, as if it were a Comma haclllus or the microbe of the Black Death. 
 Here would be villages and industries, manufactures and arts, the com- 
 moners and the gentry, living in business prosperity and domestic happi- 
 ness. Thither the drunkard would repair with his family, and, obtaining 
 a position, support himself and them and lead a useful life, as if such a 
 thing as inebriety never existed, A majority of inebriates would immi- 
 grate there of their own accord, but certain ones would need commitment 
 by law for three years. Such commitment, however, would be no hard- 
 ship, for the rights of voting, of citizenship, the solace of society, the 
 pleasure of following one's trade or calling, of earning a livelihood, and 
 of living with one's family would make existence not only tolerable but 
 blessed. The realization of such a project is not an " iridescent dream." 
 It is quite within the bounds of feasil)ility. A small additional tax npon 
 spirits and spirit venders would be sufiicient to acquire some Nantucket 
 and consecrate it to this purpose. 
 
ANJ5MIA OF THE BRAIN AND SPINAL C<.)RD. T95 
 
 ALCoiior.Kj Pakaia'his is a foi'ui of inflammation of tlic nerves wliicli 
 gives rise to wasting and palsy in tlie legs and arms. It is a multiple 
 neuritis, and is not uncommon in individuals who take large quantities of 
 alcohol for long periods of time. They become bedridden, and often 
 the mind becomes weakened in a peculiar way; but abstention from 
 alcohol almost always results in recovery. The paralysis has to be treatf;d 
 by a physician with lotions, massage, and electricity. 
 
 Anemia of tue Bkain signifies a want of blood, and consequently mal- 
 nutrition of the brain. Any disease which induces lack of blood in the 
 whole organism may affect the circulation in the brain. The symptoms 
 are faintness, headaches, dizziness, confusion of mind, nausea, sleepiness 
 or wakefulness, mental depression, spots before the eyes, and ringing or 
 roaring in the ears. Sometimes all of these symptoms, sometimes only a 
 few, are present. The treatment is directed to improving the quality of 
 the blood and increasing the supply to the head, but should only be un- 
 dertaken by a physician. 
 
 Anemia of the Spinal Cokd is a lack of blood and want of proper 
 nutrition of this great bundle of tracts and fibres connecting the brain 
 with the periphery of the body. The symptoms vary very much. Among 
 them are pain in the back, weakness in the legs, headaches, dizziness, 
 trembling, and general weakness of the whole body. 
 
 Anesthesia is a word employed to define a loss of sensation of the 
 skin in some part of the body. There is anaesthesia of the skin when the 
 prick of a needle or touch of a feather are not felt, or heat and cold 
 readily distinguished in a part. Anaesthesia is merely a symptom of the 
 cutting off of communication between the conscious brain and the area or 
 part affected. The disease may be in the brain or spinal cord, or in the 
 nerves going from the skin. Sometimes there is no actual organic dis- 
 ease to account for it, and it is termed functional or hysterical. The 
 hysterical form is generally easily cured by the .physician by means of 
 electricity or hypnotism. 
 
 Aphasia is a term applied to various forms of loss of speech. There 
 are certain parts or centres in the brain which control speech. There is a 
 spot where words heard are remembered ; another where words seen are 
 remembered ; another where the movements necessary to articulation are 
 remembered ; and another where the movements needed in writing words 
 are remembered. There are also two or three other centres connected 
 with speech, but the complexity of the arrangements underlying speech 
 is so great that special study would be required to unravel and compre- 
 hend them. These centres are joined together by tracts or strands of 
 fibres, so that they can act harmoniously. It is evident that an injury to 
 or destruction of any one of these centres, or of any of the connecting 
 fibres (such as often occurs from haemorrhage into the brain, stoppage of 
 
796 NERVOUS AND MENTAL DISEASES. 
 
 an artery going to the part, or i'rom tumourt;), would produce a disturb- 
 ance of speecli, some ])eeuliar form of aphasia. The patient might not 
 understand words heard (word-deafness), or Avords seen (word-blindness), 
 or might not be able to talk because of injury to the word-muscle centre 
 (motor aphasia), or to write (agraphia). Thus one form of aphasia may 
 be present, but the" other speech functions go on as before. The study, 
 understanding, and treatment of such atl'cctions must be left to the special- 
 ist in nervous and mental diseases. 
 
 Apoplexy. — By apoplexy we mean a sudden shock to the brain from 
 haMnorrhage into it or by phigging up of a cerebral artery, inducing 
 paralvsis. Usually there is loss of consciousness with the attack, occa- 
 sionally convulsions. Before the attack there may be some warning in 
 the way of headache, dizziness, numbness of a hand and foot on one side, 
 and full feelings in the head. As a rule, the shock is quite unexpected 
 and the patient loses consciousness and falls. His face becomes flushed, 
 the pulse hard and slow, the breathing deep, noisy, and laboured. Often 
 the paralysis is evident at once in the face ov limbs. The paralysis varies 
 with the part of the brain aifected, so tliat with apoplexy we may have 
 half of the body paralyzed (hemiplegia), or the sjieech centres may be 
 affected (aphasia), or sensory centres may be implicated (anji3sthesia), and 
 60 on. riitil the physician arrives and orders treatment in accordance 
 with the kind of disorder of the brain found by him, all that can be done 
 is to put the patient in bed and keep him perfectly quiet in a horizontal 
 position. Ice may be applied to the head in most cases in a rubber ice 
 bag, and hot-water bottles, carefully wrapped in towels, to the extremities. 
 If it is long until the physician arrives, tlie bowels may be relieved by an 
 injection or by giving the patient a cathartic (one drop of croton oil). 
 It is needless to say that no liquor should be given. As there are two 
 kinds of apoplexy (one due to luiemorrhage and one to the stopping up of 
 a blood-vessel), it is plain that the methods of treatment will be radically 
 different, and nothing more should be done until the phj'sician arrives. 
 
 Four fifths of all cases of apoplexy occur after the age of forty, and 
 with each decade of increase in age there is an increase of the apoplectic 
 tendency. 
 
 Atrophy means wasting. The word may be used in connection with 
 wasting of any tissue, but usually atrophy of muscles is more strikingly 
 apparent than any other form. There is a disease known as progressive 
 muscular atrop/iy, in which the muscles gradually waste away first in 
 one extremity, then in the others and over the trunk. The "living skele- 
 tons" of our museums are always examples of tliis disease. It is really 
 a disorder of the spinal cord, of the centres in the spinal cord which 
 govern the nutrition of the muscles. A local atrophy of the muscles may 
 occur from overuse (as in sewing, writing, hammering, etc., incessantly), 
 
PARALYSIS OCCURRIISG AT BIRTH. ^97 
 
 or from injury to a iicrvc ; but tlicso local atrophies arc nearly always 
 curable. We use massage, lotions, inunctions, and electricity in treat- 
 ment, but a physician should be depended upon to determine the nature 
 and cause of the wasting and to outline the proper treatment. 
 
 Basp:dow's Disease. — See ExopJUhalmic Goitre. 
 
 Bell's Palsy is a paralysis of the facial nerve supplying the muscles 
 of the face. There is one to each half of the face. In this paralysis the 
 forehead can not be wrinkled on one side, the eye can not be sliut, the 
 cheek can not be moved ; the patient can not whistle or blow the cheeks 
 full of air because one side of the mouth is paralyzed. It is a common 
 form of paralysis, due generally to lying with the face in a draught, but 
 sometimes to ear disease, for the facial nerve lies close to the middle ear 
 in emerging from the skull. The physician can generally tell on exami- 
 nation whether there will be recovery, and how soon ; most of such cases 
 recover ultimately. 
 
 BiBTH Palsy. — There are two kinds of paralysis occurring at the 
 time of birth which are spoken of as birth palsies. One is caused by 
 pressure on a nerve, such as a large one going to the arm, so that one 
 arm hangs useless when the child is born. Usually recovery takes place 
 under treatment directed by the physiciaiu The other kind of birth palsy 
 is far more serious, since it is apt to be brought about by hismorrhage in the 
 brain while the head of the infant is undergoing pressure during delivery. 
 This haemorrhage usually paralyzes one half of the body, or both lower 
 extremities, or even occasionally all four limbs. The damage to the brain 
 is usually so great that there is a greater or less degree of mental impair- 
 ment in addition to the paralysis, so that the child grows up an imbecile 
 or idiot ; it is also apt to have epilepsy. Yery little can be done for these 
 cases except to ameliorate the epilepsy and to place such cases in special 
 schools where they can be taught to walk, talk, care for themselves, and 
 even to learn some occupation, to such an extent that they will not be 
 altogether useless. It is surprising how extraordinary may be the mental 
 and physical progress made by these seemingly hopeless cases hy peda- 
 gogic treatment. 
 
 Caisson Disease is a paralysis of the legs due to disorder of the spinal 
 cord brought on in workers in caissons or diving bells by the sudden 
 return from condensed air to the normal atmosphere. 
 
 Catalepsy is a trance state with a peculiar rigidity of the body, often 
 called waxy flexibility. The limbs wnll remain for long periods of time 
 in any position in which they are placed. Catalepsy may be brought 
 about by hypnotism, but usually occurs in hysterical cases as one of the 
 multiform manifestations of hysteria. The sleeping individuals often 
 described in newspapers are cases of hysterical catalepsy. The state may 
 last from hours to years. Recovery is usually spontaneous and immediate. 
 
793 NERVOUS AND MENTAL DISEASES. 
 
 Convulsions, or spasms, are violent contract ions of the inii>clcs, nearly 
 always accompanied by loss of consciousness. Convulsions are not a dis- 
 ease, but merely a symptom of a great variety of morbid conditions. 
 "While they occur at all ages, they are so common in infancy and child- 
 liood that it has been well said that cofiVuL^'iona in cJt'ddren eon'enjxwd 
 mith (hUi'ium in adults. One author said that there are some children 
 who have convulsions as easily as some people have delirium or dreams. 
 
 They are then the symptom of a strong irritation of the central nerv- 
 ous system, for the seat of the ilischarge of energy is, of course, in the 
 brain. The imjierfect development of the growing nervous system of 
 infants and children renders tlieni especially prone to be affected. A 
 child is a bundle of nerves ami nerve-centres and reflexes in a state of 
 great activity, acquiring a gi-eat number of new inijiressions, and govern- 
 ing the processes of growth and rejiair. Yet true it is that the healthy 
 child rarely suffers from convulsions. It is the child with the hereditary 
 taint and unstable nervous system that falls an easy victim to convulsions. 
 There is an inherited convulsive tendency. Some families are more pre- 
 disposed to infantile convulsions than others. Drunkenness and epilepsy 
 in parents give rise to the convulsive tendency in children. 
 
 Aside from heredity there are innumerable exciting causes, such as 
 rickets, anamia, toxic states of the blood (from the infectious fevers) ; and 
 then there are the reflex causes, such as teething, disturi)ed digestion, 
 worms. They occur too in many organic diseases of the brain, like apo- 
 plexy, tumours, and so on. 
 
 The repetition of convulsions at i-egular periodic intervals constitutes 
 epilepsy. 
 
 Death may occur during convulsions, owing to disturbance of the cen- 
 tres for the breathing and the heart in the brain. Sometimes convulsions 
 induce such engorgement of blood in the brain that haemorrhage takes 
 place, and it is found that there is some form of paralysis which j)ersists 
 after the return of consciousness. 
 
 Xaturally, treatment, to be efficacious, must be directed to the cause, 
 but oidy a physician can discover the one of twenty or more exciting 
 causes for convulsions. 
 
 The home treatment should be briefly as follows : It may be laid down 
 as a safe rule in all cases to give a warm — not a hot — l)ath of 00° to 97°. 
 The patient may be immersed in this bath for a half hour or more. Perfect 
 quiet shoidd be insured. AVlien the physician comes, he will administer 
 chloroform l)y inhalation, or chloral by enema, or some other efficacious 
 remedy ; but this should on no account be undertaken without medical 
 direction. 
 
 Cramp is a painful, steady contraction in a single muscle or group of 
 muscles, generally due to fatigue in the })arts affected. Most people are 
 
CRAMP AND EPILEPSY. Y99 
 
 familiar witli a cramp in the foot, leg, or jaw. It is not iincoiiiinon as 
 a result of overuse in certain professions or callings. Ain(jng the mrist 
 common of these are writer's cramp, pianist's cramp, compositor's cramp, 
 cigar maker's cramp, telegrapher's cramp, and so on. In such individuals 
 the cramp comes on whenever the fatigued muscles are to be cmph>ycil in 
 the old way, and the disorder becomes chronic and, unless cured, disables 
 them altogether as far as their customary occupation is concerned. These 
 cramps are curable by following carefully certain directions as to particu- 
 lar exercises, massage, and electric treatment. 
 
 Epilepsy is a chronic disorder of the brain, characterized by period- 
 ical attacks of loss of consciousness and generally convulsions. It has 
 often been popularly called " the falling sickness." The convulsions may 
 last a few minutes or longer. They may take place many times a day, or 
 once in a week, a month, a year, or more. Severe attacks are called by 
 physicians grand mat. Mild attacks, where the patient merely loses con- 
 sciousness and does not fall or have a convulsion, are known 2i% petit Trial. 
 Sometimes instead of a convulsion a patient may have an outburst of 
 mental excitement with violent and destructive tendencies — a condition 
 known di& psychic epilepsy. 
 
 Like ordinary convulsions, epilepsy is not a disease in itself, but a 
 symptom of a great variety of morbid conditions. We call it epilepsy 
 where convulsions become habitual. 
 
 The causes that lead to the discharges in the higher convulsive centres 
 are, as has been said, various. Epilepsy may be due to injury to the 
 head, to organic diseas^e, such as old meningeal liEeraorrhage (as in infan- 
 tile cerebral palsies), to tumours, and the like. It may be reflex in its 
 nature, although these are extremely rare cases. Reflex epilepsy may 
 arise from genital or gastro-intestinal irritation, from nasal or dental difii- 
 culties, from old scars implicating nerve filaments, and, in some very ex- 
 ceptional cases, from eye strain. Then there are toxic blood states which 
 at times induce periodical convulsive attacks, such as auto-intoxication 
 from absorption of poisonous substances from the intestinal tract. It is 
 possible, as research progresses more satisfactorily, that a toxic condition 
 of the blood may in time be found to be the cause in the majority of 
 cases of epilepsy. At any rate, recent investigations seem to point in that 
 direction. It is thus seen that the physician's first duty to his patient is 
 to examine him very carefully for traumatic causes, for eye, ear, nose, 
 and mouth defects, for old scars on the body, for genital or gastro- 
 intestinal irritations, for the vestiges of old infantile monoplegias or hemi- 
 plegias, for symptoms of intestinal auto-intoxication, and for evidences of 
 intracranial tumour, meningitis, and so on. Now, I think it is a fact 
 that, as a rule, in the majority of epileptics, none of these evident causes 
 may be discovered. The cases in which a definite origin may be traced 
 
800 NERVOUS AND MENTAL DISEASES. 
 
 are in the minority, but, linding sneh iiulieations, tlie treatment must, of 
 course, be directed to remedying them. In a few clear cases of head in- 
 jury surgical operation is advisable, but even in such cases it must be con- 
 ceded that the results are seldom particularly favourable or satisfactory. 
 Operations do, however, often prevent attacks for months or longer, or 
 diminish their frccpiency, whether the operation consists of trcjiliining, 
 circumcision, or tamjiering with eye muscles, or what not. 
 
 So, too, in cases suspected to be of autotoxic origin. Treatment di- 
 rected to diminishing sepsis in the intestinal canal has proved, as 1 and 
 others have often found, of considei-able value in lessening the frecpiency 
 of attacks, though I can not say any are thereby cured. , In most cases our 
 treatment must l)e of two kinds — one, general, directed to improving the 
 moral and physical condition of the patient, and the other special, directed 
 rather empirically to diminishing and abating convulsive seizures. 
 
 By moral treatment I mean the placing of the epileptic in surround- 
 ings where he will not feel a sense of isolation from the rest of maid-cind ; 
 where he may occupy himself in some useful calling, especially out of 
 doors ; where his mental attributes may be developed by proper school- 
 ing ; and where social intercourse and entertainment may tend to allevi- 
 ate much of the suifering which the neglect of his family and healthier 
 associates in the busy world of men induces. Residence in an agricultural 
 colony or village community, such as the newly estal)lished Craig Colony 
 in New York State, is, then, one of the primarj' requisites to moral treat- 
 ment. 
 
 In regard to the patient's general physical health, each particular 
 physical defect or disorder demands its appropriate remedial agent. But 
 many cases require general upbuilding and tonic remedies for conditions 
 of impaired nutrition, antemia, and nervous depression. 
 
 Hydrotherapy is of considerable service in epilepsy. Cold shower 
 baths and cold sponge baths daily are beneficial. The shower baths should 
 be rainlike in character — that is, not too forcible. 
 
 In many cases a morning and evening bath (the half bath) proves very 
 serviceable. The half bath is taken in a tub only half filled with water, 
 and when taken should be accompanied by energetic rubbing of the pa- 
 tient by an attendant. This bath lasts five minutes, and the temperature 
 should not be under ."io^ and not over T<)° Fahr. 
 
 Where there is evidence of hyper.xnnia and increased blood pressure 
 to the head, the cold cap is useful. 
 
 "While these are the general indications for hydrotherapy, certain 
 measures are often of use at the time of seizures. During a fit, or during 
 a status ep'depticus^ it will be observed that there are one or two vascular 
 conditions present : either the face is pale and there are signs of brain 
 anaemia, and in this case waian wet compresses should be a])|)lied to the 
 
CEPHALALGIA OR HEADACHE. 801 
 
 head and genitals, accompanied l>y friction of tlie trunk upward, the body 
 being placed with head low and arms uplifted ; or there is turgescence of 
 vessels in the head, the face is red, the carotids beat strongly, and under 
 such conditions a contrary procedure is indicated — cold compresses to the 
 head, neck, and genitals, strong wet beating of the feet, with a high posi- 
 tion of the head. 
 
 When it comes to the special treatment of the attacks themselves by 
 means of drugs, and which I have called a rather empirical method, we 
 have a few agents which are of distinct service ; but the medical treatment 
 should be left wholly to the family physician, and indeed no form of 
 treatment should be undertaken at home without his advice, unless it 
 should be the simplest of home methods. 
 
 Exophthalmic Goitee, also known as Basedow's disease and Graves's 
 disease, is a disorder characterized by a swelling of the thyroid gland in 
 front of the throat (goitre), by bulging of the eyes, and by rapid beating 
 and palpitation of the heart. The disease is readily recognised by the 
 tumour at the throat and the protrusion of the eyes. It is supposed to be 
 due to an excessive or perverted secretion of the thyroid gland. Constant 
 medical attention is I'equisite in these cases, many of which are curable by 
 means of drugs directed to diminishing the frequency of the heartbeats, 
 by means of rest in bed, by the proper use of electricity, or by removing 
 a portion of the diseased thyroid gland. 
 
 Facial Paralysis. — See BelVs Palsy. 
 
 Graves's Disease. — See ExophthalmiG GoUre. 
 
 Headache, or cephalalgia, is the most common of nervous conditions, 
 and over a third of the population are affected with it. Fully one half 
 of womankind suffers headache at one time or another. It is not a dis- 
 ease, but a symptom of a great variety of morbid conditions. These con- 
 ditions may be grouped as follows : 
 
 1. Blood states : anaemia or hypersemia of the brain ; gout, rheumatism, 
 diabetes, ursemia ; infectious fevers and malaria ; lead, alcohol, tobacco. 
 
 2. Nervous conditions : hysteria, neurasthenia, epilepsy. 
 
 3. Reflex causes : from disorders of the eye, nose, throat, ear, stomach, 
 or sexual organs. 
 
 4. Actual disease of the brain : meningitis, tumours, disease of the 
 blood-vessels or skull bones. 
 
 Undoubtedly the most common causes of headache are anaemia and 
 dyspepsia. Headaches are sometimes in front of the head, sometimes at 
 the top, behind, or at the side. The last is often termed migraine (short- 
 ened from hemicrania). The pain varies in different persons and accord- 
 ing to the cause. It may be throbbing, dull, constrictive, burning, boring. 
 or sharp. It may last but a few hours, or may last sometimes for weeks 
 and months. Dizziness, nausea, and vomiting sometimes accompany head- 
 53 
 
802 NERVOUS AND MENTAL DISEASES. 
 
 ache. The pain is really situatetl in one of the nieinl)ranes of the hrain 
 whicli is supplied with sensitive nerves from the tit'rli pair (or trigeminal 
 nerve). 
 
 In the treatment it is absolutely necessary that the ])hysieian should 
 study each case carefully, in order to discover the one of many possible 
 causes. Otherwise treatment would be altogether em])irical. Too much 
 can not he said (((jal)tst a 2mtu'nfii taling drugs indiscriinlnately fo7' 
 relief. ^luch liaim ean thus be done in the use, for instance, of such power- 
 ful agents as antipyrine, caffeine, phenacetine, morpliine, and the like. The 
 regulation of the bowels, careful attention to diet, the application of local 
 agents like ice, or hot water, or tight bandages, and the use of hot or cold 
 foot baths, are the hoine methods of treatment which are simplest and 
 safest. Beyond this the patient should not be permitted to go unadvised. 
 
 Hydrocephalus is a condition popularly known as " water on the 
 brain.'' There is an accumulation of fluid in the cavities of the brain, 
 and in infants and children the head gradually increases in size until it 
 assumes sometimes enormous proportions. The exact cause of the disease 
 is not known. In some cases the process ceases of its own accord, but 
 in most cases it progresses, and all treatment seems to be more or less 
 futile. 
 
 IIyper.emia of the Brain means an increase of the blood in the brain. 
 The chief symptoms are a sense of fulness, pulsation and pressure in the 
 head, headache, dizziness, mental confusion, sleeplessness, and ringing in 
 the ears. They are increased by stooping over or lying down. The 
 treatment indicated is to lessen the amount of blood in the head by medi- 
 cines given to that end and by the application of ice to the head, cups to 
 the back of the neck, and quiet and rest. 
 
 IIyper.emia of the Spinal Cord is an excess of blood in that organ. 
 The symptoms are heaviness and weight in the legs, numbness, creeping 
 sensations, pain in the legs and back, and twitching of the muscles. 
 Much the same indications for treatment exist here as in the analogous 
 cerebral state. 
 
 IIyper.esthesia signifies an increased sensitiveness. Thus we speak 
 of hypertesthesia of the auditory nerve when a person is oversensitive to 
 sound, of the optic nerve when oversensitive to light, of the skin nerve 
 when slight touching is painful. Ilypersesthesia is sometimes due to dis- 
 ease of the nervous system, but is often hysterical. 
 
 Hypnotism is a trance-like state, a mesmeric condition, a morbid men- 
 tal state artificially induced, and characterized by diminution or loss of 
 consciousness, by a loss of will-power, by a concentrating of the mind 
 upon some one idea that may be suggested, and by a peculiar readiness to 
 yield and obey commands or suggestions. 
 
 One method of inducing hypnotism is to have the subject fix his eyes 
 
HYPNOTISM AS A REMEDIAL AGENT. 803 
 
 for some five or ten minutes upon sonic hriglit oliject lield a few inelies 
 from the eyes and slightly above them, so that there is some strain in the 
 effort to see the ohject. It is a species of fascination. Another method 
 is termed suggestion. The hypnotist places the subject in an easy-chair, 
 or upon a sofa in a comfortable position, and then talks to him in a posi- 
 tive and confident way (makes suggestions, so to S[)eak), telling him he 
 w\\\ be sleepy in a few minutes, that his breathing is growing deeper, that 
 he is drowsy, that his eyes are closing, and so on. After some minutes 
 (five to ten or fifteen) the subject really sleeps. 
 
 After being once hypnotized the subject falls into the state more 
 readily. It is believed that the Buddhist trance states, and the trances of 
 spiritualists and clairvoyants, when not mere trickery, are hypnotic con- 
 ditions induced by themselves (auto-hypnotism, auto-suggestion) through 
 fixing the attention upon some object or idea. 
 
 Fully a fifth or a fourth of the persons upon whom it is tried may be 
 hypnotized. Children are especially susceptible. 
 
 Hypnotism is injurious to the mind, and no one should ever permit 
 himself to be subjected to it, or allow of its trial or exhibition for mere 
 amusement. In some very rare cases it is of some value as a remedial 
 agent, but should only be employed by or under the direction of a physician. 
 A vast amount of harm has been done by its indiscriminate use. 
 
 Hysteria is a real disease. It is not an organic disease, but a func- 
 tional one, and the seat of the disorder is in the gray matter of the cortex 
 of the brain, though what actual change takes place there is altogether 
 unknown. Most people are familiar with the word hysteria, and know 
 how it is applied to the most various symptoms. It is characterized by 
 emotional states, such as excessive laughing and crying, impulsive acts, 
 great nervousness, headaches, pains in various parts of the body, a chok- 
 ing or constricted sensation in the throat (globus), and in severe cases 
 often by great mental excitement, delirium, convulsive attacks (hystero- 
 epilepsy), loss of voice, vision, or hearing, by paralysis or stiffening of the 
 limbs, or by cataleptic states. The loss of voice (aphonia), the blindness 
 or deafness, and the paralyses and contractures of hysterical subjects are 
 not organic, and therefore not serious conditions. Nearly always these 
 are quickly and easily cured by any strong appeal to the mind or any 
 sudden surprise, such as may be exercised by the physician in giving elec- 
 tricity or hypnotism. It is these hysterical cases that are so miraculously 
 cured at religious shrines, by faith healers, and the like. 
 
 Seventy-five per cent., or perhaps more, of all cases of hysteria have 
 a history of hereditary taint, of hysteria, insanity, alcoholism, or other 
 morbid state in the parents or grandparents. Four times as many women 
 as men suffer from it. Hysteria in men is not so uncommon as popularly 
 supposed. 
 
804 NERVOUS AND MENTAL DISEASES. 
 
 As regards the treatment of hysteria, the chief means should be moral. 
 It is absolutely necessary to isolate such a case from the sympathizing 
 friends and relatives. This is the first indication. In addition to the 
 new environment, the patient's life should be so regulated that occupation 
 of some kind, adapted to the needs of the case, may be carried on. The 
 patient's mind should be interested, and thus led back to a normal balance. 
 For hysterical children the discipline of well-managed schools is of great 
 value. 
 
 Phvsic'ians find, as regards other treatment, that great benefit is de- 
 rived from a proper use of hydrotherapy (^water cure), Qlectricity, certain 
 kinds of exercise, massage, and a few valuable medicinal agents in the 
 way of nervines, tonics, sedatives, and so on. Treatment should not be 
 undertaken without the advice of a physician. 
 
 Infantile Spinal Paralysis is a disease that comes on suddenly in in- 
 fants or children with fever, vomiting, diarrhcea, and sometimes convul- 
 sions. The most striking feature, however, is a widespread paralysis. 
 All of the limbs seem helpless. In a few days the paralysis begins to dis- 
 appear, and as a rule most of it passes away, leaving a group of muscles 
 in one limb permanently paralyzed and wasted. Usually it is one leg be- 
 low the knee that is paralyzed. Sometimes it is one arm, and in rare in- 
 stances two or more limbs may remain permanently affected. The cause 
 is probably an infectious one, a germ which, entering the blood, produces 
 its effects chiefly upon the part of the spinal cord which regulates the 
 nutrition and motion of the muscles. There are a few instances of epi- 
 demics of this disease on record. The disorder is usually termed polio- 
 myelitis by physicians, a word which means inflammation of the gray 
 matter of the spinal cord. Infantile cerebral paralysis must not be con- 
 founded with this spinal form of paralysis. They are totally different in 
 many ways. In the cerebral form, the brain being the part affected, we 
 are apt to have impairment of the mind and epilepsy in conjunction witli 
 paralysis of one or both sides of the body. (See Birth l^ahy.) In the 
 spinal form of paralysis the mind is never affected and there is no epi- 
 lepsy. Both at the outset and after the acute stage has passed off the 
 physician only can advise the proper treatment. The permanently para- 
 lyzed limb will need months or even years of attention, partly to stim- 
 ulate recovery of the muscles by massage, electricity, and baths, and partly 
 to relieve any deformity by the wearing of specially devised braces or 
 apparatus. 
 
 Insomnia, or sleeplessness, or wakefulness, is a condition due to a 
 great many causes. It is a prominent symptom in beginning insanity 
 and during the course of insanity. It is common in nervous exhaustion 
 or neurasthenia. It is found frequently in hysterical individuals. Some- 
 times it is hereditary and habitual through life. It is often due to or- 
 
TREATMENT OF INSOMNIA. 805 
 
 gallic diseases, sucli as heart and kidney disease, or blood states, like gout 
 or rheumatism. One can not go without sleep for longer than three 
 weeks, and such sleeplessness as that is found only in the insane. When 
 people say they have not slept for weeks, they mean that they have had 
 many sleepless nights during that time. 
 
 It is quite clear that in the treatment of insomnia one must first ascer- 
 tain what cause exists for it out of the multitude of possible causes. Then 
 this cause must be treated. The talcing of drugs of any hind to induce 
 sleejp should' he the last resort. Foremost among the methods for bring- 
 ing about natural sleep, and nearly always successful, is that of hydro- 
 therapy. 
 
 The prolonged warm whole bath may be used. Temperature, TO" to 
 90° Fahr. Duration, half an hour to two hours. When of long dura- 
 tion the patient may be suspended in a hammock made of a sheet. 
 
 As a general hypnotic agent, however, applicable to all forms of in- 
 somnia, tlie hot wet pack stands foremost. It is applied in this way : A 
 blanket nine by nine feet is spread upon the patient's bed, and upon this 
 a sheet, wrung out dry after dipping in hot water, is laid. The patient 
 lies down upon this, and the sheet is at once evenly arranged about and 
 pressed around his whole body with the exception of the head, after 
 which the blanket is also immediately likewise closely adjusted to every 
 part of the patient's body. Other dry blankets may now be added as 
 seems necessary. The patient remains in this an hour or longer — all 
 night if asleep. See Nursing the fSick, Figs. 18, 19, and 20. 
 
 When simple measures of this kind that are harmless (except in some 
 organic diseases of the brain or heart), and may be easily carried out at 
 home, prove unavailing, as will rarely be the case, then the physician 
 must be appealed to to prescribe some safe sleep-producing drug, and if 
 he is a wise physician he will guard against two dangers — first, the ac- 
 quisition of a habit by his patient ; second, the ill effects of the drug itself 
 upon the system. Fortunately we have nowadays hypnotics which may 
 be taken without fear of acquiring a habit, and a few which may be taken 
 for some time without hurtful results to the organism. 
 
 Lead Poisoning. — While lead poisoning is most common in workers 
 in white lead (painters), it is not uncommon for people having nothing to 
 do with lead, apparently, to be poisoned to a certain degree by it. Lead 
 nearly always enters the system through the stomach with water or food. 
 Painters get it upon their food from their unclean hands. Water stag- 
 nant in lead pipes becomes contaminated. Some of the cheaper kitchen 
 utensils often contain lead. Lead is found in certain face powders and 
 hair dyes. Lead shot is sometimes used for washing out bottles. Hence 
 there are various sources whence one may be unsuspectedly poisoned. 
 Headaches and constipation, followed later by attacks of colic, then by 
 
806 NERVOUS AND MENTAL DISEASES. 
 
 paralysis ol" the arms i^drojijU'd wrist), then by tli-oppcd foot, dcliriiiiii, 
 euuvulsioiis. arc tlie symptoms of load poisoiiiiii!;. 
 
 Persons, siieli as painters, who are known to be exposed to poisonings 
 by lead should use the ii;reatest care tliat the lead does not i2;et into the 
 alimentary canal. AVith this end in view, meals should ne\ er be eaten 
 in the workshop, and the greatest possible cleanliness of the hands before 
 eating should be observed ; also dilute sulphuric-acid lemonade is a valu- 
 able drink for workers in lead. A\'hen the system is once poisoned, and 
 symptoms of lead intoxication are evident, the treatment consists in elimi- 
 nation of the lead and relief of the individual symptoms. For the first 
 purpose diuretics, laxatives, and some ])reparation of sulphuric acid are the 
 most efficacious remedies. The individual symptoms should be treated 
 according to their nature — viz., strychnine and electricity for the paraly- 
 sis, laxatives for constipation, sedatives and analgesics for the cerebral 
 symptoms. 
 
 LocK.TAW. — See Tetmins^m the article on Surgical Tnjuj'iesand Sur- 
 gical Diseases, Chapter II. 
 
 Locomotor Ataxia.- -This comparatively common and distressing af- 
 fection is a disease of the posterior columns of the spinal cord, of the dura 
 mater, a membrane which surrounds the spinal cord, and of the posterior 
 nerve roots. 
 
 It occurs much more commonly in men than in women, and gen- 
 erally commences in persons between the ages of thirty and forty-five 
 years. In a large proportion of cases it has specific disease as a prede- 
 cessor. 
 
 The onset of the disease is gradual, and very connnonly the first symp- 
 tom noted by the patient is his inability properly to control the move- 
 ments of his legs and feet. It is not a paralysis, but is what is called a 
 loss of co-ordinating power, so that while the strength in the legs remains 
 as good as ever, the control of them is to a greater or less degree lost. 
 This may first be noticed by the patient on going downstairs, he finding 
 difficulty in estimating the distances of the steps, or he may be troubled 
 by an uncertainty in his gait when walking in the dark. Such a condi- 
 tion is called ataxia, and thus the disease gets its name. The symptom, 
 although not always present in the earliest stages, is seldom slow in ap- 
 pearing, and is regularly progressive until, in its most advanced form, the 
 patient is bedridden simply from an inability properly to direct his mus- 
 cles. In many instances, however, locomotion with the aid of a cane is 
 possible for many years. This uncertainty of movement more rarely in- 
 volves the hands as well. 
 
 The pains of locomotor ataxia are very severe, and generally are an 
 early symptom. They occur most frequently in the legs and are of a 
 stabbing or boring cliaracter. Tliey are often called lightning pains from 
 
LOCOMOTOR ATAXIA. 80T 
 
 the frequency with wliicli they dart, like lif^litnirii^, from one end of tlie 
 limb to the other. 
 
 Among the other symptoms which are very nunierous may l)e men- 
 tioned numbness and tingling of the hands and feet, drooping of one 
 eyelid, squint, seeing double, blindness, non-reaction of the pupil to light 
 while it responds to accommodation, loss of knee-jerk, inability to stand 
 erect with eyes closed, sudden attacks of vomiting or of shortness of 
 breath. Although the patient may ultimately be confined to bed, bed- 
 sores rarely develop. Constipation is the rule, and there may be retention 
 of urine or loss of bladder control. If the former occurs, there will pretty 
 surely result an inflammation of the bladder, which very commonly is the 
 immediate cause of death. AVhile the suffering and discomfort caused by 
 this disease are very great, the general health remains good, and the pa- 
 tient, if his life is a sedentary one, may continue at his work almost in- 
 definitely. Cure is almost impossible, and when cures are reported it is 
 easier for any one who understands the nature of the change in the spinal 
 cord to believe that the diagnosis was incorrect than that destroyed nerv- 
 ous tissue has been repaired. 
 
 The course of the disease may extend over twenty or thirty years, and 
 in fact the disease itself can hardly be said to destroy life. But its victims 
 are necessarily more exposed than healthy individuals to intercurrent dis- 
 eases, which are the direct causes of death. 
 
 Treatment is chiefly symptomatic. The treatment by suspension, pro- 
 posed in Russia and for a time largely practised in France and other 
 countries, has been almost entirely abandoned. Mercury and iodide of 
 potassium are usually prescribed on theoretical grounds, and occasionally 
 appear to be of service. The pains are difiicult to control, as, on account 
 of the long course of the disease, morphine, which relieves them, must be 
 employed with only the greatest caution and reluctance. Phenacetine is 
 often efiicacious in diminishing the intensity of the pains. Cold baths 
 are to be avoided, but warm baths occasionally do no harm and refresh 
 the patient. 
 
 In case the urine must be drawn by catheter, it is imperative that the 
 minutest antiseptic cleanliness of the instrument be observed. (See Nurs- 
 ing the Sick^ Chapter VIII, Fig. 15.) Other symptoms as they occur are 
 to be treated on the lines of general therapeutics. 
 
 Meningitis. — The meninges are two membranes by which the brain is 
 enveloped ; inflammation of one or both of them is called meningitis. Of 
 this there may be many forms. They are all popularly called in the acute 
 forms brain fever. Among the acute varieties may be mentioned — 
 
 1. Cerebrospinal meningitis is an acute infectious disease, involving 
 the membranes of the brain and spinal cord, which occurs in epidemics 
 or sporadically. Children are attacked by preference. There are gener- 
 
808 NERVOUS AND MENTAL DISEASES. 
 
 ally two or three days of malaise before the syini>toins become alarming. 
 Then develop severe headache, pain, tenderness, and ri*2;idity of muscles at 
 the back of the neck, delirium, fever, sensitiveness of the eyes to light, 
 and very commonly a rash, from which the disease is sometimes called 
 ''spotted fever," There may be also inflammation with interference of 
 function of the cranial nerves or those of the limbs. As the disease pro- 
 gresses, restlessness and delirium are replaced by somnolence or uncon- 
 sciousness. The average duration of the disease is from ten days to two 
 weeks, and its mortality, while variable, is always high. There is no 
 specitic treatment. 
 
 2. Shnple meningitis is a result of septic material acting on the pia 
 mater. Tlie most common source of infection is from a diseased ear, 
 although the poison may come from any infective focus iu the body. The 
 symptoms commence rather abruptly, and consist of intense headache, pain 
 in the back of the neck, fever and delirium alternating with unconscious- 
 ness. The respiration is irregular and the pulse apt to be slow. There also 
 may be, as in all brain diseases, paralysis from pressure on or destruction 
 of the nerves. The course of the disease is from ten days to three weeks, 
 and the prognosis is very grave. The treatment, once the disease has de- 
 clared itself, is purely symptomatic. 
 
 3. Tubercular tneniyigitis is a tubercular disease of a cerebral mem- 
 brane, just as consumption is a tubercular disease of the lungs. Both 
 owe their existence to the action of the tubercle bacillus. In its com- 
 mon form the disease occurs in young children, and its development 
 is dependent on the entrance into the body of the tubercle bacillus 
 — viz., through the air-passages, or in the food (milk), or by the ex- 
 tension to the pia mater of tubercular processes elsewhere in the body. 
 The prodromal symptoms, which generally continue for some little 
 tune, consist in a change in the child's disposition, lack of interest in 
 its play, peevishness, headache, and loss of appetite. These warnings 
 linally merge into the disease itself, which regularly ends in death. 
 There are headache, delirium, fever, and vomiting, with local paraly- 
 sis, and in the later stages coma. The breathing is very irregular, 
 and the pulse, slow at first, becomes rapid toward the end of the 
 disease. 
 
 Mesmerism. — See ITypnotisvi. 
 
 Migraine. — See Headache. 
 
 Muscular Atrophy. — See Atrophy. 
 
 Myelitis is an inflammation of the substance of the spinal cord. 
 There are several varieties, of which transverse myelitis only, acute and 
 chronic, will be considered here. 
 
 Acute transverse myelitis occurs most frequently in young men, and 
 may be a result of exposure, of injuries to the spinal column, of the 
 
NERVES COMMONLY INVOLVED IN NEURALGIA. 809 
 
 infectious diseases, or of any process whlcli allows septic organisms to 
 enter the spinal cord. 
 
 The spinal cord is involved not for its whole length, but in small foci, 
 which involve the cord in its entire circumference. The constitutional 
 symptoms are slight; the symptoms are chiefly referable to disturbance 
 of function of the cord. 
 
 The inmiediate danger to life in this disease is not great, though com- 
 plete recovery does not occur. The treatment consists in removing, if 
 possible, the exciting cause, in putting the patient on a water-bed, ad- 
 ministering counter-irritation over the seat of the inflammation, in giving 
 small doses of ergot of rye and iodide of potassium, and, when the acute 
 stage has subsided, nerve stimulants and electricity. 
 
 Chronic myelitis is a later and progressive stage of the affection just 
 described. 
 
 Nervous Peosteation. — See Nexir asthenia. 
 
 Neuealgia is a painful affection of the peripheral nerves. It differs 
 from neuritis in that the disturbance is functional, not inflammatory, while 
 in neuritis the structure of the nerve itself is altered. Some forms of 
 neuralgia, for example sciatica, very often become true neuritis. 
 
 Young adult females are the people most commonly affected with 
 neuralgia, and it is often difiicult to find any direct exciting cause. Such 
 causes should, however, always be looked for. While any sensory nerve 
 may be affected by neuralgia, the nerves most commonly involved are the 
 trigeminal, the intercostal, and the sciatic. 
 
 1. Trigeminal Neuralgia. — ^In neuralgia of this, the fifth nerve, the 
 pain is located about the eye and the region of the face immediately be- 
 low the, eye, and it may radiate from these regions. The pain is intense, 
 and comes in attacks lasting several days. There will also be swelling 
 and watering of the eye of the affected side, and at certain points the 
 slightest pressure will cause intense pain. 
 
 The first object in treatment is to look for any possible exciting cause. 
 The eyes should be examined, ear disease excluded, and the condition of 
 the teeth carefully attended to. Then the general health of the patient 
 will generally be found to be imperfect. For improvement of this, tonics 
 may be administered, such as iron, arsenic, cod-liver oil, and, if possible, 
 a temporary change of climate, with out-of-door life. For the attack 
 itself, some counter-irritation over the seat of pain is often useful — viz., 
 a mustard leaf or a small amount of cantharides, with collodion painted 
 on with a brush. Cocaine cataphoresis — a solution of cocaine introduced 
 by means of the galvanic current — has proved of benefit in the hands of 
 skilful physicians. The drug which has proved most efiicacious is aconitia 
 given in small doses, and increasing the doses. Its administration, how- 
 ever, must be attended with great care, and taken only under medical 
 
810 NERVOUS AND MENTAL DISEASES. 
 
 direction. Plienacetiuo, iuitifcbrin, uiul the broniiiles are somotimos 
 helpful. The condition is, however, an obstinate one, and old and re- 
 bellious cases are sometimes forced to have part of the nerve cut away. 
 This operation, which is a serious one, is not always successful. 
 
 "2. //t/< rcotttid Meuralyla. — In intercostal neuralgia the pain follows 
 the course of the intercostal nerves. The pain simulates that of })leurisy, 
 and often a diairnosis can be made onlv bv the neirative result of e.xamina- 
 tion of the lungs. Firm pressure at the posterior extremities of the inter- 
 costal spaces will generally elicit sharp pain, radiating forward. 
 
 The course of this form of neuralgia is similar to that of the trigemi- 
 nal form, and its treatment is about the same. The best counter-irritant 
 in intercostal neuralgia is the actual cautci-y. 
 
 8. Sclnili'a. — The great sciatic nerve issues from the pelvis at the inner 
 part of the buttock and goes down the l>ack of the thigh. Above the 
 knee joint it divides into two branches, one of which continues down the 
 back of the leg, the other down its outer side to the foot. Neuralgia of 
 this nerve appears more often late in life than the other two forms men- 
 tioned, and is common in individuals exposed to cold and wet and to 
 overstrain of the legs. 
 
 The pain, which is constant, though becoming much more severe at 
 times, is distributed over parts of or the whole of the nerve's course. 
 The duration of the disease is very tedious — three weeks to a year, or it 
 may become permanent, so that the sufferer is bedridden. 
 
 If treatment is begun at the beginning of a first attack, the prognosis 
 is good. The patient should go to bed and not bear any weight whatever 
 on the affected limb until all pain has been absent for several days. A 
 long splint, reaching from the foot to the armpit, is a valuable aid. If he 
 must walk, let him use crutches. Dry or wet cups should be applied over 
 the painful area, and the bowels kept open. These simple measures will 
 often result in a short time in a permanent cure. 
 
 When the disease has become more chronic, rest, while still essential, 
 will not give such permanently good results. Then counter-irritation 
 (cautery), tonics, etc., must be tried. Oftentimes quinine in large doses 
 (ten grains three or four times a day), combined with iodide of potassium, 
 is beneficial. Operation on the nerve rarely results in a permanent cure. 
 
 The intractability of an old sciatica is due to the fact that a neuralgia 
 of this nerve has a strong tendency to become a neuritis, the functional 
 disorder changing into a true inflammation. If a person with his first 
 attack of sciatic pain could be l)rought to realize this fact he would readil}' 
 see that a few weeks lost in bed at the outset was, after all, a valuable 
 economy. 
 
 I would be unwilling to leave the subject of neuralgia without two 
 words of caution. One, which regards diagnosis, is to call attention to 
 
NERVOUS EXHAUSTION. 811 
 
 the fact that pain aloriii; a iiei'vo trunk may mean far inorc than a func- 
 tional disease of the nerve itself. Tlic second cautionai-y word regards 
 the treatment of temporary pains with morphine. 
 
 Neukasthenia, or nervous exhaustion, is a very common disease, espe- 
 cially in the United States. It occurs in young adults of both sexes, and 
 is more prone to occur in those whose ancestors liave suffered fi'om some 
 form of nervous disease. Its advent is favoured by excesses of any kind, 
 wliether participated in in the performance of duty or in the pui'suit of 
 pleasure. Oi'ganic lesions in any part of the body may act as a causative 
 factor, and often some slight bodily irritation (eye strain) may be suffi- 
 cient to excite the disease. 
 
 The chief symptoms are impaired memory, defective will power, a 
 continual anxiety over the personal condition, depression, loss of interest 
 in surroundings, and inability for continuous application of the attention. 
 Headache is usually present in a slight degree and the sleep may be dis- 
 turbed. There is great " nervousness " over trifling accidents or sudden 
 noises which cause palpitation of the heart and a trembling of the hands 
 and fingers. There are alternate flushing and paling of the face, and the 
 hands and feet are cold. The muscular strength is impaired. From these 
 general symptoms various fairly well-defined types may be separated. 
 
 There is a gastro-intestinal form, in which gastric dyspepsia and con- 
 stipation play the most important role, and a sexual form, in which the 
 patient pays too much attention to his genital organs. The cerebral form 
 is the most serious, coming as closely as it does to the border land of in- 
 sanity. In this variety we find the morbid impulses and imperative con- 
 ceptions, which certainly are not the results of action of a sane mind, and 
 the various unjustifiable fears. In women the disease is very often char- 
 acterized by the groat loss of will power. Many women who have not 
 left their bed for years are neurasthenics with sound organs, who could 
 walk if they would, but the power of willing to w^alk is lost to thera. 
 
 The more simple forms of neurasthenia can easily be cured, provided 
 it is possible to remove the exciting cause and to apply rational treatment. 
 Patients with the cerebral form, being almost always people with a marked 
 neurotic taint, will probably never have an entirely normal nervous sys- 
 tem, although they may be very much improved. In either case the 
 treatment must be continued over several months. As already stated, the 
 removal of the exciting cause in the treatment of neurasthenia is a neces- 
 sity, without which other means will surely fail. Every possible local 
 condition which might cause the disease must be looked for — viz., ocular 
 defects, dyspepsia, etc. The food should be good and there should be 
 plenty of it. Only such articles as the patient can not digest need be 
 eliminated from the diet list. Baths are by far the most useful remedial 
 agent. They are most efficacious if given in the form of a spinal douche. 
 
812 NERVOUS AND MENTAL DISEASES. 
 
 tirst of hot water (110° Fahr.) wliii-h is suddenly changed to cold (50° 
 Fahr.). This variation of hot and cold may be continued for live to seven 
 minutes. In case douches can not be had, a similar effect may be produced 
 by sponging, the patient standing in a bath tub or foot tub. The head 
 should always be wet first with cold water. 
 
 Exercise, preferably in the open air, good in the house with a "health- 
 lift" or Indian clubs, is an important ally of the bath. Massage and elec- 
 tricitj nuiy be given when exercise is not possible. Bromides and other 
 sedative drugs arc to be used very sparingly. The most valuable drugs 
 are the nerve tonics — arsenic, strycliniiu', iron, or ])hos|)horus. 
 
 Neuritis is an inliammation of one or more nerves. AVhen moi-e 
 than one nerve is involved the disease is termed multij)h' nenritus. It 
 is caused by exposure to cold or wet, by poisons (alcohol, the metallic 
 poisons), and by infectious organisms which have found entrance to the 
 body. Influenza is often followed by multiple neuritis, and neuritis of 
 the nerves of the throat and the heart is a common sequel of diphtheria. 
 
 The symptoms vary according to the cause and the kind of nerves at- 
 tacked. Bell's palsy, or neuritis of the facial nerve, is painless, as the 
 nerve is purely motor in function. Multiple neuritis — as here both sensory 
 and motor nerves are involved — is very painful and accompanied with 
 paralysis. This paralysis, attacking as it generally does the muscles 
 which extend the hand and flex the foot, causes the condition known as 
 •'dropped wrist" and "dropped foot." The paralyzed muscles waste 
 rapidly, and there may be disturbances of nutrition of the skin. The 
 control of the bladder and rectum is never lost. The course of neuritis, 
 though always slow, tends usually to recovery. Alcoholic neuritis is 
 rarely cured before six months or a year. 
 
 The treatment is symptomatic. If the muscles are not too tender, 
 electricity should be used. Rest is essential. The general health must 
 be maintained with tonics, and recovery may be somewhat hastened by 
 the use of strychnine. 
 
 Paralysis may be defined as the loss of power of voluntary move- 
 ment. It is a symptom and not a disease. Injury or destruction to any 
 motor nerve, or group of motor nerves, will result in impairment or loss 
 of voluntary motor power. A slight degree of paralysis is usually called 
 muscular paresis. 
 
 Paresis. — See Paralysis; see also Paralytic Dementia. 
 
 Petit Mal. — See Epilepsy. 
 
 Poliomyelitis. — See Infantile Spinal Paralysis. 
 
 Sciatica. — See Neuralgia. 
 
 Sclerosis means literally a hardening, and is applied to the nervous 
 system when nervous tissue is replaced by new tissue. It sometimes oc- 
 curs as a definite disease called multiple sclerosis, in which areas of 
 
ST. VITUS'S DANUE. 813 
 
 sclerosis occur throngliout the cerebro-spinal axis. The symptoms wliich 
 it presents are a tremor elicited by intentional movements which ceases 
 when at rest, stiffness and weakness of the arms and lef^s, with increased 
 tendon reflexes, an oscillation of the eyes (nystagmus), and scanning speech. 
 
 The course of the disease is very long, and there is no specific treat- 
 ment. 
 ■ Sleeplessness. — See Insomnia. 
 
 Softening of the Brain. — This term is used by pliysicians to ex- 
 press a condition different from that popularly understood by it. Soften- 
 ing of the brain in a medical sense is when the blood supply to any part 
 of the brain is shut off. This failure of blood supply occurs as a result of 
 disease of the walls of the blood-vessels, which causes tlie blood to clot 
 and thus interfere with the blood current, or when from any cause a for- 
 eign body or blood clot is carried from some other part of the circulation 
 to the blood-vessels of the brain, and plugs the blood-vessels. As a re- 
 sult, the parts of the brain supplied normally by the occluded blood- 
 vessel are cut off from their nutrition and die. Such a death in the brain 
 is called softening. The condition occurs in old people and in the infec- 
 tious diseases, or as a result of the warty vegetations of heart disease be- 
 coming set free in the blood stream. 
 
 The effect on the brain is loss of function of the part softened, an 
 evil necessarily irreparable. Brain softening and general paresis are not 
 synonymous terms. 
 
 St. Yitus's Dance. — Chorea, as this disease is technically known, oje- 
 curs almost exclusively in children. ISTeuropathic heredity predisposes to 
 its acquisition, and fright and excitement are the most common exciting 
 causes. It consists in spasmodic contractions of the muscles of the body 
 in greater or less number, according to the severity of the attack. Barely 
 it is limited to one side (hemichorea). The tongue is involved, causing 
 difficulty of articulation, and, as a result of the disordered movements of 
 the extremities, there may be considerable weakness of the limbs. The 
 movements cease during sleep. The disease is generally a mild one. 
 though rarely cured under five or six weeks. The great danger consists 
 in the frequent complicating inflammation of the lining membrane of the 
 heart, giving rise to valvular disease of that organ. There seems to be 
 a relation between rheumatism and chorea. 
 
 As to treatment, the child should be taken from school and shielded 
 from all exciting or disturbing influences. Recovery will occur more 
 rapidly if the patient is kept in bed, and in any case he should not be 
 allowed to get up until late in the morning. Arsenic is the drug gener- 
 ally prescribed, and sometimes it seems to have almost a specific action. 
 Bromides and chloral may also be used. There is no known specifi.c for 
 preventing the cardiac complication. 
 
81-1: NERVOUS AND MENTAL DISEASES. 
 
 Tktanls. — See Sivgical Injun'i's and Surgical Diseases, Chapter II. 
 
 Tic Douloureux is an affection characterized hj attacks of very sharp 
 pain over one side of the face. Dnriiio^ the attack — wliich hists one to two 
 minutes — there is iirst paleness, followed by llushing of the face, watering 
 at the eyes, and perhaps a tine tremor in the juirts about the affected area. 
 The patient may Jiave many such attacks a day, and again may go for 
 some time with no attacks at all. The disease is essentially chronic and 
 rebellious. Here, as in facial neuralgia, aconitia is the most useful drug. 
 
 ToKTicoi.i.is. — See Wrt/ncck. 
 
 Tkkmou is a vibratory and unintentional muscular movement. It is a 
 common and important symptom in nervous diseases, and its various forms 
 have been described in the individual diseases in which it occurs. 
 
 Vektiuo, or dizziness, may be due to a variety of causes, chief of which 
 is disease of the ear. An:\?mia or impoverishment of the blood and tor- 
 pid liver may also cause it. It is a very common symptom in diseases of 
 the brain, especially of the cerebellum. Its treatment nmst be altogether 
 directed toward its exciting cause. 
 
 "Wryneck, or torticollis, is a chronic spasmodic affection of the mus- 
 cles at the sides and back of the neck. It may be bilateral or may occur 
 on one side only. As a result of the muscular contraction the head is 
 drawn forward and sideways toward the affected side. The disease is 
 rarely cured ; the various antispasmodic drugs may be tried with this end 
 in view. This disease has been the subject of much surgical discussion, 
 but the results furnished by operation are far from satisfactory. 
 
 INSANITY. 
 
 Insanity is not a clinical entity — that is, it is not a disease in itself, but 
 a symptom of disease. A fairly good definition of insanity from the 
 medical standpoint is that it is a manifestation in con- 
 duct or speech of disease or defect of the brain. Insanity 
 may l)e divided into two great gronps — one, where it comes on in youth 
 or adult life in a person born with a normal brain, and one gi-oup com- 
 posed of all such individuals as are born with defects of the brain. 
 
 I. Diseased brains. 
 
 II. Defective brains. 
 
 Under the second heading we would place all cases of congenital 
 
 idiocy, imbecility, and feeble-mindedness. These words express degrees, 
 
 of defect. The idiot is the most defective mentally ; 
 
 Tr • ET the imbecile is moderately defective ; the feeble-minded 
 
 V anous Forms. _ . 
 
 is one who shows merely weakness of the intellect. To 
 the first group belong the vast majority of cases of insanity. Any one 
 who visits an asylum for the insane is struck with the diversity of exprcs- 
 
FORMS OF INSANITY. 815 
 
 sions in the faces of tlie inmates. lie sees at onco tliat there are various 
 kinds of insanity. From mere observation of ])h_ysiognomy lie would 
 select the gloomy visage of the melancJuAiao M'ho is in a condition of deep 
 mental depression. Another class, rather lively, active, excited, and ex- 
 alted, presents the maniacal state {mania). There would Ije many pa- 
 tients, too, who would show in their expression, speech, and demeanour a 
 condition very like idiocy, yet we do not call them idiots, for their condi- 
 tion is not one of congenital defect, but an enfeeblement of the mind 
 known as dementia, following some acute brain storm like melancholia or 
 mania. It is often termed secondary or terminal dementia, and is abso- 
 lutely incurable. The word dementia often appears in newspaper lan- 
 guage as synonymous with insanity, but the word should be restricted to 
 the state of mental feebleness just described. 
 
 Still another class of cases is that known as general paresis, which is 
 a gradually developed dementia or enfeeblement of the mind combined 
 with a progressive paralysis of the body ; hence the iQxva lyaralytiG dementia 
 often applied to this class. 
 
 Finally, there is a very interesting class of cases which used formerly 
 to be called monomania, but is now denominated paranoia. In this form 
 there are fixed delusions of persecution or grandeur. 
 
 Most forms of insanity are comprised in the above statement, but 
 physicians are w^ont to speak of acute or chronic mania and acute or 
 chronic melancholia. There are also many subvarieties, such as hysteric- 
 al, puerperal, lactational, senile, epileptic, recurrent, periodical, circular, 
 and so on. 
 
 As regards home or asylum treatment a few words should here be 
 
 said. Just as a hospital is a better place than a tenement house for a 
 
 surgical patient or a case of fever, so is the asylum 
 Home or Asylum • , , i i • ,^ ^ • c ^ 
 
 Treatment superior to tlie liome m the care-taking oi the pauper 
 
 and indigent lunatic. The acutely insane of the poorer 
 
 classes are best treated at present in large State institutions ; and those 
 
 of the moderately well-to-do either at home or in the small private 
 
 asylums. Only the insane of the wealthy classes can perhaps enjoy and 
 
 carry out ideal methods of treatment in their own homes, in country 
 
 houses, or in foreign travel. 
 
 It is, of course, needless to say that there are many degrees of insanity ; 
 that there are hundreds of cases that are never obliged to go to an asylum 
 at all ; that in society are many insane people carrying on legitimate oc- 
 cupations, and caring for themselves and families ; and that, on the other 
 hand, there are cases for which nothing but commitment to an asylum 
 would be suitable or feasible. 
 
 The sooner a case of acute insanity occurring in a pauper or indigent 
 is removed to an asylum the better are his chances for recovery. AVith 
 
816 NERVOUS AND MENTAL DISEASES. 
 
 cases of acute insanity in those who are able to alTonl the expense of 
 trained nurses at home the ease is dilfereut. It would seem unfortunate to 
 have to send a patient to a large asvlum, with its kicks, its bars, its asso- 
 ciations, its overcrowding, its coniniingling of the intelligent and the re- 
 fined with the offspring of tlie slums, and its inevitable stigma, when the 
 case may prove to be mild, with an early recovery. How much better to 
 make the trial of treatment at home! Naturally the responsii)ilities of 
 the physician are often great with an insane jiatieut in a private house, 
 and it is certainly true that the asylum seemingly affords considerable 
 protection from death by exhaustion, suicide, and the like. I say ftcr/n- 
 ingly, for this protection is reall}' not as efficient as is generally supposed. 
 From the annual repoi'ts of the Xew York State Commission in Lunacy 
 I gather that the number wdio die from exhaustion in the public asylums 
 of the State of Xew York yearly is much over one hundred and fifty, and 
 that the number of suicides of patients committed to their care is in the 
 neighbourhood of tif teen per year. These facts are noted merely to show 
 that the asylum is not an absolute protection against the death of a patient 
 by exhaustion from mental disease or suicide, and that in view of this we may 
 treat many patients at home with a clear conscience, and with little greater 
 risk, always providing that the room and the nurses and minor essentials 
 are at our command. 
 
 I believe it is not fully appreciated how much the asylum authorities 
 are striving to do to effect improvement in the methods of management 
 of the insane. Not only is the asylum itself undergoing a metamorphosis, 
 but managers are actually doing all they can to extend the treatment of 
 the insane outside of asylums. 
 
 When people are sufficiently well-to-do the ideal methods of treat- 
 ment are, of course, to be found outside of an asylum. The insane of this 
 class may be treated at home, or in a seashore cottage, in a country house, 
 or they may go travelling in the charge of a physician and a nurse. The 
 kind of treatment best adapted to the nature of the case must be decided 
 by the physician. The quiet of a private house in the city or country is 
 best for some cases, while the tonic and stimulus of foreign travel are 
 indicated in others. It may be stated that M'hen travel seems to be the 
 prescription required, the greater the change from the environment in 
 which the mental disorder developed, the better. The cities of Great 
 Britain and the Continent do not differ essentially from our own cities, 
 and patients should not be sent to such places with the idea of securing a 
 change of environment. Norway or the Yosemite in summer, and Egypt 
 or Mexico in winter, are regions which offer the greatest inducements in 
 the way of tonics to the nervous system and stimulus to the mind, and 
 all of these are at the same time peculiarly restful and calmative. 
 
 If these methods of home, country house, or travel are for any reason 
 
TEEATMENT OF INHANITY 817 
 
 impracticable, then the smallest pi-ivatc asylum that can bo found is to Ix; 
 selected, for the fewer other insane people and the greater number of 
 sane people the patient comes in contact with, the better will be liis 
 chances for recovery. There is a need for physicians in practice in tlie 
 country who will be duly authorized and empowered by law to receive in 
 their own homes and care for one such patient. The chief drawback in 
 home treatment, if long continued, is usually the bad effect of association 
 with an insane person npon other members of his family, particularlv 
 if they be neuropathic. With a sufficiency of nurses and room there is 
 no contingency in the treatment of the insane that can not be guarded 
 against. These being provided, the worst features in a case, such as 
 violence, hoinicidal and suicidal tendencies, attempts at self-mutilation, 
 etc., may be as well avoided outside as inside of an asylum. There are 
 cases in which, though I am opposed to mechanical restraint in great 
 measure, I should employ long-sleeved nightgowns, or even camisoles, 
 rather than let them go from home before all means of cure had been 
 tried at least for a few weeks' time. 
 
 The conditions and propensities that we have to combat are many. 
 The choice of method must be the result of careful deliberation, and after 
 judicial survey of all the features presented. We usually need the as- 
 sistance of skilled and experienced nurses. Thanks to the asylum train- 
 ing-schools, there are numbers of such trained nurses of both sexes to be 
 had in the large cities of the United States. 
 
 In acute cases, whether of mania or melancholia, it has been my ex- 
 perience that confinement to bed is a valuable factor in cure. Hence, on 
 being called to such a case, I have the patient put to bed. Due precau- 
 tions are taken as to the removal of all sharp instruments, weapons, drugs, 
 cords, door kej's, and the like, and by a simple device the windows are so 
 arranged that they may not be opened beyond six inches; otherwise the 
 furnishings may be left as they are without attention. 
 
 Insomnia and mental and motor excitement most frequently demand 
 our best skill. Often, indeed, it is necessary to use powerful drugs hypo- 
 dermically, but for routine treatment of insomnia and maniacal excite- 
 ment I much prefer hydrotherapy to drugs. In some cases the prolonged 
 warm bath (70° to 90°) for from half an hour to two hours may be used, 
 but in all cases the hot wet pack is applicable. For full details as to these 
 procedures see Insoinnia above. 
 
 In acute depressed conditions, on the other hand, certain opiates usu- 
 ally act best in cases in which hydrotherapy does not subdue the in- 
 somnia, distress of mind, and disordered nervous system. Among opi- 
 ates, codeine seems to ofEer advantages over others, and the contraction 
 of a habit need not be feared, but it should never be given without medi- 
 cal supervision. The refusal of food is another element of danger. Acute 
 54 
 
SIS NERVOUS AND MENTAL DISEASES. 
 
 insanity, besides rest in bed, quift and repose, needs overfeeding to bal- 
 ance the great waste of tissue going on in the system. "While many cases 
 of acute mania will eat and drink ravenously at times, from the nature of 
 things their actions are uncertain, and the nurse sliould be instructed to 
 feed the patient almost hourly and keep account of what is given. Milk, 
 raw eggs, meat juice, and occasional stimulants, must in extreme cases be 
 our chief rt'liance. Having an inti'lligent and assiduous nurse at hand, 
 the necessity of feeding with a tuhr will only rarely occur. AVhen re- 
 (juired, the soft-rubber stonuich tube may be introduced l)y the ])hysician 
 through the mouth or nose, a funnel attached, and the liquid mixture of 
 the substances named allowed to flow in (see Medicines and Treatment, 
 Fig. 9V I ean not here refer to many other morbid conditions that must 
 be met by apprujiriate medication, and by moral treatment as well in 
 acute as in .^uharute and chronic forms of mental disordi'r. There are 
 cases (some of the insanities of puberty and adolescence, and other forms) 
 in which anaphrodisiacs modify distinctly the trend of delusions. There 
 are cases in which intestinal antiseptics achieve noteworthy results ; in- 
 deed, the instances are few in M'hich attention to morbid states of the 
 alimentary canal is not rewarded by considerable beneiit to the mental 
 condition of the patient. Arguments with patients upon delusions more 
 or less fixed in character often has, despite the opinions of numerous 
 alienists to the contrary, decided value in altering their beliefs, and at 
 times even eradicating their insane ideas altogether. It is true that occa- 
 sional argument is generally of no avail. Such moral treatment must be 
 sedulously and perseveringly employed, daily and for weeks or mouths, 
 to insure success. Argument is a species of suggestion. Never should 
 the j^citient he encouraged in his delusions or deceived in any manner 
 ivhatever. 
 
 "We will now proceed to define the more important forms of insanity 
 and some of the symptoms in alphabetical order: 
 
 Adolescent Insanity. — This form is nearly always one of exaltation 
 — in fact, a mania. It appears between the ages of eighteen and twenty- 
 five years. The patient is exalted, talkative, restless, sleepless, excited, 
 has no appetite, and is sometimes vicious. Sexual matters often seem to 
 have much to do with the origin of this form. Recovery is usual in these 
 cases, though relapses are very frequent. The neurotic heredity is com- 
 mon. Xo attempt should be made to treat such cases at home, except 
 under the direction of an experienced physician. They do better in a 
 sanitarium or asylum than elsewhere. 
 
 ALconoiJC Insanity. — The commonest form of alcoholic insanity is a 
 violent delirium with homicidal tendencies. Another name for it is 
 mania a potu. Sometimes instead of a maniacal condition there is a 
 state of melancholia with suicidal tendencies. 
 
ALCOHOLIC INSANITY. 819 
 
 Delirium tremens is a particular fonn of acute poisouiiig by alcohol, 
 in which there is great tremor of the body and delirium, with marked 
 hallucination. The hallucinations of seeing animals, snakes, insects, etc., 
 are especially prominent. 
 
 Chronic alcolwlic insanity is manifested by insomnia, tremor, dreams, 
 liallucinations, delusions, and either a depressed or an exalted maniacal 
 state. Delusions of persecution are especially common. 
 
 The most that can be done at liome with such cases is to cut off the 
 alcohol sharply, and follow the advice of the attending physician closely. 
 Hospital or asylum, treatment is always best. 
 
 Amenoekhosal Insanity is a name given to the melancholia or mania 
 which sometimes develops by the disorder or suspension of menstruation. 
 
 Choreic Insanity is a form of insanity developed occasionally in cases 
 of chorea or St. Vitus's dance. Sometimes the patient is depressed, 
 sometimes excited, but rather more often in a stuporous state. 
 
 Circular Insanity is a form in which maniacal and melancholic con- 
 ditions alternate and follow each other without interruption. 
 
 Climacteric Insanity is insanity developing at the period of change 
 of life. It may be either mania or melancholia. 
 
 Delusion. — A delusion is a false idea or belief out of which a person 
 can not be reasoned by adequate methods. Delusion and hallucination 
 are not synonymous terms in medicine. (See Hallucination^ Delusions 
 may be transitory, but in many cases of insanity they become fixed or 
 systematized, and the patient may give pseudo-logical reasons for them. 
 Among the commonest fixed illusions are those of persecution and 
 grandeur. A patient believes he is followed by detectives or enemies, 
 that they try to poison him, to influence him by hypnotism or electricity, 
 etc. Others believe they are enormously wealthy, that they are the Sa- 
 viour, the Virgin Mary, prophets, kings, queens, great reformers, and the 
 like. In melancholia there are usually temporary delusions (though they 
 may become fixed), of a depressed character, that everything is ruined, 
 that their friends are all dead, that the patient is going to be killed, that 
 he has committed the unpardonable sin, and so on. 
 
 Dementia. — This has already been mentioned as a term generally em- 
 ployed to represent the imbecile character of the mind after the passing 
 away of some acute form of insanity, such as acute mania or acute melan- 
 cholia. It is a condition of mindlessness, so to speak, though it varies in 
 degree, and some vestiges of the former mental state ma}- remain. AYhile 
 it is, as a rule, a terminal state, or a dementia secondary to an acute in- 
 sanity, sometimes an acute general weakening of the whole mind may 
 take place, particularly in youth, and this has been called an acute or pri- 
 mary dementia. 
 
 Hallucination. — A hallucination is the perception by one of the five 
 
820 NERVOUS AND MENTAL DISEASES. 
 
 senses of an ohject wliich has uo existence. If one fancies he sees an ob- 
 ject which is really not before him he has a visual hallucination ; if he 
 hears a sound when all is still he has an auditory hallucination ; if lie 
 smells bad odours, thouij^h none such are about, he has a hallucination of 
 smell ; and in the same manner the hallucinations of taste and feelinjjj. 
 Hallucinations are to be carefully distinguished from illusions (which see). 
 Auditorv hallucinations are often populai-ly called "false hearing." Jlal- 
 ucinations are met with in a great many cases of insanity, and the most 
 common arc those of sight and hearing. 
 
 Ili.isio.ns arc perverted or transformed perce})tions. Thus a patient 
 may see, hear, taste, smell, or feel an object, but as something else than it 
 really is. An illusion is a false perception. 
 
 I>rPKK.\TivK CoNt'Ki'TioNS are ideas which take complete possession of 
 the mind and tyrannize over it. They differ from delusions in that tlie 
 patient may l)e able to reason himself out of the imperative conceptions 
 at times. 
 
 Mania is a mental exaltation or delirium, generally accompanied by 
 delusions, by great restlessness and muscular excitement, by loss of self- 
 control, by great loquacity, incoherence, and noisiness. Such cases are 
 usually best treated in asylums, where they can be kept in bed, made to 
 sleep by baths, wet packs, or drugs, and be properly fed. In cases treated 
 at home either several nurses are needed (two for the day and two for 
 the night), or the camisole or strait-jacket is required. 
 
 Melancholia is exactly opposite to mania. The patient begins to 
 feel a lowness of s])irits, lack of interest in amusement or occupation, and 
 gradually the dejection increases until he has a feeling of anxiety, gloom, 
 oppression. He is quiet, indisposed to stir or to answer questions. The 
 intellect becomes slow and sluggish in action. He begins to have false 
 ideas, to brood over imaginary sins, to have morbid apprehensions, to 
 seclude himself from people, to wish to die, to hint at or attempt suicide. 
 There are various kinds of melancholia. A mild type without delusions is 
 termed simple melancholia. Then there is a melancholia with stnjior, 
 where the mental apathy grows deeper and deeper until the patient is as 
 if in a trance state. In melancholia with frenzy the morbid state of the 
 mind, the dreads, the horrible thoughts, and frightful hallucinations or 
 illusions, drive the patient wild. lie rushes up and down in a frenzy to 
 escape his danger and doom. 
 
 Early isolation of cases of melancholia is of paramount importance. 
 They should be removed from home, to some private cottage, sanitarium. 
 retreat, or asylum. Unceasing vigilance is needed in these cases to pre- 
 vent suicide. All cases of melancholia suffer much from constipation, 
 and the bowels require constant regulation. Melancholic patients refuse 
 food, as a rule, and often have to be forcibly fed, or exhaustion ensues. 
 
PARALYTIC DEMENTIA. 821 
 
 Monomania. — See Paranoia. 
 
 Pakalytic Dkmkntia, or general paresis, is a form of insanity pop- 
 ularly but erroneously called "softening of the brain" (wliicii see). Tiie 
 onset of this disorder is protean in its manifestations. The earliest symp- 
 toms may be either physical or mental, or both. Tremor of the fingers 
 and of the hand in writing; filjrillary tremor of the lips and tongue; 
 slight difficulty in the pronunciation of certain words, such as " tliird 
 cavalry brigade"; irregularity, inequality, or smallness of the pupils — 
 these are among the earliest symptoms. Later these become more and 
 more pronounced and others are added. 
 
 The mental symptoms vary very much. At first there may be a little 
 melancholia or hypochondriasis. This is more common as an early symp- 
 tom than the feeling of well-being and personal aggrandizement, which 
 almost always makes its appearance at some epoch in the course of the 
 disease. Loss of memory, certain incongruities of conduct, emotional 
 weakness, misplaced and inappropriate use of words — these are among 
 the most frequent early mental manifestations. Occasionally there may 
 be a sudden outburst of a maniacal state. Convulsions and attacks of 
 apoplexy are apt to occur in nearly every case in the later stages of gen- 
 eral paresis, but they may make their appearance in the very earliest 
 periods. The disease is an absolutely fatal one, and progresses constantly. 
 No case was ever cured, though intervals of improvement known as re- 
 missions are occasionally observed. The average duration of the disease 
 is two to five years, though some cases run a much more rapid and some 
 a much more slow course. 
 
 The disease is one of the few kinds of insanity in which visible 
 changes are observed in the brain after death. 
 
 As regards treatment, the physician must determine the appropriate 
 agents in each case according to the symptoms manifested. Many cases 
 can be treated in the early stages at home, but all become bedridden and 
 more helpless than babes at last ; hence a sanitarium, retreat, or asylum 
 is best toward the end, for here they have the trained supervision and 
 proper appliances for their care. 
 
 Pakanoia. — In a typical case of paranoia there will be found heredi- 
 tary taint, possibly peculiarities of the shape of the head or of the physi- 
 ognomy (degenerative stigmata), eccentricities in childhood, more marked 
 peculiarities during youth, often associated with hypochondriasis, and at 
 about the age of thirty — sometimes earlier, sometimes later — the growth 
 and systematization of delusions of persecution, which may in turn be com- 
 bined with or give place to fixed delusions of an exalted character (re- 
 ligious, philosophic, patriotic, or erotic). (See Delusions.) Such delu- 
 sions completely dominate their entire mental action without impairing 
 every faculty. These cases used at one time to be called cases of mono- 
 
822 NERVOUS AND MENTAL DISEASES. 
 
 niaiiia, but as tliey nsnally have more than one delusion — in fact, a cluster 
 of delusions — that term has fallen into disuse. The English authorities 
 call it (Itiusio?iaI ifisa/u'///. The eccentric individuals ])opularly known 
 as "cranks" are without doubt imperfectly developed cases of paranoia. 
 Italian writers speak of these imperfectly developed cases as jnattoids. 
 Paranoiacs often have considerable talent, or even genius. I have sev- 
 eral autubioiijrajihles of paranoiacs in manuscript form which evince liter- 
 ary ability of no mean order. There have been paranoiacs famed in na- 
 tional annals and in literature, such as some of the rulers of Russia, 
 Austria, l^avaria, and Spain, and the cases of Lonis Kiel, Guiteau, Sweden- 
 borg, AVilliam Blake, Joan of Arc, Benvenuto Cellini, John of Leyden, 
 and others. For studies of some of these the interested reader is re- 
 ferred to Dr. Ireland's T/ie Blot upon the Brain and TJtnuKjh the Ivory 
 Gate. 
 
 As regards treatment of these patients, little can be done except, per- 
 haps, in tlie way of moral methods, and these are of most value in the 
 earliest stages. Eccentric and peculiar children should be carefully 
 watched and studied by physicians familiar with mental disorders with 
 the idea of being able to prevent the development of insanity. The 
 asylum is the destination of most paranoiacs, and in the best of these 
 institutions the discipline, employment, recreation, and regularity of eating, 
 sleeping, and exercise, exert a beneficial influence upon the course of the 
 disease. As many paranoiacs have dangerous or homicidal tendencies, 
 they need to be carefully examined, especially those with persecutory 
 delusions, in order to determine the presence of ideas of retaliation and 
 vengeance upon their imaginary persecutors. If there is any suspicion 
 of their possessing dangerous proclivities they should, of course, be de- 
 prived of their liberty as soon as possible. 
 
 Paresis. — See Paralytic Dementia. 
 
 Puerperal Insanity is insanity (sometimes melancholia, sometimes 
 mania) developing during the puerperal ep.)ch. There are three kinds — 
 one the insanity of pregnancy, one the insanity of parturition (developed 
 within a month after childbirth), and finally the insanity of lactation. 
 
 Senile Insanity is a mania, melancholia, or dementia (usually the 
 last) developing in old age. 
 
XII. 
 MEDICINES AND TREATMENT. 
 
 By HENRY A. GRIFFIN, M. D. 
 
 INTRODUCTION. 
 
 Our entrance into life is painless and in unconsciousness, and it is not 
 until long after birth that there occurs in us a gradual awakening to the 
 knowledge of our existence. If, therefore, Nature has provided for our 
 comfortable beginning, it seems but reasonable to suppose that she de- 
 signs a similarly easy ending ; and that as consciousness appears and de- 
 velops during childhood, so it should grow less and disappear during old 
 age, keeping pace with the natural development of the body in childhood 
 and its natural decline in old age, until life ceases in unconsciousness and 
 as painlessly as it began. Yiewed thus, childhood is life's awakening 
 and old age its falling asleep, while birth and death are both physiological, 
 the one life's beginning, the other its end. 
 
 So far as it concerns the child, birth is generally physiological ; but 
 life is seldom so, and death practically never. 
 
 That life and death are thus changed, from the natural to the unnatu- 
 ral, is due to disease and to the combating of disease and the attainment 
 of the physiological life and death are our efforts more or less earnestly 
 directed. In our combat with disease two courses are open to us — to 
 prevent and to treat. 
 
 THE PREVENTION OF DISEASE. 
 
 No truer words were ever written than " an ounce of prevention is 
 worth a pound of cure " ; and though we may indeed be unable to prevent 
 and must then attempt to cure, yet it is self-evident that prevention is the 
 first to be attempted, and thus the more important. The prevention of dis- 
 ease has been the object of the medical profession since the earliest times, 
 but only with the more scientific investigations of recent years, and the 
 consequently more thorough understanding of the nature and character 
 of morbid processes, has prevention attained to any great effectiveness, 
 
 823 
 
824 MEDICINES AND TREATMENT. 
 
 and even now its attainment is \*\ ni» means compk'tc. Certain means 
 effective in prevontini; disease liave, however, been discovered, and in 
 jiersonal and ]>ul)lic hviiiene, (juarantine, isolation, disinfectit)n, vaccina- 
 tion, ])reventive inoculation anil ])reventive medication, Ave have at our 
 command agents powei-ful to protect. Preventive treatment, ov j>r<>j>/it/- 
 /awfs, as it is termed, must tlierefure l)e considered hv us in order that the 
 completeness of our article shall not be sacrificed, and thougli preven- 
 tion and treatment apply to surgical as well as to medical conditions, yet 
 the latter alone will receive consideration in this article, and for surgical 
 information the reader is referred to another portion of this book. (See 
 Surtjical Injuries and Surgical Diseases.) 
 
 To say that the exercise of common sense will protect us against many 
 a liisease is perhaps as unnecessary as it is self-evident, and yet, while we 
 
 all would avoid the eating of foods known to contain 
 
 Habits as Causes . .\^^£• • i. • ]• i j.i 
 
 ^ ... poison, the risk of incurrino- contao'ious disease, and the 
 
 of Disease. ' ' i i 
 
 deliberate exposure to cold and wet, there are many 
 
 abuses to which the intelligent subject themselves habitually, the penal- 
 ties of which are as severe as those of the things we have mentioned. 
 Among those habitual abuses none is more potent for harm than is im- 
 }) roper diet. 
 
 Three forms of food are found to be essential to the maintenance of 
 health — fats, sugary and starchy matters, and nitrogenous matters, which 
 
 occur, for the most part, in meats. In some articles of 
 FoDus of Food. T , 11 ,1 • ,1 1 , 1 . .1 
 
 diet all tliese occur, in others but two, and in others 
 
 again but one. In no one food, however, is this mixture such that a diet 
 contined to that food \\\\\ give us the proper proportion of the three neces- 
 sary ingredients, save only the mother's milk when used by the infant. 
 It is from a failure to appreciate this truth that the so-called vegetarians 
 have been led into error, for a strict adherence to their doctrine necessi- 
 tates an abstinence from animal food, and while we may, indeed, obtain 
 the nitrogenous matter from vegetables, yet its proportion in them is so 
 small that to obtain the requisite amount we are compelled to use such 
 <piantities of vegetables, the main ingredient of which is starch, as to 
 overload our digestive systems with that substance, and this results in 
 digestive overwork and ultimately in digestive and bodily impairment. 
 
 In diseased conditions, indeed, it may be necessary to abstain from 
 one or another form of food, an example of this being seen in the ne- 
 cessary avoidance of sugary and starchy foods in sac- 
 charine diabetes. In health, however, a mixed diet is 
 invariably the best, and of the proportions of that mixture both our edu- 
 cation and our experience will teach us. It is not the purpose of this 
 article to deal exhaustively with foods ; but it may be stated as a gen- 
 eral rule that the su^rars and the starches are to be used onlv in modera- 
 
KEGULARITY AND MODERATION IN EATING. 825 
 
 tion, since they are of less value than are tlie nitroj^enoiis matters and the 
 fats. In their overuse, too, tliey are productive of the greatest harm, 
 whether that liarm be ilhistrated by the indigestion foHowing a candy 
 debauch, or by the more chronic and serious disturl^ances following their 
 continued abuse, of which chronic dyspepsia and gout are examples. The 
 meats are next most liable to overuse and consequently to al)U8e, while 
 least harmful of all are the fats, the greatest of whose penalties lies in an 
 unfashionable obesity. 
 
 The importance of regularity in eating can not be overestimated, and 
 while for some few a morning and an evening meal will suffice, for the 
 
 large majority of people the customary three meals a 
 '^^Eatinq^^ day are requisite. That these should l)e taken at 
 
 stated hours each day and separated by regular and 
 constantly kept intervals is probably generally appreciated ; but many 
 people who in other respects educate their children wisely and well, 
 educate their stomachs to the grossest sort of wilfulness and misbehaviour, 
 for they forget that the stomach acquires bad habits and retains them, as 
 does the individual. A thorough training in dietetic regularity^ there- 
 fo7'e, is of prime importance for the preservation of health. The habit 
 of " eating between meals" is in general to be strictly avoided. While the 
 delicate are often unable to take at their customary three meals amounts 
 sufficient to sustain them in the intervals, and therefore they may be 
 allowed a biscuit or a glass of milk " between times," or may even take 
 six small meals instead of the three larger ones, yet in health the practice 
 is unwise and harmful. So is the habit of eating before going to bed ; 
 and though some conditions warrant us in permitting or even encourag- 
 ing this practice, the most important among them being nervous sleep- 
 lessness, yet in such cases a morsel will suffice, and a heai-tj' meal must 
 never be allowed. 
 
 The appetite is not a trustworthy guide to physiological eating unless 
 it shall have been physiologically trained from our earliest days ; for, 
 
 especially in early years, the individual will feel hungry 
 
 about as often as he sees toothsome food. That the 
 head must govern the appetite is clear, and in no way can it more wisely 
 do so than in the prevention of overeating. This is largely a matter of 
 habit, and while we too often hear the words " I love to see a person with 
 a good appetite," the exhibition which calls them forth is usually one of 
 continued and excessive eating, not because the individual needs so much 
 food, but simply because the food tastes good. To eat thus, and to rise 
 from the table with a sense of satiety and fulness, can not be too stronglv 
 discouraged ; and while the author can not agree with those who rec- 
 ommend rising from the table while still hungry, he is thoroughly con- 
 vinced that overeatino; is more dangerous than is undereatino;. and can tes- 
 
S2G MEDICINES AND TREATMENT. 
 
 tifv to tlie direct reliition botwoon gluttony ami iiicuraltlo disoaso. As a 
 rule, people eat far too niiu'li, aiul in notliini^ is luotk'ration nmro impor- 
 tant than in eatiiiir. 
 
 Haste in eatin<; is a tliorou^lilv nnnarural ami liarmful jiractico, but 
 one which is unfortunately far too Cdiiinuiu iu Aiiu'rica, where haste and 
 
 hurrv make all thinixs unithvsiologieal. It is self-evi- 
 
 Hasiu Eating. , * , , • ' ^ " £ ^\ ±- 
 
 dent tiiat our teeth wore ii;i\en to us lor the purpose oi 
 
 dividing our food into such small particles as WLiuld make them more 
 easily digestible. The failure to observe this provision of Nature, there- 
 fore, results in the swallowing of food in pieces so large and undivided 
 as to liinder or jirevent the digestive juices from penetrating and digest- 
 ing them. In many animals this fine division is not necessary, since in 
 them the gastric juice is of such strength that even the toughest and 
 densest of foods are penetrated and digested. AVith man this is not so, 
 and the failure properly to chew or divide the food soon results in dys- 
 j^eptic and other diseases. Chewing must therefore be thorough, or, in 
 the absence of teeth — as in old age — the fine division of the food must be 
 accomplished otherwise. 
 
 Another reason for slow eating is too little realised, for many are 
 ignorant of the fact that the saliva is a digestive fluid, and that its mixing 
 with the food is as necessary to perfect digestion, in its way, as is the 
 action of the gastric juice. For these reasons, then, the habit of " bolt- 
 ing" our meals is harmful in the extreme, and its continued practice is 
 responsible for many an ill. 
 
 The greatest diversity both in theory and in practice exists upon tlie 
 
 subject of water drinking. Xo hard-and-fast rule can be given as to the 
 
 requisite amount for the maintenance of health, for the 
 
 Water Dnnlxing. '■ ^ ^ ■^^ • ^ ^ • ^' • ^ ^ » ^ 
 
 amount needed M^ill vary with the individual. A onod- 
 erate amount of water taken with our meals is of great value in dissolv- 
 ing many of our foods and in promoting their absorption. The taking 
 of lar(ie quantities of water with food is, on the contrary, unhygienic, 
 since thereby the digestive juices are rendered more dilute and hence less 
 active. Very cold water, too, lias the disadvantage of reducing the 
 warmth of the stomach, which is necessary to the perfect accomplish- 
 ment of digestion, and while this action will be slight and soon overcome, 
 if but small amounts of the iced water are taken, larger amounts may be 
 productive of harm. The drinking of water between meals is, however, 
 to be recommended, since its effect is to wash and cleanse and flush the 
 tissues throughout the body, and thus to render them more healthy and 
 more active. By this action it sweeps the collected impurities from the 
 body, and in the increased amount of urine and perspiration produced by 
 water drinking are thrown off excrementitious substances whose retention 
 in the body would be productive of harm. AVomen in particular are 
 
WATER DRINKING AND EXERCISE. 827 
 
 guilty of neglect of this wise use of water, possil>l_y from the embarrass- 
 ment connected with the necessity for more frequent urination. Young 
 children, too, offer examples of this neglect, and it is simply astonishing 
 that mothers should experience and gratify thirst in themselves, and never 
 
 entertain the idea that their infants can be thirsty. And 
 Water Drinking in , ^i ■, •^ ^ • n .1 • . ^ 
 
 In fancy ^°' whenever tlie ciiild cries 01 t/urst, tlie ever-ready 
 
 bottle is produced, and to obtain the drink he wants he 
 is compelled to take the food he does not want, with the result of keep- 
 ing his digestion ever acting and ultimately of producing its disorder. 
 Not a little of the vomiting and diarrhoea of young children could be 
 prevented by the occasional giving of a teaspoonf ul of cool water. 
 
 The power of water to promote the activity of the bowels is not the 
 least of its good qualities, and a cup of cold water taken on an empty 
 stomach will often suffice to relieve the milder grades of constipation. 
 
 If water, then, is so necessary for our continued health, its quality must 
 be even more carefully considered than its quantity, since by contamina- 
 tion it may become the vehicle of infection and disease. 
 Pure Water, 
 
 If, therefore, any doubt of the purity of our drinking 
 
 water arise, its use is to be avoided entirely, and bottled waters of known 
 purity are to be substituted. It is not always convenient to do this, how- 
 ever, and so we may resort to purifying the polluted water by thoroughly 
 boiling it (filtering is worse than useless), after whicli it may be cooled 
 and drunk. Such precautions are especially required during the preva- 
 lence of cholera, diarrhoeal diseases, and typhoid fever, for the poisons 
 of these diseases are known to reside in water and with it to enter the 
 body. 
 
 No man can continue healthy without exercise in some form, and 
 though, as is the case with food and drink, some require more and others 
 less, yet the practically complete avoidance of it results, 
 as IS seen every day, m digestive and nervous disturb- 
 ances, loss of vigour, and, if continued, in organic degeneration and dis- 
 ease. (See Physical Training) 
 
 The form of exercise must vary with the habits, time, sti-ength, and 
 requirements of the individual, and the most that can be done here is 
 briefly to allude to the more common forms. 
 
 Walking is within the power of all in health, and should be practised 
 each day, and, if possible, at a regular hour. The pace should be brisk, 
 . and an effort made to have the whole body participate, 
 
 so far as may be, in the exercise, that it may not be an 
 exercise of the legs alone. The distance must be regulated by the effect 
 upon the walker, for anything beyond a healthful weariness is to be avoided, 
 while up to this point nothing but good can result from a continuance of 
 the walk. To name a standard, then, is impossible, and a greater absurdity 
 
8-2S MEDICINES AND TREATMENT. 
 
 than j)laeint; tlie reijuired daily distaiuH' for a man in lu-altli at iiiiu' niiU's, 
 as has been done Uv a (iernian autli>ii-ir_v. can not hi' iniau-ined. Like all 
 other forms of exereise, walking, save of the niikiest, shonld neither be 
 (lone just after a hearty meal nor. on tlie other hand, upon an empty 
 stomach. 
 
 Horseback i-iding is an ideal exercise, since in it no one set of innscles is 
 benefited to the exclusion of others, but all are brought into play. More- 
 over, the mental activity required is distinctly advanta- 
 Jlorscbark Ruhng, fjeous and the motion conducive to digestive vigour, 
 
 Hutminq, Biry- ' . .. , , ... • j i. .1 • a. j: 
 
 ,. n ■ ifiinninsr, 11 not too violent or carried to the point ot 
 
 chug, luiwint/, ^^ _ ^ 
 
 ami Biuinq. exhaustion, is an excellent exercise ; beyond these points 
 
 it is dangerous. Bicycle riding has many advantages; 
 it is novel and entertaining; it is beneficial, too, if not excessively or vio- 
 lently done, but it has a serious disadvantage in the stooping position so 
 generally assumed by those who "ride the wheel." Ilowing, if done in 
 moderation, is well, but if speed be attempted, especially for any distance, 
 there result such great strains upon the circulation and respiration as to 
 be the possible causes of serious mischief. Boxing is an admirable exer- 
 cise, for in it all the muscles are emj)loyed and the mind as well, and by 
 it are cultivated strength, agility, rapidity of thought, and control of 
 temper. 
 
 Milder forms of exercise are more suitable for the young, for the deli- 
 cate, and for Avomen, and of these, tennis, golf, fencing, and dumb-bell 
 and Indian chib exercises are examples. AVhatever the form of exer- 
 cise, however, let it be done regularly, not violently, and continued only 
 until a healthful weariness is produced. 
 
 Cleanliness is of the utmost importance as a preventer of disease, and, 
 
 if possible, a bath should be taken each day. This daily bath should not, 
 
 however, be a soaking, for in this there is no advantage, 
 
 ,„,,." and, furthermore, there is produced a weakening of the 
 
 and Bathing. ' ' r n 
 
 body generally, and a removal of the oily secretions of 
 the cuticle by which the skin is rendered less healthy and less active. A 
 sponge bath or a brief dip or a shower should be the daily practice upon 
 rising; the "soak" should not be employed more often than once a week. 
 The temperature of the water used is of much importance, for while the 
 weekly tub bath should be given warm and with soap, since thus is cleans- 
 ing more perfectly effected, the daily dip, or sponge, though indeed 
 cleansing, is more to invigorate, and therefore is more effective if cold. 
 
 Cold-water baths, however, cause in some people shivering, blueness 
 
 of the fingers, toes, and lips, and a feeling of weakness. Such people 
 
 shonld never take cold baths, and indeed persons vary 
 
 much as to the degree of cold they can bear. Yet in 
 
 many, a healthful glow follows the cold bath, and, with a feeling of in- 
 
THE USE AND ABUSE OF STIMULANTS. S20 
 
 vigoratiun and warintli, constitutes tlic " re!u;tion," and this is the surest 
 evidence of the bath's vahie, without wliich sucli cold applications only 
 do harm. 
 
 If we spur a horse he will respond ])y increasing the power and i-ujjid- 
 
 ity of his movement, but if we contiime the spurring from time to time, 
 
 lie will become accustomed to it and respond less ac- 
 
 Stimulants. ^. i ^ ^^ -c • ^^ .11 
 
 tivelj, while if we incessantly use the spur he soon 
 becomes exhausted by his efforts, and further spurring serves but to com- 
 plete his exhaustion. It is so with stimulants, no matter whether tlie 
 form be alcohol, tea, or coffee; their occasional use produces increase of 
 nerve action, their more frequent use produces less response, and their 
 habitual use, and especially their habitual overuse, produces a weakening 
 and ahnost impotence of nerve structures. It is not intended to argue 
 against the use of such stimulants, but simply against their abuse, for while 
 individuals vary greatly in their ability to use them, and in some persons 
 the slightest quantities act to disorder nerve function and are practically 
 poisons, yet others bear them well and are benefited bj' them. Exces- 
 sive use is, however, dangerous to all. A glass of wine with a hearty 
 meal is often an aid to digestion, and especially in the aged, in whom cir- 
 culation, digestion, and all nerve action are deficient in strength. A cup 
 of coffee is similarly beneficial, as is a cup of tea, though both have the 
 power to cause " nervousness " to a degree relatively greater than that 
 caused by alcohol. Tea, too, has a marked tendency to cause constipa- 
 tion, and its general use by women, toe-ether with the 
 Tea Drinking . ' o 
 
 little exercise they usually take, serves to account for 
 
 the constipation so often found in that sex, together with its attendant 
 ills. This power of tea is dependent upon the tannin the leaves contain, 
 and the longer the tea stands or steeps, the more tannin it contains and 
 the more constipating it is. The evil results, then, of drinking such a 
 beverage can not be overestimated. It is all very well for the tea victim 
 to call it the " cup which cheers but not inebriates " ; but she deludes her- 
 self, for though indeed not intoxicated, yet she is constantly stimulated, 
 thoroughly dependent upon a drug, and to all intents and purposes a 
 drunkard. Alcohol is, of course, a more powerful drug, and one whose 
 power to poison and to cause disease is more marked, but the principle is 
 still the same whether in use or abuse. 
 
 The continued overuse of alcohol causes incurable diseases, of which 
 gout, chronic catarrh of the stomach, and Bright's disease may be taken 
 as examples. Its occasional excessive use causes intoxi- 
 cation, but, so far as danger to life is concerned, the 
 occasional drunkard is far better off than is the habitual " tippler.'- Xot 
 only does this habit cause disease, but it weakens one's resistance to any 
 illness, since it so weakens the circulation (by lessening nerve force) that. 
 
830 MEDICINES AND TREATMENT. 
 
 with the extra demands upon the heart in ilhiess, especially if acute, that 
 ororan eives out under the strain and death results. It is of little use in 
 such cases to spur on the weakened heart with wine and liquor, for, like 
 the jaded horse, it feels the sjiur. indeed, hut has no strength to respond. 
 The frctpiencv of death from j)neunK»nia in alcoholic cases is thus e.x- 
 jdained. 
 
 That "what is one man's meat is another man's poison" applies to 
 nothing more forcibly than to tohacco smukinii:. Some are injured by the 
 slightest smoking, indigestion and "nervousness" being 
 ntg. ^.^^^ penalty for the sin ; while others really derive bene- 
 
 fit from the after-dinner cigar, a mental soothing and digestive rapidity 
 following. No rule, then, can be given for the safe or proper amount to 
 be smoked. It is simjily a matter for the individual to ascertain by expe- 
 rience and honesty with himself. Excessive smoking, there can be no 
 doubt, is harmful in all cases, but what will be excessive for one will be 
 moderate for another. Two or three cigars a day, smoked, not upon an 
 empty stomach, will, in general, not be excessive. Pipe smoking, too, 
 may be beneficial if done in moderation, but no matter hoio tobacco is 
 s7)iol'ed, it should not he inhaled. The most al)ominable form in which 
 tobacco is smoked is the cigarette, and unless one can smoke cigarettes as 
 infrequently as one does cigars, in moderation, and without inhaling, they 
 should not be allowed. It is not the paper which does the harm — that is 
 practically innocuous ; but the evil effects are due to several reasons : 
 first, because they are so cheap that economy exercises no restraint upon 
 the number smoked ; second, because they are generally inhaled ; third, 
 and most important of all, because of the well-known fact that, to produce 
 the greatest effect from a given drug, it is given, not in large and long- 
 separated doses, but in small amounts frequently repeated. For the last 
 reason the system of the ordinary cigarette smoker is practically never 
 free from tobacco. The harmful results from such continued saturation 
 may be inferred. Of tobacco chewing it suffices to say that the practice 
 is more disgusting than it is harmful, though some digestive impairment 
 is usual. 
 
 In concluding this consideration of common drug habits, let it again 
 be accentuated that for them all moderation is necessary or harm will re- 
 sult ; that moderately used they may be of much benefit, and that personal 
 peculiarity will often entirely prohibit them. Let it l)e remembered, too, 
 that such practices are strictly to be prohibited in childhood and early 
 youth. 
 
 Sleep is the periodical and physiological rest by which Nature refreshes 
 
 us when wearied. The necessity of such rest is self- 
 Sleep . . . . 
 
 evident, and the loss of it is a familiar cause of illness. 
 
 The amount of sleep requisite varies with the individual, and an arbitrary 
 
HYGIENIC VALUE OF REGULAR HABITS. 831 
 
 assignment of " six lionrs for a n^ian, seven for a woman, and eiglit for a 
 fool " is absurd. In fact, the amount of sleep we require we shall find 
 out by experience, and, having once found it, that amount becomes the 
 normal amount for us. As a matter of fact, the average duration of sleep 
 of the healthy man is nearer eight hours than six. 
 
 Late hours are apt to be injurious because they are usually associated 
 with excitement, exposure, and perhaps excess of eating and drinking; 
 and because, in many cases, a necessarily early rising upon the following 
 day robs the person of his normal amount of sleep. The mere lateness of 
 the hour in itself has little to do with it, providing it is haljitual for the 
 individual to retire late, sleep his normal amount, and rise when refreshed. 
 The habit of " early to bed and early to rise " is no doubt a good one, but 
 late to bed and late to rise is in itself as good if regularly practised. 
 
 The taking of " cat naps " and " forty winks " is beneficial in some 
 persons M'hen tired, but this is largely a matter of habit and as disturbing 
 to some as it is refreshing to others. Such naps should not be permitted 
 after hearty eating, and should never come to act as substitutes, even in 
 part, for the full night's sleep. 
 
 It is really astonishing, as well as amusing, to see what individuality 
 our organs jDossess, for they are as much creatures of habit as we our- 
 selves. In no way is this more clearly manifested than 
 in the action of the bowels. Once form the habit of 
 evacuation at a certain hour, and, while health continues, at that same 
 hour each day will the bowels move, if permitted to. It is the same with 
 eating and sleeping, and the wisdom of forming and following such regu- 
 lar habits is one of the greatest protections against disease. Regularity 
 may be carried to a ridiculous degree in unimportant occupations, and we 
 often hear such practices referred to as fussy and foolish ; but in the taking 
 of food and exercise, the evacuation of the bowels, and in sleeping, there 
 can be no variance or irregularity if health is to be preserved. 
 
 Exposure to cold and wet plays an important part in disease produc- 
 tion, whether that exposure be habitual, as is the case in certain outdoor 
 occupations, or whether it be occasional and unusual. 
 The latter is, however, the more commonly injurious, 
 and its ill effects are seen every day in the production of coughs, colds, 
 pneumonia, sore throats, and rheumatism. Cold in itself is not so potent 
 for harm as is dampness, but when they are combined the partnership is 
 indeed a dangei'ous one. It is in climates like ours that this combination 
 is particularly to be feared, for its action is especially noticeable where 
 sudden changes of climatic conditions occur. To the dweller of Xew 
 York city it is no rare thing to leave home early in the day lightly clad 
 and rejoicing in a bright and temperate atmosphere, and to return home 
 chilled by penetrating, damp, and cold winds, and perhaps drenched to 
 
832 MEDICINES AND TREATMENT. 
 
 tlie skin. No (.'on>titutii.tn is al)le to aeooiiunodate itself coiitiiuiously to 
 
 such nipidly changing conditions, and the prevalence here of catarrhal 
 
 and respiratory diseases bears evidence to this fact. Much, however, can 
 
 he done to combat such injurious inliuences, for a grad- 
 
 Protectiim aqainst ^ ^ \ • -n i i j- i 
 
 „ ^ ual touirlienmg process will niake our bodies less sensi- 
 
 hxposure. ^ _ f ^ 
 
 . tive to climatic conditions and changes. The way to 
 
 accomplish this is not by keeping ourselves warmly housed and protected 
 in our rooms — for we become weakeneil thiTLby and less resistant — veri- 
 table hot-house plants, to be chilled or killed by the tirst attack of cold 
 and damp ; rather should wa toughen ourselves against cold and damp, 
 and to this end the following hints will conduce: Avoid the common 
 mistake of keei)inir the rooms in which vou live at too high a temi)era- 
 ture — 70° Fahr. is sufficiently warm. Do not sit in the house with your 
 overcoat or street clothing on. Sponge the throat and chest each morn- 
 ing with cold water. AVear woollen underclothing the year round, modi- 
 fying the weight, if desired, with the season, and varying the outer cloth- 
 ing with the demands of the outdoor temperature. Remember, too, that 
 draughts are far more dangerous than is an atmosphere free from draught, 
 even if much colder ; that exposure is especially dangerous when you are 
 overheated ; that far more colds are contracted from cold and wet feet 
 than from cold and wet bodies; that thick or cork-soled shoes should be 
 worn in cold and damp weather; and that artificial protections, such as 
 ''chest protectors," are of more harm than benefit — for, as has been well 
 said by a physician of this city, '' the best place to wear a chest protector 
 is on the soles of the feet, and the worst is on the chest." 
 
 The prevalence of certain diseases suggests the adoption of special pre- 
 cautions, and particularly in the ease of those of a contagious nature. In 
 general, isolation, avoidance of infected rooms, houses. 
 
 Prevention of i j- i. • i. -^i t • r i.- ^-^ .. xi 
 
 ^ . . and districts, with disinfection, constitute the precau- 
 
 tions, and for more detailed information the reader is 
 
 referred to the article on Hygiene. A few diseases, indeed, there are to 
 
 which specific protection may be applicable, and of these smallpox first 
 
 claims consideration. 
 
 The introduction of vaccination proved one of the greatest blessings 
 
 to mankind, for smallpox up to that time had devastated every inhabited 
 
 land. Since that time, however, the disease has become 
 Vaccination. ,.,.,. i n i • • • 
 
 relatively intreipient. and all this we owe to vaccination. 
 
 In vaccinating, the "virus" used is a fluid obtained from the blisters 
 
 which form on animals suffering from a disease called "cowpox." This 
 
 disease is believed to be not identical with smallpox, but the introduction 
 
 of its virus into the human system serves to protect the individual from 
 
 an attack of smallpox, or at least to insure his having none save a light 
 
 attack. TIow long the protection thus acquired lasts it is impossible dcfi- 
 
PREVENTION AND TREATMENT OF DISEASE. 883 
 
 nitely to state. The tlrne proljablj varies witli the individual, Ixit in gen- 
 eral it is considered wise to revaccinate once in seven years, and also 
 whenever the prevalence of the disease suggests additional caution. The 
 first vaccination is to be done in infancy. 
 
 It is as yet too early to speak conclusively upon the prevention of 
 diphtheria by the use of the recently introduced diph- 
 Antitoxine. ^''^"^ antitoxine, but, SO far as present indications are 
 to be depended on, it would seem that its effective- 
 ness is considerable. 
 
 The precautions taken to prevent cholera and typhoid fever by atten- 
 tion to the drinking water have already been alluded to, and it remains 
 but to say that strict attention must be paid to intes- 
 Typkoid Fever. ^"^^^ disturbances, and all diarrho3as must be promptly 
 checked, for it is in an unhealthy intestine tliat the germs 
 of these diseases find their most favourable soil. To leave the districts of 
 infection is, if possible, always to be done. 
 
 Malaria, too, may often be prevented, and those who live in malarious 
 districts are wise to have their houses built upon ground as high as pos- 
 . sil)le, and as far as may be from marshy ground or 
 
 stagnant water, to attend carefully to the condition of 
 their drainage, and to avoid the night air. If the residence in such places 
 is but brief, the taking of from six to ten grains of quinine each mornini^ 
 after breakfast is often a trustworthy preventive. 
 
 These, then, represent, in general, the preventive means possessed by 
 us. The avoidance of evident dangers need not be detailed, since they 
 are not matters of medicine but of common sense. An observance of 
 these laws will certainly conduce to a long and healthy existence, and 
 though it is true that contagious and infectious diseases may not always 
 be preventable, yet it must be remembered that all such diseases are far 
 more likely to attack the unhealthy and the debilitated. The observance 
 of hygienic laws will therefore ward off not only the organic and systemic 
 diseases, which are usually chronic, but will in no small measure protect 
 against the acute contagions and infections, or will, if thej' are contracted, 
 render recovery from them more likely. 
 
 In conclusion, it may be said that the 'preventive or proj^hylactic treat- 
 ment of disease rests ujpon three essentials — regularity^ moderation^ and 
 common sense. 
 
 THE TREATMENT OF DISEASE. 
 
 If disease can not be prevented, then it must be treated, and, thouo-h 
 it is a rule with many exceptions, in general it may be said that the tend- 
 ency of all chronic diseases is to progress and increase, while the tendency 
 of acute diseases is to recover spontaneously. Chronic disease, from its 
 55 
 
834 MEDICINES. AND TREATMENT. 
 
 very duration, will permit vi tre:itiiient bv a physirian. In acute disease 
 the inference is clear that meddling by a lay person is impruiient anil dan- 
 ji^eroiis. Of treatment, too little is far preferable to too much. JVothing is 
 more deplorable than the injury of a ])atient by the very medicine which 
 is intended to do him good, and therefore, in all things medical, prudence 
 is strictly and mrnutely to be observed, for it is the prime requisite to 
 safetv and to success. Two rules., therefore, are ever to he renianhered : 
 Fh'ftt, 7ievef' to (jive a medicine without a very good reason fo^r it ; second., 
 always to consult a physician ichen in douht. The importance of the 
 latter rule is apparent and of the former scarcely less so, and yet its 
 violation, as seen in the " dosing habit," is an every-day occurrence. The 
 prevalence of such dosing is indeed alarming, and the habit itself is not 
 onlv ludicrous but dangerous, for this constant drug nibbling interferes 
 with and disturbs digestion, weakens resistance to disease, and so accus- 
 toms the system to the presence of the drug that when 
 'Hie Drug Habit. . ] c -j. • -i. i i j. j 
 
 the need for it arises it no longer lias power to produce 
 
 an effect. The patent-medicine victim is an example of this foolish " drug 
 liabit," as is a man who, to the knowledge of the author, carries in each 
 of his four waistcoat pockets a medicine — one for headache, one for pal- 
 ])itation, one for liatulence, and one for any symptom not covered by the 
 other three. 
 
 " To every man his own " is an excellent motto, and treatment of dis- 
 ease therefore belongs to the physician. This is generally recognised and 
 granted by the laity — in fact, there are those who too frequently summon 
 their doctor needlessly — and yet there are forms of disease which may 
 wisely and properly be treated by those not physicians. 
 
 These are : Simple and trivial ailments ; emergencies, pending the 
 arrival of the physician ; conditions requiring professional treatment and 
 where no physician can be obtained. 
 
 THE FAMILY MEDICINE CHEST. 
 
 A family medicine chest is well enough in its way, and in default of 
 
 easily obtainable medicines is indeed a necessity ; but certain disadvantages 
 
 are connected with its presence in the home, some of 
 
 jec '^^«« them orrave ones. Thus the fact that a medicine is con- 
 
 tke Chest. ^ ^ ^ 
 
 stantly within reach may be responsible for its too fre- 
 quent administration, or its administration upon insufficient grounds. Of 
 this practice the evil results have already been mentioned. Many fluid 
 drugs, too, are liable to deterioration upon keeping, and if alcohol be an 
 ingredient, evaporation also occurs, with a resulting concentration of the 
 medicine and a consequent increase in its powers. This concentration is 
 especially likely in the case of tinctures, and the giving of a dose of the 
 concentrated tincture, which would have been safe and proper in the un- 
 
CONTENTS OF THE MEDICINE CHEST. 835 
 
 evaporated preparation, has frecpicntly been the eause of serious and even 
 fatal poisoning. 
 
 If circumstances require the possession of a medicine chest, its dan- 
 gerous features may be diminished and largely ])revented by the observ- 
 ance of a few ]>recautions. The place in which it is 
 kept should be one which, while easily accessible, will 
 be secure from meddlesome attacks, especially by children. It should 
 never be locked, for a misplaced key may be the cause of serious or fatal 
 delay. The bottles in it should be of clear white glass with smooth glass 
 stoppers, save when they contain actively poisonous drugs, in which case 
 bottles of blue glass with glass stoppers studded with sharply pointed pro- 
 jections are recommended, that by night as well as by day these peculiari- 
 ties may give warning of the poisonous contents. Wooden, leather, and 
 rubber bottle cases are manufactured, and these may well be used to pro- 
 tect the bottles against breaking when travelling. The label upon the 
 bottle should be printed or clearly written, that all may read it. It should 
 be kept spotlessly clean, and if soiled should at once be replaced. Upon 
 the label should appear the name of the drug contained, the diseases or 
 conditions to which it is applicable, and the dose. The stoppers must be 
 replaced at once after using, and the greatest care must be observed that 
 they are tightly fitted and remain so — a precaution of the utmost necessity, 
 and especially in case the drug is a fluid. 
 
 Many drugs — fluid as well as solid — are now prepared as tablet tritu- 
 rates by thoroughly mixing tliera with some indifferent substance, such as 
 
 sugar of milk, and then pressinoj into small cylindrical- 
 Tahlets. ^' . . 
 
 shaped masses. This form of preparation is exceedingly 
 
 useful, and especially when drugs must be kept long. Convenience of 
 administration, accuracy of dosage, and safety from evaporation and de- 
 terioration are qualities sufflcient to make this method of employment 
 preferable to all others. The difficulty of administering them to children, 
 too, is easily overcome by dissolving them in water and then giving, or 
 by crushing them to powder and then placing on the tongue. 
 
 Such, then, are the pros and cons of the family medicine chest, and 
 such the precautions necessary to its safe employment. A medicine chest 
 is, however, but a substitute at best, and if a good pharmacy be near at 
 hand, and therefore if drugs are readily and quickly obtainable, it is 
 generally wnser altogether to dispense wath it, for, as has aptly been said, 
 '' the best family medicine chest is a teaspoon and a drugstore." 
 
 Still, the medicine chest is often a necessity, and the contents recom- 
 mended are as follows : Tablets of morphine sulphate, one eighth of a 
 grain each. Blue bottle. Label to read : " Tablets of 
 Morphine Sulphate, one eighth of a grain each. For 
 pain. Dose for an adult, one tablet." Of all the drugs the chest con- 
 
830 MEDICINES AND TREATMENT. 
 
 tains, none is to be so cantiously employed as is this, for even tlie laity 
 are aware of the dangers of morphine poisonini:: and the dangers of form- 
 ing the morphine huhit, if the nse of tlie drng he anything more tlian 
 rarely occasional. Morphine will relieve any })ain if given in snthcient 
 amount, and the indiciition for giving is solely the severity and (the pains 
 of labi)nr being excepted) not at all the character or the location. The 
 drug is to be used, therefore, in pains of such severity and duration as can 
 not well be borne, and whose effect is manifestly injurious to the patient. 
 For such cases, then, let one tablet be given ; if no relief occur in a half 
 hour let another be given, and similarly, and if necessary, a third and a 
 fourth. ^Morphine may also be used in similar doses for sleeplessness 
 (see SleejyU'ssness) ; but, unless the sleeplessness be due to pain, there are 
 other and less harmful ren\edies which should invariably be tried first. 
 For vomiting, too, a tablet may be dissolved in a teaspoonful of ice-cold 
 water, and given thus will at times suffice to relieve, A second may be 
 given if no benefit results from the first. One of the great objections to 
 the use of morphine is nausea and vomiting, together with headache and 
 depression, appearing some hours after the administration of the drug. 
 These svmptoms may sometimes be relieved by the administration of 
 strong black coffee. The first symptoms announcing the over-eff!ect or 
 poisonous action of morphine are drowsiness, contracted pupils, and 
 slowed breathing (see Morphine Poinonuxj). Morphine should never 
 be given to children or to the aged. 
 
 Tablets rhinitis. Label to read : " Tablets Khinitis. One half strength. 
 (Dr. Lincoln.) For cold in the head. Dose for an adult, one every hour 
 
 till throat becomes drv." The amount of suffering 
 Rhinitis Tablets. , , , . , i i • li i i ^ • i 
 
 which a simple cold m the iiead can produce is known 
 to us all, and nothing so well serves to relieve it as these tablets. They 
 should be given in the earliest hours of the disease — as soon as sneezing, 
 obstruction, and rawness of the nose make their appearance, for later in 
 the disease they are less efficient, if not positively useless. Beginning, 
 then, with one tablet every hour, we continue until the dryness of the 
 throat informs us of the full effect of the belladonna the tablets contain. 
 After this it is customary to give the tablets at longer intervals — usually 
 of three or four hours — that the dryness of the throat may not become 
 too great and yet may be maintained to a slight degree. Marked relief is 
 generally observed within a few hours. 
 
 Tablets of tincture of aconite, one minim each. Blue bottle. Label 
 
 to read : " Tablets. Tincture of Aconite. One minim each. . For fever. 
 
 For sore throat. Dose for an adult, one tablet every 
 
 half hour until tongue and lips feel numb." The 
 
 power of aconite to reduce fever and to diminish inflammation depends 
 
 upon its action to lessen the force of the lieurt and to cause sweating, 
 
TABLETS OF IPECAC, TINCTURE OF ACONITE, ETC. 837 
 
 fur sweating will he followed by inereased evaj)oratioii from tljc surface 
 and consequent cooling, while botli actions result in a lessening of the 
 congestion in the inflamed areas. The drug is ca])able of causing dan- 
 gerous poisoning, but of this it fortunately gives warning in a numbness 
 of the lips and tongue. Upon the appearance of these symptoms, tlien, 
 the giving of aconite must be stopped, and is to be resumed oidy upon 
 tiieir complete disappearance, when it may be given as before, and again 
 suspended upon the reappearance of the numbness. In the sore throats 
 of children and in their simple fevers aconite is of great value. In such 
 cases one tablet may be dissolved in four teas[)Oonfuls of water, and one 
 teaspoonful of this may be given every half hour until the lij)S and tongue 
 become numb, if the child is old enough to notice and describe these sensa- 
 tions, or until the skin becomes moist and perspiring. An intermission 
 should then be made, and a subsequent repetition of the giving if neces- 
 sary. The fevers in which aconite is applicable are those of brief dura- 
 tion and some violence, and where the strength is well preserved. In 
 long-continued and "low" fevers, and if exhaustion is present, as shown 
 by a weak pulse, it will do harm. 
 
 Tablets of ipecac, one tenth of a grain each. Label to read : " Tablets 
 of Ipecac, one tenth of a grain each. For bronchitis. Dose for an adult, 
 one tablet every hour." It maj^ be said that some people 
 will not recognise bronchitis when they have it ; but 
 practically by far the larger number will not fail to do so, for cough, a 
 feeling of rawness beneath the breast bone, and a sense of oppression over 
 the chest are symptoms with which almost all of us have become familiar 
 by experience. If these be present, and especially if exposure to cold 
 and wet have preceded them, the inference of bronchitis is very strong. 
 Should nausea at any time appear while taking the ipecac tablets the drug 
 should be suspended until this symptom passes, when the tablets may again 
 be resumed and may be taken at longer intervals. 
 
 This treatment is not proper for children, and in them drugs are in 
 general to be avoided ; confinement to a warm room, cotton worn over 
 the chest and back, and, if necessary, a rubbing of the chest two or three 
 times a day with a mixture of turpentine and sweet oil — equal parts — are 
 usually quite sufficient. If the attack be severe, however, and fever 
 marked, in addition to these measures we may administer tincture of aco- 
 nite as already described. 
 
 Tablets of aloin, belladonna, and podophyllin, compound (Fraser). 
 
 Label to read : " Tablets Aloin, Belladonna, and Podo- 
 
 om e a onna, p]^y]-]jjj Comp. For constipation. Dose for an adult, 
 
 and Podophyllin , . i i • .^ tt i • i • • 
 
 Tablets *-'"^ ^^ ^^^ tablets at bedtime. Habitual constipation 
 
 is the condition for which this medication is intended, 
 and according to the severity so will the dosage vary. Until the necessity 
 
S3S MEDICINES AND TREATMENT. 
 
 for a larger dose becomes apparent one tahlet only slionkl be taken, and, 
 
 though it may be used if necessary each night, it is often possible to get 
 
 along with a less frequent administration. (See Const ijuitl 0)1.) These 
 
 tablets must not be given to children. 
 
 Tablets of •' sun " cholera mixture (Fraser). Label to read : " Tablets 
 
 Sun Cholera Mi. Mure. For diarrluva. Dose for an adult, one tablet." The 
 
 " sun "" cholera mixture has for many years enjo3'ed a 
 
 L ,, ,"'*"' irreat rt'outarioii in the treatment of chok'i'a morbus and 
 TaOlefs. ' . . 
 
 diarrlueas. 1 hese tablets contain the same ingredients 
 
 as do the mixture, and four of them represent the equivalent of one tea- 
 spoonful of the mixture. They should be given at intervals of a few 
 minutes until tliree have been taken ; thereafter one may be given after 
 each movement of the bowels. As they contain capsicum (red pepper), 
 they must be quickly swallowed, and, to prevent irritation of the stomach, 
 a drink of hot water should follow; or they may be taken dissolved in 
 hot water. They contain opium, too, and hence the necessity for fre- 
 quent administration should make us careful to observe the possible 
 evidence of opium poisoning, in the presence of which the medicine must 
 at once be stopped. These tablets must not be given to children. 
 
 Tablets of Dover's powder, one grain and a quarter each. Label to 
 read : " Tablets of Dover's Powder, one grain and a qnarter each. For 
 
 diarrhoea. To cause sweating. Dose for an adult, one 
 Dover's Powder. ^ • i . . i i . •>, ta ? i i 
 
 to eight tablets. Dover s powder also contains opium, 
 
 and on its presence the value of the preparation in diarrhoea depends. 
 According to the severity of the diarrhoea, the dose will range from one to 
 two tablets, given every two or three hours. The signs of opium's over- 
 effect must be watched for in giving this preparation. 
 
 It is common knowledge that if a person takes a cold and within the 
 lirst few hours thereafter has a thorough " sweat," he is likely to " break 
 up" his cold. For the production of such a sweat there is nothing so 
 useful as one full dose of Dover's powder. For such cases the dose is 
 eight tablets, taken as one dose, and to increase and augment the sweat- 
 ing the patient should be warmly covered in bed and take hot drinks 
 freely. The sweating thus induced is usually profuse, and when it has 
 reached a sufficient amount, and its continuance might induce weakness, 
 it is to be terminated by rubbing the patient vigorously witli rough towels 
 until dry and then changing his bedclothing, with the application of a 
 lesser amount of covering. Exposure to draught and cold must be care- 
 fully avoided, since there is an especial danger of taking cold when sweat- 
 ing. Dover's powder is not to be given to children. 
 
 Tablets of calomel, one tenth of a grain each. Label to read : " Tal)- 
 lets of Calomel, one tenth of a grain each. To purge. Dose for an adult, 
 one tablet every half hour." Calomel is to l)e used when a free open- 
 
THE USES OP CALOMEL AND QUININE. 830 
 
 ing of the bowels is desired, occasionally only, and not frcjuontly or for 
 habitual constipation, as are the aloin, bcllad(jrina, and j»o(lo]jhyllin tablets 
 of which we have spoken, (furiously enouirh, diar- 
 rhcea is as often benefited by calomel as is constipa- 
 tion, and for the reason that dian-luea is often an evidence of Nature's 
 attempt to free the body from irritating and indigestible food, the reten- 
 tion of which in the intestines would do liarm. If, then, calomel be given 
 to such a case, Nature is aided in ridding the body of the unhealtliful 
 matter, and the intestine being emptied, the diarrhoea ceases. Any diar- 
 rhoea associated with much flatulence and discomfort in the abdomen (tlie 
 evidence of fermentation) may wisely be so treated. Such a condition is 
 often seen in tiiose people called '' bilious," and is apt to alternate with a 
 condition of constipation. For such patients no treatment is so desirable 
 as an occasional calomel purgation. Constipation is an evidence of the 
 inability of the intestine to empty itself, and, if occasional only, may well 
 be relieved by calomel. A free purging will often be beneficial at the 
 beginning of an acute feverish attack, in the same manner as is a free 
 sweating, and for tliis object calomel is excellent. To produce purgation 
 by these calomel tablets let one be taken every half hour until the bowels 
 have moved freely or until ten have been taken. As a rule, ten tablets 
 will be required. If no movement has occurred six hours after the last 
 tablet has been taken, a dose of salts should be given. The variety of salts 
 is unimportant, and Epsom salts, Rochelle salts (in tablespoonful dose re- 
 peated once if necessary), or a wineglass of Ilunyadi water are equally 
 applicable, for it is necessary only that the assistant purgative be a saline. 
 Calomel is best given on an empty stomach, and. usually, though not nec- 
 essarily, just previous to retiring. In the fermentative diarrhoea of young 
 children, in which flatulence and foul-smelling movements occur and with 
 which vomiting may be present, calomel is a most effective remedy, and 
 one of the tablets may be given every three or four hours, according to 
 age and necessity. The vomiting, too, is relieved by the drug. 
 
 Pills of quinine sulphate, two grains each. Label to read : " Pills of 
 Quinine Sulphate, two grains each. For chills and fever. As a tonic. 
 
 Dose for an adult, one to five pills." Quinine is a direct 
 
 Quinine. • . .-i ■ • i • •• ^ ■ ^\ ■ 
 
 poison to the micro-organism wlncii causes malaria ; tins 
 
 has been determined beyond all question. The administration of the 
 drug for the treatment of malaria is therefore eminently proper and 
 rational. For well-marked chills and fever three of the pills should be 
 given three times a day, unless buzzing in the ears and headache are pro- 
 duced, in wdiich case a few doses are to be omitted, and thenceforth the 
 dose may be reduced to two pills. This dosage is continued until the 
 symptoms have been gone several days, when a gradual reduction of the 
 dose may be made. This reduction, however, should be a matter of two 
 
8-iO MEDICINES AND TREATMENT. 
 
 or three weeks, for a sudden cessation of tlie dnij:; is not infroi]uently fol- 
 lowed by a reappearance of the syinptonis. 
 
 So much for true "chills and fever,'' which occurs in attacks at the 
 sjune time every day, or every second (rarely every third) day, the at- 
 tacks beinji: marked by chill, fever, and sweatinir in re<2:ular sequence; 
 but malarial ])ois.oning manifests itself in other and less characteristic 
 symptoms. Thus each day there may be sli«i;ht fever, headache, indiges- 
 tion, or general discomfort. The main point is that, as a rule, these dis- 
 turbances, if malarial, occui* at the same time on each dav. Less vijjorous 
 treatment will sutfice in such cases, doses of two or even one of the pills 
 being generally sulHcienr. The recognition of the malarial disturbances 
 will generally be more easy to those who have ]ireviously been sutlerers, 
 or to those whose residence in malarious localities entitles them to the 
 disease. It is the fashion, however, to describe as malarial every ache 
 and pain from which a patient may suffer, providing there be no more 
 evident reason for the illness. The name malaria has therefore become a 
 sort of medical " charity," since it certainly is made to cover a multitude 
 of diagnostic sins. Fortunately this error, though foolish and unscien- 
 tific, is usually not productive of much harm, for quinine is a valuable 
 bitter tonic, applicable in cases not malarial. For children the dose of 
 (luinine is from one to tw^o grains, according to age. In all malarial dis- 
 eases it is of great advantage to begin the treatment by a free purgation, 
 ])referablj by calomel. Quinine, too, is valuable in preventing malarial 
 infection. (See The Prevention of Disease.) 
 
 Compound cathartic pills. Label to read : " Compound Cathartic Pills. 
 For constipation. Dose for an adult, two at bedtime.'' For the correction 
 
 of occasionally occurring constipation thei-e is nothing 
 Cathartic Pilh ^"^re trustworthy and efficient than these ]nlls. They 
 
 are reliable in action, thorough and agreeal)le. Taken 
 upon going to bed, they in no way interfere with a good night's sleep, 
 and their action is usually seen early upon the following morning. They 
 are not to he given to children, and are not suitaMe for any save an occa- 
 sional use. 
 
 Tablets of sodium bicarbonate, ten grains each. Label to read : " Tab- 
 lets of Sodium Bicarbonate, ten grains each. For acidity and heartburn. 
 
 Dose for an adult, one tablet." This sodium bicarbon- 
 D- J / ate, or " bicarbonate of soda," is the cooking soda (not 
 
 baking powder and not washing soda) used in our 
 kitchens. It might be kept in the medicine chest in powder instead of 
 in tal)let, for the latter form is to be preferred only on account of con- 
 venience in handling and in the measurement of dosage. The drug is, 
 however, practically harmless, and if kept in powder may be administered 
 in dose of a quarter of a teaspoonful dissolved in water. The tablets 
 
BORACIC ACID AND SODIUM BROMIDE. 841 
 
 may be swallowed whole and followed by a drink of water, but a more 
 satisfactory method of administration is to give them dissolved in water. 
 The dose may be repeated, if necessary, in two liours. liopcated doses 
 are often beneficial in rheumatism. 
 
 Tablets of boracic acid, five grains each. Blue bottle. Label to read : 
 
 " Tablets of Boracic Acid, five grains each, l^'or external use." Though 
 
 its chief value is in external application, internally the 
 
 T, ■ A ■. drug is harmless, in mmlerate amounts, and tlierefore it 
 
 Boric Acid, . 
 
 is to be kept in a blue bottle, rather to call attention to 
 
 its being intended for external application than from any danger likelv 
 to result from the swallowing of several tablets. Tlie use of boracic acid 
 in solution is as a soothing and healing application to mucous membranes 
 and delicate structures. For red and bloodshot eyes, with burning, smart- 
 ing, and watering, whether in adults or in children, nothing is so good as 
 to dissolve one of the tablets in a tablespoonful of warm water, and then 
 to drop the solution into the eye by means of a medicine dropper. This 
 may be done twice or three times a day, according to the severity of the 
 case, when improvement will soon result. In the sore mouth seen espe- 
 cially in children, when it is apt to accompany teething or indigestion, 
 and to which the names of " sprue " and " thrush " are sometimes applied, 
 boracic acid is very healing. For use in such cases two tablets may be 
 dissolved in a tablespoonful and a half of warm water, and the solution 
 used in washing out the mouth at intervals of two hours and, in particu- 
 lar, after feeding. The addition of an amount of glycerin equal to the 
 amount of water used makes the solution even more healing, and such a 
 mixture is much to be preferred to the familiar " borf^x and honey." 
 
 Tablets of sodium bromide, five grains each. Label to read : " Tab- 
 lets of Sodium Bromide, five grains each. For sleeplessness, for convul- 
 , ,. „ ., sions. Dose for an adult, three tablets." Sodium 
 bromide, or bromide of sodium (often incorrectly called 
 "bromide of soda"), may be employed to produce sleep when the other 
 and simpler remedies spoken of elsewhere (see Sleejjiessness) are ineffi- 
 cient. The dose is three tablets followed by a drink of water. The dose 
 may be repeated in an hour, if necessary. No drug is so useful in stop- 
 ping and preventing convulsions as is bromide of sodium ; it is therefore 
 the drug regularly used in the treatment of epilepsy ; but this disease, being 
 chronic, will permit of professional attention, and its treatment should not 
 be attempted in the family save when an attack requires relief (see JEjoi- 
 lepsy). Convulsions in children are due to many causes, and a consider- 
 ation of these will be given later. The cause, if possible, will of course 
 be removed, but to quiet the attack and to ])revent its recurrence bro- 
 mide of sodium should be employed. Of this the appropriate dose for 
 a child one year old is two grains, which may be repeated in two hours if 
 
842 MEDICINES AND TREATMENT. 
 
 necessary. The two-<;rain dose nuiy bo nuule bv dissolving one of the live- 
 grain tablets in water ami then adiiiinistei-iii<jj two lifths of the solution. 
 
 Spirits of turjK'ntiiie. JJliie bottle. Label to read : "8])irits of Tur- 
 pentine. For external use.'' Turpentine swallowed is a daui^erous 
 
 ))(iisi)n. anil its intei'ual usr should never be allowt'd 
 
 Turpeiitiuc. , , ,. . .. , . . ,, ^ n -^ 
 
 • save under the direetion oi a pliysicum. hxternally it 
 
 is valuable to jiroduee counter-irritation bv means of liniments aiul stujies. 
 Combined with an ecpial (piantiry of sweet oil. it nuikes an excellent lini- 
 ment to rub on the chest in bronchitis ^for children, also, this is Jiot too 
 strone;), and a turpentine stupe is very eii'ective for abdominal pain and 
 colic (see Stupes). 
 
 Alcohol (ninety-five percent.). Label to read: "Alcohol. For ex- 
 ternal use.'' Alcohol may indeed be used as a substitute for whiskey or 
 brandy when these can not be obtained, but if so used it 
 must be given in half tlicir dose and freely diluted with 
 water. Its main use is for the alcohol rub, a procedure most restful in 
 lameness, muscular soreness, and fatigue. Diluted with an equal (piantity 
 of warm water, it may be used for the alcohol sponge bath, an applica- 
 tion most soothing in nervousness and sleeplessness, and valuable, too, in 
 slightly reducing the temperature of fever. In giving the bath, one part 
 of the body at a time is to be sponged, dried, and covered by the bed- 
 clothes, until by parts the whole body has been treated. It is exceedingly 
 refreshing and grateful to patients, and may be repeated at frequent in- 
 tervals, and is suitable to use for children as well as for adults. 
 
 Castor oil. Label to read : " Castor Oil. To move the bowels. Dose 
 for an adult, one or two tablespoonfuls. Dose for a child, ten drops to a 
 teaspoonful." The cases in which castor oil is suitable 
 are the same as those treated by calomel, but while calo- 
 mel is to be preferred for adults, castor oil is by all means the purge for 
 children. For a child a few weeks old the dose of castor oil is ten drops. 
 The amount to be given increases with the age, until a teaspoonful may 
 be given when the age of one year is reached. Its action is usually prompt 
 and thorough, but its after-effect is often to cause constipation (hence its 
 double value in diarrluea), and it is apt to gripe. This griping may be 
 prevented in a child over six months old, by adding to each dose five drops 
 of paregoric. Children younger than this should not be given paregoric. 
 
 AVhiske}'. Label to read : " "Whiskey. For stimulation. Dose for an 
 adult, one tablespoonful." All conditions in which the circulation is 
 weakened call for the administration of stimulants. Of 
 these, the most generally useful is whiskey, though brandy 
 is little less desirable and may be used as a substitute for it. Its action is 
 increased and hastened by administering it mixed with liot water. The 
 conditions in which it is most valnalde are fainting, shock, drowning, ex- 
 
THE CLINICAL THEllMOMETEK. 
 
 848 
 
 Method of talcing 
 the I'emperalure. 
 
 hausting illness, exposure, cliill, and, in ^•encral, wlicre the jjulse is rapid 
 and weak. Its continued use must never be permitted, save under the 
 direction of a physician, lest thereby a habit be established. 
 
 In addition to these drugs there are certain medical appliances which 
 
 may wisely be kept in the household, since they are likely to be required 
 
 from time to time, and when needed must be had 
 
 The Thermometer. ^, -r^- . r ^^ • .^ .^ j. r\^^ r i 
 
 promptly, l^rst oi all is the thermometer, ihe useiui- 
 ness of the thermometer is self-evident, and no arguments 
 in its favour or details of its applicability are required. ^P 
 
 The form needed is the so-called "clinical thermometer," 
 and should be self-registering. Of such thermometers, that 
 manufactured by Ilicks is undoubtedly the best. 
 
 The method of taking the temperature is as follows : 
 First shake the column of mercury within the thermome- 
 ter down below the point of normal tem- 
 perature (98'4:° Fahr.). This point is 
 indicated by an arrow engraved upon the 
 glass. Place the bulb containing the mercury beneath the 
 tongue and have the patient firmly close the lips, but not 
 the teeth. Allow the thermometer to remain thus five 
 minutes, then remove it and read the amount of tempera- 
 ture registered. Wash the thermometer in cold water, 
 since, if hot water is used, the mercury contained is ex- 
 panded beyond the capacity of the thermometer and the 
 glass is broken. The temperature in health varies, within 
 certain limits, at various times of the day, and is affected 
 by transient and unimportant causes. Thus temperatures 
 slightly less or slightly greater than 98"4° Fahr. are not in 
 themselves indicative of disease. As a rule, a temperature 
 under 100° Fahr. is not to be considered febrile. Instead 
 of taking the temperature by the mouth it may be taken 
 in the axilla, or armpit, by placing the bulb within the 
 hollow, bringing the elbow of that side firmly against the 
 chest, and placing the hand across to the other side of the chest. The 
 axilla thus becomes practically within the body, and the temperature thus 
 taken, though usually about half a degree lower than the mouth tem- 
 perature, is sufiiciently indicative of the body temperature to be useful. 
 This method is exceedingly valuable when a ditiiculty in breathing or 
 a state of unconsciousness makes it impossible to keep the lips closed. 
 In young children it is customary to take the temperature bv slicrhtlv 
 greasing the bulb of the thermometer and inserting it in the rectum. 
 where, as in the case of the mouth and the axilla, it is to be retained 
 for five minutes. Exceptionally, this method is employed for adults. 
 
 Fig. 1. — HicKs's 
 
 CLINICAL THKK- 
 ilOMZTER. 
 
S4i MEDICINES AND TREATMENT. 
 
 The temperature taken thus is usually about half a ilei::ree higher than 
 the mouth temperature. 
 
 Prepared mustard leaves are exceedingly useful for the traveller, but 
 are in no wav so useful in the family as are well-made mustard pastes, 
 since thev are of unifurm streni;-th, and. tliou^^'h cloth of 
 JJustunl Leaves, ^..^^.^^.j,,^, 'thickness i)laced between them and the skin 
 will to varyino- degrees lessen their action, yet is this action seldom so 
 etticient as is that of the old-fashi..iicd mustard plaster. These prepared 
 mustard leaves come in tin bo.xes which, if ke[)t tightly closed, will pre- 
 serve their strength. AVhen tlipped in warm water the leaf at once be- 
 comes ready for application. The home-made mustard ])laster will receive 
 consideration hereafter. 
 
 A hot-water bag, of three quarts' capacity, should be kept in every 
 
 household. Beside the drugs and apparatus wliicli may wisely be kept 
 
 in the house, because not otherwise quickly obtainable, 
 
 o -wa er a;/. ^jjg,.g ^^q others, the use of which by the laity is reason- 
 able and ]M-oiier, but which, because not necessary in emergencies and be- 
 cause many of them deteriorate on keeping, are not to be included in the 
 family medicine closet. No extended consideration will be given to these, 
 because their ajiplications are not generally to emergencies, and therefore, 
 the saving of time being less an object, there will be opportunity for con- 
 sulting a physician ; and this, let it be emphasized again, should always be 
 done when possible and save in the slightest and mildest of disturbances. 
 
 " Stimulating Liniment." A well-known hospital of New York city 
 has in its formulary a liniment bearing this name. It is applied in con- 
 ditions of soreness, lameness, muscular stiffness, and 
 ' """ " '"^ -oain not accompanied by any evidence of inflammation 
 
 Liniment. ^ m- a a ./ ./ 
 
 or hy a broken skin. For such conditions as muscular 
 rheumatism, lumbago, stiffness, long-continued lameness, rheumatism, and 
 pleurisy (when not acute), a weak, stiff, or painful joint, if no active in- 
 flammation be present, it is often beneficial. It is to be rubbed on twice 
 a day, at first gently, later more vigorously, the object being to produce 
 moderate redness of the skin. No pain should be caused by its applica- 
 tion, and if pain appear, the rubl)ing should at once be stopped. If it be 
 used upon an extremity, the rubbing should be away from the hand or 
 foot and in tlie direction of the body. When the skin has become well 
 reddened the rubbing should be stopped and the part protected against 
 cold by wrapping it in cotton or in fiannel. The composition of the lini- 
 ment is — 
 
 Tincture of capsicum 1 ounce. 
 
 Ammonia water 1 " 
 
 Soap liniment 2 ounces. 
 
 Mix them and let the label read : '' For external use oidy." 
 
AROMATIC SPIRITS OF AMMONIA, ETC. 845 
 
 This liniuient is too stronf^, as a rule, f(;r yoiiii^ chil'lron, and for 
 them the mixture of ef(ual j)arf,.s of turpentine and sweet oil ah-eadv re- 
 ferred to wiJl take its place. 
 
 Sjrup of ipecac is the best emetic for use in .youni^ children. Its 
 
 dose is half a teaspoonful, administered every fifteen minutes until vomit- 
 
 iua; occurs. If four doses have been i^iven, liowever. 
 Syrup of Ipecac. ^, •.• i . i • • • , 
 
 and no vomiting has occurred, it is wiser tlien to cease 
 
 its administration and resort to the other emetic procedures spoken of 
 under Vomiting. For older children the dose is a teaspoonful adminis- 
 tered in a similar way, and for adults the dose is a tablespoonful. Syrup 
 of ipecac is so useful and valuable in emergencies that it might well be 
 added to the family medicine chest; and indeed it may Ije so added, if 
 occasionally it be replaced by a fresh supply, for considerable time mu.-t 
 elapse before deterioration is sufficient to influence the action, and, if 
 well corked, it is not liable to dangerous concentration. To cause the 
 emptying of an overloaded stomach or one which contains irritating or 
 poisonous materials ; to check vomiting by hastening the thorough empty- 
 ing of tlie stomach ; to expel the mucus from the windpipe and lungs, 
 when much rattling in the throat indicates its presence, and the child 
 shows inability to clear the throat by feeble and ineffectual coughing ; as 
 well as to terminate an attack of spasmodic croup, are the occasions for 
 its administration. 
 
 Brown mixture is a cough mixture of much value in the early davs 
 of a cold upon the chest, when the cough is tight and harassing and the 
 oppression of the chest is great. In marked hoarseness, 
 too, which often is the result of such a severe " cold," 
 it is one of our best medicines. In both these cases its early administra- 
 tion, combined with confinement to a warm room, careful protection of 
 the chest and throat, a thorough movement of the bowels, and perhaps 
 the rubbing of the chest and throat with one of the liniments already 
 mentioned, will in a very short space of time produce relief from all dis- 
 tressing symptoms and a softening and loosening of the cough, which 
 with the continued use of the mixture will soon disappear. The mixture 
 alone, indeed, will cure those cases in which the symptoms are but slight. 
 Brown mixture is also known to apothecaries under the name of com- 
 pound licorice mixture, and is exceedingly pleasant, as medicines go, to 
 the taste. Its dose for an adult is a teaspoonful every three hours ; for a 
 child, half that amount. It is not to be used for infants. 
 
 Aromatic spirit of ammonia is given for a weak pulse, and especially 
 
 for fainting conditions. For these purposes the dose is 
 Aromatic Spirit i ij. , ^ r -, • i ,i • i i 
 
 of Ammonia ^ teaspoonful m water, and this dose may be re- 
 
 peated in half an hour if necessary. Aromatic spirit 
 of ammonia may be continued in this dosage every three hours, but if a 
 
840 MEDICINES AND TREATMENT. 
 
 weakened circulation or fainting hist so lon^; as to make repeated medica- 
 tion necessary, it is clearly an indication for the sumiiioniiii;- of a ])liysi- 
 cian. Fifteen drops of the spii-it may be given in water to an atlult 
 when an acid condition of the stomach is shown to exist by the presence 
 of tlatnlence and heartburn, and used then will often give relief from 
 these symptoms. ■ 
 
 Paregoric is a tincture of opium with camphor, and is also known 
 under the name of the camphorated tincture of opium. Like all opium 
 preparations, it is to be used with caution, and a careful 
 watch kept of the eyes and the breathing that poisoning 
 does not result. Paregoric is probably more abused than is any other 
 medicine, and the practice of giving it indiscriminately to children, as is 
 the case, can not be too strongly condemned. That the child who cries 
 is at once to be dosed with the ever-handy paregoric seems to be the 
 guiding principle of many women, and to them it makes little difference 
 whether the cause of the crying be colic, temper, thirst, a pin misplaced, 
 or serious illness; for they have the quieting remedy at hand, so in it 
 goes. More than once has it happened to the writer to have a mother 
 bring her child to him in a condition of stupor, the cause of which was 
 the paregoric administered for crying, and a glance at the pupils of pin- 
 point size has sh<jwn the condition to be one of opium poisoning. That 
 such treatment is not more often fatal is remarkable when the extent of 
 the practice is known, and when it is realized that children bear all opium 
 preparations badly. That children are often benefited by paregoric is 
 not denied, but carelessness in its use is harmful and dangerous in the 
 extreme. If a child cries there is always a reason for it, and if that reason 
 be not soon apjiarent, and if the crying persist, then the physician should 
 be consulted ; for the ready alternative paregoric can not cure indigestion, 
 or earache, or tooth-cutting, or serious disease. And so, while its occa- 
 sional use for the relief of pain is allowable, it must never be employed 
 save occasionally and most cautiously, and never to the neglect or exclu- 
 sion of remedies calculated to cure. In colic, paregoric is often of benefit, 
 but so is .the harmless peppermint water, and yet more is attention to the 
 proper diet, and the time and method of feeding. In diarrhoea, too, it 
 will often check the discharge, but a safer and more rational remedy usu- 
 ally is castor oil. In restlessness and sleeplessness of acute disease pare- 
 goric is quieting and sleep-producing, but so is the safer sodium bromide. 
 One serious disadvantage of paregoric is a power to disturb digestion, 
 which is possessed by all opium preparations. The occasional and moder- 
 ate use of this preparation is, however, not objectionable, and, if used, a 
 safe dose for a child a year old is five drops, while a child of two years 
 may take ten. Paregoric is not often used by adults, but occasionally it 
 is given for diarrh<jea, when its dose is one or two teaspoonfuls. 
 
TINCTURE OF IODINE, LEAD AND OPIUM LOTION, ETC. 81 
 
 Peppermint water lias, as already stated, an excellent effect in flatu- 
 lence and colic in children, and for this ])urt>(;se it may 
 Peppermiid Water. , . . , j- ^ tc ^ ^ r \ • 
 
 be given m doses oi a liait to one teaspooniul m warm 
 
 water and repeated as often as necessary. 
 
 Limewater is beneficial in conditions of indigestion associated with 
 vomiting. For adults it is usually given with milk in pro{)ortions vary- 
 ing from one eighth the quantity of milk to one lialf. 
 Such a mixture, if taken at intervals in teaspoonful 
 doses and very cold, will often allay the vomiting, after which the inter- 
 vals may be shortened and the doses increased in size. In bottle-fed chil- 
 dren the vomiting of milk in large curds will often be relieved by the 
 addition to each bottle of a tablespoonful of limewater. As an external 
 application limewater is sometimes used mixed with an equal quantity 
 of olive oil (the mixture being known as " Carron oil "), for application 
 to burns. (See SurgiGal Injuries and Surgical Diseases.) 
 
 Tincture of iodine. Deep-seated pains, muscular soreness and stiffness, 
 chronically lamed and stiffened joints, are sometimes benefited by paint- 
 ing the affected area with tincture of iodine. In using 
 Tincture of Iodine. ... . , . , /.i fiis 
 
 it, the tmcture is to be painted on (m the cases of adults) 
 
 until the skin is stained a deep brown. At the end of twenty-four hours 
 this will have faded, when the colour may be reproduced by painting on 
 a few additional coats of the tincture. This treatment is to be persisted 
 in until the skin over the area treated begins to peel off. In children the 
 iodine must be less generously applied, the skin must not l)e so deeply 
 stained, and in them two or three coats are usually sufficient. The ap- 
 plications of tincture of iodine, then, are practically those in which the 
 "stimulating liniment" are useful, and in practice sometimes one will 
 work the better, and sometimes the other. In general the iodine will be 
 more applicable in cases where the rubbing would cause pain. Like the 
 liniment, too, the tincture of iodine is not to be painted over actively in- 
 flamed areas or over denuded surfaces. If the iodine bottle is to be kept 
 for any time in the house it should be carefully labeled, " For external 
 use only." 
 
 Lead and opium lotion is an application useful in bruises, contusions, 
 and sprains. It is to be kept applied to the injured part on cloths wrung 
 
 out in it and arranged, not thickly, so that evaporation 
 
 Lead and Opium i ^ i n i /c-i o • 7 t • • -1 
 
 J .. may be freely allowed. (See bargical Injuries and 
 
 Surgical Diseases.) It is to be used for external appli- 
 cation only. Its formula is as follows : 
 
 Solution of subacetate of lead 1 ounce ; 
 
 Tincture of opium ^ " 
 
 Water enough to make 1 pint. 
 
 Mix. 
 
84:8 MEDICINES AND TREATMENT. 
 
 DobelTs solution is a i-loansiiii; and liealini; sv)lutiun nuu'li used hy 
 
 specialists in diseases of the throar and no.<e. It may be used as a gargle 
 
 in sliijlit intlaniniati(,»ns of the throat, but is more efTect- 
 DobelFs Solution. . , ^ ,. , . i i ^i ^ • t . i 
 
 ivcly apphed in spray and by tlie atomizer, in catarrfis 
 
 it mav well i)e sprayed into one iK)stril. and, the head being well held 
 baek, the solution- will pass eomjiletely thrdugh the nose to the throat. 
 The head being then bent forward, the solution will run ivoin tlie nostril 
 of the other side as well as from the one sprayed. Several attempts may, 
 however, be iieeessary before the jvissages are made suthciently elear for 
 this action, and in the more serious conditions of nasal* stoppage it may 
 not occur at all. Under these circumstances the physician or specialist 
 must be consulted. In blowing the nose after a spraying but one nostril 
 should be blown at a time, the other being stopped by pressure of the 
 finger. Tlie neglect of this precaution may be followed by forcing dirt 
 from the throat into the passage connecting it with the ear, when intlam- 
 mation of the ear may result. If in spraying thus a little of the fluid be 
 swallowed no harm will result, though the solution is not to be taken in- 
 ternally. This spraying may be done once or twice a day, and in case the 
 fluid burns or irritates the nose or throat too much, it may be dilutfed 
 with an equal quantity of water. This is especially to be done in case 
 the patients are cliildren. 
 
 Coffee is not only a drink and a beverage, but is a drug and a medi- 
 cine. Its function is to arouse and excite nerve action, and particulai-ly 
 the action of the brain. For this reason it is useful in 
 ' conditions of exhaustion, fatigue, overwork, and debility 
 
 in general. It will produce wakefulness, too, but its continued use to 
 avert a natural desire to sleep is unhealthful and injurious. It is more 
 active if given strong and without milk. In opium poisoning it is one of 
 the best means we possess to arouse and awaken the patient, and should be 
 given freely. This is not the place for a consideration of coffee as a bever- 
 age, and beyond the statement that its use is forbidden in youth, nervous- 
 ness, most diseases of the heart, some forms of indigestion, and, generally, 
 the bilious tendency, nothing will be said. 
 
 Tincture of ginger is to the flatulent adult what peppermint water is 
 
 to the colicky child, and fifteen or twenty drops taken in a cup of hot 
 
 water will generally be followed by relief. The dose 
 Tincture of Ginger. , ,!•/•' i t i i 
 
 may be repeated it necessary every hour, in those wdio 
 
 misuse and abuse alcohol, similar doses given three times a day and before 
 eating will often restore tone to the stomach and relieve the loss of appe- 
 tite, nausea, and even vomiting, from which these unfortunates so often 
 suffer. 
 
 Chlorate of potassium (commonly called chlorate of potash), though 
 at times prescribed by jjhysicians f or internal administration, should nciver 
 
PHENACETINE VERSUS ANTIPYRINE. 840 
 
 be 80 used by the laity, since the (Jrug is capable of causin<^ a most danger- 
 ous poisoning. It is in the simple forms of tonsilitis and sore throat 
 that, used in solution and as a gargle, it is applicable in 
 
 oiaeof domestic practice. The solution appropriate for this 
 
 l-'oiassmm. ^ _ _ . 
 
 employment is made by dissolving a teaspoon ful of the 
 
 drug in half a tumbler of water. It should be used every two or three 
 hours, and there is some advantage in using it very cold. Though poi- 
 sonous in large doses, the accidental swallowing of a little of the lliiid in 
 gargling need not cause alarm, 
 
 Phenacetine powdei's, live grains each. Plienacetine is one of the 
 newer drugs, and is used to relieve headache, rheumatic and neuralgic 
 
 pains, and to reduce fever. For these purposes it is 
 Phenacetine and m • . -i -. • ^^ j_j_ t t •,^ 
 
 ... . very erncient, and its use is generally unattended with 
 
 danger. It will sometimes cause profuse sweating and 
 rarely some weakening of the circulation, but this almost never reaches 
 a dangerous degree. In these respects it differs from antipyrine, which 
 is much used by the laity for the relief of similar painful and febrile 
 symptoms, for whereas phenacetine is practically harmless, antipyrine is 
 an exceedingly dangerous drug. The popularity as well as the dangers 
 of antipyrine suggest a few words on that drug, and though a digression, 
 the importance of the subject will excuse it. The danger of using anti- 
 pyrine lies especially in its treachery, for while in some persons it will 
 act safely and well, in others it will, without the slightest apparent rea- 
 son, cause fainting, sweating, prostration, weakened circulation, collapse, 
 and even death, and these, too, after doses exceedingly small. For these 
 reasons the popular use of antipyrine is in every way unsafe. If phen- 
 acetine is given to reduce fever and to diminish the painful and lame 
 feelings associated with it, the dose for an adult is five grains every three 
 or four hours, according to necessity. In such cases it works admirably, 
 and the cooling and comforting alcohol bath may wisely be used in con- 
 nection with it, the results being soon apparent in the comfort of the 
 patient and frequently in refreshing sleep. For rheumatic pains similar 
 dosage is allowable, but for severe headache and neuralgia more of the 
 drug will, as a rule, be needed, and it is customary to give five grains of 
 the powder every half hour until three doses have been taken, unless the 
 pain shall have ceased before that time. Subsequently the five-grain dose 
 may be administered at intervals of three or four hours, if the pain re- 
 turns. As phenacetine is not soluble in water it is generally given dry 
 upon the tongue and then washed down by a sip of water, and as it is 
 tasteless, no difficulty will be met in taking it thus. It may, if preferred, 
 be taken in compressed tablets (five grains each), but if these are used they 
 should be bitten or broken into fragments before swallowing, to insure 
 their rapid and complete absorption. Though sometimes given to cliil- 
 50 
 
S50 MEDICINES AND TREATMENT. 
 
 dreii iu doses of from one to two grains, acc't>rding to age, this use of the 
 
 drug is more safely intrusted to the physician. 
 
 lehthyol ointment (^tive per cent.). Ichthyol also is a recently introduced 
 
 drug and is prepared from a l)itnminous substance containing fossil fishes 
 
 and found in the Tvrol. It is possessed of a powerful 
 
 Ichthyol Ointment. , i ^ xi ' i n -i. -i i j i i. 
 
 odour, and to tliose wlio once smell it no possible doubt 
 
 can occur as to the entire truth of the " tish story." However, we may 
 well forgive it for a characteristic that is "the only fault in an otherwise 
 perfect character." In bruises, in sprains, in " water on the knee," or 
 " water " on any other joint, in old joint injuries, where from time to time 
 slight pain and stiffness recur, in slight intiammations of the skin, as in the 
 moderate grades of burns and scalds, in ivy poisoning and stings, there is 
 nothing which so promptly, so permanently, and so easily causes relief and 
 cure as ichthyol. For such cases the severity will determine the strength 
 of the application, but as a rule a five-per-cent. ointment will be suitable 
 and harmless in them all. Let the ointment be made by having the apothe- 
 cary thoroughly mix twenty-live grains of ichthyol with one ounce of oint- 
 ment of zinc oxide. Let the label read : " Ichthyol Ointment, five per 
 cent.," and in using let the salve be smeared thickly over the affected part 
 and a snug-titting bandage applied. Of the conditions thus treated, more 
 complete information will be found in the chapters on Surgery / our con- 
 sideration is not of the diseases, but of the drug. 
 
 Vaseline. It seems scarcely necessary to do more than to mention the 
 name of vaseline to have the subject thoroughly understood, for its use is 
 so common in every household, and its applications are 
 so many, that the housewife is indeed more familiar 
 with it than is the physician, and hence is more competent to speak. To' 
 protect, to soothe, and to heal are its functions in disease, and, if fresh 
 and clean and uncontaminated, it can do no harm wherever applied, save 
 only in open wounds. 
 
 Blaud's pills. Though we so often hear the expression, " I think I 
 
 need a tonic," made by those who are in riotous good health, or at most 
 
 are suffering from nothinor more severe than overeat- 
 BlauiVs Pills. . ° , . ^ . Ill 
 
 ing, or oversmoking, or overexcitement, and though a 
 
 *' tonic," in the popular mind, means any medicine which tastes bad, still, 
 of all those who tliink they need a tonic a small proportion really do. 
 Xow a tonic is something which, regardless of colour, smell, or taste, makes 
 strength, and one of the best of these is iron. There are many prepara- 
 tions of iron, but among them all there is none more convenient or bet- 
 ter than Blaud's pills. These are prepared in several sizes, but the most 
 practical is the five-grain pill. Now, there are other tonics besides iron, 
 and of those who really need tonics not all need iron. For these reasons, 
 then, and particularly because time will always permit of obtaining a pro- 
 
IRON AND SALINE CATHARTICS. 85 L 
 
 fessional opinion, tonic treatment should bo Jeft to tlie pliysician. And 
 yet an understanding of the tonic application of iron will Tiot bo out of 
 place, and the facts are as follows : The blood contains 
 iron — in fact, iron is its most important mineral in- 
 gredient. From time to time the iron in the blood, from one cause and 
 another (sometimes it is disease, sometimes overwork, and sometimes the 
 cause is unknown), becomes lessened in amount, and the condition of 
 impoverished or " watery " blood thus established is called anaemia. The 
 rosy hue of health is dependent upon the richness of the blood in iron, 
 and one of the most striking appearances of anaemia is pallor. Pallor, 
 however, is not necessarily indicative of anaemia, for many are habitually 
 pale whose blood is normal in every respect, and a high colour, too, is 
 consistent with a considerable anaemia. While this is true of the skin, 
 however, it is usually not true of the mucous membranes, and a glance at 
 the colour of the tongue will in general be a safer guide than the colour 
 of the skin. In anaemia the tongue is pale. More reliable information 
 still is at the hand of the physician in an examination of the blood itself ; 
 but this is technical and beyond the laity. Practically, however, the 
 tongue is pale in anaemia. To restore to the blood its lost iron is the ob- 
 ject of treatment, and so the various forms of iron are given internally, 
 that being absorbed by the blood they may thus accomplish this object. 
 As has been said, Bland's pills are among the best of iron preparations 
 and are given usually in doses of one or two pills three times a day, after 
 eating, until, with the return of colour to the tongue and of vigour to 
 the patient, they are no longer needed. During the administration of 
 iron it is of great importance that the bowels remain regularly open, for 
 constipation interferes with the desired absorption of the iron. 
 
 " Salts " scarcely need a definition ; all are familiar with their object ; 
 but, strictly speaking, the term salts includes far more than substances 
 
 which taste salty and move the bowels; yet the more 
 Salts. . . . . 
 
 scientific name, saline cathartics, scarcely adds to their 
 
 effectiveness, and whether they are called by this name or called " salts " 
 will make but little difference in their action on the bowels. The saline 
 cathartics in general use include Epsom salt, Glauber's salt, Eochelle salt, 
 Carlsbad salt, Seidlitz powder, and " citrate of magnesia." Their use is 
 to move the bowels thoroughly and promptly, and, as has already been 
 said, they have a special usefulness in increasing and completing the ac- 
 tion of calomel. They differ somewhat in their applications, and a brief 
 consideration of the members of the group will therefore not be amiss. 
 
 Epsom, Glauber's, and Rochelle salts are for occasional use only — when 
 it is desired to sweep thoroughly and clean the digestive canal. They are 
 not intended for continued use in habitual constipation, for in such a case 
 they would, as a rule, be weakening and injurious. They have the dis- 
 
852 MEDICINES AND TREATMENT. 
 
 advantages of being vorv disagreeable to the taste aiul ^f (.'luisiiig gi'ijung. 
 For an adult the dose is a tabk'spooiit'nl, or even two tablespoonfuls, thougli 
 the hitter dose would often be unnecessai-ily energetie. They are given 
 dissolved in water, and the less the water administered with them the 
 more will l>e abstracted from tin* hotly l)y thom. for water they must have 
 in order to act. For this reason they are given in the first hours of acute 
 intlaintnatory disease, and in very little water, that they may abstract 
 water from the body, in the Huid movements they cause, and thus may 
 diminish the congestion in the inflamed area. A better way of admiTiister- 
 ing them is to give the selected salt in dose of a teaspoonful, dissolved in 
 water, every liour until the bowels have moved freely, or until six or even 
 eiijht doses have been taken. Given thus they are quite as effective as in 
 the other form of administration, and even more so, for the amount neces- 
 sary may more easily be judged, overdosing is less likely, and griping is 
 less severe. Similarly, they may be given to children over twelve, in tea- 
 spoonful doses every hour until three have been taken. 
 
 Carlsbad salts, on the other hand, are generally employed for the 
 habitual constipation associated with the " bilious," the plethoric, and the 
 gouty tendencies. They are to be taken dissolved in a glass of hot water 
 each morning and before breakfast, the dose usually being between one 
 half and one teaspoonful, depending upon the effect upon the patient. 
 The end sought is to produce one or two movements during the morning, 
 and the dose necessary will vary with the individual. These salts are not 
 given to children, and their continued use for adults is only for the strong 
 and the rol)ust. 
 
 Seidlitz powders and "citrate of magnesia" offer marked advantages 
 over the " salts" of the first group, since they are not disagreeable to the 
 taste and are of a milder action. Otherwise their employments are the 
 same. The Seidlitz powders come in boxes containing a number of pow- 
 ders, of which half are wrapped in blue papers, the other half in white. 
 In using the medicine we dissolve the contents of a white paper in a third 
 of a tumbler of water and the contents of a blue paper in another ; Ave 
 then mix the two solutions and, effervescence resulting, we drink the 
 mixture " while it bubl)les." "Citrate of magnesia" is a fluid prepara- 
 tion, and a half bottle is drunken as a dose, the other half being taken in 
 about two hours if the first dose has not been effectual. This " citrate of 
 magnesia" (its proper name is the solution of magnesium citrate) is an 
 excellent cathartic for children of ten and over, for it is mild, and, more- 
 over, it tastes like lemonade. For such a child the dose is a claret-glass- 
 ful, repeated in two hours if necessary. 
 
 All cathartic medicines are to be given, when possible, upon an empty 
 stomach, and the salines in particular are to be so administered, else they 
 are likelv to prove unreliable or inactive. As a rule, saline cathartics are 
 
THE ADMINISTRATION OF OXYGEN. 
 
 85 
 
 Hhubarb- mid 
 Soda- Mixture. 
 
 Oxygen. 
 
 to be given only to the strong and vigorous, for in tlie weuk and feeble 
 thej are apt to exhaust, especially if given frequently or in large doses. 
 They have an especial value in the gouty and rheumatic, and in attacks 
 of rheumatism and gout are a valuable jjart of the treatment. 
 
 "Rhubarb and soda mixture" may be obtained at all ])lianiiacic.s, and 
 is especially of value in dyspei)tic conditions traceable to improper food, 
 whether in the case of adults or of children. If, there- 
 fore, the breath becomes offensive and the tontrue 
 slightly coated, if distress occurs in the stomach after 
 eating, and wind and heartburn be complained of, a properly regulated 
 diet, with the administration of rhubarb and soda mixture, before each 
 meal will usually, and in a few days, result in relief and cui-e. The dose 
 of this preparation for an adult is a tablespoonful, and for a child a half 
 to one teaspoonful, taken in w^ater. 
 
 Oxygen, as all know, is contained in the air we breathe, and is the 
 life-supporting element in the atmosphere. In certain diseases, such as 
 pneumonia, the absorption of oxygen by the lungs is 
 interfered with, and as a consequence the patients be- 
 come " blue in the face," or, as it is technically called, cyanotic. Hence 
 the belief arose that if the air the patient breathed were made to contain 
 more than the usual 
 amount of oxygen, he 
 would get a sufKciency 
 of it into his body in 
 spite of the fact that 
 liis lungs were not 
 working normally, 
 and so oxygen came 
 to be given by inhala- 
 tion. This remedy is 
 one which would hard- 
 ly be used save under , „ . ,^^'''- ^--^^ ^^'^'^^^ ^^^^'^^ 
 
 ■ . J- ^ ^ ^^^ A pipe and tube respectively conducting the oxveen from 
 
 tlie direction of a phy- the cylinder into the flask ; C and i>, tube and pipe conducting 
 
 j; . . " the oxysen from the flask to the patient; ^'.inhaler: i^, bub- 
 
 SlCian, tor a state so blcs of oxygen ; (?, water. 
 
 grave as to require 
 
 oxygen inhalations would certainly require a physician if one could be 
 had. No harm would result from its administration hj the non-profes- 
 sional, however, for the gas is harmless. It can be obtained in all large 
 cities from those who make it, and the addresses of these can be obtained 
 at any pharmacy. The gas comes in iron cylinders, and with them comes 
 the tubing and apparatus necessary for the inhalation process. In cases 
 of moderate severity the gas may be inhaled for a few minutes every 
 hour or every half hour, while very severe eases may require the playing 
 
854 
 
 MEDICINES AND TREATMENT. 
 
 of the streain of oxyfjon constantly across the lips of the patient. Tlie 
 indications for the acliiiiiiistratiou are, as we have said, cyanosis and ditli- 
 culty of breathing from any cause, and if the remedy is efKcient, the evi- 
 dence is snon seen in a disappearance of the liviiiity and a return of the 
 liealthful ct>l(iur. 
 
 There are certain meclianical devices wliich are very nscful in lay 
 liands ; and though they are not, many of them, strictly speaking, neces- 
 sary, yet thev are often great conveniences. The atom- 
 
 Afomizirs. . " . " , , . . , , 
 
 izer IS one oi tliese, and an important one, its use m the 
 
 employment of Dobell's solution having already been mentioned. The 
 
 Fiii. 3. — An AToMizEis. 
 
 proper kind is one which works by pressure of the hand bulb, all steam- 
 spray apparatus being much too complicated and likely to get out of 
 order. 
 
 The croup kettle is simply a tin kettle 
 placed on a stand over an alcohol lamp. 
 
 From the cover of the 
 The Croup Kettle. , ^^, . , 
 
 kettle projects a long tin 
 
 spout. In use the kettle is filled half full 
 of water, the lamp is lighted, and the col- 
 umn of steam pouring fnjin the spout is 
 directed toward the mouth of the patient, 
 that the warm, moist air inhaled may ex- 
 ert its soothing effect upon the inflamed 
 throat and windpipe. Care must be exer- 
 cised, however, that the spout is not placed 
 too near the patient's mouth, for if hot 
 steam is inhaled it is as irritating as ivami 
 steam is soothing. 
 
 Though the hot-water bottle of which 
 we have spoken may be filled with ice 
 water or finely cracked ice and used as an 
 ice cap, there is considerable advantage in Fio. 4.— a group kettle. 
 
MECHANICAL DEVICES. 
 
 85 
 
 using a regular ice cap for tlic purpose, and of all ice caps, the so-called 
 "Monitor" pattern is the best. This is a fiat rubber bag, on one surface 
 of which is a large opening with a projecting rim 
 "'^' through which the cracked ice is introduced, and clos- 
 ing which is a tightly fitting cover. 
 The use of the ice cap will be 
 spoken of in treating of convul- 
 sions and headache. One caution 
 is always to be observed in its use, 
 and that is to place between the 
 skin and the rubber cap an amount 
 of cloth sufficient to prevent the 
 blisteriner or even the freezing of 
 
 ¥m. 
 
 -!m Jth,W-(JM'i'hlJ I' t, JiAi. 
 
 The Invalid 
 Cushion, 
 
 the skin, an accident which has 
 
 many times occurred, and which, though usually not dangerous, is none 
 the less to be avoided. With these precautions the ice cap may be left 
 on until the sensations of the patient require its removal, and even if the 
 patient be unconscious no harm is likely to result from its use. 
 
 An invalid cushion is an excellent contrivance for use in cases re- 
 quired to maintain the same position for long periods 
 of time. The best are made of rubber, in form like 
 the old-fashioned doughnut, and are inflated with air. 
 They are often spoken of as the " Peter Cooper " air cushions, from the 
 fact that that philanthropist was in the habit of carrying one wherever he 
 might go. They are placed beneath the buttocks of 
 the patient, whether his position be that of sitting or 
 lying upon the back, and, by their elasticity and their 
 moulding themselves to the form, remove from the 
 parts a pressure which might be injurious. Especially 
 are they of service in conditions of low vitality and 
 emaciation, for it is in these conditions that pressure 
 upon the parts is so painful, and bedsores are so likely 
 to result. 
 A glass rod is a cleanly and convenient instrument for dissolving and 
 mixing medicines, and a glass dropper, with a pointed tip and a rubber 
 
 bulb at its other extremity, is serviceable not onlv in 
 Bods, Spoons, Cups, . ^ ^ , ^ • j • j • ■ "• ^ 
 
 j^ , measuring drops but also m dropping medicines into 
 
 the eye, as has already been described in speaking of 
 boric acid. One precaution is to be observed in the use of the medicine 
 dropper, and that is the careful removal from the rubber bulb of all rub- 
 ber dust before it is used for the first few times. A failure to observe 
 this precaution might result not only in filling the medicine to be taken 
 with rubber dust, but might act to fill the eye with that dust and thus 
 
 Fig. 6. — A rubber 
 
 RING. 
 
S5G 
 
 MEDICINES AND TREATMENT. 
 
 ])e responsible for severe and even serious iiillaimiiatimi. Of medicine 
 spoons, cups, and graduates there are many, and tliev are often convenient. 
 A ii'lass tube is often used iov takiiii:; acids and thiid preparations of 
 iron, that injury to the teeth may not result. Such medicines are, how- 
 ever, not included in our list of household remedies, 
 T/w Glass Tube. ,, c.i i .11 -ni j^ • l ^ ^ 
 
 and tlie use of the glass tube l)y us will be restricted to 
 
 the taking of medicines the more easily when lying upon the back, and 
 the similar taking of lluid noiii-i>iiiiU'nt. In this way the necessity of 
 
 having the patient dis- 
 Mhi iM^ 1111,11 turbed bv assumino: the 
 
 FlO. 7. — A GLASS ROD, 
 
 Fig. 8. — .V olass* dkoim-kk. 
 
 A GLASS FEEDING TlllK. 
 
 The Stomach Tube. 
 
 erect attitude is avoid- 
 ed. In serious or even 
 milder illnesses this 
 saving of effort and 
 strength is of much 
 importance, and while 
 lying upon the back 
 the patient may suck 
 his medicine through 
 the tube in ease and 
 comfort. 
 A stomach tube is recommended by some for use in the household, 
 but its manipulation is one of considerable delicacy, and practice is re- 
 quired properly to perform it ; even physicians sadly 
 bungle the operation unless skilled in its practice. The 
 object of the operation is to wash the stomach thoroughly and thus re- 
 move from it all noxious contents, but in the household the same result 
 may be easily and safely accom- 
 plished by making the patient 
 di'iidc freely of vjarni water, 
 and then causing him to vomit 
 Ijy placing the finger in his 
 throat. A repetition of this 
 process several times will result 
 in as complete a washing of 
 the stomach as could be done 
 through the tube, and the pro- 
 cess is one which requires no 
 training, and can be done by 
 anybody ; besides, it is less dis- 
 agreeable to the patient than is the tube in unskilled hands. The prin- 
 ciple of the stomach tube or gastric siphon is, however, interesting, and 
 though its use is not recommended, its working may be described. The 
 
 A STOMArll TUBE. 
 
STOMACH WASHING OR LAVAGE. 857 
 
 tube is made of rubber wliich, wbil(3 soft and easily lj(;iit, is yet elastic 
 and firm enough to maintain its calibre and not to Ije easily doubl(;d u])(;n 
 itself. It is usually about two feet in leiii^th ; the end for introduction 
 is conical and closed, and near its point are two openings, one on either 
 side. To its other end is fitted a similar tube of any convenient length 
 and of any quality. The joint of the two tubes is made by inserting into 
 the neighbouring ends of each tube a small glass tube, three or four 
 inches long, in such a way that an interval of an inch or two of glass 
 tube shall occur between the rubber tubes. This glass tube serves as a 
 window through which the operator may look and observe the flow of 
 fluid into or from the stomach, and observe its quality. The stomach 
 tube proper is that portion first described, whose length is two feet ; the 
 common tube joining it may be called the external tube. Into the end 
 of the external tube is inserted a funnel of hard rubber or glass. 
 
 In using the stomach tube the patient is seated in a chair, leaning 
 over a basin. The operator moistens the conical end of the stomach tube 
 
 in warm water and introduces it into the patient's throat ; 
 ,,, I rr I at the moment when it encounters the back of his throat 
 
 the patient is told to swallow. By this action the tube 
 is carried into the gullet, and the operator then, by gently pushing, forces 
 the end of the tube down into the patient's stomach, the distance of the 
 stomach from the teeth being sixteen inches in the adult. The intro- 
 duction of this length of tube will therefore mean that it has entered 
 the stomach. As a precaution the patient is now told to breathe deeply, 
 for though it is unlikely to happen without a sufficient warning occurring 
 in choking and coughing, it is theoretically possible to pass the tube, not 
 into the gullet and stomach, but into the windpipe and lung. If the 
 patient now breathes freely, and not through the tube, it is safe to assume 
 that the passage of the tube to the stomach has been safely performed. 
 The funnel is now raised, and warm water poured into it slowly and 
 steadily until several cupfuls have passed down. (The capacity of the 
 adult stomach is about three pints.) Then while the funnel still contains 
 water it is quickly lowered to a level below that of the patient's stomach, 
 when, a siphonage having been established, the fluid will flow through 
 the tube from the stomach, carrjang with it the stomach's contents. ^Yhen 
 the flow has ceased the funnel is again raised, and the process is repeated 
 as many times as are necessary, until the water returns from the stomach 
 as pure and clean as when it was introduced. The stomach is then held 
 to be clean and the operation is concluded b}^ the gentle withdrawal of the 
 tube. This procedure is known as stomach washing, or lavage. 
 
S5S MEDICINES AND TREATMENT. 
 
 OTHER CUKATIVK PROCEDURES, NOT DRUGS. 
 
 The part wliicli dniijjs play in the treatment of disease is of course no 
 small one, but yet then' are other procedures the values of which are as 
 great, and on d'wt, diink, rest, ventilation, and bathing many physicians 
 place more dejiendence than they do on drugs. !So strongly do many feel 
 this that the era of drug-giving doctors, or "druggers,'' seems more than 
 on the wane ; and, while none doubt the necessity and value of certain 
 drugs in certain conditions, the tendency of the profession is now to give 
 far fewer drugs than did our medical ancestors of half a century ago. Of 
 curative means other than drugs, none is more important than is diet. 
 
 The diet in disease is a subject so extensive that a complete considera- 
 tion of it can not be given here. A few brief statements in regard to it, 
 
 however, will save our study from the accusation of in- 
 Diet in Disease. , t j- i.i >.• -i. £ i.i j- i.- 
 
 completeness. In disease tlie activity oi tlie digestion 
 
 is generally lessened. IIow much this diminution amounts to will diifer 
 with the disease, but in general it may be said that the sick can digest less 
 than can the well. The illness may be so mild that the diminution of 
 food will properly be but slight, or it may be an acute fever, in which 
 only the smallest amounts of the most easily digested foods are allowable. 
 In acute disease, with the prostration of the patient, the foods generally 
 withheld are the nitrogenous substances, such as meats. The sugars and 
 the starches are only little more desirable, but the fats are our mainstay. 
 Of fat foods Nature has provided us with one which is the ideal diet of 
 the acutely ill, and that is milk. Milk is readily digested and highly nu- 
 tritious ; moreover, it is easily taken and generally well 
 liked. In acute febrile disease of adults a tumbler of 
 milk is to be given (if vomiting is not present) at intervals of two hours, 
 and, generally speaking, it is the only food required in the more severe 
 fevers. Broths and soups, indeed, may be given from time to time for 
 variety's sake, but are in no sense substitutes for milk, since they in no 
 degree possess its value as a food. Of late there has been a tendency to 
 feed the feverish patient upon the simpler solids — such as meats, eggs, and 
 the more easily digested vegetables — providing that his appetite demands 
 them ; and though to err on the side of prudence is wiser, yet there really 
 seems to be no reason why a slight amount of fever should require the 
 starvation of a hungry man. With the fall of temperature, however, the 
 usual diet is gradually to be resumed with the gradual recovery of diges- 
 tive power. 
 
 Chronic disease requires no such limited diet, for though, in general, 
 what is true of digestion in acute disease is also more or less true of diges- 
 tion in chronic disease, yet the preservation of nutrition in chronic disease 
 becomes, from the very time involved, of a greater importance. In chronic 
 
DIET AND DRINK IN DISEASE. 859 
 
 diseases, tlierefore, tlie highly nutritious foods arc the most valualjle; hut 
 at the same time the diet must be varied to some extent and not rigidly 
 exchisivc, else both appetite and strength will suffer. 
 
 Particular diseases require particular diets, but space does not permit 
 of their consideration here, and for information upon the diets of s^icli 
 diseases as rickets, scurvy, consumption, dyspepsia, gout, rheumatism, 
 and diabetes, the reader is referred to the chapters which treat of these 
 diseases. 
 
 The thirst experienced by the feverisli patient is most annoying, and 
 
 the torture he suffered at the hands of the old-fasliioned doctor must have 
 
 ^ . , . ^. been intense; for then, as we know, the idea prevailed 
 
 Drinlc m Disease. ,i,, • . ^ „ . ' ^ '■ 
 
 tliat to give water to one suffering from fever was to 
 
 invite disaster. This belief is by no means entirely relinquished even at 
 the present day, for, though physicians have long since learned the folly 
 of this practice, it is no uncommon thing to find the feverish patient suf- 
 fering unspeakably from thirst while water is withheld by the well-mean- 
 ing but ill-informed attendant. So far from injuring the fever patient, 
 water will only do him good, and now our effort, indeed, is to encourage 
 his drinking freely of cool water as much as it was for- 
 merly to deny it. A moment's thought will show why 
 the liberal drinking of water by such a patient will be beneficial. Pri- 
 marily, it will relieve the suffering from thirst ; it will increase the activity 
 of the bowels, which fever ties up ; it will tend to promote perspiration, 
 which in turn, by evaporation, reduces the fever ; it will increase the 
 quantity of urine and make it less concentrated and irritating ; it will of 
 itself, if cold, reduce temperature somewhat ; and, most important of all, 
 by increasing all secretions of the body, it will carry off in them the waste 
 products which fever causes, and wdiich would otherwise remain to poison 
 and to injure the body. Water, therefore, must be allowed to the fever 
 patient freely, the sole forbidding condition being actual or threatened 
 vomiting. Even if vomiting is present, small quantities of cracked ice, 
 or water intensely cold, may be given at intervals, until the stomach has 
 become quieted. 
 
 Water is the drink usually to be employed in fever, and though its 
 use, unchanged and unmodified, in general will be suflicient, there are, in 
 n • 7. some cases, advantages in flavouring it. Thus, if thirst 
 be msatiable and excessive, and if the free indulgence 
 of water, in quantities sufiicient to satisfy it, causes distress or nausea, it 
 is well to acidulate it by adding to it a little lemon or orange juice, or 
 even a little vinegar. A lemonade, in the same way, is beneficial, but 
 care should be taken to add but little sugar. A cup of tea or a cup of 
 coffee is often beneficial to the feverish patient, and possesses some ad- 
 vantage in the stimulating and strengthening actions these druo-s exert 
 
800 MEDICINES AND TREATMENT. 
 
 uii nerve power. So far, therefore. frLini denying the jxitient acciistomed 
 to liis occasional cnp of tea or coffee the indulgence in them simply be- 
 cause he has fever, their moderate use is only to be recommended, and 
 they may be given hot or cold. Alcoholic beverages will Tiot be consid- 
 ered by us here. They are employed in fever, as in (Uher diseases, but 
 only for their valile as stimulants where circulation is impaired. 
 
 It is not likely that the amateur practitioner will ever make use of the 
 procedure to be spoken of, but it is interesting to kmiw that water, intro- 
 duced by the rectum and retained, will satisfy thirst practically as well as 
 though swallowed. It is for this purpose, then, in cases where vomiting 
 is continued and incessant and thirst is extreme, that injections of water 
 into the rectum are at times employed with success. 
 
 The position or posture of a sick person has much to do with the 
 
 favourable or unfavourable progress of his disease, and therefore is an 
 
 important element in treatment. To illustrate this im- 
 
 Posture in J)iKease. , •, ,i j i- ■ n 
 
 ]K)rtance we may cite tlie good results seen m cases ot 
 
 typhoid fever where the patient has been placed in bed in the earliest 
 days, or even hours, of the disease, and the poor results in cases in which 
 he continues around and al^out for some time after the invasion of the 
 attack. In general, it may be said that in all diseases attended with 
 M'eakening of circulation and impaired vitality the recumbent posture is 
 to be insisted on, since circulatory and bodily power are subject to smaller 
 denumds, and hence are the better preserved when lying down. 
 
 In many cases the weariness and lassitude of a patient will be suffi- 
 cient to determine his going to bed ; and while this is a good guide, it is 
 
 bv no means always a safe one. The reasons for this 
 Confinement to Bed. " i r " i • /> i 
 
 are many : the tact that in many levers the onset is so 
 
 gradual that the patient, though seriously ill, does not realize this gravity ; 
 the fact that many people seem to have a constitutional objection to 
 "giving up" and going to bed; the fact that some natures suffer little 
 from prostration, even at the height of serious illness (as cases of pneu- 
 monia are often found in persons who have for days been about and at 
 work) ; the fact that business interests may keep a man on his feet when 
 he ought to be in bed ; and the fact that in the first few days of fever the 
 patient seems rather in a condition of excitement and stimulation than in 
 one of prostration. For such reasons, then, the sensations of the patient 
 should be consulted, and often serve as excellent guides to the treatment 
 by posture, but they are certainly not blindly to be trusted. 
 
 The choice of rooms for the sick, the ventilation, the lighting, the 
 heating — all these are important elements in treatment. 
 
 Room, Vent iUitlon, \ . .■\'^- • i i- n i i . .u 
 
 TT f- but their consideration more properly belongs to other 
 
 articles, and mention alone is necessary here. (See 
 
 Nursing the Sick and Hygiene.) 
 
poulticp:s in medicinp: and surgery. 861 
 
 Ponlticos, like almost everything else, arc capal^lo of cuiising harm or 
 
 good, according to their applications; and though tlieir employment in 
 
 surgical affections is generally harmful, and for reasons 
 Poultices. , /• ji • ,1 1 . ' 1 ■, . . 
 
 set forth in trie chapters on surgery, yet the physician 
 
 often finds them useful, hut in most inflammations in which pus forma- 
 tion is a probability, both sui-geons and physicians agree that tlieir applica- 
 tion is unscientific and harmful. Poultices act by virtue of their warmth 
 and moisture, and the soothing and relaxation they produce is of much 
 benefit in the relief of pains. The pain of pleurisy and of pneumonia are 
 among these, and it is probable that poultices not only relieve but aid to 
 cure, since they are mild counter-irritants. 
 
 In peritonitis, as in pleurisy, the action of poultices is beneficial, and 
 
 their application to the throat in a severe cold associated with hoarseness 
 
 , „ , . is excellent. In marked abdominal pain not due to in- 
 
 Uses of Poultices. ^ .■ r i^, • n J- T 
 
 Haramation — tor example, the various lorms of colic — 
 poultices will often give much relief. As a generally safe rule, the laity 
 may be advised never to poultice an area of superficial inflammation, hut 
 rather to refer the case to the surgeon ; yet, on the other hand, they may 
 wisely apply a poultice for the relief of pain and inflammation of the 
 deep-lyiiig structures of the body. 
 
 The size of the poultice will depend upon the area of the pain, and 
 generosity in its construction is advised, since it is one of tliose good things 
 of which one can scarcely have too much. 
 
 The materials from which poultices are made are many, for, as has 
 been said, the ]>oultice is active only by virtue of its warmth and mois- 
 ture, and hence any application which possesses these 
 p ... • characteristics alone is entitled to the name of poultice. 
 
 Practically, however, the materials which we employ 
 are flaxseed (linseed), bread, Indian meal, starch, and slippery elm. Of 
 these, the most useful and most commonly used is flaxseed. How to make 
 poultices will be told in the article on Nursing the Sick, and it remains 
 but to say that care must be exercised not to apply 
 th P If them too hot, lest blistering result, an accident especially 
 
 liable to happen if for any reason the patient's faculties 
 are dulled. To avoid this danger, apply the poultice first to your own 
 cheek, and if it can be tolerated there for a short space of time, it is not 
 likely to injure the patient. The warmth of poultices may be retained 
 for a considerable time by covering them with oiled silk, or even with 
 several layers of thick cloth ; but even so they will grow cold, and it is 
 generally necessary to replace them after a period of two hours. Another 
 precaution, too, as to poulticing will suggest the protection against cold of 
 an area recently poulticed. 
 
 The "dry poultice" is a name given to a thick layer of cotton wad- 
 
8tJ3 MEDICINES AND TREATMENT. 
 
 dins: applied to the body and covered by oiled silk or other heat-retaininc^ 
 
 material. The secretions of the patient beneath this apjilieatiun result 
 
 in the necessary moisture, and the application itself 
 
 The ^' Dru Poultice." ,. . , ^, ' ^i nii i i^- • -i 3 • 
 
 furnishes tlie warmth, ihe dry poultice is milder in 
 
 action than the onliiiary poultice, but has the advantages of being less 
 
 annoviui; to the patient and less troublesome to the attendant, for it re- 
 
 (juires no removal and reapjilication. In the milder internal intlamma- 
 
 tious it is effective. It is also an excellent a])plication to the acutelj' in- 
 
 tiamed joints of rheunuitism and gout. 
 
 Of plasters there is a large variety in the "patent-medicine" market, 
 
 and though most of them are possessed of the negative value of doing 
 
 no harm, some few capsicum and poi\)Us plasters do 
 
 seem really serviceable in diminishing the pain and in- 
 flammation of the muscles and deeper organs, since their action is mildly 
 and continuously counter-irritant. These plasters are, however, essen- 
 tially mild and generally applicable to the less acute affections. More 
 energetic and more useful, too, is the old fashioned mustard plaster, or 
 mustard paste. 
 
 The method of making a mustard plaster will be found in the article 
 on Nursing the Sick; it concerns us now to consider its applicability. The 
 
 action of the mustard plaster is as a counter-irritant ap- 
 e Hs OK plication in the same conditions in which poultices are 
 
 employed and in similar ones — indeed, mustard is some- 
 times added to the flaxseed poultice to make it more active. Though the 
 applications of mustard plasters are similar to those of ordinary poul- 
 tices, yet they are invariably more active, and to a greater or less degree 
 depending upon the proportion of mustard employed. In general, it may 
 be said that the strength will, or should, range from one part of mustard 
 in four of flour up to one in twenty, the former being applicable where 
 prompt action is necessary, as to relieve vomiting (in which case it is 
 applied to the " pit of the stomach "), and the latter where a prolonged 
 effect is desired, as in bronchitis. The age of the patient, too, and the 
 delicacy of his skin will determine the strength of the application, those 
 of weaker strength being applicable to children. The weaker mustard 
 plasters may be left on for days at a time, and serve to maintain a con- 
 stant and gentle irritation sufficient to keep an additional amount of 
 blood in the skin covered, and therefore probably a smaller amount in 
 the structures beneath. Care must always be observed, however, to avoid 
 blistering, either by an application too strong or a continuance too long, 
 and though the sensations of the patient are in general to be trusted, they 
 are not always so. Subsequent protection of the area acted on against 
 cold should be provided, as has been said in speaking of poultices. 
 
 A stupe is sim]ily a cloth wrung out in hot water and applied to the 
 
APPLICATIONS OF WATER IN DISEASE. 863 
 
 skin as a convenient motliod of obtaining the well-known sootliing effect 
 of heat upon pain. Though the stupe is to be covered thickly with 
 liannel to promote the retention of the heat, as far as 
 " j^ossible, yet even so stupes will rapidly cool, and must 
 
 therefore frequently be replaced. For these reasons, then, stupes are 
 more applicable to pains of limited duration, and, as a rule, to those which 
 are not dependent upon inflammation. Thus they are especially appli- 
 cable for the pains of intestinal colic. For such a purpose the activity 
 of the stupe will be promoted by sprinkling upon it a few drops of tur- 
 pentine just previous to its application. The skin, if reddened, should 
 be protected after the withdrawal of the stupe. 
 
 Bathing is not only of preventive value, but is also a curative pro- 
 cedure which has really been nmch neglected, and is even now scarcely 
 receivino; the attention it deserves. Not many years 
 
 fl IS, an e ^ indeed, the application of cool or even warm water 
 
 LJs& of WcitBV <~J ■' ' X 1- 
 
 in Disease. ^^ ^^^® fever patient w^as looked upon as quite as crimi- 
 nal as the giving to him of water to drink, and with 
 about as much reason and success. Space does not permit us a full or 
 even a sufficient study of the applications of water in disease, but a few 
 words may well be given to the various methods employed. In this 
 place, however, Ave shall deal only with the simpler applications of water 
 in diseased conditions, reserving the consideration of the more elaborate 
 employments of water, generally called " baths," for later consideration. 
 
 The hot tub bath is stimulating and exciting, unless it is too long con- 
 tinued, in which case it becomes exceedingly weakening. Medical sci- 
 ence has settled upon the number of thermoraetric de- 
 
 The Hot " Tub:' ^ • ^ ^ ^^ .-. . ^^ ^ . ^ ^ 
 
 grees w^nch shall constitute the hot bath, as well as the 
 number proper to the warm, tepid, and cold baths. Such miimteness is 
 not necessary for our purposes, however, and no error is likely to occur 
 from a difference of opinion upon the meaning of the words " hot " and 
 " cold." 
 
 To arouse and stimulate weakened vitality we may use the hot bath, 
 and it is employed in cases of exposure (not, however, in frostbite or 
 general chilling approaching the frozen condition [see Fi'osthite'^)^ after 
 drenching resulting from cold rain or from falling into cold watei', in 
 shock, and in impending death — particularly in the case of children, for 
 in them the lifting into and from the tub will be easy, while in adults in 
 itself it might precipitate a fatal termination. In such cases, then, the 
 brief immersion in hot water will often suffice to stimulate the depressed 
 and flagging vitality. The patient should remain in the bath only suffi- 
 ciently long to experience stimulation, for a longer continuance is weaken- 
 ing. Great care, too, must be observed that exposure to cold does not oc- 
 cur after removal from the bath, else dangerous results may follow. 
 
8tU MEDICINES AND TREATMENT. 
 
 The warm bath is soothing, quieting, anil relaxing ; but its long con- 
 tinuance is little less exhausting than is that of the hot bath, and after it 
 
 the daiiijer of taking cold is even greater. For this rea- 
 The Warm Bath. , ' .... " . , , ,, ^- ^ ■ i i i 
 
 son, tlien, it is tar wiser to place the ])atient in bed sub- 
 sequent to tJiese baths. The conditions in which tlie warm bath is most 
 valuable are those of nervousness, restlessness, and sleeplessness, and it is 
 })referably to be taken just before retiring, and followed by a good rub- 
 bing. In hysterical and nervous subjects the warm bath is a curative 
 procedure of much value. 
 
 The cold bath is tonic, invigorating, and potent against fever. For 
 its tonic and invigorating action it is usually administered by the sponge 
 
 or the " dip," for from its very temperature a prolonged 
 The Cold Bath. . . . , • • xi i. nii • , • 
 
 immersion is depressing in the extreme, ihis tonic 
 
 employment of cold water is useful in conditions of overwork and loss of 
 nervous force in those otherwise strong, and, as has already been said, its 
 use should not be continued unless a healthy ''reaction" follows. To 
 lower the temperature of fever the cold bath may be given by sponging 
 the patient with cold water at frequent intervals, drying him, and be- 
 tween the spongings covering him but lightly. It may be given in the 
 
 form of the "cold pack," which consists in applying 
 , J, , to the patient's body cloths wrung out in cold water 
 
 and changed as frequently as heated, the procedure be- 
 ing continued until the temperature falls. Finally, the cold bath may 
 favourably affect fever if the patient be immersed in a tub of water of 
 65° or 70° Falir. as often as his temperature reaches or passes 102° Falir. 
 While in the bath the patient is vigorously rubbed to prevent depression, 
 and for the same reason whiskey is usually given before the bath is begun. 
 Moreover, when in the bath, cold water is frequently poured over the 
 patient's head. It is this form of cold bathing which is now so often 
 used in the treatment of typhoid fever, and it is generally referred to as 
 the " Brand treatment." The common idea that bathing should not be 
 done soon after a hearty meal is a good one, and is equally applicable 
 whether the bath be hot, warm, or cold. 
 
 The foot bath is invariably given hot, and its effects are to stimulate 
 the circulation, to reduce congestions within the body, and to induce 
 
 sweating. The addition to it of a handful of mustard 
 The Foot Bath. . -. rr • t • •. .i . 
 
 increases its enectiveness. In using it tlie tenijierature 
 
 of the water is usually as high as can be borne, and the immersion of the 
 
 feet continued as long as may be until the desired effect is accomplished. 
 
 The cases in which the foot bath is generally emplo3'ed are those where a 
 
 congestion has taken place in some part of the body. In such cases the 
 
 bath acts to stimulate the circulation, to relax the vessels of the skin, to 
 
 induce sweating, and thus to equalize the circulation and withdraw the 
 
HIP, SPONGE, ALCOHOL, AND MUSTARD BATHS. 805 
 
 blood from the congested parts. Its use in tlie first or congestive stage 
 of colds, and in the pain so often present in the first days of a inenstrnal 
 period, is thus explained. 
 
 The hip bath (or " Sitz" ])ath, as it is sometimes called) is of similar 
 
 action, the heat, however, being applied by the patient 
 The Iliv Bath. .. • ,, ,' ' t^ ^ ' i, '^ '• 
 
 Sitting in the hot water, it is generally more incon- 
 venient and rather less effective than is the foot bath. 
 
 Sponge batiis are given hot or cold, and as hot and cold baths have 
 already been considered, but few words will be devoted to tlieir applica- 
 tion by sponge. The cold sponge bath is refreshing 
 The Sponge Bath. , / w • ,... . , ■, i 
 
 and stimulating m conditions or overwork and exhaus- 
 tion, but, as in health, should never be given to those in whom vigorous 
 " reaction " does not follow its employment. The cold sponge is also 
 effective in reducing the temperature in fever, and in using it it is cus- 
 tomary to sponge off one portion of the body at a time, to dry it and to 
 cover it, that unnecessary exposure shall not take place. The warm or 
 hot sponge is employed to soothe the patient, and especially in cases of 
 nervousness and sleeplessness, where the brain contains too much blood. 
 It is thought to determine a flow of blood to the skin, leaving the brain 
 in an unstimulated and quiet state. Care must be taken to avoid sub- 
 sequent exposure to cold, for so much blood being in the surface, there 
 is then great danger of chilling, and serious results may follow. For 
 this reason it is better to have the patient rapidly dried and at once put 
 to bed. 
 
 Alcohol baths are usually alcohol rubs, and especially after exercise 
 and muscular fatigue. The rubbing is probably a more valuable factor 
 
 in such cases than is the alcohol, for bv it the circula- 
 The Alcohol Bath. ^ . . t , ^ i , i " -, ^ 
 
 tion is accelerated, and thus are removed the waste 
 
 products in the muscles which result from exertion and on which the 
 sense of weariness and lameness depends. The alcohol is a lesser factor, 
 but yet is useful in cooling and in soothing the skin and safely stopping 
 the sweating v/hich has followed this exercise. In fever nothing is so 
 grateful to the patient as sponging him at frequent intervals with a mix- 
 ture of equal parts of alcohol and warm water. One part of the body 
 should be sponged at a time, dried, and replaced in bed. This is calming 
 and soothing ; it diminishes the lameness and soreness so often present, 
 and tends to reduce the fever. It may be used as often as the patient de- 
 sires it. 
 
 Mustard baths are hot-water baths to which mustard is added. Its 
 irritating action upon the skin increases the effect of the heat. The ad- 
 
 _, „ , „ , dition of mustard to the foot bath has alreadv been 
 The Mustard Bath. • i » t ^ ^ • -, 
 
 mentioned. As a general bath m the convulsions of 
 
 children the mustard bath is invaluable, for by its action the quantity of 
 
 57 
 
SCO MEDICINES AND TREATMENT. 
 
 blood in the t-kin is niiK-li increased and the head is relieved of the niorhid 
 congestion on whieh the convulsions depend. The strength employed is 
 u>nally of one handful of mustard to a child's tub of hot water, and the 
 infant is kept in the bath until his skin has become well reddened, or 
 UTitil the tingling of the skin u[K")n the nurse's arm shall warn her of a 
 presumably similar tingling of the child's body. 
 
 If a person is exposed to cold and wet, and especially, though it is 
 singular, if his feet have been wet, there often results a congestion of 
 some internal organ. Almost any organ may be thus 
 altected, though the commonest are the nose, the throat, 
 the lungs, and in women the pelvic organs. To such a condition we often 
 give the name of a " cold," and say that the patient has " taken a cold." 
 Tliis naming is hardly scientific, but it certaiidy is descriptive, and con- 
 veys a clear meaning of cause and effect. Under such circumstances, if 
 we can immediately produce a flow of blood away from the congested 
 area, we may succeed in '' breaking up the cold," and for this purpose 
 nothing is more effective than a " sweat." By this the blood is made to 
 go to the surface of the body, and in the relaxed vessels of the skin so 
 much room is made for the blood that it drains away from the deeper or- 
 gans, and among them the congested one. 
 
 To produce the sweat we place the patient in bed, cover him thickly 
 with blankets, make him partake freely of hot drinks, and if some of 
 them are alcoholic so much the better, though of course intoxication is 
 carefully to be avoided. The sweating produced by these means is usually 
 considerable, though it will be appreciably increased by a previously given 
 hot tub bath. Dover's powder, eight tablets, administered to an adult only, 
 will produce a perspiration still more marked. In fact, this medicine is 
 usually employed by the physician for this purpose, and the sweating it 
 causes is generally profuse. The degree of sweating necessary mil vary 
 with the severity of the case. After the " sweat " has continued suffi- 
 ciently long for our purpose it is stopped by drying the patient, rubbing 
 vigorously one part of the body at a time with rough towels, removing the 
 superabundance of his bedclothing, and, if possible, placing him in a fresh 
 bed which has previously been thoroughly warmed and dried. Such is the 
 " sweat," and properly applied and in suitable cases it is a curative means 
 of great value ; it must not be used without caution, however, and for 
 weak subjects it may not be proper to use it at all, since it is for them 
 too exhausting. Even the strong and robust may be weakened if the 
 •' sweat " is continued too long, and the occurrence of weakness and faint- 
 ness must in all cases be a sufficient reason for stopping it. Above all 
 things, it must be seen to that at no time during or immediately follow- 
 ing the ''sweat" is exposure to cold permitted, for the danger from ex- 
 posure when one is overheated can not be exaggerated. 
 
LEECHING AND DOUCHES. 
 
 8G7 
 
 Leeching. 
 
 Leeching is a treatment formerly most popular but now little prac- 
 tised. It is not likely that the lay practitioner will often wish to use the 
 leech, and indeed he is not advised to, for a case requir- 
 ing bloodletting is usually one which should- be confided 
 to the physician. A few words on the subject may not come amiss. The 
 object of leeching is to diminish local inflammation by withdrawing blood 
 from the inflamed area or its neighbourhood. Inflammations within the 
 ear and severe inflammations of joints are often treated by this method. 
 In the former case the leeches are applied just behind the ear, in the lat- 
 ter over the inflamed joint. Swedish leeches are supposed to be the best. 
 The ordinary medicinal leech is a small, wormlike animal, one extrem- 
 ity of which is provided with a sucking apparatus, h>y which it fastens 
 itself to its victim and through wdiich it draws into itself that victim's 
 blood. The amount of blood which the leech will abstract depends upon 
 his size and species, the range being from one to four teaspoonfuls. To 
 apply the leech, the skin over the site of application is well cleansed, and, 
 that the animal may be given a hint of what he is expected to do, a drop 
 of blood or of milk is placed upon the chosen spot. The leech is then 
 placed with his " business end " in contact 
 with this drop, when he will at once begin 
 his work, and after having consumed the 
 decoy drop, which seems to have the effect 
 upon him of an appetizer, he will fasten 
 to the skin and withdraw blood to his ca- 
 pacity. When full the leech will fall off 
 of his own accord ; but if it be desired to 
 rid the patient of him before that time a 
 few drops of salt water placed upon his 
 sucking end will cause him to let go. It 
 is not at all uncommon for the bleeding 
 from the leech bite to continue for some 
 time after the withdrawal of the animal. 
 If this occurs, the application of firm press- 
 ure upon the part with a thoroughly clean 
 piece of cloth, or, this failing, the rubbing 
 of the wound with a bit of alum, will 
 usually check it. The number of leeches applied at one time will vary 
 with the severity of the case ; two or three are usual. 
 
 A douche is, strictly speaking, the forcible projection of water against 
 the body, and therefore the shower bath, the needle bath, and the throw- 
 ing of water in bulk against the patient are as much 
 douches as is the irrigation of the vagina with water. 
 The popular use of the word douche, however, has this latter significance. 
 
 Fig. 11. — HiRUDO aiEDicns-ALis. 
 1, the leech ; 2, anterior extremity mag'- 
 nified ; 3, jaw detached magnified ; 
 4, part of belly magnified. 
 
 The Douche. 
 
80S MEDICINES AND TREATMENT. 
 
 The use of tlie vaginal doiu-lio. in liealtli aiul in disease, has a special 
 rather than a general aspect, and for information upon this matter the 
 reader is referred to the article which deals with the diseases of women 
 and midwifery. 
 
 An encjna is a rectal injection. Its objects are three : To move the 
 bowels, to introduce food and drink within the body, and for the adminis- 
 tration of medicines. The enema given to cause a move- 
 ment of the bowels generally consists of soapsuds, made 
 bv agitating white Castile soaji with warm water. Of this fluid about two 
 pints will be the proper amount for an adult; for a child of eight or ten, 
 a half pint. The method of introduction is as follows: Lubricate the 
 small nozzle attached to a hand-bulb syringe with vaseline and place the 
 other end of the syringe in .the bowl of warm soapsuds. Compress the 
 bulb of the syringe once or twice, and thus fill the apparatus with soap- 
 suds; for if this is not done before 
 the introduction of the nozzle within 
 the bowel, the effect of the first 
 squeeze on the bulb will be to fill the 
 bowel with air, which accident will 
 materially add to the patient's distress. 
 Now gently insert the nozzle about 
 one inch within the bowel, and then 
 gently and steadily inject the fluid 
 until the whole amount has been put 
 Fig. 12.— a hand-bulb syringe. in, or Until the patient complains of 
 
 pain. In doing this a towel will gen- 
 erally have to be pressed about the nozzle and against the opening of the 
 bowel, that a tight junction of nozzle and bowel may result. Xow with- 
 draw the nozzle and hold the towel firmly over the bowel until it becomes 
 evident that expulsion of the bowel contents must take place, then allow 
 the intestine to rid itself, and with the water ejected will usually come the 
 expected fa?cal matter. If, however, the injection is not effectual, wait a 
 slmrt time and repeat it, and if the first injection is not discharged do not 
 be alarmed, but give another, and with the second will usually come aw^ay 
 the first. In obstinate cases the ordinary soapsuds enema may be insuffi- 
 cient, and the addition to each injection of one or two tablespoonfuls of 
 castor oil, or one or two teaspoonfuls of glycerin, will add to its powers. 
 If much intestinal wind disturbs the patient, one or two teaspoonfuls of 
 spirits of turpentine in each injection may make it more effectual ; but 
 this addition is rarely necessary. 
 
 The " nutritive" enema is designed to introduce into the body the 
 food which for some reason the stomach rejects. It becomes necessary, 
 therefore, when vomiting is so persistent that starvation becomes a dan- 
 
THREEFOLD OBJECT OF ENEMATA. 809 
 
 ger. Since the ol)jCct in the use of nutritive enemas is tliat they shall Ije 
 retained, they must, in contrast to the soapsuds enemas, be small. A lialf 
 tumbler is the usual quantity. The enema is introduced usually riot more 
 often than once in four to six hours, for tlie bowel is an irritable; tube, 
 and a more frequent introduction would defeat the object of the pro- 
 cedure by causing the expulsion of the food. Such an enema may be 
 made of peptonized milk (the directions for making this are given in the 
 article on Nui'sing the Sick)^ and the addition to it of a tablespoonful of 
 whiskey is generally advisable. Peptonized soups and prepared meat 
 juices are also at times employed in nutritive enemas, as are the whites 
 of eggs. While giving these enemas it is well to cleanse the Ijowel once 
 a day by an ordinary soapsuds enema, that thereby absorption of the food 
 may be less interfered with. Great care, too, must be liad that the neces- 
 sary manipulations are as gentle as possible, else irritation of the parts 
 will result and a rejection of the food. 
 
 The introduction of medicines by the rectum will not be considered 
 here save by the briefest of references, for that is a matter which concerns 
 only the experienced practitioner. One drug alone may properly be so 
 given by the non-professional, and that is alcohol. If a patient is in shock 
 or collapse he usually can not swallow, and yet stimulation is what he 
 needs above all things. Therefore it is eminently proper in such a case 
 to inject into the bowel, and hold it in, a tablespoonful or two of whiskey 
 or brandy mixed with a half tumblerful of rather hot water. A repeti- 
 tion of this injection may or may not be necessary, according to the effect 
 of the first one upon the patient. 
 
 In two other conditions enemas of water are very beneficial — jaun- 
 dice and haemorrhage. In jaundice the injection into the bowel once a 
 day of a quart of cold water will often produce rapid improvement ; and 
 it certainly ought to, for the treatment is disagreeable enough. In large 
 haemorrhages from any part of the body the injection into the bowel at 
 once of moderately hot water to which common salt has been added in 
 the proportion of a teaspoonful to a pint will often save life. The salt 
 water thus injected when absorbed takes the place of the fluid the body 
 has lost, and though not blood, it is better than nothing, and often suffi- 
 cient. In such cases the hot salt water should be injected a pint at a time 
 and held in, and after each injection the condition of the pulse carefully 
 noted. If it becomes strong the treatment is sufficient ; when it grows 
 weak again the procedure is to be repeated. 
 
 In certain conditions — notably opium poisoning and drowning — the 
 great danger lies in a cessation of respiration, and under such circum- 
 stances it may become necessary to employ artificial respiration. There 
 are several methods of doing this, but by all odds the best is Sylvester's. 
 It is done as follows : The patient is laid upon the back and a roll of 
 
S70 
 
 MEDICINES AND TREATMENT. 
 
 clothing is placed beneath him in the region of the lower ril);?, to raise 
 
 his chest slightly. The tongue is drawn from the mouth aiul held out, 
 
 either bv gras]>ing it between two layers of cloth or by 
 
 Artificial running a loui:^ hat pin throuiih it. This " spearing" 
 
 Hespira/iou : ,. i ^. " i i . ^i .• j. i -i. 
 
 c 1 I > \f ,1 J of the tonijue may seem cruel, but tlie patient, be it 
 
 remembered, is unconscious, and a tongue subsecpiently 
 slightly sore is a small price to pay for a recovery from asj^hyxia. Espe- 
 cially is the pin of value when no one can be spared to hold the tongue. 
 
 Fig. 13.— Sylvester's method — first movement (inspiration). 
 
 The necessity for a protrusion of the tongue is almost self-evident, for 
 the tongue of an unconscious patient who is lying upon his back will of 
 necessity fall back into his throat and interfere with his breathing. Now, 
 the operator should stand or kneel at the patient's head, and, grasj^ing the 
 patient's arms at about the elbow, should draw them up above the patient's 
 head. This pulls the ribs of the patient up and out, the capacity of the 
 
 Fi(i. 14. — Sylvester's method — second movement (expiration). 
 
 chest is increased, and air rushes in as in a deeply indrawn breath. As 
 soon as this has happened the o])erator lowers the arms of the patient to 
 the sides of the chest and firmly but not roughly presses the elbows 
 against the chest. This results in a forcing in of the patient's ribs, a 
 diminution of his chest capacity, and air therefore rushes out through 
 the throat, as happens in a forcible breathing out. Thus breathing is 
 imitated, and, that the imitation shall be natural, the inspiration and 
 expiration are each produced eighteen times in a minute, as is the case in 
 
THE HOME TREATMENT' OF DISEASE. 871 
 
 health. A persistence in this procedure for liours is often necessary l^efore 
 hope is to be abandoned, for often lias it happened that such a pei-sistence 
 has been followed by the occuri-ence of spontaneous breathing and ulti- 
 mate recovery. As the patient begins to breathe it is very important 
 that the artificial expiration and inspiration shall be made to coincide 
 with his breathing out and in, that the procedure may assist, and not 
 oppose, the natural breathing. As the natural breathing grows stronger 
 our efforts may be gradually relaxed and finally discontinued ; but a re- 
 lapse to the former condition is not uncommon, and for some time we 
 must be prepared to repeat the treatment. 
 
 THE DISEASED CONDITIONS WHICH MAY WISELY AND 
 PROPERLY BE TREATED AT HOME. 
 
 Our study so far has been of medicines and curative procedures, and in 
 dealing with them it has been from the side of the remedy and not of the 
 
 ^ , , ,. disease. It is now necessary to study the subiect from 
 
 the other side and, taking the diseased conditions as our 
 starting points, to apply to them the proper remedial measures. Medi- 
 cines have concerned us hitherto, but now we come to treatment. So 
 much has already been said of the uses of drugs and their applications 
 to disease that in our study of treatment it seems only necessary brieflv 
 and pointedly to lay down for each disease the appropriate treatment. 
 
 In an earlier part of this article a division into three sets was made 
 of those conditions in which home treatment is justifiable. These are : 
 
 (1) Simple and trivial ailments. 
 
 (2) Emergencies pending the arrival of the physician. 
 
 (3) Conditions requiring professional treatment, and where no phvsi- 
 cian can be obtained. 
 
 A discussion of class three would mean a treatise on medicine, and this 
 the author is not prepared to give or the reader to receive. With onlv 
 a passing reference to this class, then, and an exhortation to " use vour 
 common sense" and " do the best you can," the author proceeds to deal 
 with classes one and two. 
 
 SIMPLE CONDITIONS NOT REQUIRING A PROFESSIONAL ATTENDANT. 
 
 " Biliousness " is a chronic ailment often running in families. It is 
 
 very common in America, and yet it is as foolish to attribute every 
 
 ^.,. symptom not otherwise accounted for to biliousness as 
 
 Biliousness. • • r- . t.^.t, 
 
 it IS to fasten it on malaria, for indeed some people hold 
 
 one of these responsible for every ill, from headache to corns. The 
 
 symptoms of biliousness vary in number and severity with time and with 
 
 individuals. They are a sallow, muddy skin, headache, foul breath, bad 
 
S72 MEDICI^'ES AND TREATMENT. 
 
 taste in the mouth, dizziness, duhioss, drowsiness, liatulenee, and consti- 
 pation, which at times is varied by an irritating, foul-smelHng diarrhoea. 
 The treatment should forbid overeating, sliould reduce the starclies and 
 suirars in the diet to a minimum, should reduce or exclude alcohol and 
 tobacco, and should prescribe plenty of active and even violent exercise. 
 There is nothing so good for the '' torpid liver " as is exercise, especially 
 horseback riding. The milder cases need no drugs; in the more severe 
 ones a morning dose of Carlsbad salts is excellent. If at any time the 
 symptoms become more severe, there is much boneiit in a })urgation by 
 calomel. Children are rarely " bilious." 
 
 Chills are characterized by pallor, sliivc ring, chattering of the teeth, a 
 sense of coldness, faintness and prostration, a weak pulse, and sometimes 
 vomiting. Anythinoj less marked is not a true chill, 
 " *■ but a " chilly sensation," Chills often mark the begin- 
 
 ning of serious illness, and are pronounced features of malarial fever. If 
 the patient has previously had malaria, if he lives in a malarious locality, 
 or if the chills occur at the same time on each day or on alternate days, 
 the administration of quinine as already described should be begun. 
 Whatever the cause of the chill, the relief of the immediate suffering is 
 the same, and is summarized briefly in the word warmth. The patient is 
 at once to be put to bed and warmly covered up, hot-water bags, or bot- 
 tles filled with hot water and wrapped in flannel, are to be placed about 
 him, care being had that they are not placed in immediate contact with 
 his skin lest they burn him. Hot drinks are to be freely administered 
 and a moderate amount of whiskey is beneficial. If fever follows the chill 
 the usual treatment of fever is required, and if sweating occurs the precau- 
 tions against taking cold should be observed, and have already been given. 
 
 Choking occurs from the entrance of a foreign body, especially a 
 piece of food, into the opening to the windpipe. Coughing will often 
 remove it, and as aids may be mentioned a sudden and 
 forcible compression of the chest by which the air is 
 quickly ejected from the lungs and the foreign body blown fi-om the 
 windpipe, a vigorous slap on the back, and, in children, turning them 
 '* upside down " and gently shaking them. It is occasionally possible to 
 remove the obstruction by introducing the fingers into the throat ; but if 
 this is done care must be observed lest the obstruction be forced down 
 into the windpipe. In all severe cases the physician should be called at 
 once. 
 
 Cholera morbus is marked by vomiting, purging, and cramps. In the 
 severer cases it may become very dangerous, the patient's flesh melting 
 
 away almost as we look at him. In such cases it re- 
 
 Cholera Morbus. i i a • x- i i m\ t n 
 
 sembles Asiatic cholera, ihe disease usually occurs in 
 
 hot weather, and is apt to follow eating indigestible food or drinking con- 
 
CHOLERA MORBUS AND CHOLERA INFANTUM. 87;j 
 
 taminated water. In ordinary cases castor oil is first <^iven to remove 
 
 decomposing and irritating food from the intestine. This alone may be 
 
 sufficient, and tlie diarrhoea stops. If tlie purging continues, tablets of 
 
 ''Sun Cholera Mixture" should be given, as already described. If much 
 
 pain is present in the abdomen a generous one eighth mustard paste (one 
 
 part of mustard to eight of flour) is to be applied and left on as long as 
 
 possible. Food should be restricted to milk in small quantities, and if 
 
 vomiting is present it may be modified as necessary for that condition. 
 
 Water is allovi'ed in small quantities, if intensely cold. In convalescence 
 
 the food must be most simple and digestible. In all severe cases the 
 
 treatment is upon a similar plan, but the physician's care is necessary. 
 
 Cholera infantum is a disturbance similar to cholera morbus wliich 
 
 occurs in children under two years of age. The most valuable treatment 
 
 is at once to remove the child to a different climate. If 
 Cholera Infantum, , , , ^ , . , . , . , ^ ^ ^ ^ ^ 
 
 lie lias been taken sick in the city, he should be taken 
 
 to the country ; if at the seashore, he should be taken to the mountains ; 
 if at the mountains, let him go to the seashore. The object sought is 
 change, and its effects are often miraculous, no matter how sick the child 
 has previously been. Further than this the treatment is by a good wet- 
 nurse or carefully prepared food, by calomel, and a mild mustard paste 
 applied to the abdomen. 
 
 Colic is popularly known as " cramps," and is the intestinal pain re- 
 sulting from the effort of the bowel to expel undigested matter or faecal 
 
 accumulation. It is a symptom of cholera morbus, and 
 Colic. . . . 
 
 is illustrated in the " green-apple " sensations of our 
 
 childhood. The treatment is obviously the removal of the irritant, and 
 
 castor oil or one of the " salts " is most effective. If the pain is very 
 
 severe a mustard paste may be applied to the abdomen, and morphine 
 
 may be necessary. Morphine, however, is only to be given to adults. 
 
 Constipation is a sluggishness of the bowels, and, though it is not an 
 
 invariable rule, the normal intestinal condition requires one movement a 
 
 day of a sufficient quantity and a hardness not too 
 Constipation. r^ • • -\, c i 
 
 great. Constipation results from many causes, and a 
 
 removal of the cause is always to be sought, for the mere taking of 
 cathartics is wrong in every way, and aggravates the intestinal torpor, 
 making the patient a mere dependent upon his pill. 
 
 Habit is one of the most common causes of constipation, and those 
 indolent individuals who are too lazy to attend to this duty are sooner or 
 later sure to reap the harvest of neglect in misery and ailing. The regu- 
 lar habit has already been discussed, and now we repeat only, have a 
 regular hour for moving the bowels each day and keep the appointment 
 religiously, for the bowels are good business men, and will be prompt and 
 faithful if you are. 
 
87-t MEDICINES AND TREATMENT. 
 
 If constipation is duo to biliousness, nse tlie tivatniont alrcad}- laid 
 down for that condition. If it is duo to old aire — and ir frequently ac- 
 companies advanced years — it is an evidence of the loss of strength of the 
 intestine which must be expected, and as constipation is serious and even 
 dangerous to the aged, it is wise for such patients to take each night, if 
 necessary, one of even two of the coinpnuiid aloin, lu'lladonna, and 
 podophyllin tablets. 
 
 Constipation often occurs in acute disease, and if so an occasional 
 dose of a salt is beneticial unless the disease is one of the abdominal 
 organs, in which case it is wiser to move the bowels by the soapsuds 
 enema, for this disturbs and excites the bowels less than do cathartics 
 taken by mouth. In the constipation of acute disease it is not worth 
 while to upset the patient by causing his bowels to move every day ; every 
 second day is quite often enough. 
 
 The occasional occurrence of constipation in people otherwise healthy 
 is to be treated by a glass of Ilunyadi water, two compound cathartic 
 pills, or even a few of our calomel tablets. In children the remedy by 
 all means the best is castor oil or a small soapsuds enema. 
 
 The occasional constipation of infants is better not treated by cathar- 
 tics, lest the habit be acquired ; but by giving a little more water to drink, 
 or a little oatmeal water occasionally, and, if necessary, by the introduc- 
 tion into the rectum of a small piece of Castile soap cut into the shape 
 and of about the size of the sharpened (wooden) part of a lead-pencil. 
 Indeed this soap suppository, as it is called, is one of the best means to 
 combat the constipation of infants. 
 
 In treating constipation let the following hints be borne in mind : That 
 milder measures must always be used first ; that the danger of a depend- 
 ence upon drugs is great ; that exercise, free water-drinking (indeed, a 
 glass -of ice water taken before breakfast is an excellent laxative), an 
 avoidance of tea, and a diet which contains green vegetal)les, fruits, oat- 
 meal, cracked wheat, prunes, dates, and figs, are agents more valuable for 
 this purpose than all the drugs our medicine chest contains, and far less 
 likely to do harm. 
 
 Cough is a symptom produced by so many diseases that a thorough 
 consideration of its treatment is out of the question, but the commoner 
 conditions causing it may be discussed briefly. In in- 
 flammations of the throat cough is generally present, 
 and in such cases is usually hacking and accompanied by little expectora- 
 tion. For these cases a throat specialist should be consulted, or, at any 
 rate, the physician. A spray of Dobell's solution used three or f(jur times 
 a day will, however, often be beneficial, and never harmful. 
 
 If cough is associated with hoarseness, it Tueans an inflammation in the 
 neifrhbourhood of the vocal cords. It is well in such cases to surround 
 
COUGH, CROUP, AND DIARRHOEA. 875 
 
 the neck with a thick iniiff of cotton, that tlie sootliiiii^ valiu; of warmth 
 may be had, and care should he taken that no exposure to cold occurs. 
 If the hoarseness is extreme, the inhalation of warm steam is of great 
 benefit. Ipecac, -^-^ grain every fifteen minutes, is very useful. 
 
 If the cough is accompanied by oppression over the chest and tlie 
 other evidences of a lieavy cold, bronchitis is to be inferred, and the 
 treatment should include ipecac in small doses and frequent rubbing of 
 the chest with turpentine and sweet oil, or the " stimulating liniment." 
 Cotton, too, should be thickly applied to the chest, and exposure avoided. 
 If the bronchitis is a very severe one, there is considerable efhcacy in a 
 calomel purge and a " sweat " if the case is seen very early. 
 
 The cough of pneumonia and the cough of consumption are scarcely 
 to be treated by the laity, and in the suspected presence of these diseases 
 the physician's advice should always be sought. 
 
 Croup is the hoarse, brazen, crowing noise made in the throats of 
 
 children when suffering from inflammation or spasm of 
 Croup. 1 ■ 1 1 
 
 the vocal cords. 
 
 The spasmodic croup occurs in attacks. In the intervals the breath- 
 ing is normah In these attacks the child will suddenly begin to breathe 
 M'ith difficulty, and to make at each inspiration the " croupy " noise in 
 his throat. Nothing so well suffices to relieve as to make the child 
 vomit. To produce vomiting in young children it is best to give a half- 
 teaspoonful of the syrup of ipecac every fifteen minutes until vomiting 
 occurs, or until four or five doses have been taken. Warm water may 
 also be given, and the finger inserted in the child's throat to cause 
 vomiting. 
 
 If the croup is of the inflammatory kind (" catarrhal croup "), the 
 symptoms are not paroxysmal, but continuous. In these cases a weak 
 mustard plaster should be placed upon the neck of the child and kept on 
 as long as possible, the skin being protected subsequently by a thick cov- 
 ering of cotton. The inhalation of steam from the croup kettle will also 
 be of benefit. The physician's advice should be sought in such cases, 
 however, for catarrhal croup may become a serious condition, and, too, 
 there is often much diflSculty in telling whether the case is one of 
 catarrhal croup or diphtheria. 
 
 Diarrhoea means past or present intestinal irritation, and as, generally 
 speaking, we can not be sure that the irritation is past, it is wiser to free 
 the bowels by a good cathartic, such as castor oil or a 
 " salt." Often this alone will stop the diarrhoea by re- 
 moving the irritant, but if not, tlie administration of the " Sun " cholera 
 tablets is to be recommended. If the diarrhoea has lasted for some time, 
 and it is probable that the irritant has escaped from the bowel, the purge 
 should be omitted and the tablets at once be given. Especially is this 
 
8T6 MEDICINES AND TREATMENT. 
 
 practice recoinineiulod in case the j>atient is so weakened that further 
 purging of itself would be objectionable. The diet in diarrluea should 
 in adults be restricted to milk, and if there is any doubt as to the fresh- 
 ness of the milk it should be boiled. In children diarrha^a sometimes 
 calls for a diet containing no milk at all. 
 
 Earache is very common in children, and may often be relieved either 
 by wrajiping in cotton or by the application of a well-covered hot-water 
 bag. Another way of treating earache is by placing the 
 ear over a pitcher of hot water, and covering both ear 
 and pitcher with a cloth to conline the steam. This treatment is said to 
 be most excellent. If, in spite of these remedies, the pain persists, no 
 time should be lost in calling a physician. Never put any liuid in the 
 ears without first consulting a doctor. 
 
 Epilepsy is commonly known as '* fits," and is a disease characterized 
 by convulsive attacks of uncertain causation, which from time to time 
 affect the unfortunate "epileptic." The attack itself is 
 almost never dangerous, no matter how alarming, and 
 though the physician can do much to benefit the disease, the uninitiated 
 can do nothing save to prevent self-injury during an attack. Interfer- 
 ence, then, be3'ond the prevention of falling downstairs and similarly 
 dangerous accidents, is not only useless but harmful. In those suffering 
 from e])ilepsy an unstimulating diet, largely composed of fats and green 
 vegetables, will tend to reduce the frequency of the paroxysms, and in 
 these patients the bowels should be kept freely open. 
 
 Inflammation of the eyes may be very innocent or very dangerous, 
 
 and therefore, if any doubt upon the subject occurs, the physician is at 
 
 once to be summoned. In that simple condition, how- 
 Inflammation • ^ • ^ .^ ^ i • • c ^ i 
 
 ^41, -IP ever, m which the eves become burnins:, painful, and 
 
 of the Eyes, ' _ . . " . 
 
 watering, and in which their appearance is "bloodshot," 
 
 the solution of boric acid (see Boric Acid) dropped into the inflamed eye 
 two or three times a day will be of great benefit. In all cases of severity 
 an avoidance of light is to be recommended. 
 
 Fainting is really so harmless a thing that no treatment is needed for 
 it, and it is rather for the sake of doing something, and for the satisfac- 
 tion of sympathetic friends, that treatment is pursued. 
 As a matter of fact, the necessary treatment is confined 
 to placing the patient in such a position that the head shall be slightly 
 lower than the heels, so that with the return of blood to the head, thus 
 produced, the fainting will cease. There is no objection, however, to 
 holding smelling, salts beneath the patient's nose, to sprinkling water 
 upon him, and to chafing his hands ; but practically these things are gen- 
 erally unnecessary, since the faint will terminate of its own accord within 
 a very few minutes. Upon recovery from such an attack, rest, warmth, 
 
TREATMENT OF ACUTE FEVERS. 877 
 
 loose clothing, and a mild alcoholic stimulant arc to be I'ocommended. 
 Exceptionally, fainting attacks are of longer duration, and then the J>hj- 
 sician becomes necessary, for not seldom such an attack is the evidence of 
 a condition of some danger. The effect of lowering the head in curing 
 fainting may also be used to prevent an attack, for when the premoni- 
 tory symptoms appear the patient will often succeed in warding off their 
 further development by promptly seating himself and placing his head 
 between his knees. 
 
 While it is true that fever is an elevation of temperature alxjve tlie 
 normal, it is equally true that in this connection the normal point can 
 not be fixed arbitrarily at 98'4° Fahr., for many things 
 operate to cause trivial elevations above that point, and 
 these can scarcely be dignified by the name of fever. Generally speak- 
 ing, then, 100° Fahr. will "be a safe dividing line between fever and no 
 fever. An elevation of temperature above 100° Fahr. is a frequent 
 accompaniment of chronic diseases, but it is usually slight, and in itself 
 seldom requires treatment. The temperature of acute diseases is more 
 pronounced, and it is the treatment of acute fevers which we shall now 
 discuss. Absolute rest in bed and a fluid diet have already been laid 
 down as generally essential to the treatment of fever. The care of the 
 bowels has also been mentioned. It remains, therefore, to speak of treat- 
 ment of the temperature itself. This temperature may be reduced and 
 the patient made far more comfortable if the sponge bath of alcohol and 
 warm water is frequently given. In adults the administration of phen- 
 acetine in five-grain doses every four hours will produce similar results, 
 and in the larger number of fever cases this combination of alcohol-bath- 
 ing and phenacetine-giving constitutes a treatment of great effectiveness. 
 In all fevers, if long continued or severe, circulatory weakening becomes 
 a danger, and must be combated by the administration of alcoholic stimu- 
 lants in quantity sufficient to slow and strengthen the pulse. The mouth 
 of the fever patient must be kept scrupulously clean by frequent washing 
 with water or the glycerin and boric acid solution already mentioned. 
 The importance of this care can not be overestimated, and applies equally 
 to the patient's comfort and his safety — his safety, because the connec- 
 tion between a foul mouth in fever and a complicating pneumonia is a 
 direct one. 
 
 The popular idea that a patient with fever is to be bundled up in thick 
 bedclothing is as erroneous as is the idea that cold water to drink is not 
 to be allowed him, and a greater absurdity than to bundle a patient up in 
 clothing and expect his temperature to fall can not be imagined. So far 
 from this, his bedclothing should be light in the extreme, for the patient 
 with a high fever can not take cold in the ordinary sick-room unless such 
 folly is practised as allowing a direct draught of air to fall upon him. 
 
878 MEDICINES AND TREATMENT. 
 
 Moreover, light coverings tend to allow the fever to fall and thus con- 
 tribute to the patient's recovery and his comfort. With the fall in tem- 
 perature only does the necessity for more covering arise. AVhether it 
 will be allowable for the patient to rise from bed to attend to the evacua- 
 tion of his bowels and bladder Mill depend njion the severity uf his dis- 
 ease ; but in case of doubt the recumbent position should be absolutely 
 and continuously maintained, and the use of the bedpan therefore i)e- 
 comes necessary. Such, then, is the ti'catment of the condition, fever, 
 whatever its cause. Further than this the treatment of the feverish pa- 
 tient is the treatment of the cause producing his fever, or, if that is im- 
 possible, the relief of his various symptoms. In convalescence from acute 
 fevers the return to the usual habits must be gradual, though this too will 
 vary with the severity of the attack and the exhaustion it has ])roduced. 
 At first sitting up in bed is allowed, and then a few minutes or hours in 
 a comfortable chair till, with returning strength, the usual habits are 
 resumed. 
 
 Flatulence means the occurrence of gas in the stomach or the intes- 
 tines, and is the result of decomposition of the food. It is especially 
 common in the bilious and those who eat the sugars and 
 starches in large quantity. For the relief of the con- 
 dition the biliousness and the diet must be corrected, and in many cases 
 the administration of the rhubarb-and-soda mixture in doses of one table- 
 spoonful before eating is advisable. For immediate relief from the pain 
 which flatulence may produce ('•' wind colic") almost anything hot, stimu- 
 lating, or aromatic will be beneficial — hot water, tea, whiskey, or tincture 
 of ginger. For children, peppermint water will answer the same purpose. 
 Headache may be due to any of "a thousand and one things," and 
 space permits of consideration of only the commonest of the causes. Con- 
 stipation is one of these, and a removal of the contents 
 of tlie bowel is followed by relief from the pain. Eye 
 strain is another very common cause, and may be inferred if the headache 
 follows much use of the eyes, or if there be smarting and watering of the 
 eyes. The care of the specialist is, of course, necessary in such cases. 
 The nervous headache is one of the most difiicult to treat, for it involves 
 the removal of the hysterical " habit " of the patient. Briefly, for such 
 cases we employ exercise, diet, rest and sleep in plenty, the removal of 
 irritations, and all measures which may be necessary for a perfectly healthy 
 life. At the time of the pain nothing is so good as sodium bromide 
 given in doses of five grains every half hour until the headache has ceased, 
 or until four or five doses have been taken. " Sick headache " is another 
 common form, and is most defiant of permanent cure, though the relief 
 of the attack is not difiicult. It is accompanied by nausea and vomiting, 
 and is apt to be located in one side of the head only. For relief, phena- 
 
HEADACHE, HICCOUGH, AND HYSTERIA. 870 
 
 cetine may be given in doses of five grains every liulf liour until tliree 
 doses have been taken; but a free purgation l;y culoiiuJ followccJ by a 
 " salt," though slow in action, is a good treatment. Jleadacljc often occurs 
 as a symptom of fever, and re(piires the treatment appropriate to fever. 
 Malaria is a frequent cause of headache without other manifestations of 
 the disease. The pain is apt to be located in tlie forehead, and hence is 
 often called "brow ague." It is to be inferred from the probability of 
 malarial infection. The appropriate treatment is by quinine — five grains 
 three times a day for a few days, and then a gradual lessening of the 
 dosage. Biliousness is often a cause of headache, and is to be recognised 
 by the other symptoms of that condition. Headache is a constant symp- 
 tom of meningitis, or, as it is popularly though incorrectly called, " inflam- 
 mation of the brain." In this case it is exceedingly severe. In general it 
 may be said that if a headache is sufficiently severe to prevent sleep en- 
 tirely, it is indicative of cerebral mischief. For such cases as these the 
 physician is, of course, to be summoned. Though each of the foregoing 
 headaches has its appropriate treatment, they are all more or less slow in 
 operation, and for the immediate relief of the pain there is nothing more 
 effective than the giving of phenacetine, as has already been described. 
 The ice bag applied to the head is valuable in many cases, as is generally 
 a freely and rapidly acting purge. In the severer forms of headache mor- 
 phine may be necessary. For the headache of children the ice bag is the 
 safest treatment. 
 
 Hiccough is due to a spasmodic contraction of the diaphragm, the 
 large flat muscle which separates the chest cavity from that of the abdo- 
 men, and by whose movements air is drawn in or forced 
 Hiccough. ^ ^ ,i' i t, -, , ■, ■, . 
 
 out from the lungs. It may be caused by many thmgs, 
 
 among which are fever, diseases of the brain, and hysteria ; but of all 
 causes the commonest is indigestion. An attack of hiccough is usuallv 
 a slight thing, and easily remedied by holding the breath until the spasm 
 of the diaphragm ceases, by taking a little bicarbonate of soda, or even 
 by taking a glass of hot water. Sometimes, however, hiccough is a per- 
 sistent and exhausting condition — so exhausting, indeed, as occasionally 
 to be the cause of death. In persistent cases, therefore, professional ad- 
 vice is to be sought. 
 
 It is impossible to give in the short space allowed to us a complete 
 or even a fair description of hysteria and hysterical manifestations — in- 
 deed, volumes might be written on the subiect, and the 
 Hysteria. ,. .,, . . ^ ^ , ., , -rr^ 
 
 disease still remain incompletely described, \\ e all 
 
 know what hysteria is ; it is nervousness of an exaggerated kind — not 
 merely the alternation of crying and laughing which occurs in attacks, 
 but any strange and sensational and exaggerated manifestation which 
 has no physical and demonstrable cause. The hysterical nature of 
 
880 MEDICINES AND TREATMENT. 
 
 "queer" performances may ho iiiforrt'il if the suhjoet is a yonnf]j woman, 
 if she is in poor health, if she is known to he "nervous,'" and if she lias 
 had previous attacks. In all the hysterical mauifostations, moreover, the 
 patient evinces a marked desire for attention and ohscrvation, and in the 
 absence of a witness the hysteria usually will (lisajijicar. The ti'catmcnt 
 is to cure any present disease and hy regulation of life, and by all hygienic 
 means to establish "a healthy mind in a healthy body." For the attack, 
 or violent manifestation, nothing is so bad as sympathy and coddling, and 
 if the symjitoms are sufficiently severe a vigorous sousing with cold water 
 will generally bring the hysteria to terms — in fact, the contents of a siphon 
 of Vichy water well aimed and discharged in tlie face of a hysterical pa- 
 tient was formerly so popular a treatment in our hospitals that its very 
 popularity necessitated its abolition from motives of economy. 
 
 Intoxication generally requires no treatment, and the usually mani- 
 fested desire of the victim to sleep is Nature's cure, on which we can not 
 improve. If we can make the patient vomit — and it is 
 usually not difficult — we shall hasten his recovery, and 
 for this the repeated administration of warm water is the most simple 
 method we can employ. 
 
 Loss of appetite is one of the symptoms of ill health, and its relief 
 
 will generally depend upon the removal of the cause, whatever that may 
 
 be. In acute illness the appetite need not concern us, 
 Loss of Appetite. .. . .„ , . , ,i ,. ,, ,^ 
 
 for it will return witli the patients recovery, rrom 
 
 time to time, however, we see patients in whom loss of appetite seems 
 their only ailment. In such cases exercise will often restore the desire 
 for food, and the administration of the rhubarb-and-soda mixture will 
 accelerate that restoration. 
 
 Muscular rheumatism is a painful condition of the muscles which 
 usually follows exposure to cold and dampness. The muscles oftenest af- 
 fected are those of the neck, back, and chest. The pain 
 rj, ,■ usually is more marked upon moving the affected mus- 
 cles. The trouble may be so slight as really not to 
 necessitate treatment, and disappears of its own accord in the course of a 
 few days. If treatment is required, however, phenacetine may be given 
 in doses of five grains every four hours, and the muscles rubbed with the 
 " stimulating liniment." In very severe cases rubbing may be too pain- 
 ful a procedure, and here nothing does so much good as a l-to-6 or l-to-8 
 mustard paste applied over the painful area. In children the treatment 
 is by rubbing with the mixture of turpentine and sweet oil already de- 
 scribed. 
 
 Nosebleed needs no definition. In cases of mildness it may be suffi- 
 cient to have the patient sit in the erect position, to apply ice to the 
 nape of the neck and bridge of the nose, or to press firmly and eontinu- 
 
ANTIFAT ABSURDITIES. 881 
 
 ously upon tlie npj)er lip. In cases more marked nothing is so good as 
 tlie irrigation of the bleeding nostril with hot water. This is flone l>y 
 filling a fountain syringe with water as hot as can Ije 
 borne, and then directing the end of the tubing a short 
 distance up the nose and allowing the water to pass up the nostril and 
 even back into the throat. This treatment is generally efhcient, and 
 should be persisted in. In very severe cases, however, nothing succeeds 
 but plugging the nose tightly with cotton or clean cloth ; but here, and 
 indeed in all cases, the throat must be looked into, lest the bleeding con- 
 tinue from the posterior part of the nose and into the throat. In such 
 cases the patient may swallow the blood and later vomit it, or may ex- 
 pectorate clotted blood by clearing the throat. These things will of course 
 call our attention to the condition of affairs, but they do not invariably 
 occur, and hence the necessity for inspecting the throat. If posterior 
 bleeding does occur and is continued, the physician's skill will be re- 
 quired. (See Surgical Injuries and Surgical Diseases.) 
 
 So many people have an objection to growing fat, and so many anti- 
 fat absurdities are practised, that it seems advisable to give a few words 
 to the subject. With the exception of extreme cases it 
 is as natural for some people to be stout as it is for 
 others to be thin, or to have blue eyes or light hair, and the pursuit of 
 fashionable slenderness by such people is unnatural and often productive 
 of ill health. In cases of extreme and unnatural obesity^ however, we 
 have a real disease and one which should be combated. To accomplish 
 this, exercise should be had in plenty, the food should exclude the fats, the 
 sugars, and the starches, the bowels should be kept open freely by the use 
 of "" salts," and an occasional Turkish bath may be employed. The too 
 frequent use of the Turkish bath is unwise and w^eakening. By sufficient 
 employment of these means the desired result will generally be accom- 
 plished. Of the many " cures " for this condition now popular, let it be 
 understood that they are principally humbug. Moreover, the popular 
 impression that drinking little water, smoking, and drinking vinegar will 
 produce diminution of flesh is false. Starvation will of course cause ema- 
 ciation, but it will also cause disease. Few people realize that in their 
 employment of artificial aids to getting thin they are using remedies which 
 are either worthless or which, if effective, are likely to cause serious dis- 
 ease and hence are dangerous. To reduce the flesh, then, pursue the le- 
 gitimate means we have given, and if you lose weight well and good, if 
 you do not carry it too far and also lose health and strength ; but if, in 
 spite of these means, j-ou remain fleshy, then be content, for Xature in- 
 tended it to be so. 
 
 The condition of painful menstruation is one which usually has some 
 local cause, and therefore such cases are usually appropriate for the spe- 
 58 
 
8S2 MEDICINES AND TREATMENT. 
 
 cialist ; l)ut tlie suffering at the time of sickness is susceptible of consid- 
 erable relief by simple aiul harmless means. As in the convulsions of 
 children the problem is to bring the blood away from 
 
 ainju ^j^^ congested brain, so in painful menstruation the 
 
 Menstruation. ^, ^ , 
 
 ]>roblem is to reduce the congestion of the pelvic organs 
 
 which is associated with this condition, and it is accomplished by similar 
 
 means. The jKitient sulfering from this painful menstruation should have 
 
 a hot mustard foot bath and quickly get into bed, should be well covered 
 
 up, and have a hot-water bag applied to the feet. Hot drinks should be 
 
 taken, and though a vigorous "sweat" is generally to be avoided, yet the 
 
 warmth is eminently beneficial. 
 
 Many people complain of " rheumatism " when they are suifering from 
 
 vague pains in the joints, in the muscles, and in the bones. These pains 
 
 may or may not be rheumatic, and as a matter of fact 
 p . in a considerable proportion of the cases they are not. 
 
 Many of these patients are aged, and treatment is of 
 little avail, but yet something can be done and sometimes much benefit 
 will result. For such patients are reconmiended an out-of-door life, yet 
 with avoidance of exposure, an abstinence from alcohol, tea, coffee, and 
 tobacco, a diet to consist largely of fats and green vegetables, and the ad- 
 ministration daily of Carlsbad salts in sufficient doses to move the bowels 
 once or twice. For the pains themselves rubbing with the " stimulating 
 liniment" is to be recommended. 
 
 Sleeplessness is an ill which requires much care in treatment, for if 
 drugs are employed the danger of forming a drug habit is great. No 
 
 such drugs should therefore be given bv the laity, and 
 
 Sleeplessness. , -^^ ^ . " -, ' i i- 
 
 lience it is not our purpose to recommend or speak ot 
 
 them. There are simple means, however, which are often sufficient to 
 cause sleep, and these act by causing a removal of blood from the over- 
 supplied brain to some other part of the body, for in sleep it is supposed 
 that the brain contains less blood than in wakefulness. The means to be 
 recommended for this purpose, then, are a warm bath immediately before 
 retiring, a cup of hot water taken at bedtime, or a light and digestible 
 supper, a hot-water bottle at the feet, warm bedclothing, a quiet room, 
 and — though the possible habit is not to be lost sight of, and therefore the 
 suggestion is made with reluctance — a glass of beer. In the sleeplessness 
 of acute disease, where from the brevity of the time of employment no 
 habit is likely to be formed, the use of sodium bromide is allowable. 
 
 Sore feet is a name by which we mean to describe not distinctly in- 
 flamed feet, but that condition of soreness often associated with burning 
 
 sensations and an abundant production of perspiration. 
 
 Such a condition is exceedingly common, and occurs 
 particularly in certain individuals and families, in hot weather and fol- 
 
SORE FEET, MOUTH, AND TllKOAT. 883 
 
 lowing much walking. For its relief the feet (should be bathed once or 
 
 more each day in equal parts of alcohol and water, the stockings should 
 
 be white and changed each day, and the wearing of the yellow or tan- 
 
 colonred shoe is undeniably advantageous, especially if two pairs are used 
 
 in daily alternation. A powder consisting of one pai't of salicylic acid 
 
 with fifty parts each of starch and zinc oxide may be kept a})[»lied to the 
 
 feet, and is a most effective remedy. 
 
 It often happens that persons in whom there is indigestion suffer f i-om 
 
 slight spots and sores in the mouth, to which the popular name " canker 
 
 sores " is applied. These are an annoyance rather than 
 Sore Mouth. ,. , ,, .„ t ,. .« , ,. 
 
 a disease, and usually will promptly disappear if the diet 
 
 is regulated and the rhubarb-and-soda mixture is taken for a few days. 
 
 In children there occur from this cause, as well as from neglect to keep 
 
 their mouths clean (the mouth of a child should be washed out with warm 
 
 water or boric-acid solution after each feeding), small white spots and 
 
 ulcers upon the tongue, gums, lips, and cheeks. For the removal of these 
 
 " sprue " or " thrush " spots nothing is more valuable than a frequent 
 
 washing of the parts with a mixture of glycerin and saturated solution 
 
 of boric acid, equal parts (see Boric Acid). (See Surgical Injuries and 
 
 Surgical Diseases.) 
 
 So many are the kinds of sore throat that in the presence of doubt as 
 well as of severity the physician's advice must be sought, for it is to be 
 remembered that the onset of so grave a disease as 
 diphtheria is not infrequently mild. If previous ex- 
 perience, however, has produced familiarity, if contagion can be excluded, 
 if exposure or indigestion has been present, if the appearance of the 
 throat is indicative only of mild and simple inflammation, then may home 
 treatment be employed. For the relief of the simpler forms of sore 
 throat a gargle of hot water may be used every two or three hours, or the 
 iced solution of chlorate of potash already described, for either hot or 
 cold applications seem efficient. If fever is an accompaniment of the 
 attack — and it often is — the usual treatment of that condition is required. 
 Some patients, and especially children, are sufferers from frequently re- 
 peated attacks of sore throat, and to combat this tendency the stomach 
 and the diet should receive attention, only the plainest of foods being al- 
 lowed. In such cases the plumbing of the patient's house may be found 
 faulty, and with its correction the attacks cease. Local throat conditions 
 may account for the attacks, such as overgrown tonsils, and then the 
 specialist is required. To lessen the tendency to repeated attacks, daily 
 sponging of the throat and upper part of the chest with cold water is of 
 considerable value, as it is in the prevention of bronchitis. 
 
 Styes are abscesses of the eyelids which, though small in size, are 
 large in their power to torment. They are apt to be rapidly repeated 
 
8S^ MEDICINES AND TREATMENT. 
 
 for some length of time unless checked by treatment. AVhcn the early 
 symptoms of stye appear and are recognised by those familiar with them, 
 frequent bathing of the lid in very hot water will some- 
 times suffice to "head off " a further development. More 
 effective than this, however, is a preparation to be had at any pharmacy, 
 which is called " the syrup of the hypophosphites with iron." A tea- 
 spoonful of this taken three times a day, after meals, and in water, will 
 often stop an incipient stye, and, furthermore, prevent the aj^pearance of 
 its descendants. 
 
 Toothache needs no definition, but it calls for treatment. "We need 
 not describe the application of the hot-water bag to the cheek ; its use 
 is familiar to all, and generally is remarkable for its 
 failures. If the aching tooth contains a cavity nothing 
 is more effective to relieve the pain than the placing in it of a small piece 
 of absorbent cotton which has been soaked in creosote, oil of cloves, or a 
 strong solution of carbolic acid. These drugs are powerful irritants as 
 well as poisons, and therefore they must not be carelessly dropped upon 
 the gums and lips, and the bottles containing them must not be allowed 
 carelessly to stand around. The occurrence of toothache is a warning to 
 visit the dentist, and so strong a hint should never be neglected. 
 
 To cause vomiting is a procedure necessary whenever anything ab- 
 normal in (jiiality or quantity has been swallowed the retention of which 
 
 would be prejudicial to health. It is also desirable in 
 To Cause ^ onnting. , , . . , ^ ,^ ■ r tt • 
 
 obstruction or the breathing irom croup. Various means 
 
 are employed for this purpose, and include the drinking of lukewarm 
 
 water in large amount, irritating the palate and pharynx with the finger, 
 
 the drinking of warm salt water, or of warm water containing mustard 
 
 in the proportion of a tablespoonful to each tumbler. Syrup of ipecac 
 
 is a most valuable emetic, and especially useful for a child. The use of 
 
 the drug for this purpose has already been described (see Syi'np of Ipecac). 
 
 To stop vomiting becomes necessary in derangements of the stomach 
 
 in which it is not harmful food which is being ejected, but in which 
 
 water, milk, soups, and the blandest and most suitable 
 
 lo Stop \ Omiting. r r -, y • ^ rr m i 
 
 or loods are being tlirown oir. io cause the vomiting 
 to stop, milk should be given in very small amounts at intervals of a 
 quarter to half an hour, should be intensely cold, and if not then retained 
 may be modified by the addition to it of limewater, as already described. 
 To assist in the retention of food a strong mustard paste (1 to 4 in adults) 
 should be placed upon the " pit of the stomach," and retained there as 
 long as possible. If the vomiting is frequently repeated and exhausting, 
 there is much value in washing out the patient's stomach, and this is done 
 by inducing him to drink liberally of \varm water, which, being almost 
 immediately rejected, brings with it the irritating matter, on the presence 
 
VOMITING, APOPLEXY, BLEEDING. 885 
 
 of wliicli in the stomach the persistence of the vomiting depends. This 
 procedure is to be repeated until the vomited water returns clear and pure, 
 when a cessation of the trouble, at least temporary, will almost invariably 
 ensue. In severe vomiting, however, one of our morphine tablets may be 
 required, but should never be employed unless otlier means have failed. 
 If necessary, it should l)e given dissolved in a teaspoonful of ice water, 
 but only to an adult. 
 
 So much, then, for simple and trivial ailments, though in our discus- 
 sion of them we have again and again spoken of the possible necessity 
 for calling the physician, and have attempted to indicate tliose conditions 
 which require his presence. Remember that in general mild cases only 
 are to be treated at home, and that severity and doubt always call for 
 medical advice. 
 
 EMERGENCIES DEMANDING A PROFESSIONAL ATTENDANT. 
 
 In this class there naturally belong more conditions of a surgical than 
 of a medical nature, but, as has already been said, this article relates to 
 medicine only, and for information in regard to surgical emergencies the 
 reader is referred to the article on Surgical Injuries and Surcjical 
 Diseases. 
 
 Apoplexy may be inferred if a man beyond middle life suddenly be- 
 comes unconscious, with possibly slight convulsive movements of some 
 part of the body which last but a short time, and if his 
 appearance in the " stroke " is of marked redness of the 
 face, snoring, noisy breathing, and slow and over-forcible pulse. In such 
 a state it seems almost imperative that " something must be done" ; but, 
 unfortunately, nothing can be done by the laity, and little in fact by the 
 doctor. Send for the doctor at once, however, and in the meantime raise 
 the head of the patient upon pillows, loosen the clothing about his throat 
 and chest, place him in as comfortable a position as possible, avoid shaking 
 or moving him unnecessarily, avoid giving anything alcoholic, and — wait. 
 Bleeding from the lungs is more alarming than dangerous, and though 
 it may cause death, it does so rarely. This bleeding usually occurs as a 
 symptom of consumption, but many consumptives never 
 the L bleed from the lungs, and, on the other hand, the bleed- 
 
 ing not infrequently occurs without consumption. Quiet 
 is to be insisted on in such cases, both to reduce the activity of the heart 
 which would result from excitement and which would increase the bleed- 
 ing, as well as to diminish the cough. Still more surely to accomplish 
 these ends, give (to an adult) two of our morphine tablets dissolved in 
 water and await the arrival of the physician. Remeiriher that under no 
 circumstances should alcoholic drinJcs he used. As a matter of fact, the 
 haemorrhage will usually cease of its own accord, and the physician can 
 
SS6 MEDICINES AND TREATMENT. 
 
 do little more tluui the things we have mentitnied. Yet he should invai-i- 
 ablv he called, for the condition may turn out grave in spite of first 
 api->earanees to tlie contrary. 
 
 Some ditiiculty may arise in distinguishing bleeding from the lungs 
 from bleeding from the stomach, and in such a case the following points 
 mav be fouTui of service : In bleeding from the lungs a cough is almost 
 invariable ; in bleeding from the stomach it is not, but vomiting is present. 
 In bleeding from the lungs the blood is usually bright red and frothy ; in 
 the other case it is more apt to be dark, tan-y, clotted, and to contain 
 food. 
 
 Bleeding from the stomach is to be combated by ap})lying the ice caj) 
 over the pit of the stomach and keeping the jiatient as quiet as possible — 
 if necessary, by the administration of niorj)hine (for 
 Bleeding from ^^^ ^^^^^ ^^^ ^^ ^j^^ tablets dissolved in a very small 
 the Stomach. . x mi • ^ • ^ i" i i- 
 
 quantity of ice water), iiiis morplune lias tiie addi- 
 tional advantage of tending to diminish the vomiting. It is recommended 
 by many that ice should be sucked, and even that small pieces of it l)e 
 swallowed, in cases of vomiting of blood. This, however, is treatment of 
 doubtful value, for the water swallowed may increase the vomiting, and 
 hence the bleeding it is our object to stop. As in other bleedings, the 
 giving of alcoholic drinks is strictly to be avoided. 
 
 In bleeding from the bowels the same treatment is pursued as in 
 
 bleeding from the stomach, save only that the ice bag is applied over as 
 
 much of the abdomen as possible. Whether this treat- 
 
 Bteeding from ^^^^^^^^ -^ effective is doubtful, and the outcome is prob- 
 
 the Bowels. , , t i . i . <• , 
 
 ably little iimuenced by our interference, and yet we 
 
 use these means in the absence of others more trustworthy. In bleeding 
 from the bowels no purgative medicines or enemas should be used for sev- 
 eral days lest by the activity of the intestines thereby induced the haemor- 
 rhage should again begin. 
 
 The treatment of unconsciousness, save those states already described, 
 is, from tlie standpoint of the laity, mainly one of non-interference. In 
 
 such cases, therefore, loosen the patient's clothing that 
 U/iconsciuusness. ^ i ,i -i i i • • c , ■< ^ 
 
 he may breathe easily, place liim m as comtortable a 
 
 position as possible, and avoid disturbing and exhausting him by unneces- 
 sary moving ; if his face is pale, let the head be placed low ; if the face is 
 red and flushed, let it be elevated on pillows. Further than this, do noth- 
 ing until the physician arrives, unless the unconsciousness is manifestly one 
 of those we have more carefully described, such as fainting, drowning, 
 apoplexy, sunstroke, epilepsy, shock, and o])ium poisoning. For these 
 the treatments have been given. 
 
 Convulsions in adults are relatively uncommon, and if they occur the 
 uninitiated can do nothing more than prevent self-injury by the patient. 
 
CONVULSIONS, CHILLS, AND DROWNING. 887 
 
 In children convulsions are of frequent occurrence, and arihc fj-oni a gi-eat 
 variety of causes. First and foremost, the convulsion is to the young 
 child what the chill is to the adult, and therefore wljen 
 a disease would begin with a chill in an adult, its in- 
 vasion in a child is marked by a convulsion. For this reason a convulsion 
 in a child may mean the beginning of measles, of scarlet fever, of dipli- 
 theria, of pneumonia, and a host of other acute diseases. Beyond these, 
 convulsions in children often result from the most trivial causes. Thus 
 they not infrequently arise from the cutting of teeth, from constipation, 
 from worms, and from an indigestible and undigested meal. Tiie child 
 suffering from a convulsion should at once be placed in the mustard bath 
 already described and kept in it until his convulsion ceases, or until, from 
 the reddened appearance of his skin, we think it unwise to let him remain 
 longer. Removed from the tub, he is at once put to bed and the ice cap 
 is applied to his head that, by its action, the supposed abnormal quantity 
 of blood in the brain may be lessened. The cause of his convulsion must 
 then be sought and, if possible, removed, that the trouble sliall not recur. 
 If constipation is present the soap suppository or the enema is employed. 
 If there has been a debauch upon banana or candy, the aid of syrup of 
 ipecac is invoked. If worms or troublesome teeth are the cause, the 
 physician will attend to them, and if no cause can be found, we can only 
 await the possible occurrence of another convulsion (for which the treat- 
 ment must be repeated), and wonder what disease the child is "in for." 
 
 Drowning causes death in either of two ways — by shock or by suffoca- 
 tion. In death from the former the appearance is one of pallor, while in 
 death from the latter lividity is present, as it is in all 
 cases of asphyxia. K^otwithstanding these appearances, 
 however, and the probability in many cases that death has already taken 
 place, we are not justified in allowing the patient to go without an effort 
 at resuscitating him, for it has often happened that the efforts of hours 
 expended upon those apparently drowned have finally resulted in recov- 
 ery. The following rules should be pursued in such cases : The patient 
 having been taken from the water, the clothing over his chest should be 
 removed, that his breathing shall be less interfered with. If the air is 
 cold it will be wiser to withdraw the patient into a warm and sheltered 
 place ; but if this is not possible, the additional danger of exposure may 
 be lessened by covering him with warm blankets and clothing. As rap- 
 idly as possible let the patient be turned upon his face, and, with his head 
 hanging down, let his stomach and hips be elevated upon a pile of cloth- 
 ing, or something similar, that as much water as possible shall drain from 
 his air passages. Following this he should be rolled upon his back again, 
 and his throat thoroughly cleared and wiped of all mucus and water by 
 the finger well covered with cloth. The tongue of the patient is then to 
 
8SS MEDICINES AND TREATMENT. 
 
 he drawn l\ir\vard that it may luit fall hack aiul t)l)striu't the throat, ami 
 iirtiticial respiration is begun. Coincident with the juM-fornianee of arti- 
 ficial rcs]>iration all stimulating means are to be employed, for the condi- 
 tion in all cases is not merely one of the failure of bri'athing, but of fail- 
 ure of circulation as well. To this end hot-water bags, hot bi-ieks, or hot 
 cloths are to be ai>[)lied to the extremities, in the armpits, and along the 
 inner surfaces of the thighs. AVarm coverings are to be applied. Hot 
 water containing whiskey may be given by enema, and as soon as the pa- 
 tient is able to swallow, M-biskey should be administered internally. It 
 may be that none of these things will be at hand, aud then we must get 
 along as well as possible with warm coverings and rubbing. These meas- 
 ures should not be discontinued in a less time than two hours, for, as has 
 been said, recovery may occur only after long and persistent efforts. 
 
 Shock or collapse is practically fainting of an exaggerated and pro- 
 longed nature. It is more often a complication of surgical injuries than 
 it is a medical condition ; but then we not infrequently 
 have a state of shock produced purely by emotion, such 
 as excessive joy, fright, grief, and suffering. The condition is one of 
 pallor, with cold, clammy skin, sighing respiration, and feeble pulse. 
 The state, in short, is that of cold limpness, and the treatment, as would 
 naturally be inferred, is by the application of artificial heat and the free 
 administration of stimulants. 
 
 Poisoning belongs properly within this group of cases, but the subject 
 
 is so important that it seems wiser to consider it under 
 Poisoning. , ,. 
 
 a separate heading. 
 
 Starvation is fortunately a condition which we are not often called 
 
 upon to treat, and yet the occasion may arise at almost any time. In the 
 
 relief of this condition it must always be remembered 
 Starvation. ^, , , ^ , . .,, ' . i , i . 
 
 that the hunger of the patient will often lead him to 
 
 eat so largely that his digestion, even if it were strong (which, because of 
 his general weakness, it is not), would be unequal to the task, and thus 
 produce a serious and even dangerous condition. The food is therefore 
 to be administered in small quantities which may be frequently repeated, 
 and the more concentrated and nourishing foods are first to be employed, 
 such as milk and soups. The quantity of these given at one time may be 
 gradually increased, and finally the more easily digestible solids, until, 
 with slow progression and careful observation, the usual diet is resumed. 
 The condition in severe cases of starvation is generally one of exhaustion, 
 and therefore hot drinks are often required for their stimulating effect. 
 Alcoholic drinks may be given, but caution is required in their adminis- 
 tration to a starving man, for the danger of overstimulation is, under the 
 circumstances, not slight. 
 
 Suffocation is the condition which results from obstruction to the en- 
 
SUFFOCATION AND SUNSTROKE. 889 
 
 trance of air to the lungs. Its causes are many, and incliidr; drowninf^, 
 choking, hanging, and the inlialation of noxious gases, if concentrated. 
 The appearance is that of hluencss of tlie face, with 
 swollen and distorted featni-es and protruding and blood- 
 shot eyes. The treatment consists in the removal of the immediate cause 
 of the suffocation, the restoration of breathing by dashing cold water for 
 cold and hot in alternation) in the face and on the chest of the patient, 
 the holding of annnonia water before the patient's nose to stimulate liis 
 breathing, the performance of artificial res])iration, and the use, in some 
 cases, of the stimulating agents, heat and whiskey. 
 
 Sunstroke, contrary to the general idea, is produced not only by ex- 
 posure to the heat of the sun, but to extreme heat from any source. As 
 
 predisposing factors of great importance are recosrnised 
 Sunstroke. ^ i i i -t. ^ i • 
 
 overwork, debihty from any cause, and intemperance. 
 
 If a man subjects himself to the possibility of incurring sunstroke lie will 
 often experience before the onset of the attack itself certain warning 
 symptoms, and if these are heeded it may be possible to avoid the attack. 
 These premonitory symptoms are headache, dizziness, faintness, " seeing 
 double," the appearance of all objects to have the same colour, a sense of 
 distress in the stomach, nausea, and " weakness in the knees." A defi- 
 ance of these warnings and a persistence in the exposure means sudden 
 unconsciousness and — sunstroke. The appearance of one suffering from 
 sunstroke is generally as follows : A face red and congested, laboured and 
 noisy breathing, groaning, sometimes delirium and convulsions, a pulse 
 which is full and strong but also very rapid, and above all things a skin 
 which is intensely hot to the touch. The insertion of the thermometer in 
 the patient's bowel will generally show intense fever — temperatures of 
 1 10° Fahr. are not uncommon — and still higher have been observed. In 
 treatment the problem is to reduce the temperature without incurring at 
 the same time the danger which intensely cold applications have of caus- 
 ing collapse ; for this reason it will not do to place the patient in a tub of 
 ice water, as has often been done, and expect him to survive. The treat- 
 ment by all odds the best for sunstroke is to remove the patient to a cool 
 place, to strip him naked, and then to sprinkle him with ice water, the 
 water being discharged from an ordinary garden sprinkler held at a con- 
 siderable distance above the patient's body. At the same time vigoroush' 
 rub him with ice. This may appear quite as dangerous as is " playing ice. 
 berg " with him, but it is not, for the rubbing and dropping of water on 
 the body with considerable force from the sprinkler are highly stimulat- 
 ing, and it is not rare for the pulse to improve and remain good through- 
 out the treatment. If, however, the pulse grows M'eak, the enema of 
 whiskey and water should be employed. If the method recommended 
 is followed there usually appears a gradual improvement in all the pa- 
 
S90 MEDICINES AND TREATMENT. 
 
 tient's symjitoins until consciousness rotui-ns. One caution nuist over l>o 
 observed : take the patient's temperature (by tlie ht)wel) at frequent inter- 
 vals durinir the treatment, and when it has fallen to 101° Fahr. stop, for 
 the temperature continues to fall following the removal of the cold ap])li- 
 cations, and if these are kept up until the temperature falls to the noiinal 
 ])oint it will sub"seciuently become subnornuil and collapse will result. 
 SVhen the temperature has fallen to this point the patient must be put to 
 bed. lightly covered, and an ice bag applied to his head, for there is 
 considerable danger that '* intlamnuition of the brain " may follow the 
 attack. As a subsequent rise of temperature may occur, it may be neces- 
 sarv to repeat the bathing, though if the rise is not marked the milder 
 remedies for fever suffice. The subsequent treatment consists of confine- 
 ment to bed in a cool room and the employment of a diet which is light, 
 unstimulating, and easily digestible. AVhiskey may indeed be needed if 
 the pulse weakens, but it is to be avoided if possible. 
 
 " Heat prostration " is far different from sunstroke. It is sim]>ly a 
 
 mild exhaustion or fainting from exposure to heat, and may result from 
 
 nianv other causes. The treatment is rest in a cool 
 
 Ihat Prostration. ' , ^, ,. -i n x- i i.- j. i. ^ 
 
 room and the ordinary mildly stimulating treatment 
 
 employed in fainting. 
 
 In concluding this portion of our chapter let a few words of caution 
 be expressed. Bear in mind that, of treatment, too little is better than 
 too much, that coolness and thoughtfulness are pre- 
 requisites, and that tlie faintest doubt or uncertainty 
 requires the summoning of the physician. 
 
 POISOXING AND ITS TREATMENT. 
 
 In no class of cases is '' home treatment " so important as in poison- 
 ing, for here minutes even may mean life or death, and the time lost in 
 sending for the physician and in awaiting his arrival is 
 
 Introduction. . ^ . \ . ., iii-ir-.i 
 
 often sulncient to place the patient beyond all aid. bend 
 for the physician by all means, but do not delay the treatment for him, 
 and above all things keep *' cool," for presence of mind in these cases 
 means everything. 
 
 Though some poisons are taken by inhalation or by hypodermic in- 
 jection, by far the larger number of them are taken by swallowing. If 
 
 the stomach, then, can be made to eject the recently 
 X f swallowed poison, its effect is lessened in proportion to 
 
 the time involved. Therefore in all cases of poisoning 
 make the patient vomit as soon as possible, and for this purpose M-arm 
 water, or still better M-arm soapsuds, drunk in large amount and followed 
 by the introduction of the finger into the throat offers many advantages. 
 The value of this method lies particularly in the facts that warm water 
 
SYMPTOMS AND TREATMENT OF POISONING. 
 
 891 
 
 Antidotes. 
 
 can almost always 1)C had ; that it washes the poison fi'oin the stomach 
 more thoroughly than do emetics given in smaller amount, and tliat it 
 dilutes the poison, and therefore renders it less irritating and often less 
 harmful. Kepeat this treatment many times, that the stomach may be 
 thoroughly washed. In the meantime let the antidote proper to the 
 poison taken be brought as rapidly as possible, and let it be adniini.-tered 
 at once npon its arrival. 
 
 Antidotes are those drugs and procedures which counteract the effects 
 of other drugs (poisons). They accomplish this by intervening between 
 the poison and the surface which it would otherwise 
 affect (mechanical antidotes); by uniting with the poi- 
 sons chenj.ically and producing combinations which are harmless (they are 
 then called chemical antidotes), or by producing symptoms the opposite 
 of those the poison produces (in which case they are called physiological 
 antidotes). The chemical antidote should, of course, be given as soon as 
 possible in all cases of poisoning, if it is at hand, even before the vomiting 
 is induced, but if not, let the stomach washing be vigorously carried on 
 and the antidote be given when it arrives. The physiological antidote, 
 on the other hand, must be given subsequent to the washing, since its 
 constitutional effects are desired. Whether the antidote be used or not 
 the stomach should be washed ; for there are few perfect antidotes, and 
 it is not safe to trust too much to the efficiency of any of them. 
 
 Poisoning m.ay result from an overdose of almost any drug, and hence 
 the varieties of poisoning are innumerable, but practically the dangerous 
 poisonings, and especially those likely to be met in domestic practice, are 
 comparatively few. These are presented in the following table, together 
 with their prominent symptoms and their antidotes : 
 
 Poison. 
 
 Symptoms. 
 
 Antidotes and Treatment. 
 
 Strong 
 acids. 
 
 Acetic acid. 
 
 Muriatic acid or hy- 
 drochloric acid. 
 
 Nitric acid. 
 
 Sulphuric acid (vit- 
 riol). 
 
 Oxalic acid. 
 
 Sour taste; burning pain 
 in mouth, throat, and 
 stomach ; blistered and 
 burned appearance about 
 mouth: vomiting: great 
 prostration ; cold extrem- 
 ities ; convulsions ; death. 
 
 Limewater, soap, plas- 
 ter (from the wall), chalk, 
 magnesia, cooking soda 
 (3 or 4 teaspoon fuls in a 
 glass of water). Later, 
 soothing fluids, like olive 
 oil and cream ; stimulants 
 if necessary ; morphine, 
 for pain. 
 
 Prussia 
 acid. 
 
 Prussic acid or 
 Hydrocyanic acid. 
 Oil of bitter almonds. 
 Laurel water. 
 
 Large dose causes in- 
 stant death; very small 
 dose causes nausea, giddi- 
 ness, rapid pulse, pain in 
 the head, spasms, convul- 
 sions, death. Poisoning 
 may result from smelling 
 the drug only. 
 
 Stimulating drinks 
 promptly and freely. 
 
892 
 
 MEDICINES AND TREATMENT. 
 
 Poison. 
 
 Symptoms. 
 
 Carbolic 
 acid. 
 
 Alkalies 
 and their 
 salts. 
 
 luiliiic. 
 
 Silver. 
 
 Arsenic. 
 
 Copper. 
 
 Il'OIl. 
 
 Lead. 
 
 Mercury. 
 
 Carliolic acid. 
 Creosote. 
 
 Ammonia (hartshorn). 
 
 Sniellinj; salts. 
 
 Canst if jintasli. 
 
 Caustic soda. 
 
 Lye. 
 
 Pearlash. 
 
 Saltpetre. 
 
 Tincture of iodine. 
 
 Xitrate of silver (lunar 
 caustic). 
 
 Arsenious acid. 
 "White arsenic." 
 Fowler's solution. 
 Paris green. 
 Suheele's jrreen. 
 Green colouring mat- 
 ters. 
 " Rough on Rats." 
 
 Blue vitriol. 
 Verdigris. 
 
 Food cooked in copper 
 vessels. 
 
 Copperas. 
 Green vitriol. 
 Chloride of iron. 
 
 Sugar of lead. 
 Wiiite lead. 
 Red lead. 
 
 Corrosive sublimate 
 (bichloride of mer- 
 cury). 
 
 Vermilion. 
 
 Vomiting; mouth cov- 
 ered Willi white burns and 
 lienunibed; se\ ere abdom- 
 inal pain ; cold, clammy 
 skin ; unconsciousness ; 
 coma; noisy breatiiing; 
 odour of carbolic acid 
 about the patient. 
 
 Antidotes and Treatment. 
 
 Burning in mouth and 
 throat ; dilliculty in swal- 
 lowing; severe pain in 
 stonuich; vomiting, i)er- 
 haps of blood ; colieky 
 pains; may pass blood 
 from bowels ; cold skin ; 
 weak i)ulse ; collapse ; 
 death. 
 
 Syrup of lime; vrliite of 
 C';;iX. Later, repeated doses 
 of Epsom sail ; morphine 
 if necessary. 
 
 Pain in throat and 
 stomach ; nausea and 
 
 vomiting ; prostration ; 
 cold skin; weak pulse; 
 collapse. 
 
 Same as ammonia. 
 
 Severe pain in stomach 
 and bowels; tenderness 
 over bowels ; retching ; 
 vomiting; thirst; hoarse- 
 ness ; vomited matter may 
 be green and may contain 
 blood ; skin cold and clam- 
 my ; feeble pulse ; convul- 
 sions; death. 
 
 Symptoms same as in 
 arsenical poisoning. 
 
 Colicky pains in stom- 
 ach ; vomiting; purging; 
 pain in throat ; cold skin ; 
 weak pulse ; prostration. 
 
 Pain in stomach ; 
 cramps; nausea: vomit- 
 ing; metallic taste in 
 mouth ; paralysis ; con- 
 vulsions ; stupor. 
 
 Metallic taste in mouth ; 
 severe pain in abdomen ; 
 vomiting; purging, often 
 of blood; irritation of 
 the bladder; burning in 
 throat; dtdness; stupor; 
 coma; increased saliva; 
 death. 
 
 Vinegar, lemon juice; 
 olive oil freely given; 
 fats, melted butler, eream ; 
 morphine if necessary. 
 
 Starch dissolved in wa- 
 ter and freely given. 
 
 Salt water in hirge quan- 
 tity. Later, oil, cream, etc. 
 
 Hydrated oxide of iron 
 with magnesia (obtainaljje 
 under this name at phar- 
 macies). Jjater, castor oil 
 and olive oil ; may need 
 stimulants and morphine. 
 
 I\rilk ; white of eggs in 
 quantity. Later, oils, 
 flour and water; mor- 
 phine if necessary. 
 
 White of eggs; cooking 
 soda in water. Later, 
 oils; morphine if neces- 
 sary. 
 
 Epsom salts, Glauber's 
 salts freely given ; stimu- 
 lants and morphine if 
 necessary. 
 
 White of eg^ in largo 
 amount, if possil)le; other- 
 wise, flour and water; 
 milk. Later, sweet oil; 
 stimulants and morphine 
 if necessary. 
 
A TABLE OF POISONS. 
 
 808 
 
 Poison. 
 
 Symptoms. 
 
 Antidotes and Treatment. 
 
 Phosphor- 
 US. 
 
 Matches. 
 
 In Hoirio cases suicide 
 has been committed 
 by eating the heads 
 of matches. Acci- 
 dental poisoning is 
 not uncommon in 
 children. 
 
 Pain in stomach; vom- 
 iting; purging; collapse; 
 weak pulse ; death. 
 
 Magnesia in water ; 
 soapsuds; niorpliiiic if 
 necessary. OiLa nol to he, 
 given. ,^ 
 
 Glass. 
 
 Glass is sometimes 
 swallowed accident- 
 ally or with suicidal 
 intent. 
 
 Pain in stomach ; purg- 
 ing, often of blood; col- 
 lapse. 
 
 Bread should be eaten 
 in quantity, to entangle 
 and cover the particles 
 of glass. Do not cause 
 vomiting or give cathar- 
 tics ; leave it to Nature. 
 
 Aconite. 
 
 Wolfsbane. 
 Moidvshood. 
 
 Great weakness; cold, 
 clammy skin; feeble 
 pulse; numbness of lips 
 and extremities ; collapse. 
 
 Stimulatingdrinkswith 
 freedom. 
 
 Bella- 
 donna. 
 
 Belladonna. 
 
 Atropine. 
 
 Deadly nightshade. 
 
 Eyes bright, pupils di- 
 lated; face flushed, ap- 
 pearance as of fever ; pulse 
 rapid; dry throat; deliri- 
 um: convulsions; skin 
 hot and dry. 
 
 Morphine to point of 
 quieting. 
 
 Strych- 
 nine. 
 
 Strychnine. 
 Nux vomica. 
 
 Stiffness of jaws ; 
 twitchings of muscles ; 
 convulsions ; ghastly grin 
 on face. 
 
 Tannic acid ; morphine 
 to point of quieting ; rest ; 
 bromide of soda; chloro- 
 form or ether by inhalation. 
 
 Chloral. 
 
 Chloral. 
 
 Dulness ; sleepiness; 
 breathing weak ; pulse 
 weak and rapid and ir- 
 regular; fainting. 
 
 Stimulants. Keep pa- 
 tient awake. 
 
 Opium. 
 
 Morphine. 
 Laudanum. 
 Paregoric. 
 
 Sleeping mixtures in 
 general. 
 
 Dulness ; sleepiness ; 
 stupor ; pupils much con- 
 tracted, even to pin point ; 
 breathing very slow (2 to 
 10 a minute) ; skin per- 
 spiring. 
 
 Strong coffee ad. lib. ; 
 warmth. Keep patient 
 awake by any means, and 
 constantly ; dash with 
 cold water ; artificial res- 
 piration if breathing stops. 
 
 Vegetable 
 poisons. 
 
 Berries. 
 Tobacco. 
 Horse-chestnut, etc. 
 
 Nausea: vomiting: pain 
 in abdomen ; depression ; 
 stupor; collapse. 
 
 Warmth ; stimulants ; 
 morphine if necessary. 
 
 Mush- 
 rooms. 
 
 Toadstools. 
 Poisonous mushrooms. 
 
 Nausea; pain in abdo- 
 men ; vomiting ; purg- 
 ing; thirst; convulsions; 
 delirium ; stupor ; col- 
 lapse ; death. 
 
 Emetics ; frequent doses 
 of Epsom salts: stimu- 
 lants; morphine if neces- 
 sary. 
 
 The antidotes of this list are mainly chemical, but the administration 
 of morphine, stimulants, coffee, and sodium bromide together ^vith later 
 treatment in general must be considered as physiologically antidotal and 
 should follow the stomach washino;. 
 
89-lr MEDICINES AND TREATMENT. 
 
 The frequent reference to the later use of sweet oil, cream, milk, ami 
 flour and water in poisonings marked hv irritative symptoms of the stom- 
 ach and intestines will have been noticed, and in all such cases these sooth- 
 ing preparations (^or demulcents, as they are called) should be given after 
 the active treatment has been applied, that by their bland and soothing 
 effect the inflammation of the stomach and intestines resulting from the 
 poison shall be diminished. Indeed, these denmlcents have nmch to do 
 with the lessening of " after-synn)toms" and the speedy and complete re- 
 covery of the patients. 
 
 THE TREATMENT OF DISEASE BY CLIMATE, MINERAL 
 
 WATERS, BATHS, AND VARIOUS PROCEDURES 
 
 GENERALLY CALLED ''CURES." 
 
 We now come to those elaborate methods of treating disease which 
 
 only concern the laity as patients and observers, for the employment and 
 
 application of the means about to be described must always be left to the 
 
 physician, 
 
 CLIMATE. 
 
 The effect of climatic conditions upon health and disease is a marked 
 one ; indeed, there are some diseased conditions which will yield to cli- 
 matic influences alone, and many in which suitable climate is the only 
 thing which seems in any way to benefit them. For purposes of medical 
 classification we divide climates into dry and cold climates, moist and 
 warm climates, dry and warm climates, high elevations, and sea air. 
 
 Dry and cold climates are generally beneficial in those chronic diseases 
 which as yet are localized and not extensive, and in which general bodily 
 
 vigour is retained. Their effect is to stimulate, to tone, 
 L. . and to strengthen, and they are inapplicable where 
 
 weakness is present (for then they are too stimulating), 
 and where the kidneys are diseased (for then the cold would throw too 
 muoh work upon the kidneys by diminishing the activity of the skin). 
 Of all diseases so treated, consumption in its early stages is the most 
 prominent, and to the value of the treatment the many cures resulting 
 from residence in the Adirondacks bear testimony. Similarly active are 
 the climates of Minnesota and some portions of Canada and Switzerland. 
 Moist and warm climates, on the contrary, are not stimulating, but 
 soothing and even weakening. If not overdone, therefore, residence in 
 
 these climates will often prove of value in troubles of a 
 
 '.„. , catarrhal nature, for the beneficial effect of moisture and 
 
 Climates. 
 
 warmth upon catarrhal diseases is great. The climates 
 of Madeira and the Canary Islands are excellent examples of this class, 
 for they seldom suffer from cold winds and almost as seldom from hot 
 
INFLUENCE OF CLIMATE UPON HEALTH. 805 
 
 ones, the temperature and tlie moisture remaining Bingiilarly uniform 
 both in winter and summer. They may benefit consumptives, but have a 
 weakening tendency which, added to the exhausting nature of tlie disease, 
 is sometimes injurious. Bronchitis is a di.sease more generally benefited. 
 Dry and warm climates are soothing, too, but liave a less weakening 
 effect and a marked power to increase the activity of tlie skin, which are 
 due to the dryness. Of such climates Egypt offers the 
 CV t' ^^^ ^^^^ example, though the south of France and parts of 
 southern California are similarly effective. Bright's dis- 
 ease is much benefited by a residence in Egypt, from the effect of the dry 
 heat in causing an activity of the skin, which thus relieves the strain upon 
 the kidneys. Bronchitis is also improved by this climate, as is asthma. 
 High elevations are beneficial in early consumption, but from the 
 
 „. , ^, work such elevations throw upon the circulation, dis- 
 
 High Elevations. /• ,i i r i -r-i i /. 
 
 eases oi the heart are often made worse. Examples of 
 
 high elevations made use of medically are seen in Colorado, the Alps, and 
 
 South Africa. 
 
 Sea air is beneficial in chronic bronchitis, chronic pleurisy, and scrofula, 
 
 and especially if the air be had by a voyage. Early consumption, too, is 
 
 benefited in some cases, Nervous diseases, however, are 
 
 Sea Air. , , i i i • ^ ^ ^ ^ 
 
 apt to be aggravated by sea air, whether of the ocean 
 
 voyage or of the seashore, for in the sudden changes, the moisture, and 
 
 the salt air, irritable nerves find too many exciting agents. Debility from 
 
 overwork and conditions of convalescence from acute disease, however, 
 
 are generally more benefited than are any other conditions. In fact, the 
 
 effect of a voyage upon such patients is often miraculous. 
 
 In all treatments in which leaving home is required there are other 
 
 factors besides the change of air ; and people are too apt to forget that in 
 
 such cases the air may be only one, and perhaps the 
 Other Elements . . . 
 
 '■".-. ^ least, of the good things. In aidina; the ffood effect 
 
 m the Cure. ' ° ^ ^ _ _ o & 
 
 there must certainly be given credit to such factors as 
 change of scene, of occupation, and of diet, and particularly^ to that men- 
 tal condition of repose and confidence which invariably predisposes to a 
 
 cure. 
 
 GYMNASTICS, MASSAGE, AND MOVEMENT CURES. 
 
 A reference to these agents is all that can be given here, for with the 
 words on exercise contained in an earlier part of this article, as well as the 
 contents of the article on Physical Training., further discussion would 
 be superfluous. Let one thing be said, however. All animals need and 
 must have exercise ; we, as animals, are not exempt from that rule. If. 
 therefore, our debility, save only in acute disease, prevents our taking this 
 necessary amount of exercise for any considerable length of time, massage 
 will not only supply its place, but by its invigorating action will, provid- 
 
80G MEDICINES AND TREATMENT. 
 
 ing recoverv is possiMe, bring altout a rotuni to ninsoular strength whicli 
 sooner or later will restore the ability for aetive exercise. 
 
 iivr.NoTis.M. 
 
 That hvpiuitisui is a genuine coiidirion is bcvond all doiiltt, but its 
 ]>raetit'e has beensurroundeil by and associated with so much mysticism 
 and humbug and cheaj) ])ublicity that it has obtained a reputation more 
 notorious than lofty. A\ irli recent years has come a more careful and 
 scientitic investigation into the subject, and in the hands of reputable 
 men its position has been made more clear and its value ascertained. 
 Yet even now it can scarcely be said that we know all about it. 
 
 The definition of hypnotism is not an easy one to give, but it may be 
 said to be a condition simulating 'sleep, produced not by drugs, but by 
 the moral suasion of the operator upon the operated, and during which 
 there exists the power of perceiving things wdiich act upon the senses, 
 and the marked tendency to perform acts appropriate to received " sug- 
 gestions." 
 
 The curious things which the hypnotized may be made to do are un- 
 limited, and as it has been found that suggestions made to the patient 
 while hypnotized may even operate after his awakening from this state, 
 this has been taken advantage of in the cure by " hypnotic suggestion " 
 of various sj-mptoms, and especially tliose of a hysterical nature. That 
 this treatment has been effective is undoubted, but scarcely permanently, 
 and certainly no more reliably than many other moral agents em]>loyed 
 against hysteria. There seems reason to believe, too, that the effect of 
 this hypnotization may be harmful, and especially if practised upon the 
 nervous and intellectually mediocre. Amateur hypnotization, therefore, 
 can not be too strongly condemned, and the practice should be left to 
 the experienced physician. 
 
 MINERAL WATERS. 
 
 The waters of mineral springs are employed in medicine both for 
 internal administration and for bathing, and though the former does not 
 require a residence at the spring — since many of the waters are bottled 
 and exported — yet the full benefit of treatment is in that case not expe- 
 rienced. Nothing mysterious or " occult," however, is required to ex- 
 plain the infei'ior efficacy of the bottled mineral water, for the water itself 
 is in no way responsible for the difference, but simply the factors already 
 alluded to under climatic treatments — namely, change of scene, life, diet, 
 physician, and favourable mental conditions. In many cases, indeed, 
 these factors should be credited with the larger part of the success in 
 cases of cure. 
 
 Various classifications of mineral springs are made, Itut no elaborate. 
 
SEA BATHING, AND THE USE OF MINERAL WATERS. 807 
 
 arrangement is necessary for our purposes, and a few words upon the 
 more important and common ones is all that we contemplate. 
 
 The alkaline waters are the commonest wliich are used medicinally, 
 and, though as baths they are of little benefit, their internal administra- 
 tion is often valuable in chronic catarrh of the stomach, 
 
 The Alkaline i • ^• j^ ,^ • , .• -, -,. ,, 
 
 Waters chronic diseases of the intestines and liver, gout, gall- 
 
 stones, and those- conditions which are said to be caused 
 by "acidity." In M'asting diseases and in anaemia the alkaline waters are 
 injurious. The alkaline class is a very large one, for it includes all those 
 whose marked constituents are alkalies, but the greatest variation among 
 them exists both as to the quantity and kind of the prevailing alkali. 
 Of simple alkaline waters many of those of Saratoga and Carlsbad are 
 excellent examples. In some of the alkaline waters bitterness is a 
 more pronounced characteristic, and hence the "bitter waters" are a 
 subdivision of the alkaline class. Of bitter waters Ilunyadi is a familiar 
 example. 
 
 The class of alkaline waters includes some of a taste so salt that they 
 have been called " salt waters," but their employment is generally for the 
 effect of the alkalies they contain, and when we speak 
 of " salt waters " we usually refer to waters the principal 
 mineral ingredient of which is sodium chloride or " salt." Of this class 
 sea water offers the best example, though, strictly speaking, the two classes 
 of salt waters which we have made differ each from the other quantitative- 
 ly only. The salt waters are usually more employed for bathing than for 
 internal administration, and thus used their effect upon scrofula, chronic 
 joint diseases, and chronic diseases of the skin is often good, especially 
 if the temperature of the water is warm. Of salt-water springs so used 
 are those of St. Catharines Wells in Canada, and some of the Saratoo-a 
 waters. 
 
 Sea bathing is salt-water bathing undeniably ; but other elements enter 
 
 into its curative activity, the factors of value being the cold, the salt 
 
 „ „ „ . in the water, the motion of the waves, and the sea air, 
 
 y&ea Bathing. , ^i j. -it t n -, ■, - , , 
 
 together, oi course, with the change of habits and the 
 
 amusement, generally accompaniments of life at a "watering place." 
 The especial value of sea baths is seen in those debilitated from over- 
 work and those likely to " take cold." In convalescence from acute dis- 
 ease it is valuable, but is to be forbidden to those in whom debility is 
 marked or in whom congestive disease exists. 
 
 Hot springs furnish waters which are generally more efficient for 
 ^ . bathing than for drinking. Their employment by this 
 
 method is of considerable value in chronic skin dis- 
 eases, rheumatism, gout, and neuralgia. The hot springs of Virginia 
 
 and Arkansas are the most familiar examples of this class. 
 59 
 
89S MEDICINES AND TREATMENT. 
 
 Sulphur waters are generally also alkalliu', ami the hirger part of their 
 beneficial effects, if taken internally, is probably due to this fact. If ad- 
 ministered by bathing, however, it is probable that their 
 Sulphur Waters. . ,. ' ,. i- i i ^ •, -, ^ ^ 
 
 ingredients are of little value, and, though they may be 
 
 either hot or cold, the hot ones are the more effective. In fact, it is 
 probable that any effect these waters may have as baths is due, not to 
 sulphur, but to heat. Exaiujiles of sulphur waters are found at Kich- 
 tield and Sharon, in New ^Ork, and the AV'hite Sul[)liur Springs of Vir- 
 ginia. The cases supposed to be benetited by these waters are chronic 
 rheumatism, gout, and nervous diseases, and while the drinking is thought 
 to benetit chronic catarrhs the bathing is considered especially good for 
 chronic skin diseases. 
 
 Lithium waters (popularly called " litliia waters''), if natural, are prac- 
 tically of no use, since no natural lithium water contains enough lithium 
 
 to be of benetit unless drunk in (juantity almost impos- 
 ,.^ ,,. , .. sibly large. The application of lithium is in gout, and 
 
 it is far wiser and more practical to give the drug itself 
 rather than the best of " lithia waters." Iron waters are about as useless 
 as lithium waters, and for the same reason — they contain so small a quan- 
 tity of iron as to be medicinally of little value. 
 
 Natural arsenic waters are known, but their value is 
 Arsenical Waters. ■,• t . c. ,^ . . i , ,, 
 
 slight so far as the arsenic is concerned, because the 
 
 amc)unt of that drug present in them is infinitesimal. 
 
 So many elements enter into the success or failure of treatment by 
 mineral waters that it is certainly unjust to ascribe all benefits as due to 
 the mineral they contain. Some of these factors have already been men- 
 tioned, and in conclusion it may be said that water itself, without mineral 
 contamination, is a medicine of no small effectiveness, and this whether it 
 is drunk or applied to the skin ; and, furthermore, that warm water is 
 especially valuable in the very conditions in which warm mineral baths 
 are supposed to be so effective; and, finally, that the mineral-water busi- 
 ness is a great field for humbug. 
 
 BATHS. 
 
 A consideration of bathing in health and in acute disease has already 
 been given, and mineral-water baths have necessarily been included in the 
 general consideration of mineral waters ; it remains, therefore, to com- 
 plete the consideration of baths by the brief presentation of a few remain- 
 ing curative procedures to which the name is more or less appropriately 
 applied. 
 
 The Turkish bath is simply an exposure to dry heat in a series of 
 rooms of which the temperature is artificially raised, the temperature of 
 the coolest being about 120° Fahr., while the temperature of the hottest 
 
TURKISH AND RUSSIAN BATHS. 800 
 
 may be even 250° Fahr. Into tlie.se rooms, boginriiri<^ with tlio coolest, 
 
 the naked patient walks, the result beirii:^ that excessive perspiration soon 
 
 results. After a variable time the patient is rubbed 
 
 Tlie Turldtih Bath. , i t t • i i i , i i , ' 
 
 and concludes his batli by a cold Kpray, cold needle bath, 
 
 or cold plunge. He is then dried and usually lies about for a while in a 
 warm room and wrapped in a liglit covering. The effect of the bath is to 
 deplete the system and to promote fluid exudation from it. It is thus 
 valuable, as has been said, in obesity, but is no substitute for the more 
 rational treatment laid down for that condition. The bath acts also to 
 remove those ailments due to exposure to cold, such as muscular rheuma- 
 tism and bronchitis, and is effective here, as is the " sweat." The imme- 
 diate effect of the bath is stimulating and invigorating, and hence by 
 many it is taken occasionally for these pleasurable effects. The effect of 
 the excessive heat, however, is sometimes to produce palpitation of the 
 heart and even fainting, and therefore the Turkish bath is not allowable 
 for those suffering from diseases of the heart or blood-vessels. 
 
 The Eussian bath is similar to the Turkish bath save that the heat is 
 not dry but moist, the rooms containing steam. The moisture present 
 . thus acts to prevent the cooling effect of evaporation of 
 
 perspiration on the patient, and thus in the Russian 
 bath no such high temperatures can be borne as in the Turkish bath. Its 
 effects are similar, however, with the added value that moisture and 
 warmth have in catarrhal diseases of the respiratory passages. 
 
 The immersion of patients in various mixtures and " messes " has from 
 
 time to time been practised by enthusiasts and others less sincere, the 
 
 ^r -, T^ ,. . i^ea being that the ingredients of the ''bath" would 
 
 Jjj.ii(a/ jjOith,^ etc 
 
 exert a specific and healing action upon various diseases. 
 As a matter of fact, no such action takes place, and though benefit, indeed, 
 may result, it is from the action of the heat and moisture present, and the 
 value of these has already been considered. It is not necessary to describe 
 these procedures, for their names carry with them all necessary informa- 
 tion. The class includes mud baths, pine-needle baths, herb baths, sand 
 baths, tan baths, and malt or bran baths. And for a supposed nutritive 
 effect — which is utterly absurd, for no absorption takes place — there have 
 been used, for the poorly nourished and debilitated, soup and milk baths. 
 
 TREATMENT BY RAREFIED OR COMPRESSED AIR. 
 
 In some diseases, especially those of the lungs, the patient is made to 
 
 breathe air the pressure of which is different from the ordinary atmosphere. 
 
 ^ , , . This is performed in one of two ways. The first is that 
 
 ^^^■^ in which his whole body is surrounded by the (usually) 
 
 compressed air, and in this case the treatment is referred 
 
 to as the " compressed-air bath." The effect of breathing in this com- 
 
900 MEDICINES AND TREATMENT. 
 
 pressed air has been found good in some cases of asthma, clironic bron- 
 chitis, and sometimes in consumption. The other method is that in which 
 only the pressure of tlie respired air is changed, the atmosphere surround- 
 ing the patient being of the normal pressure. The usual method of this 
 application is for the pressure of the air breathed in to bo increased, while 
 in breathing out the patient breathes into air of which the pressure is 
 lowered. The result of this treatment is that inspiration becomes more 
 deep and expiration more complete, and tlius, with an c.\j)ansion of lung 
 capacity, more oxygon is taken into the system and more waste products 
 (especially carbonic-acid gas) are thrown olf. The diseases thus treated are, 
 in general, those treated by the compressed-air bath. Occasionally the air 
 used in these compressed-air methods is medicated, in the expectation that 
 thus the healing drug will more perfectly and completely reach and act 
 
 npon the diseased surfaces. 
 
 "CURES." 
 
 To say that a treatment is a '' cure " would primarily seem high 
 praise or the height of sarcasm and sneering. Neither of these is intended 
 to apply to the subjects to be considered, for the word " cure " is here 
 used for want of a better one, meaning- system of treatment. The word, 
 therefore, is rather a convenience than an accurate description, and so far 
 as. a sarcastic meaning is concerned and an intimation of " quackery," it 
 suffices to say that the treatments here considered are legitimate, well 
 recognised, and generally excellent. 
 
 The milk cure consists in putting the patient on a diet composed ex- 
 clusively of milk, and, that the intolerance likely to arise from such mo- 
 notony may not occur, the quantities are at first small 
 and the administration frequent. The treatment owes. 
 its value to the bland, soothing, easily digestible, and nourishing qualities 
 of milk. The treatment may be persisted in for several weeks, and is 
 often very ejffective in cases of ulcer of the stomach, dyspepsia, and 
 Bright' s disease. 
 
 The whey cure is now little employed, though it was formerly popular. 
 
 "Whey is that portion of milk which remains after the " curd " has been 
 
 removed, and consists of water, milk-su^ar, a little fat, 
 The Whey Cure. . . ... . 
 
 and mineral salts. It is medicinally equivalent to a mild 
 
 mineral water, and was thus used ; but as a matter of fact it presents few 
 
 advantages over the water and has the marked disadvantage of causing 
 
 dyspepsia and indigestion, a result for Avliich the sugar it contains is 
 
 responsible. 
 
 The grape cure is practically the same thing as the whey cure, for the 
 
 remedy consists of water, salts, and sugar. Several 
 The Grape Cure. i r . ^ i •^ i • e i '^ 
 
 pounds of grapes are taken daily, and m cases oi obesity 
 
 some benefit is probable from the laxative effect produced by the grapes. 
 
MOUNTAIN CLIMBING AND THE REST CURE. 001 
 
 The treatment, however, presents no advantages over that by mineral 
 waters, and is open to all the objections made against the whey cure. 
 
 Oertel's treatment of diseased hearts by mountain climbing is rather 
 surprising, in that it prescribes an exertion which had previously been 
 supposed injurious in such cases. His views would ap- 
 ^j. ,. pear sound, and certainly his treatment is often effective. 
 
 Briefly described, its action is as follows : By active ex- 
 ercise perspiration is increased and thus the bulk of the blood is lessened. 
 This diminution of the blood results in a lessening of stagnant blood in 
 the body, which is generally an accompaniment of heart disease, and that 
 drinking may not replace the fluid thus lost the treatment requires the 
 taking of less drink. Furthermore and most important, the exercise, by 
 increasing the force and rapidity of the heart action, causes the heart 
 muscle to enlarge and gain strength just as any muscle will grow if 
 regularly exercised. The amount of exercise, of course, is so regulated, 
 gradually increased and alternated with rest, that the danger from over- 
 strain, always a great one in disease of the heart, is avoided. 
 
 The " rest cure," which is sometimes described as the Weir Mitchell 
 treatment, from its introduction by Dr. Mitchell, is not merely a treat- 
 ment by rest, but one in which several prescribed factors 
 The Rest Cure. . . . . 
 
 participate. These, in Dr. Mitchell's own words, are 
 
 " a combination of entire rest and of excessive feeding, made possible 
 by passive exercise obtained through the steady use of massage and elec- 
 tricity." The cases in which the treatment is applicable are those of 
 nervous, hysterical women in whom nutrition is deficient, and its success 
 is certainly remarkable. Especially is this so when we consider the de- 
 fiant nature of such conditions — conditions so obstinate to treatment, 
 indeed, as to make these patients the bane of the physician. 
 
 Space does not sufiice for a full and minute delineation of the Weir 
 Mitchell treatment, but a little amplification of the definition given is 
 necessary to a comprehension of the subject. The patient placed upon 
 this treatment is removed from home, and, save for the presence of her 
 physician and her nurse, is absolutely isolated. Xo books are allowed, 
 no work, no letters, nothing save treatment to break the absolute monoto- 
 ny. Ordinarily she is required to remain continuously in bed, and even 
 the " sitting-up " position is forbidden. Then she is fed, and fed. and 
 overfed with nourishing materials, and at regular intervals massage and 
 electricity are given. This absolute seclusion, regularity, rest, and mo- 
 notony are marked features of the method, and though it would perhaps 
 seem that to take a nervous woman from the sympathy and loving atten- 
 tions of her home and to subject her to such treatment is cruel, yet this 
 view is but a part of the sentiment which keeps these patients sick, for 
 the surest proof of the value of the plan is its success, while the effect of 
 
902 MEDICINES AND TREATMENT. 
 
 pampering and petting and coddling the hysterical is undeniably to make 
 them worse. The elfect of the treatiiioiit is to reduce the patient practi- 
 cally to the condition of a vegetable, and she lies there without occupa- 
 tion, diversion, or motion, until from very necessity the unused brain and 
 nerves sleep, and in sleeping regain their power. According to the prog- 
 ress of the case the restrictions are gradually and carefully relaxed, until, 
 with the return of nervous tone and vigour, the invalid is permitted, step 
 by step, to return to her every-day life. 
 
XIII. 
 NUKSING THE SICK. 
 
 By anna CAROLINE MAXWELL. 
 
 CHAPTER I. 
 CHOICE OF THE SICK-ROOM. 
 
 CARE OP THE SICK-ROOM, INCLUDING HEATING AND VENTILATING. 
 
 The points to be kept in mind in choosing tlie sick-room are sunshine, 
 pure, fresh air, and freedom from noise and odour. To obtain a maxi- 
 mum of the former and a minimum of the latter, the 
 The Sick-room. /■ -i r^ , , ^ • • i 
 
 family are often put to great inconvenience and an 
 
 extra amount of labour. This is especially true in cities, where only the 
 upper stories of dwelling houses are provided with sunlight, and in apart- 
 ment houses, where the darker rooms are often used for sleeping. In 
 these cases either the top of the house or the best room in the apartment 
 has to be chosen. The room should have, if possible, an open fireplace 
 and a southern exposure, thus taking advantage of the greatest amount 
 of sunlight and favouring winds. It is important that the sick-room be 
 kept free from odours of a pungent nature, such as highly-scented soaps, 
 perfumery, and certain flowers that affect the sick unpleasantly. 
 
 Plain walls, or those decorated with paper of subdued colour and pat- 
 tern, are most pleasing to the eye and produce a sooth- 
 
 „ ., inff effect. It is a well-known fact that the mind of a 
 
 Jbnrniture. »_ 
 
 delirious patient is often disturbed by a wall paper of 
 gaudy design and colour, or by a picture of startling or pronounced char- 
 acter. 
 
 Without seeming to make too much disturbance, unnecessary articles 
 of furniture and heavy drapings that obstruct the free entrance of sun- 
 light and air should be removed. Rocking chairs should invariably be 
 banished on account of their disturbing qualities. When sitting in one 
 of these chairs it is almost impossible to avoid rocking, and their motion 
 often makes an invalid nervous and irritable while unconscious of the 
 cause. A still further objection is the fact that, upon getting up suddenly 
 If 903 
 
004 
 
 NURSING THE SICK. 
 
 from tliein. the li;iek may strike against some other article of furniture^ 
 thus causing noise or breakage. 
 
 An easy chair should be left to be utilized when the patient tirst sits 
 up, and a small table is essential to stand at the bedside upon which to 
 place the food tray, keep a bell, or any small belongings of the patient. 
 A second table is .useful for writing, as all orders of the physician should 
 be written down and notes of the patient's condition kept. There is a 
 bedside table made especially for use in the sick-room, which extends over 
 the bed in front of the patient. It is supported by an upright at one end 
 furnished with a spring by means of which it can be raised and lowered to 
 suit changes of position. The foot piece attached to the upright extends 
 under the bed, thus giving balance to the table and preventing its upsetting. 
 
 It is often necessary for the one in charge of the nursing to sleep in 
 the sick-room, and some ]irovision for this purpose has to be made. Al- 
 though most of the modern sleeping rooms are furnished with a sofa or 
 couch of ample dimensions that may be made to answer in place of a bed, 
 they are seldom long enough to admit of a person lying at full length. 
 The cot is therefore the most convenient and easy arrangement. It is 
 inexpensive, light, and quite as comfortable as a single bed, and can be 
 folded and placed out of sight in the daytime for economy of space. It 
 can also be used by the patient. Being nearly the same height as a bed, 
 it is easy to have him moved on to it; and during convalescence, w^hen 
 change of scene is desirable, it can be easily carried to other parts of the 
 house. 
 
 The ideal bed for taking care of a sick person is one made of iron — 
 either single or three quarters in size — provided with a woven-wire spring 
 and hair mattress. This bedstead, with woven wire 
 mattress, can be purchased for a comparatively small 
 sum. The double bed so uni- 
 versally used will answer, but 
 can not be made as comfortable. 
 The mattress is apt to sink in 
 the centre on account of its 
 width, and it is almost impos- 
 sible to keep the under sheet 
 drawn tightly enough to pre- 
 vent wrinkles. A hair mattress 
 should be used in preference to 
 one made of any other mate- 
 rial. Feathers are especially 
 objectionable on account of the 
 
 warmth and moisture created by them, and the impossibility of making 
 the bed properly when it is occupied. 
 
 The Bed. 
 
 Fio. 1. — An ikon bedstead. 
 
POSITION AND ARRANGEMENT OF THE BED. 
 
 005 
 
 In making a bed the mattress should first be cover(;d by a sheet 
 
 tightly stretched from side to side and tucked firmly in as far as possible 
 
 on all sides under the mattress. Another siieet folded 
 
 Malcinq the Bed. ^ ^-t • i • i .^ . /• i i i 
 
 lengthwise and carried across the centre of the bed 
 
 should also be drawn tightly and tucked in at either side. This is called 
 
 a draw-sheet. It should extend well up under the pillows, as it serves to 
 
 keep the bed firm, and to cover the rubber sheet when one is necessary 
 
 Fig. 2. — Method of changing the bed of a helpless patient. 
 
 to protect the mattress. The top sheet, with each succeeding blanket, 
 should be tucked in separately and firmly. The spread should be of 
 dimity or some light texture, a sheet being preferable to a spread of 
 heavy weight. 
 
 Single blankets are more desirable than double ones, as they admit of 
 the introduction of air between the layers. Cotton sheets are best for 
 ordinary use, the linen ones being used when great radiation of heat is 
 desirable. 
 
 The bed should be placed so that the light will fall from behind rather 
 than in the eyes of the patient, and free from the walls so that access to 
 all sides is possible. Freedom from direct draught must also be consid- 
 ered, and sometimes screens have to be used permanently where the win- 
 dows are inconveniently placed. 
 
900 NURSING THE SICK. 
 
 In changiiiii: tlie l>etl of ;i lieljiless person, or one who is very ill, the 
 
 greatest care must be taken not to cause unneeessarv disturbance, and in 
 
 extreme cases a second person should be called to assist. 
 
 Changing the Bed ^jj. jg ^^,g]i ^q ^^^q ^ little beef tea or hot milk before 
 
 Z,f.^f beffinninti:, when the patient is verv weak, as it will 
 
 Patient. & ^' x .. ^ ' 
 
 enable him to bear the change better.) The fresh linen 
 should be thoroughly aired and warmed and everything in readiness. 
 AVhen possible the patient should be turned on one side ; the soiled sheets 
 are then loosened and rolled closely to the back of the patient, the roll 
 (Fig. 2) being placed next to the mattress. The clean sheets rolled to- 
 gether to their centre are tlicn placed just under the edge of the other 
 roll, and the loose edges tucked as far under the mattress as they will 
 admit. The patient is then gently turned on the other side over the roll, 
 the soiled sheets removed, and the clean ones tucked lirmly and tightly 
 into place. The object of turning the roll downward next to the mat- 
 tress is to prevent its disarrangement, and also to facilitate grasping the 
 roll when the patient can not be entirely turned over it. 
 
 In changing the top sheet the spread and one blanket should be re- 
 moved first, and over the remaining l)lanket should be ])laced the fresh 
 sheet. The discarded blanket or a fresh one is then placed on top of the 
 clean sheet and tucked lirmly about the shoulders of the patient, or else 
 held in place with one hand while the soiled ones are drawn out at the 
 foot or side of the bed. The remainder of the bed is then completed in 
 the usual manner. 
 
 Another plan by which the bed can be changed is that of folding the 
 sheets back and forth in fan-shape, as given in the accompanying illustra- 
 tion (see Fig. 3), instead of rolling 
 them. This makes a flatter surface 
 under the patient, but it is difficult 
 to get the folds even on account of 
 the length of the sheets, and they 
 are much more liable to become 
 disarranged. Still another way is 
 to gather the sheets tightly in a fluffy roll and place them at the l)ack 
 of the patient, as previously described. These methods are useful when 
 the patient can help himself, but the first mentioned is by far the most 
 practical and satisfactory when the ])atient is helpless. 
 
 When clianging the personal clothing the soiled garments should be 
 pulled well up under the shoulders and slipped over the head, and the 
 
 arms removed last. The clean clothing is then sub- 
 
 Changing Personal ^-^ , i i • xi • ^ i i i i i n j 
 
 Clothina stituted by reversing this order, and should be pulled 
 
 down smoothly under the back. When it is necessary 
 
 to change the Ijed and the patient's undergarments at the same time, the 
 
CHANGINa PERSONAL CLOTHING AND BED LINEN. 90T 
 
 latter should be changed first to avoid cruinhs I)eirj;^ left in tlio fresh 
 bed. 
 
 The greatest possible comfort is derived from fresh linen and fresh 
 pillows, and as an economy it might be well to keep two sets in use 
 letting one set air while the other is in use. If there is scarcity of 
 linen the fresh sheet should be put on below, next to the patient, rather 
 than above. 
 
 In acute diseases, when the mattress becomes soiled or uncomfortable, 
 
 and in paralysis or any case in which there is constant evacuation of the 
 
 bowels, involuntary passage of urine, or excess of per- 
 Chanqing the • j_- -^ t ' i , 
 
 Mattress. spiration, it becomes necessary to change the mattress. 
 
 If this is not done a very disagreeable odour will be 
 
 produced, and in time the materials of the mattress will become decayed. 
 
 If the patient be very ill, helpless, or very heavy, four people, two on 
 
 either side of the bed, will be required to accomplish this chans^e without 
 
 injurious disturbance. The bedclothes should be untucked at all sides, 
 
 the patient moved to the edge of the bed, the clothing rolled firmly up 
 
 to him, and the side of the mattress on which he is lying pulled to the 
 
 centre of the bedstead. The fresh mattress is partially doubled and placed 
 
 alongside the soiled one, and the patient lifted by the bedclothes on to 
 
 the fresh mattress. The soiled one is now removed, the other drawn 
 
 into place, and the patient lifted to its centre. The sheets are then 
 
 tucked in place, and the bed made up as previously described. 
 
 Koises are to be avoided, not only in the sick-room, but in other parts 
 
 of the house where they are liable to disturb the patient, and if they occur 
 
 ,, . the cause should be removed as soon as possible. Un- 
 
 Jyots&s 
 
 explained sounds, or sounds of a startling nature, are the 
 ones most irritating to the nerves. Rattling window shutters have to 
 be removed, as their noise can not be overcome in any other way, and in 
 their absence the light can be controlled by tacking a piece of dark cam- 
 bric inside the window frame. When the windows rattle they can be 
 wedged apart between the sashes with pieces of wood, matches, a folded 
 newspaper, or a pair of scissors. 
 
 The attention of the patient should always be attracted before ad- 
 dressing him, as he may be startled and a nervous attack brought on by 
 
 being spoken to suddenly from behind. Great care 
 Regard for the Pa- ^ -,-,■,. ■, . i . , 
 
 tienrs Sensibilities. ^^^^^^^ ^^ ^^^^"^ ^^^ *» pr the patient by striking 
 
 against the corners of the bed in passing. It should 
 always be remembered that the bed is sacred to the patient, and should 
 not be leaned against, sat upon, or joggled. Whispering, always a dis- 
 courtesy, is not so intended when brought into the presence of the sick 
 but it does disturb them by awakening them when asleep or bv irritating 
 them when awake. 
 
OOS NURSING THE SICK. 
 
 The best method of heating a sick-room is by an open fire ; eitlier 
 coal or wood should he used. The Enji^lish cannel coal is ])referred on ac- 
 count of its freedom from dust. In removing ashes from the grate they 
 may be sprinkled to prevent flying, and should be shovelled up quietly. 
 The fire must be noiselessly replenished. In using coal it can be pre- 
 pared in little paper bags outside the room and placed on the fire without 
 disturbing the patient. 
 
 In cleaning the room, dissemination of dust is to be avoided. If there 
 is a carpet on the floor and the patient can not be removed from the 
 room, it should be swept by using a damp whisk broom and the dustpan, 
 and going over it afterward with a damp cloth, being careful to avoid 
 too much moisture. 
 
 True ventilation consists in keeping the air of the room as pure as the 
 
 air outsi(,le ; this can be accomplished quite easily in several different 
 
 wavs. The best means of constant ventilation is 
 Ventilation. .1 " i ^1 i. i • ^ i • 
 
 tlirough an open fireplace, a current being created m 
 
 winter l)y the fire. In summer this may be accomplished by placing a 
 lighted candle or lamp inside the chimney. Window ventilation is best 
 carried on by double windows with double sashes. The lower sash of the 
 outer window is raised about two feet and the inner upper sash lowered 
 about the same distance. This allows of a constant passage of air directed 
 upward, thus preventing a direct draught upon the patient ; or the ordi- 
 nary windows can be raised and lowered top and bottom even with the 
 woodwork, allowing of about an inch space of ventilation between the 
 sashes. Another plan is to tack a piece of cotton about four inches wider 
 than the window, and twelve inches in depth, to the top of the upper 
 sash. The upper corners of this cotton can then be tacked to the window 
 frame and the window lowered to the extent of about one foot. The air 
 as it passes in is directed toward the ceiling, in addition to the current 
 between the sashes. A still further method is to raise the window by 
 the introduction of a board fitted to the opening, the air passing in and 
 out between the sashes. When there are two windows in the sick-room — 
 and if possible this should always be the case — the upper sash of one 
 should be lowered and the lower sash of the other raised, draughts being 
 prevented by the measures previously taken or by screens. 
 
 In modern buildings heating and ventilating is carried on by propul- 
 sion and extraction of air by means of fans. This method is very 
 expensive, and has not yet reached perfection. 
 
 When possible the entire air of the room should be changed at least 
 twice a day, but this should never take the place of the constant intro 
 duction of air in small quantities. 
 
 In certain diseases it is necessary to have the air warmed before it 
 comes in contact with the patient. This should be done by opening the 
 
PATIENT AND NURSE. 909 
 
 windows and heating the air in an adjoining room before it passes into 
 the sick-room. The corridor or bath room should never be used for tliis 
 purpose, the objection being the dangers of contamination with sewer 
 gas and impurities from tlie kitchen and sleeping apartments. 
 
 CHAPTER II. 
 CARE OF THE PATIENT. 
 
 It is essential to the well-being of the patient that one member of the 
 family be cHosen to have entire charge of the sick-room, including the 
 
 carrying out of the physician's orders. When it is 
 
 One Person in x i x i ' i • r -c i n ,. 3 
 
 „, necessary for her to have relief lor hours 01 I'est and 
 
 Charge. ^•' 
 
 recreation she should leave written directions concern- 
 ing treatment, food, and medication, so tliat during her absence no 
 mistake can be made. These directions should be so minute as to 
 include even the position the patient should maintain (for example, the 
 recumbent or upright), and should be adhered to strictly. Rest and 
 recreation are necessary to the performance of good work, and it is not 
 kindness on the part of those caring for the sick to go for days and 
 nights without proper rest or without undressing. If long hours are un- 
 avoidable, a cold bath with change of garments gives great refreshment 
 and sharpens the faculties. In diseases of long duration, especially in 
 those that may at any time become critical, the strength of the person 
 undertaking the duty of nurse should be in a measure reserved for this 
 emergency, as change at such a time may result seriously. If the patient 
 be conscious it is undesirable to introduce new faces, and if unconscious, 
 the stranger, not understanding his individual habits, might be unable to 
 make him take nourishment or submit to treatment. 
 
 The dress of the one in charge of the patient should be of cotton or 
 some washable material, and the greatest possible care should be exercised 
 in regard to change of personal clothing, bathing, and disagreeable odours 
 of the breath so often due to indigestion, or neglect of the teeth. 
 
 In learning to lift it is important to stand firmly, to balance the body 
 
 well, and to stand as erect as possible. The lirm, careful grasp, showing 
 
 strength and power, imparts a feeling of confidence and 
 
 \ mg an reassures the patient. Avoid usino- the ends of the 
 
 Handling. _ ^_ _ _ » 
 
 fingers, or sticking the nails into the flesh, as this causes 
 
 pain and irritation. Use, instead, the balls of the fingers, making the 
 hand as flat as possible. Do not be afraid of hurting an infant when lift- 
 ing him. A baby prefers to be lifted with decision, and objects to noth- 
 
910 
 
 NURSING THE SICK. 
 
 ing so much as tlie lack of it. It is a curious fact tliat lie is always afraid 
 of falling, as shown by the startled way in which the hands are thrown 
 up and the frightened look upon the face. This feeling of fright is soon 
 overcome by taking him up as one would a bundle of clothes, firmly and 
 gently, and holding him without fear. The left hand is the better one to 
 use, three fingers supporting the head and neck, while the shoulders are 
 held by the thumb and little finger. In this way the body of the infant 
 lies along the arm and the whole is well suj)]Kirted before leaving the 
 bed. 
 
 When a patient has slid down and needs to be lifted uji in bed, one 
 hand should be placed under the shoulders, the other under the thighs, 
 and the invalid carried gently upward. If he be heavy or very ill, and 
 motion is undesirable, two persons, one on either side of the bed, should 
 do the lifting as above described. If the patient be on a double bed 
 and needs changing to the other side, the bedclothes should first be 
 loosened all round and rolled tirndy up to him. Two persons should 
 then kneel on the mattress on opposite sides and lift the patient by the 
 bedclothes, moving him over by walking on the knees, one forward and 
 
 Fii.. 4. — Mktiiod 
 
 im: bed to ANOTIIKR. 
 
 the other l)ackward. This sounds much harder than it really is, for, if 
 care be taken to have the knees freed from the skirts, it is a compara- 
 tively easy matter. 
 
 AVhen it becomes necessary to change a sick person from one bed 
 to another, the beds can be placed opposite and parallel to each other 
 about five feet apart (Fig. 4). the head of the fresh bed on a line with the 
 
MANAGEMENT OF A HELPLESS PATIENT. 
 
 Oil 
 
 foot of the occupied bed. Two people standing on the same side of tlie 
 bed can lift the patient by patting the hands of one under the shoul- 
 der and buttocks, the other under the thighs and ankles, and by keep- 
 ing the patient flat they can readily turn half round and place him gen- 
 tly on the new bed. 
 "When the patient is 
 very ill, or of very 
 heavy weight, three 
 people should help in 
 the lifting, and if they 
 all stand on one side 
 and lift in perfect 
 unison, the patient 
 will hardly be con- 
 scious of any move- 
 ment. 
 
 In raising a patient's head for medicine or nourishment always place 
 the hand under the pillow and see that the head is well supported. As a 
 preparation for sitting up, and in cases where the recumbent position 
 is hurtful or impossible, a back rest should be used, as shown in Fig. 5. 
 A great variety of these are to be had both in shape and construction, 
 some being made entirely of wood, while others have the framework 
 only of wood with canvas stretched across. They are 
 inexpensive, and are the most comfortable means of 
 propping up an invalid in bed. A very good substitute is a straight- 
 backed chair turned upside down. A back rest with arms that rest upon 
 the bed is very useful in cases of heart disease ; or when for any reason 
 the patient has to maintain the upright position constantly, it furnishes 
 support to the arms, and if the patient needs to lean forward for relief 
 and change of position, a board well padded can be placed across in front 
 of him for this purpose. Plenty of pillows should be provided, and, if 
 possible, one of hair should be placed first well under the back, so that 
 the patient can sit upon it, and each succeeding one so as to form an in- 
 cline of any degree that is comfortable. It is important that the head 
 should be well supported, as a patient who has been lying flat for some 
 time is apt to feel weak and often dizzy upon having the head raised for 
 the first time. 
 
 There are a number of " lifters " or appliances intended for the com- 
 fort of the sick, and to save the strength of those in attendance. The 
 
 ^, simplest form of these that can be introduced into the 
 
 The Crane. . , . , . -r-,. rr^, . 
 
 Sick-room is the crane, as seen in iig. 6. This crane 
 
 may be attached to the wall or to the frame of an unused door, and the 
 
 bed so placed that the arm swings in front of the patient. Bv this 
 
 The Back Rest. 
 
912 
 
 NURSING THE SICK. 
 
 Fig. 6. — A cranp;. 
 
 means he can change his position easily and help in lifting himself. 
 Many other appliances are to be had. Some are arranged with canvas 
 that can be slipped under the patient and attached to hooks suspended 
 
 from ])ulleys in the ceiling by wliit'h 
 the lifting is done. These ajipliances 
 are useful for chronic invalids, but 
 not for those suffering from acute 
 disease. 
 
 The great value of rest can not 
 with impunity be underestimated. All 
 Nature has its periods of rest. The 
 organs of the body are so constructed 
 that they have their periods of compul- 
 sory rest as well as those of compulsory 
 work, the heart, for example, in the 
 intervals of its beats, resting about nine 
 hours in every twenty -four. This 
 brings us to the greater question of com- 
 plete rest both of mind and body, so 
 important to the building up of im- 
 paired tissue. 
 
 There is little doubt among thinking people that the mind has a 
 most powerful intlnence upon the tissues, and that anything that tends to 
 keep the mind at rest, free from worry and excitement, 
 tends to restore the condition of health. Let it be, 
 therefore, the first thought of the person in charge of 
 the sick to remove, as far as possible, all minor causes of worry ; to adapt 
 herself to the idiosyncrasies of the patient, standing always between him 
 and any cause for alarm or irritation. Extreme quiet, lack of haste in 
 manipulation, gentle methods of performing the small offices, garments 
 that do not rustle, noiseless shoes, etc., tend to soothe and produce the 
 desired quieting influence upon the mind. 
 
 Rest of the body can be accomplished in a variety of ways : by fre- 
 quent change of position, by the use of small pillows of different sizes 
 (one of the refinements of nursing), or by larger pillows and sand bags 
 used to give support and fixation. A given position, essential to recovery 
 from disease or from an important surgical operation, becomes irksome 
 and hard to bear, making the patient restless and often sleepless. In such 
 cases the greatest relief can be afforded by placing these small pillows 
 under the shoulders, the hollow of the back, or under the knees or ankles, 
 and removing them at intervals. This gives change and rest to the 
 muscles, and cools and refreshes the different parts of the body. If both 
 knees need support at one time, a hair pillow can be doubled through its 
 
 Rest of Mind 
 and Body. 
 
PREPARATIONS FOR THE BATH. 913 
 
 length and placed firmly iiiidor tlioiri. Tin's relievos ull sfruin from the 
 abdominal muscles, and can also be used when the joints of the knees arc 
 affected. Other joints can be similarly supported or kept perfectly quiet 
 by placing pillows on either side. Small bags made of ticking and filled 
 with sand are most useful for keeping an extremity immovable. J'*ainful 
 joints should be disturbed as little as possible, and when they have to be 
 moved should be lifted with great care and without bending. If an 
 injured extremity has to be moved, grasp it firirdy near the joints and 
 carry it in the direction of its most natural movements. 
 
 It has already been stated that light should be admitted from belli nd 
 a patient, and if the headboard of the bed be not solid, a shawl or rug 
 can be thrown over it to subdue the light. More ob- 
 jectionable than light shining directly in the face are 
 streaks of light coming in at the sides of the window shades. They 
 annoy and irritate the patient, and are very injurions after inflammation 
 of the eye or operations upon the eye. Such streaks can be overcome 
 either by pinning the shade to the window sash with a strong shawl pin 
 or covering the window entirely with dark cambric. 
 
 CHAPTER III. 
 METHODS OF GIVING BATHS.— TEMPERATURE. 
 
 Before beginning a bath all the articles necessary for use should be 
 brought together, and in cold weather the room should be made warm 
 and comfortable. 
 
 Sponge baths, whether for cleansing or cooling purposes, require that 
 the bed be protected either by a rubber sheet covered by an ordinary 
 sheet, a thick blanket, or a heavy Turkish towel. 
 When given for cleanliness, soap, towels, and a large 
 basin or foot tub are required. The face and hands are washed first. One 
 portion only of the body is exposed at a time, and this portion, after being 
 well dried, should be carefully covered, unless the body temperature is 
 high, in which case there is no danger of the patient's taking cold. The 
 patient should be guarded against fatigue by giving the bath rapidlv, with- 
 out haste, and turning the body as little as possible. 
 
 A sponge bath for the reduction of temperature is given bv first 
 
 sponging over the bodj^ rapidly with warm water from 80° to 90° Fahr.. 
 
 followed by a slow sponging (long strokes being used) with water, to 
 
 which alcohol and ice are sometimes added. Alcohol and ice are added 
 60 
 
914 
 
 NURSING THE SICK. 
 
 only by the physician's order. This bath may be continued for twenty 
 
 jninutes, and the cooliiii; process carried still further by leaving the body 
 
 uncovered and fanning the patient briskly for ten or tifteen minutes, till 
 
 thorough evaporation of heat has taken place. 
 
 When the foot bath is to be given in bed, the bed should be protected 
 
 l)v a covered rubber sheet, the foot tub, half full of water, placed in the 
 bed, the knees flexed, and the feet raised with one liand 
 under the ankles while the tub is drawn under them 
 
 with the other. The knees and tub are then covered with a blanket. 
 
 The feet should be thoroughly rubbed after removing them from the 
 
 bath, and an extra blanket used to keep up the heat produced by the bath. 
 
 \'erv hot water or mustard added — two tablespoonfuls to the ordinary 
 
 foot bath — will increase the revulsive action. 
 
 A full tub bath requires that the tub be filled three quarters full, so 
 
 that the entire body is enveloped in water. The patient can be protected 
 by a sheet while the bath is being given, so that no ex- 
 posure of the body is necessary. The sponging and 
 
 rubbing can be done perfectly well under the sheet, and a wai-m, dry sheet 
 
 put over the bath tub before taking the patient out. The duration of the 
 
 Full Tub Bath. 
 
 FlO. 7. — A PORTABLE BATH TUB. 
 
 bath should not exceed ten minutes. Warm towels give the greatest 
 comfort when drying the patient. A bath that acts favourably should 
 produce a warm, healthy glow upon the skin after rubbing. 
 
 In carrying out the " Brand treatment " for the reduction of tempera- 
 ture in typhoid fever (as described in the article on Medicines and Treat- 
 ment) it is necessary to have a portable bath tub that 
 can be wheeled to the bedside, and to have the patient 
 lifted very carefully and by persons strong enough to hold him firmly and 
 steadily. Stimulation should be given both before and after the bath — 
 whiskey or hot milk. There are two ways of putting the patient into 
 the tub : either by lifting him over the side of the tub or moving him 
 down in a straight line, having the tub placed at the foot of the bed. 
 
 Brand Treatment. 
 
STANDARD TEMPERATURES FOR BATHS. 
 
 915 
 
 the 
 
 spiiie- 
 
 Sitz or Hip Bath. 
 
 A rubber ring should bo used to give support to tlie heud, and a sheet 
 stretehed across the tub for the slioulders to rest upon, as indicated in 
 Fig. 7. 
 
 It is important to give plenty of friction especially \() 
 .surface friction, constant but light — and avoid rubbing 
 too heavily, as the skin becomes tender, and this often 
 makes the giving of the baths painful and almost hn- 
 possible. After the bath heaters are applied to the feet, 
 in most cases the patient is covered only by a sheet, that 
 the evaporation of heat may not be interfered with. Great 
 care must be exercised in disinfecting the liands of those 
 who have given the bath, as carelessness may result in in- 
 fection. 
 
 The "sitz" or hip bath is given in a tub made express- 
 ly for the purpose, about fourteen to eighteen inches deep, 
 with a high back, to give support to the 
 shouldei's. This tub should be filled only 
 one third with water, to prevent its flowing over when 
 the patient sits into it. A i)lanket is pinned about the 
 patient's shoulders, enveloping the tub as well, and by this 
 means keeping in the heat. 
 
 The temperature of the bath should be equalized 
 throughout its duration by removing some of the water 
 and adding that which is hot. The "Davidson bulb 
 syringe " is used for this purpose, the water being pumped 
 out and in. The usual duration of this bath is from 
 twenty to thirty minutes, and the desired temperature will 
 be ordered. 
 
 The average standard temperatures for baths are as 
 follows : 
 
 -lu 
 
 i. 
 
 ^Si 
 
 Fig. 8. — A bath 
 
 TIlERlIOlfETER. 
 
 Cold 33°-65° Fahr. 
 
 Cool 67°-75° " 
 
 Temperate. . . 75°-85° " 
 
 Tepid 85°- 92° Fahr. 
 
 Warm 92°- 98° " 
 
 Hot 98°-112° " 
 
 Bath thermometers are to be had partially inclosed in a plain wood 
 frame to protect them against hard usage and to bear the action of water 
 (Fig. 8). The ordinary atmospheric thermometer can, however, be used 
 just as well. 
 
010 NURSING THE SICK. 
 
 CHAPTER IV. 
 THE PREVEXTIOX AND TREATMENT OF BEDSORES. 
 
 A BEDSORE is f>:ano:roiie or death of a ]iart : the immediate cause, slnit- 
 
 tiug: off tlie circulation of the bk^od from tlie tissues. This condition 
 
 mav l)e brouglit on very readily uidess prompt prevent- 
 Cnuses and . " " i ' , li i i • ^i 
 
 , ive measures ai-e used, wlien the body is greatly enia- 
 
 ciated, the circulation poor, or wlien the position is such 
 as to cause constant pressure on a given area. The parts of the body 
 most liable to be affected are bony prominences, as the lower part of the 
 spine, the shoulder blades, the heels and the elbows, and the tleshy por- 
 tion of the hips in very heavy people unable to be turned. "With chil- 
 dren, lying constantly ujion the back, especially if there be iuces.«ant move- 
 ments of the head, the back of the head is most commonly affected. The 
 symptoms apparent to the patient, if conscious, are heat of the part, a 
 pricking sensation, redness and roughness of the skin, and pain on 
 pressure. 
 
 In diseases where there is predisposition to bedsore — as, for example, in 
 typhoid fever and in cases of impaired circulation — the back should re- 
 ceive attention from the very beginning of the illness. 
 Treatmeiii . ./ o o 
 
 Moisture, wrinkles, and crumbs are the commonest 
 
 enemies to be combated. Moisture softens the skin ; wrinkles and crumbs 
 irritate and roughen it. The presence of moisture is most often due to 
 the accumulation of perspiration from the body, or of discharges either 
 from wounds or from the l)0we]s or bladder. Frequent changes of linen, 
 pads made of oakum or jute placed in old muslin or cheese cloth, or large 
 sheets of Japanese paper that can be readily burned, are useful for receiv- 
 •ing such discharges. Wrinkles are most often present because the under 
 sheet is not drawn tightly enough. The draw sheet previously described 
 is perhaps the most valuable aid in preventing them, its length being 
 greater than the width of the ordinary sheet, holds firmly when carried 
 well under the mattress, and can be changed readily. Crumbs have a 
 persistent tendency to fall into the sick-bed despite all efforts to prevent 
 them. The fault lies in allowing them to remain, causing irritation and 
 excoriation of the skin. A small whisk broom proves a very efficient 
 means of removing them, but this will Tiever take the place of the human 
 hand. A thorough search should be made after each meal, and not one 
 should be allowed to remain. Position, or rather changes of position, by 
 which pressure is relieved, are perhaps of the greatest importance. Air 
 pillows, folded sheets, pillows made of hair, rubber rings covered with 
 bandages to prevent moisture on the surface, rings made of batting or 
 
THE RELIEF OF PRESSURE AND CLEANLINESS. 
 
 on 
 
 slieet wadding wound with lumdngcs (V'l'^. '.)), arc ii.sed. Tiio.sc rings can 
 be made to lit any part of the body, from a tiny one Bmall enough to pre- 
 vent pressure upon the ear to one large enough to support the buttock. 
 Tliese are placed so as to 
 prevent pressure upon 
 bony prominences or to 
 raise tlie body from the 
 bed. When there is ex- 
 treme weakness and a 
 tendency to lie constantly 
 upon the back the patient 
 can be turned gently on 
 one side by placing one 
 hand under the shoulder 
 and the other under the 
 buttocks and drawing them 
 forward ; a pillow folded 
 lengthwise so as to form a 
 wedge can then be placed 
 
 well under the back for support. This can be done first on one side then 
 on the other. It gives great relief and comfort, and often prevents the 
 much-dreaded bedsore. 
 
 Extreme cleanliness is of the titmost importance. The parts most 
 liable to pressure should be washed daily with soap and water and rubbed 
 frequently with alcohol to cleanse and toughen the skin. A powder com- 
 posed of equal parts of oxide of zinc and starch or talcum powder is 
 useful when applied sparingly to the irritated skin. Avoid using too 
 much powder, as it may form cakes upon the surface and do injury rather 
 than good. A preparation of equal parts of collodion and castor oil 
 painted over the surface forms an artificial skin and sometimes prevents 
 a breakino; down of the tissues. 
 
 Fig. 9. — A cotton rino. 
 
 CHAPTER Y. 
 
 METHODS OF TAKING THE TEMPERATURE. PULSE, AND RES- 
 PIRATION—BEDSIDE NOTES, ETC. 
 
 The object of taking the bodily temperature is to ascertain the heat 
 of the blood. The instrument used is the so-called " clinical thermom- 
 eter." These thermometers varv in delicacv. the finest ones rearisterinor 
 the temperature in one minute, others in from three to five minutes. 
 
«»1S NURSIxNG THE SICK. 
 
 The more expensive ones magnify the scale. The Hicks thermometer 
 
 is probal)ly the best. In taking the temperature it is tiie aim to place 
 
 the thermometer within a closed cavity from which 
 Temperature. , ^ , . . i i i m ^i ,i 
 
 tlie external air is excliuieu. ilie mouth, tlie armpit, 
 
 and the rectum furnish the best cavities for this purpose, tlie rectum 
 
 being surest when, any question of inaccuracy arises, or in cases in which 
 
 the circulation of blood on either side of the body differs. This last 
 
 method should always l)e employed with children. 
 
 Before using the clinical thermometer the mercury should be shaken 
 below the normal puint, OS^^g." to 05°. Avoid shaking it entirely into 
 the bull), as this will prevent future self-registration. If the temperature 
 is to be taken by mouth make sure that no very hot or cold fluids have 
 been recently used ; place the thermometer under the tongue at either 
 side, where the i)lood-vessels lie ; instruct the patient to keep the tongue 
 well down over the l)ull) and the lips firmly closed till the time expires. 
 When the armpit is used, all moisture should be removed and the ther- 
 mometer placed against the chest with the bulb well embedded in the 
 armpit; the arm is then folded across the chest and held in place by the 
 other arm, and the patient constantly watched that the thermometer does 
 not slip down. "When the temperature is taken by the rectum, ascertain 
 first if the rectum is free ; otherwise an enema should be given, and the 
 taking of the temperature delayed half or three quarters of an hour till 
 tlie former heat has returned. When the temperature is found to be un- 
 usually high or unusually low, it should be taken over again and, if pos- 
 sible, a duplicate thermometer used, to prove that there is no inaccuracy 
 in the thermometer itself. The temperature is sometimes ordered to be 
 taken every hour in certain cases, as when baths or medication for its 
 reduction are employed ; otherwise it may be taken every four hours, or 
 twice daily — at about eight in the morning and five in the evening. It 
 will probably be found to be lowest in the early morning. A thermom- 
 eter is less liable to be broken when in constant use if kept in a small glass 
 or wide-mouthed bottle with cotton in the bottom. 
 
 The pulse — the index to the heart action — may be taken at any point 
 
 where the arteries are superficial. The most convenient points are the 
 
 thumb-side of the wrist, the temple, the side of the 
 Pulse 
 
 neck, and the top of the foot. In learning to count the 
 
 pulse it is probably best to count through the whole thirty seconds and 
 afterward to count by the quarter, or by tens. A thorough knowledge 
 of the pulse is to be gained only by study, unlimited experience, and con- 
 stant practice. 
 
 The respiration is taken by watching the movements of the chest as 
 it rises and falls upon inspiration and expiration. This is best done while 
 still holding the wrist, as if taking the pulse. The attention of the 
 
TEMPERATURE, PULSE, AND RESPIRATION. 
 
 919 
 
 TEMPERATURE CHART. 
 JS'ame '^"^'''''' ^^'"'- Datk SepUmhar 17, 1805. 
 
 
 7 
 
 8 
 
 '.) 
 
 10 
 
 11 
 
 
 Houn 
 
 12 
 
 4 8 12 4 8 12 
 
 4 8 12 4 8 12 
 
 4 8 12 4 3 12 
 
 A . M. P . M . 
 
 HOUR 
 
 TEMP. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 TEMP. 
 
 104 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 104 . 
 
 
 
 
 
 
 
 1 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 103 
 
 
 \ 
 
 
 
 
 
 1 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 a 
 
 
 
 103 
 
 O 
 
 \ 
 
 
 
 
 
 ' 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 a 
 
 
 
 102 
 
 B 
 
 
 \ 
 
 
 
 / 
 
 
 \ 
 
 
 
 
 
 
 
 A 
 
 
 
 
 
 
 
 
 
 
 
 
 102 
 
 
 
 
 s, 
 
 ■ 
 
 / 
 
 
 \ 
 
 
 
 
 
 
 
 / 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 101 
 
 
 
 
 \ 
 
 / 
 
 
 \ 
 
 
 
 
 
 
 
 / 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 101 
 
 
 
 
 
 
 
 
 
 
 ^ 
 
 V 
 
 
 
 
 / 
 
 
 
 
 V 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 / 
 
 
 
 
 
 \ 
 
 
 
 ^r- 
 
 
 \ 
 
 
 
 
 100 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 _^ 
 
 / 
 
 
 
 
 
 
 9!) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \ 
 
 
 
 99 
 
 
 
 
 
 
 
 
 ~ 
 
 
 
 
 
 
 "~ 
 
 
 
 ' 
 
 
 
 
 
 
 
 
 
 
 -^ 
 
 
 08 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 98 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 R 
 
 g S 
 
 T^ •* T»- CD ^i- ■* 
 
 ■* CO 03 Ti- O (O 
 
 s s s s s s 
 
 ?i ?i 
 
 R 
 
 1> 
 
 o o 
 
 O O 
 
 03 („ O •* CO O 
 
 — oi ■* ■* O O 
 g o O O O O 
 
 S g S § 1 2 
 
 § s 
 
 P 
 
 BEDSIDE NOTES. 
 
 Name J'^^"^ Doe. 
 
 Date. 
 
 Hour. 
 
 Medicine. 
 
 Urine. 
 
 Dej. 
 
 Remarks. 
 
 Day of 
 Disease. 
 
 June 1st. 
 
 7 P. M. 
 1 A. M. 
 
 ]J Whiskev § ss., every 
 4 h., 4, 8, 12. 
 
 5 Strychnine gr. -^n, 
 every 4 h., 4, 8, 12. 
 
 5 Typhoid precau- 
 tions. Fluid diet. 
 
 IJ Tub bath, 80°, 15 
 min., every 4 h., for 
 temp. 102-5 or +. 
 
 8 P. M. 
 
 11-30 p JI. 
 I viii 
 
 2 
 
 Admitted to ward 6 
 p. M. Temp., 102-5°; 
 pulse, 92 ; resp., 24. 
 Cleansing bath giv- 
 en. Patient com- 
 plained of head- 
 ache. 
 
 
 June 2d. 
 
 7 A. M. 
 
 ]J Typhoid precau- 
 
 10 A. M. 
 
 
 11-40 A. M. Temp., 
 
 
 
 
 tions. 
 
 i vii 
 
 1 
 
 104-4°; pulse, 96; 
 
 
 
 
 R Fluid diet. 
 
 
 
 resp., 22. Tub bath. 
 
 
 
 
 5 Tub bath, 80°, 15 
 
 
 
 Stood bath at 4 p. m. 
 
 
 
 
 min., every 4 h., for 
 
 
 
 well. Slight shiver- 
 
 
 
 
 temp. 102-5 or +. 
 
 
 
 ing for 10 min. after 
 
 
 
 1 P. M. 
 
 5 Whiskey § ss., stat. 
 and every 4 h., 4, 8, 
 12. 
 
 Total, 24 hours 
 
 6 p. M. 
 
 
 bath. Low delirium 
 and muttering at in- 
 tervals during the 
 day ; somewhat rest- 
 less. 
 
 
 
 I XXXV 
 
 3 
 
 
 Total 
 
 Nurse 
 
020 NURSING THE SICK. 
 
 patient is attracted toward the pulse, over which he has no control, and 
 the respiration remains unchanired ; otherwise the attention has to be 
 drawn to other things and valuable time is lost. 
 
 To make a record of value the temperature, pulse, and respiration 
 should, if jiossible, be taken about tlie same hours daily. A chart for 
 keeping tlie record is given on the ]>reeeding page, but 
 e pirn urn. ^ gi,nple method giving the hours, etc., by figures is use- 
 ful when charts are not to be obtained. Notes of the condition of the 
 appetite, the skin, the mouth, the excretions from the bowels and bladder, 
 the amount of sleep, etc., can be ke})t either by noting these j>oints on a 
 sheet of paper, or having a chart or notebook expressly for this j)urpose. 
 
 CHAPTER YI. 
 MEDICINES AND THEIR ADMINISTRATION. 
 
 There are a number of avenues through which medicine can be intro- 
 duced into the system, thus finding its way by absorption into the blood, 
 and through this medium, in most cases, to the organs 
 
 arwus e j ^^^ ^issues to be affected. The first and most important 
 
 Medication. , . '■ 
 
 of these avenues is the stomach. This, however, some- 
 times fails to retain and absorb drugs, and they have to be given by 
 rectum. The absorption through the stomach is slow, and that by rectum 
 still less rapid ; and when time is an important factor, as in the relief of 
 severe pain or heart failure, the method of introducing medicine under 
 the skin by a hypodermic syringe has to be resorted to. AVhen the lungs 
 and throat are affected, medication by inhalation through an atomizer or 
 steam kettle has to be instituted. An ordinary tea kettle, with stiff 
 paper twisted into cone-shape, so that it will fit well over the mouth and 
 be attached to the spout, can be used, or a canopy can be made over the 
 bed to keep in the steam. An alcohol lamp is necessary to keep the wa- 
 ter boiling, and this can be placed between the bricks upon which the 
 kettle is to stand. Local applications to the skin and mucous membrane 
 can be made by means of ointments, liniments, lotions, etc. 
 
 Most alcoholic stimulants, with the exception of wines, should be 
 diluted about one half. Cough mixtures, composed of substances which 
 are intended to form a coating along the mucous membrane and allay 
 irritation, should never be diluted. Oils can not be diluted with water. 
 They should be given in some vehicle to disguise the taste — for example, 
 hot coffee or milk, beer, Vichy, soda water — or they can be given with 
 lemon, brandy, or whiskey. Other bad-tasting drugs can be inclosed in 
 
MEDICINES AND THEIR ADMINISTRATION. 
 
 021 
 
 o-elatin capsules or wafers that are readily dissolved by the juices of 
 tlie stomach, or the sense of taste can he deadened h}- the use of ice or 
 something pungent, like peppermint, l)randy, or whi.skey. Iodide of 
 potassium can be given in milk or vi^ell diluted with Vichy. Effervesc- 
 ing drugs, like Seidlitz powder, sliould he given in a large glass of 
 water, allowing most of the effervescence to pass off before it is taken. 
 Powders that can not be dissolved should be given dry on the tongue 
 and washed down with fluids. Pills, unless freshly made, should be 
 pulverized and given in jam or bread crumbs. Many of the com- 
 pressed tablets so universally used are often unaffected by the digestive 
 tract and should usually be dissolved or broken up before being given. 
 
 Cheap or stale drugs are to be avoided, as disease is often prolonged 
 
 by their failure to relieve the symptoms for which they are given. 
 
 Choose always a trustworthy chemist rather than a 
 
 Druqs. . . . 
 
 cheap one. Medicine not in use should be discarded ; 
 
 chemical change, due either to excess of light, heat, or cold, may take 
 
 place, or the drugs may become stronger by evaporation, thus making 
 
 them unsafe for use. Prescriptions used for any particular disease 
 
 seldom contain the necessarj' combinations for another, and should not 
 
 he kept. 
 
 All bottles containing drugs should be distinctly labeled and the label 
 
 read twice before giving. Poisonous drugs should be kept in blue bottles 
 
 with rough exterior, that the touch may call attention 
 Bottles. . .1 ^ ^ ^T -1 • 
 
 to the fact. JNever, under any circumstances, allow an 
 
 incorrect label to remain on a bottle even for a few minutes. Failure to 
 lahel poisons has caused many deaths. 
 
 Medicine should be measured accurately, if possible in a graduated 
 glass marked for the purpose (Fig. 10). If the tea- 
 spoon or tablespoon be used instead, 
 remember that the medium-sized tea- 
 spoon answers to the drachm (sixty 
 minims), and the ordinary tablespoon to four drachms, 
 or half an ounce. Drops of different drugs vary so 
 nmch in size that it is always well to use the minim 
 measure. The glass should be held on a level with 
 the eye when measuring. In this way the marks can 
 be seen better and. the exact amount insured. 
 
 There are few general directions about the giving 
 of medicines to be laid down except that the mxlers of 
 the physician are to ie carried out implicitly almost 
 without exception.^ that the medicine is to be made as pleasant to the 
 taste as possible, is never to be measured in the presence of the patient, 
 and should be given without discussion. If carried to the bedside 
 
 Measuring 
 Medicine. 
 
 Fig. 10. — The peer- 
 less GRADUATED 
 MEASURE. 
 
922 NURSING THE SICK. 
 
 quickly nml the lic;ul raisi'd, tlie patient will often take the dose almost 
 without thinking about it. If medicines are ordered to be given before 
 
 meals they are probably intended to influence the gas- 
 -, , . . • trie luice and act as an aul to digestion, and tliev should 
 
 be taken half an hour before eating. Ihose ordi'red 
 to be given after meals may be of an irritating nature, and their action 
 less felt when food is still ])resent in the stomach ; they should therefore 
 l)e given half an hour aftrr meals. Other forms c»f medication have 
 tlie desired eft'ect only when a certain amount has accumulated within 
 the system ; such medicines are often given in small, fre(piently repeated 
 doses, every hour or every two or four hours, because of the danger of 
 upsetting the stomach by larger quantities. These medicines, as well as 
 those intended for the relief of pain, should be given promptly as 
 ordered. Indeed, it might be said that all doses ordered should be 
 given except when the stomach is greatly irritated or upset by them, and 
 in this case the physician should be communicated with early. 
 
 The small glass holding from two to four tablespoonfuls is most 
 useful for administering medicine. Spoons or tubes are objectionable to 
 many people. The small glass, not over half full, can be managed readily. 
 The head should be lifted gently on the pillow without bending the 
 neck, in such a way as uot to cause any constriction on the throat, and 
 the medicine can be swallowed with ease. If the patient is partially 
 unconscious, moistening the lips will often attract attention and mak<5 
 him swallow. The glass medicine tube, flattened at one end and bent 
 about three inches from the end, to adapt itself to the chin, is neces- 
 sary when iron is given, to protect the teeth. Oil or medicine that im- 
 parts a disagreeable odour should never be given in a glass used for other 
 purposes. 
 
 CHAPTER VII. 
 FOODS AND FEEDING. 
 
 It is impossible in an article so limited to enter into the classification 
 
 of food and its value, or to give an adequate idea of the important part 
 
 it plays in the repair of tissue waste in the body. This 
 
 „ ., ,. is a much-neglected field in general education. One of 
 
 Considerations. ^^ ^ 
 
 the greatest signs of the advancement of civilization is 
 that the "chemistry of food " and the "chemistiy of cooking" are begin- 
 ning to be more generally taught to the young. The proverb that 
 " Man is either a fool or an epicure at forty" should no longer hold true. 
 
FOODS AND FEEDING. (>2:i 
 
 He sliould liave learned liis lesson before lie is twenty. Then, too, a 
 knowledge of the right quantities of proper material for j^hysieal develop- 
 ment is important, llow inany an impaired digestion can be traced to 
 overfeeding as an infant, or a stunted growth due to improper or nnder- 
 feeding ! 
 
 In health Nature generally demands the foods most needed to huild 
 up the tissues and supply waste ; but in sickness tlie taste and appetite 
 are not always trustworthy guides. It often happens that the foods that 
 have pleased most in health can not be endured when sickness comes, or 
 that the desire for food is entirely absent. The sense of smell often he- 
 comes more acute, and inhaling the odours of certain foods or of tlie 
 breath of the person administering the food, may be the occasion for its 
 rejection. The use of any perfumery while tending the sick is to be 
 avoided, for its odour is very apt to cause distaste for food in a sensitive 
 invalid. 
 
 In administering food to the sick there are a few general principles im- 
 portant to bear in mind : First, that a little food well tolerated, digested, and 
 assimilated is far better than the larger quantitv that irri- 
 of Food ^?^^Q^ and obstructs by its bulk ; second, that this food must 
 
 be of the best quality, prepared without destroying its 
 nutritive properties, and made toothsome without overseasoning ; third, 
 that it must always be presented in a dainty and attractive maimer. 
 Many devices to aid in the toleration of food have to be resorted to when 
 the stomach is irritable — i. e., the addition of lime water, Yichy, or 
 Apollinaris to milk, giving milk and eggs under cover of other names 
 (milk "jelly," milk "sherbet"), somal (koumiss in siphons), egg soup, raw 
 egg made cold and flavoured M-ith wine {^\we frappe)^ egg in coffee, or 
 frozen beef juice flavoured with lemon, etc. These foods should be given 
 either very cold or very hot and in small quantities often repeated — a 
 teaspoonful every hour or half hour, or even half that quantity. There 
 are also aids to digestion in the form of predigested foods, milk, beef, etc. 
 
 The quality of the food should be of the best : milk, eggs, and oysters 
 
 above reproach ; beef and game well seasoned, but free from taint ; 
 
 vegetables fresh from the garden, etc. In the cooking. 
 Cooking. ^^1,1 , ^ -, . . ^ , 
 
 care must be taken to preserve the juices of the meat, 
 
 to have the farinaceous foods thoroughly cooked through, and to avoid 
 too high seasoning. As a rule, sick people prefer more salt and less 
 sugar. When the largest amount of nutritious substance is to be ob- 
 tained from meat (extracts, broths, etc.) the meat should be set to cook in 
 cold water and not allowed to boil, as this coagulates and destroys the 
 albuminous portions of the meat. Food cooked in small quantities retains 
 its flavour better. It should never be given when over- or under-done or 
 burned. Infinite pains should be taken also with the cooking utensils 
 
'J-J-t 
 
 NURSING THE SICK. 
 
 Fluid Diet. 
 
 FlO. 11. — A PORCELAIN FEEDING CUP. 
 
 Fig. 12. — A glass feeding tukk. 
 
 and the refrigerator in wliicli food is kept. T/tei/ f<}iouhl he l-ept scrujm- 
 lously clean and free from odour. 
 
 Fluids sliould be served from a small glass brought on a tray \\\t\\ a 
 dainty fresh cover, and with a napkin used to prevent spilling on the bed- 
 clothes and to Nvi[)e the mouth afterward. Feeders 
 (Fig. 11) should be employed only when the head can 
 not be raised. The glass tubes (Fig. 12) are generally unnecessary. 
 
 In feeding a patient unable to be lifted, the head should be turned 
 slightly on one side and the tiuid given slowly and in small quantities, to 
 
 prevent choking and too great 
 fatigue. If there is difficulty 
 in swallowing, pinching up 
 the throat gently just on 
 either side of the windpipe 
 will often accomplish it. 
 
 AVhile the diet is confined 
 
 to fluids, it should be given 
 
 at regular intervals, and a 
 
 strict account kept of the 
 
 amount taken. Three pints 
 
 of milk (the most complete 
 
 form of food we have) or 
 
 its equivalent is the amount essential to sustain life for twenty-four hours. 
 
 ( )f course there are exceptions to this rule, but many times the sick have 
 
 suffered seriously from being underfed. 
 
 The more solid foods should be served in small quantities, separate 
 dishes being used ; and when the variety is limited, it is well to serve in 
 conrses. The linen must be fresh, the china, silver, and 
 glass of the best the house affords, and spotlessly clean 
 and shining. A flower or bunch of green adds much to the appearance 
 of the tray, and the dress of the person presenting it should be im- 
 maculate. A bed tray with small feet to stand on the bed without resting 
 on the chest (Fig. 13) is a great convenience and saves the strength of the 
 patient. 
 
 When the appetite is poor, the sight of a large quantity of food bronght 
 to the bedside is upsetting ; a portion should always be kept out of sight 
 and brought forward gradually, if possible, without the knowledge of the 
 patient, AVhen the patient is being fed solids the food should be cut in 
 small pieces and plenty of time allowed for mastication. A small amount 
 of fluid should be given at the time of eating, as a large quantity taken 
 into the stomach at this time undoubtedly interferes with digestion. 
 
 Special diet in the present day enters so largely into the treatment of 
 most acute and many chronic diseases that it may be well to call attention 
 
 Solid Foods. 
 
THE PREDIGESTION OF POODS. 
 
 925 
 
 Fig. 13. — A bed thay. 
 
 to the necessity of rigid adherence to the plan laid down hy tlie jiliysician. 
 In certain diseases (diabetes, for instance, being the most commonly 
 known) sngar acts as a poison to the system, increas- 
 pecia ifl . .^^^ ^j^^ severity of the disease and diminishing the pa- 
 tient's chances of life. In this case all foods containing an appreciable 
 amount of sugar or starch which is convertible into sugar are prohib- 
 ited, or in the case of an ulcoi-atcd 
 or diseased stomacli the foods that 
 are digested largely by the intes- 
 tines and tax the stomach least arc 
 given, and m case of intestinal dis- 
 turbance just the reverse — tliose 
 that are digested entirely by tlic 
 stomach being used. A diet com- 
 posed entirely of starchy foods, 
 gruels, arrowroot, rice, tapioca, etc., 
 should never be given, as many cases may be cited where both children 
 and adults have been literally starved by strict adherence to this form of 
 food. The nitrogenous principle, even in the smallest quantity, must be 
 introduced. 
 
 In these cases it becomes almost an art to present the few articles of a 
 limited diet in such an attractive manner that they are not always recog- 
 nised as the same, or to overcome a morbid distaste for food in any form 
 and keep the patient properly nourished. . In chronic diseases of long 
 standing this task becomes even more arduous, and yet a little thought 
 and attention to the details will accomplish wonders. 
 
 In the first acute stage of almost any disease it 
 is important that nourishment be introduced in 
 condensed form and in a condition that puts the 
 least possible tax upon the digestive organs. This 
 suggests the predigestion of foods, and milk and 
 beef lend themselves most readily to this process. 
 
 STERILIZED MILK. 
 
 Sterilization of milk is best accomplished with 
 the Arnold sterilizer, as shown in Fig. 14. The 
 bottles, which fit into a light frame, each contain 
 eight and a half ounces. They are to be boiled 
 and then filled with milk to within half an ounce 
 of the top, plugged with cotton, absorbent or 
 plain, and put in the sterilizer. The base of the 
 sterilizer is filled with hot water, placed over a gas or ordinary stove 
 and boiled for forty minutes. The steam thus generated rises through 
 
 Fig. 14. — The Arxold 
 sterilizer. 
 
926 NURSING THE SICK. 
 
 the perforation in the base of the steamer, and the milk is thoroug-hly 
 sterilised. As a substitute for tlie Arnold sterilizer, a kettle or clothes 
 boiler may be used Avith straw or excelsior in the bottom on wliich to 
 ])lace the bottles. 
 
 PEPTOXIZKI) MII.K. 
 
 Milk mav be pejitonized l)y the cold or warm ]irocess, and is supposed 
 to be equally well predigested in either case. The cold process, being the 
 simpler, is generally employed : To one i)int of fresh milk add the con- 
 tents of one of Fairchild's ]x^ptonizing tubes dissolved in warm -water. 
 (This tube contains live grains of pancreatic extract and fifteen grains of 
 bicarbonate of soda.) Then place the bottle in ice for half an hour, re- 
 move, and keep in a cool place. Warm process : Heat the milk to 180° 
 Fahr. and add the contents of the tube dissolved in water ; then place 
 the bottle for fifteen minutes in a pail of Avater at the boiling point. It 
 should then be placed immediately upon ice to check the peptonizing 
 
 ])rocess. 
 
 KOUMISS. 
 
 Heat one quart of perfectly fi'esh milk to [h)° Fahr., add one third of 
 a two-cent cake of Fleischmann's yeast and one tablespoonful of sugai-, 
 cork tightly, tying the cork down, and let it stand twelve hours in a 
 temperature of 75° Fahr. Shake thoroughly and keep on ice. Five 
 davs are required to complete thorough fermentation. 
 
 SOMAL. 
 
 Another form of fermented milk is known as " soma!," and can be 
 procured in siphons. It has the advantage of being sterilized. " Somal " 
 keeps perfectly till the whole bottle is consumed. 
 
 BEEF .JUICE. 
 
 Broil a piece of roimd steak an inch thick for seven minutes, squeeze 
 
 the juice into a hot cup with the lemon squeezer, and season with salt and 
 
 ])epper. 
 
 BEEF TEA. 
 
 Beef tea is valuable for its stimulating ]n-o))erties and for the warmth 
 that it gives ; it is also somewhat nutritious, containing, as it does, the 
 albuminous juices of the meat, some salts, and the very important flavours. 
 Beef tea should be prepared in such a manner that the juices are held in 
 solution in the water, not coagulated, to secure which the cooking tem- 
 ])erature should never be allowed to exceed that of 100° Fahr. 
 
 To make hoitled beef tea, put into a large-mouthed bottle one pound of 
 beef free of fat and chopped fine ; add half a pint of cold water ; let it 
 stand one hour ; then place the bottle in a saucepan of cold water, put 
 
BEEF TEA AND BEEF BROTH. 927 
 
 it on the fire, and licat tlio water slowly almost to the hoilinj^ point, 
 Imt do not let it hoil. Cook for two lionrs, then strain and season with 
 salt. 
 
 . The thick sediment which falls to the bottom when the tea stands 
 awhile is the most nutritious part. It is to keep tliis sediment (the 
 albuminoids) in a soft digestible condition that care is taken not to let 
 the water that surrounds the bottle boil, as great heat hardens the albu- 
 minoids. For the sake of variety (if the patient tires of beef tea), change 
 the flavour occasionally by adding a piece of cinnamon an inch square to 
 the meat and water. 
 
 Bottled heef essence is made in the same way as the above, only omit- 
 ting all water. It can also be made by standing the jar in the oven for 
 three hours instead of cooking over the fire. 
 
 For economical heef tea, cut one pound of juicy round steak into small 
 pieces and add one cup of cold water. Let it stand several hours. When 
 ready to serve, squeeze the meat over a bowl, strain the juice obtained, 
 add salt to taste, and heat just enough to make it palatable (not enough 
 to curdle). Serve at once. 
 
 If heated directly over the fire it must be stirred constantly and taken 
 off the moment it looks thick and is hot. The better way is to heat it 
 carefully over hot water. 
 
 Add another cup of water to the scraps of meat and soak again. 
 Often the third cup of tea may be made from the same meat. Beef tea 
 is excellent in cases of great exhaiistion. 
 
 To vimko, frozen heef tea, set a small tin pail or can in a wooden pail 
 and surround it with salt or crushed ice, and be very careful the salt does 
 not get into the tin pail. Put cold beef tea into the pail and let it stand 
 ten minutes. Then take off the cover and scrape the congealed beef tea 
 from the sides. Beat well and put back the cover. Do this two or three 
 times and the tea will be frozen smooth. This is intended for patients 
 who must have their food cold. 
 
 NUTRITIOUS BEEF BROTH. 
 
 Take three pounds of solid beef from the shoulder or shin, and three 
 pounds of bone from the same. Remove the dried skin and any soft or 
 bloody portions. Cut the meat into small pieces and put it, together with 
 the cracked bones, into an earthen jar. Cover it with four quarts of cold 
 water, set in a slow oven, and cook from eight to twelve hours. Strain 
 through a colander, add two teaspoonfuls of salt, and cool quickly. When 
 cold, skim off the fat, and serve cold as jelly ; or heat to 170°, but not 
 above 180°, as boiling injures its value. 
 
92S NURSING THE SICK. 
 
 BOUILLON. 
 
 Take a dilute solution of gelatin and salts of meat flavours, of about 
 lialf the nutritive value of the broth; two (juarts of the cold beef broth. 
 Beat the white of an egg just enough to break it, crush the shell, and add 
 both to the cold liijuid. Mix well, heat slowly, and let boil ten minutes, 
 then stand at the back of the stove for half an hour. Remove the scum, 
 and strain. If allowable, the bouillon may have added to it, Mdien put 
 on to clear, two tablespoonfuls of chopped vegetables, turnip and carrot, 
 one teaspoonfnl of onion, an inch of stick cinnamon, and a blade of mace. 
 
 CONSOMME. 
 
 Take a dilute solution of gelatin and salts of meat flavours, three 
 pounds of lean beef and three pounds of the knuckle of veal. Cut the 
 meat into small pieces and crack the bones. Add to them four quarts of 
 cold water, two teaspoonfuls of salt, one onion, one small carrot, one 
 small turnip, a blade of mace, an inch of stick cinnamon, three cloves, a 
 sprig of thyme, the same of sweet marjoram and of summer savory, and a 
 bay leaf. Cover closely and let simmer on the back of the stove for eight 
 liours. Strain and set it away to cool. AVhen cold, it is clear like bouil- 
 lon. Season and serve. 
 
 MUTTON imOTIL 
 
 Weigh two pounds of the neck of mutton, cut it into small pieces, 
 crack the bones, cover it with two rpiarts of cold water, heat very slowly 
 and let simmer three hours, or cook in a double boiler for five or six 
 liours. AVhen the meat has been cooking two hours add two ounces of 
 rice and, if desirable, a small onion. At the end of three hours remove 
 the meat, season and serve. Unless it can stand overnight to cool, skim 
 off the fat when it first comes to a boil, and again after putting in the rice. 
 Yeal and chicken broth are made in the same way. 
 
 CHICKEN BROTn. 
 
 Free one half of a young fowl of skin and fat, wash it, and cut it into 
 small pieces ; put in a stewpan with one quart of cold water ; place on 
 the fire and heat slowly to the boiling point ; then skim carefully and set 
 it back where it will simmer three hours. Season with salt and strain. 
 
 If the patient can take tapioca, sago, or rice, add one tablespoonful to 
 the broth after it has been cooking one hour. 
 
 CL.'VM BROTH. 
 
 Take six large hard-shell clams washed well with a brush. Put them 
 into a kettle with two or three tablespoonfuls of water. over the fire. As 
 
VARIOUS KINDS OF GRUEL. 020 
 
 soon as the clams open tliey are sufficiently cooked. More cooking will 
 only make them tough. The broth does not require any seasoning, as the 
 clear juice is salt enough ; it has sometimes to be diluted with hot water 
 to reduce the salt flavour. This broth is as much a standard dish now as 
 beef tea. It can be retained on the stomach when other food disagrees 
 with the jDatient, it is a valuable substitute for milk when that can not be 
 taken, it is nourishing and stimulating, and can be given by the teaspoon- 
 ful in cases of severe illness, or by the cupful to convalescents. 
 
 OATMEAL GRUEL. 
 
 Pound one half a cup (two ounces) of coarse oatmeal in a mortar until 
 it is mealy, then put it into a tumbler and fill the tumbler up with cold 
 water. Stir and pour off the mealy water into a saucepan. Fill up the 
 tumbler again and pour off, and repeat as long as the water looks mealy. 
 Set the saucepan on the back of the stove and let it simmer at least one 
 hour, or cook in a double boiler two hours. Strain, season with salt, and 
 serve. Thin with milk or cream if too thick. 
 
 INDIAN-MEAL GRUEL. 
 
 Blend two tablespoonfuls (one ounce) of Indian meal in a little cold 
 water and stir into one quart of boiling water. Boil on the back of the 
 stove two hours. Salt to taste, sweeten, and add milk if desirable. Strain 
 and serve. 
 
 FLOUR GRUEL (WITH MILK). 
 
 Mix one ounce, or two tablespoonfuls, of flour with a little cold milk 
 and stir into one quart of boiling milk. Cook in a double boiler two 
 hours, or on the back of the stove in a saucepan. Salt to taste. Strain 
 and serve. Sweeten if desired. 
 
 BARLEY GRUEL. 
 
 Blend one ounce, or two tablespoonfuls, of barley flour (Robinson's) 
 "with a little cold milk and stir into one quart of boiling milk. Cook in 
 a double boiler two hours. Season with salt to taste, and with sugar if 
 desired. Strain and serve. 
 
 RICE GRUEL. 
 
 Blend one half ounce, or one tablespoonful, of rice flour into a little 
 cold water. Turn into one quart of boiling water and cook in a double 
 boiler until transparent. Salt to taste. Sweeten and add milk if desired. 
 Strain and serve. 
 
 Flour and arrowroot gruel may be made in the same way. 
 61 
 
030 NURSING THE SICK. 
 
 RECIPES FROM VARIOUS SOURCES. 
 
 ARROWROOT. 
 Take one tablespoon fiil of arrowroot, one saltspoonfiil of salt, one 
 teaspoon ful of sugar, one cup of hot water, and one cup of milk. 
 Wet the arrowroot with the salt and sugar in two tablespoonfuls of 
 cold water, then pour on the hot water, stirring constantly ; boil it for 
 twenty niinutes, then add the milk and bring just to the boiling point. 
 Strain and serve immediately. 
 
 RENNET. 
 Take one half pint of fresh milk heated to 100° Fahr., add one tea- 
 spoonful of essence of pepsin, and stir just enough to mix. Let it stand 
 till firmly curdled. It may be served plain or with sugar and grated 
 nutmeg. 
 
 WINE JELLY. 
 
 Take one quarter of a box of Nelson's gelatin, one quarter of a cup 
 of cold water, one and one quarter cup of boiling water, one half cup 
 of sugar, one half square inch of cinnamon, one clove, and one half 
 cup of sherry wine. Put the gelatin and cold water together in a dish 
 large enough to hold the whole mixture, let it soak for half an hour, and 
 pour the boiling water in which the clove and cinnamon have been sim- 
 mering over the softened gelatin ; add the sugar and wine and stir until 
 the sugar and gelatin are perfectly dissolved, then strain through a fine 
 napkin into a granite- ware basin and cool in a refrigerator or in a pan of 
 iced water. 
 
 ORANGE JELLY. 
 
 Take one quarter of a box of gelatin, one quarter cup of cold water, 
 one half cup of boiling water, one half cup of sugar, one cup of or- 
 ange juice, and the juice of half a lemon. Soften the gelatin in the 
 cold water by soaking it for half an hour, then pour in the boiling 
 water as previously directed until the gelatin is dissolved ; add the 
 sugar, orange juice, and lemon juice in the order in which they are 
 given ; stir for a moment, then strain the liquid through a napkin into 
 moulds and set it to cool. Use earthenware or granite-ware moulds, 
 not tin. 
 
 The point most to be observed in making this jelly is getting the 
 juice from the oranges. The most natural way would be to cut the 
 oranges in halves and squeeze them in a lemon squeezer ; but that will 
 not do, for the orange oil of the rind is extracted in such large quantities 
 as to destroy the delicate flavour of the jelly. The proper way is to peel 
 the fruit, cut it in pieces, put it in a jelly bag, and squeeze out the juice 
 with the hand. 
 
DELICACIES FOR AN INVALID. 931 
 
 CHICKEN JELLY. 
 
 Clean a small chicken, disjoint it, and cut the meat into small pieces; 
 remove the fat, break or pound the bones, and put all into cold water, 
 using the following proportion : a pint for every pound of chicken. 
 Heat the water very slowly at first, and then let it simmer until the meat 
 is tender, three or four hours being required. Boil down to one half the 
 quantity ; strain the jelly and remove the fat ; then clear with an egg and 
 season with salt, pepper, and nutmeg or lemon. Strain through a fine 
 napkin, pour into small cups, and cool. Parsley, celery, and bay leaves 
 give a good flavour. A suspicion of red pepper is also an addition. 
 
 BEEP SANDWICHES. 
 
 Cut slices of bread (a day or two old) as thinly as possible. Cover the 
 slices with scraped raw beef, salt, and cut into squares one inch thick or 
 into diamonds. Butter can be added if allowed. 
 
 BROILED BEEP PULP. 
 
 Scrape raw beef to a pulp, make it into small cakes, and broil as steak. 
 Season with salt, a few grains of Cayenne pepper, and serve hot. 
 
 BROILED SWEETBREADS. 
 
 Parboil and split the sweetbreads, season with salt and pepper, rub 
 thickly with butter, and sprinkle with flour. Broil them over rather a 
 quick fire, turning constantly ; cook about ten minutes and serve with 
 cream sauce. 
 
 CREAM SAUCE. 
 
 Take half a pint of cream, one half a generous tablespoonful of flour, 
 salt and pepper to taste. Let the cream come to a boil. Have the 
 flour mixed and smooth, with one half cup of cold cream (reserved from 
 the half pint), and stir it into the boiling cream. Add the seasoning 
 and boil three minutes. 
 
 CHICKEN SOUFFLE. 
 
 Chop half a cold chicken, cooked and freed from skin and bones, as 
 fine as possible ; pound in the mortar, then rub through a sieve. (The 
 white meat is best.) Place in a saucepan a piece of butter the size of 
 a pigeon's egg, and when it bubbles stir in with an egg whisk a dessert- 
 spoonful of flour. When evenly blended stir in three quarters of a cup 
 of hot water and let it cook a few minutes, stirring smoothly together 
 with the egg whisk. Then stir in the chicken pulp and season palatably 
 with salt and Cayenne pepper. Let the paste get entirely cold (covering 
 it so that it will not get hard), then mix into it lightly first the yolks of 
 
932 NURSING THE SICK. 
 
 two eggs beaten to a cream, tlien the whites of three eggs beaten to a 
 stiff froth. Put into paper eases or small pudding cups. ]kkc al)()ut 
 tifteen minutes in the oven, and serve as soon as done. 
 
 SHIRRED EGGS. 
 Butter small earthen dishes (one for each egg), put an c^rvr in the dish 
 without mixing the white and yolk, dust a little pepper and salt over it, 
 then place upon the back of the stove or in a modei-ate oven until the 
 whites of the eggs are set ; the dishes are sent to the patient and the eggs 
 eaten from them. If the eggs be put in the oven, cover with buttered 
 paper to keep them from browning. 
 
 CREAMED POTATOES. 
 
 Cut cold boiled potatoes into cubes one third of an inch thick ; put 
 
 them into a shallow pan ; cover with milk (or half milk and half water). 
 
 Cook until the potatoes have absorbed nearly all the milk. Add to one 
 
 pint of potatoes one tablespoonful of butter, one half teaspoonful of 
 
 salt, one half teaspoonful of pepper, and one teaspoonful of chopped 
 
 parsley. 
 
 CREAM OF ASPARAGUS. 
 
 Cook half a bunch of asparagus and one small onion in one quart of 
 white broth half an hour or until the asparagus is done. Remove the 
 onion, strain, and rub through a sieve ; put back on the stove. Blend 
 two tablespoonfuls of milk and two tablespoonfuls of flour, add to the 
 soup, and cook fifteen minutes. Then take from the fire and beat in one 
 tablespoonful of butter, and at the last minute add half a cup of hot 
 cream. Season to taste with salt and pepper. 
 
 CREAM OP BARLEY. 
 
 Moisten half a pint (eight ounces) of well-washed barley with one 
 quart of white broth, add one small onion, and cook one hour. Season 
 with half a tablespoonful of salt and one saltspoonful of pepper. Strain 
 and thicken with one cup of cream and the yolks of two raw eggs. 
 
 Cream of rice may be made in the same way. 
 
 DRIED FRUIT SOUP. 
 
 Weigh one half pound of dried peaches, wash until perfectly clean, 
 and cook in one quart of water till very soft. Strain and squeeze out all 
 the juice. Sweeten to taste and serve. 
 
 Soup may be made from any of the dried fruits in the same way. 
 
 PANADA. 
 
 Sprinkle a little salt or sugar between some crackers (Boston, soda, or 
 Graham, or hard pilot biscuit) ; put them in a bowl ; pour over them 
 
THE IMPACTION OF REFUSE MATTER. 
 
 o;« 
 
 just enough boiling water to soak well ; put the l>owl in a vessel of boil- 
 ing water and let it remain fifteen or twenty minutes until the crackers 
 are quite clear and like a jelly but not broken. Lift carefully into a liot 
 saucer. Sprinkle on more sugar or salt, whichever is liked, and add a 
 few spoonfuls of sweet cream or wine if it be allowed. Never njake 
 more than enough for one time, as it is very insij)id when cold. 
 
 CHAPTER VIII. 
 ENEMATA.. SUPPOSITORIES. DOUCHES. CATHETERIZATION. 
 
 In the normal adult the rectum (the lower part of the bowelj lies 
 to the left of the spinal column, curving inward and upward (Fig. 15). 
 The length is about eight inches, and it is lined with 
 mucous membrane that has the power of absorbing 
 partially digested food. Above the rectum the intes- 
 tine is curved somewhat like the letter S, and it is in this curvature 
 that faecal or refuse matter (a product of the food) accumulates and 
 
 llie Rectum and 
 Intestine. 
 
 Fig. 15. — The curve of the eectum. 
 A, the pubic bone ; B, the bladder , C, the vagina ; E, the perinEeum ; D, the rectum. 
 
 becomes impacted. Still higher up, at the junction of the small and 
 sometimes large intestine (see Physiology: The Vital Processes in Health, 
 Fig. 2), there is also sometimes an impaction of this refuse matter, and it 
 is in these cases that an enema of larger quantity gives relief. 
 
934 NURSING THE SICK. 
 
 The simple enema is made of soapsuds. About two pints should 
 be given at a temperature of 10u° Fahr. The cleanest appliance for giv- 
 iuix ini enema is a glass funnel holding about half a pint 
 ^^'^"iniml'/a"" ""^ of^Huid, furnished\vith a rubber pipe to which the noz- 
 zle is attached. The ordinary " Davidson bulb '' (see 
 Jfedii'hies and T^vatmoit, Fig. 12) or "fountain syringes" are the most 
 useful in the home. In using the fountain syringe the nozzle is lirst 
 screwed into place and the bag filled to about three quarters its capacity 
 with the warm soapsuds. This bag should be hung high enough to per- 
 mit the water to flow with moderate force. The bed should be ])rotected 
 against accident by a rubber covered by a sheet or a sheet folded in 
 four thicknesses and placed directly underneath the patient. When it 
 is possible the patient should lie on the left side with the knees flexed 
 upon the abdomen, so as to relieve all strain, Tlie nozzle should be 
 lubricated with soap and the water allowed to flow freely to expel the 
 air and warm the tube, so that the rectum will not receive a shock by 
 the introduction of air or cold water. The nozzle is then inserted up- 
 ward, backward, and toward the left at least two or three inches of its 
 leno-th, extreme care being taken not to perforate or injure the walls of 
 the rectum. It will be remembered that the rectum lies to the left of 
 the spine, and the object of placing the patient on the left side is to 
 favour the flow of the fluid downward instead of upward. When the 
 fluid causes pain the enema should be stopped for a few seconds until 
 the pain passes off, and then continued until the patient can bear no 
 more. The nozzle is then gently withdrawn and a folded towel pressed 
 firmly against the anus (the opening to the rectum), thus aiding the 
 Ion O'er retention of the fluid and making the result more effectual. In 
 usino- the " Davidson bulb syringe " great care must be taken that too 
 much force is not used and that the air is expelled from the syringe 
 previous to its introduction. This is done by squeezing the bulb until 
 it is filled with fluid, keeping the suction end always Avell under water. 
 If the enema be retained another should be given, which will probably 
 be effectual in bringing away the preceding one. If it should be re- 
 tained altogether no harm is done, as the soap is harmless and the water 
 is readily taken up by the blood. 
 
 An enema of oil is useful in softening hard substances in extreme con- 
 stipation. This should be given warm (quantity about half a pint) entirely 
 by itself. It is to be retained and followed in lialf an hour by a soap- 
 suds enema. 
 
 A very useful combination for an enema is : 
 
 Glycerin 1 oz. 
 
 Rochelle salts 1 " 
 
 Water 2 " 
 
ENEMATA, PURGATIVE AND NUTRITIVE. 935 
 
 When turpentine is added to an enema it sliould fli-st be mixed with 
 oil or the white of an egjj;, to prevent irritating' the rectum. 
 
 The larger enema is given in what is known as the " knee-chest po- 
 sition," the patient kneeling, with tlie chest on the hed. ""J'his larger 
 quantity of water acts by distending the intestine, thus inci-easiug its 
 natural wormlike movements, so that the refuse matter impacted higher 
 up in the intestine is propelled downward and expelled. 
 
 " Nutritive " enemata should be administered every four or six 
 hours. Their long continuance is to be discouraged because of the ex- 
 treme irritability so often caused in the delicate mucous 
 Nutritive Enemata. , -ji i • t i . ,. , , . , 
 
 membrane with which the rectum is Imed, and for the 
 
 additional reason that this membrane, if overtaxed, will cease to absorb, 
 thus shutting off a valuable avenue for the introduction of much-needed 
 nourishment. A rectal douche of cold or tepid w^ater or one containing 
 half a teaspoonful of boric acid to a pint of water should be given once 
 or twice daily, to cleanse and give tone to the rectum. Food introduced 
 in this way should, as far as possible, be predigested, and should never 
 exceed four ounces in bulk. The materials generally used are peptonized 
 milk, beef juice, or extract of beef (Eudisch's Sarcopeptones) and yolks 
 of eggs, with some form of alcohol added when stimulation is required. 
 Many authorities maintain that the white of an egg, being largely albu- 
 minous, is to a very limited extent absorbed by the rectum, and is there- 
 fore objectionable, as it adds to the bulk and in this way interferes with 
 the usefulness of the enema. 
 
 A good size for a nutritive enema is the yolk of one egg. one or two 
 teaspoonfuls of beef extract, eight tablespoonfuls of peritonized milk 
 (four ounces), and half a teaspoonful of salt. This should be warmed to 
 the temperature of 100° Fahr. (blood heat) by putting it in a mug or 
 tumbler placed inside a large vessel filled with boiling water. The great- 
 est care is necessary in cleaning the inside of the syringe after a nutritive 
 enema has been given. If any portion of the material remains it is apt 
 to decompose, stop up the syringe, and make it foul. The nozzle must 
 always be boiled before using. Disease has heen conveyed from one 
 person to another hecause of neglect in this ^natter. 
 
 " Suppositories" are used as a convenient means of introducing medi- 
 cation into the rectum. Those containing drugs are made of cacao butter, 
 which melts at the temperature of the bodv. Those 
 
 Suppositories. , ^- ^ ji ^ • T J- " . 
 
 made entirely of glycerin are used lor purgative pur- 
 poses. In giving a suppository the patient should lie on the side, with 
 the knees well flexed, and the suppository should be inserted about an inch 
 and a half into the rectum. Care should be taken to be sure that the 
 rectum is free, and to ascertain afterward that the suppository has been 
 retained. 
 
936 NURSING THE SICK. 
 
 The object of the " vaginal douche " is to bathe and cleanse the vagina 
 
 and to reduce iutiannnation of the opening to the uterus. This is done 
 
 by introducing into the vagina several pints of warm or 
 
 ,, . , „ , „ hot water twice or three times daily. The recumbent 
 " \ affinal Douche. i » i 
 
 position should always be taken. Any other position 
 
 fails to accomplish the desired effect. The douche pan (of which there are 
 several makes) should raise the buttocks three or four inches from the 
 bed, the head should be low, and the hollow of the back well supported 
 by pillows. This position allows the water to flow well back into the 
 vagina, so that all parts are thoroughly bathed and irrigated. The foun- 
 tain syringe or an agate douche-can holding from two to four quarts can 
 be used. The vaginal nozzle containing a perforation at its end should 
 never be employed, as there is danger by this means of water being forced 
 into the uterus, causing serious trouble. The glass nozzle is by far the 
 best for this purpose, as any impurities can be seen and removed. This 
 should be done immediately after use, and before using again the nozzle 
 should be boiled. The temperature of the water, the amount to be used, 
 and the frequency of the douche will be ordered by the physician, and he 
 will also prescribe any medication or disinfectant necessary to be added. 
 A higher degree of heat can be borne after the vaginal walls have become 
 accustomed to the douche. Thus at first the douche may be ordered at a 
 temperature of 105° to 108° Fahr., and later gradually increased to a tem- 
 perature of 115° or 120° Fahr. 
 
 When a patient is very ill or unconscious the evacuations of the 
 bowels and the passage of urine have to be carefully looked after by 
 
 others. The bowels ought to be well freed once in 
 Care of the Bowels j. j. j: \ •£ -u .i £ 
 
 d El dd every twenty-iour hours, it necessary, by the use oi an 
 
 enema, suppository, or cathartic, and the bladder should 
 be emptied every eight or twelve hours. When there is difficulty in 
 passing urine there are a variety of simple means by which this can 
 often be accomplished, and tliey must he tried faithfully. The patient 
 should be placed upon the bedpan and water poured from one vessel to 
 another or allowed to run from a faucet within hearing ; or warm water 
 can be squeezed from a sponge directly over the lower part of the ab- 
 domen. Hot stupes can be applied, or alternations of heat and cold by 
 fomentation and ice. When all these devices fail, the catheter has to 
 be resorted to. 
 
 A catheter is a small tube perforated at the closed end and entirely 
 open and free at the other. Catheters are made of a variety of materials. 
 
 Those in common use are of glass, silver, or rubber. 
 
 Previous to using, the catheter should be sterilized. 
 Absorbent cotton, pieces of old linen, a basin or large-mouthed bottle in 
 which to receive the urine, should be provided. The hands of the per- 
 
THE USE OF THE CATHETER. 
 
 <m 
 
 son who is to catheterizc should ho well scrubhcd with a clean nail hrusli 
 and disinfected with the hichloride. Without touching other ohjects, the 
 left hand should be used to open the labia (entrance to the vaginaj, and 
 all secretions should be carefully washed away with the bichloride, a fresh 
 piece of cotton being used each time. The urethra in tlie female is one 
 and a half inches long, and the bladder, when moderately distended, is 
 about live inches in length and three inches across. It is tipped slightly 
 toward the front, so that, in passing the catheter, the inclination is in 
 that direction. The meatus or opening to the tube leading to the bladder 
 is to be found just above the entrance to the vagina. The catheter, held 
 firmly in the right hand, is then gently introduced into the meatus and 
 allowed to pass into the bladder. Force should never be used in intro- 
 ducing the catheter, as its direction may be wrong and a false opening 
 made. An apparent obstruction to the progress of the catheter may be 
 the walls of the bladder. The catheter should always he introduced hy 
 sight. If, owing to the nervousness of the patient or other causes, several 
 successive attempts to introduce the catheter result in failure, the patient 
 should be left to herself for a few minutes and allowed to 
 rest before resuming operations. When the catheter has 
 reached the bladder it will be known by the urine flowing 
 through it. If a constriction of the muscles upon the cathe- 
 ter takes place, a few seconds should elapse before attempting 
 to move it in either direction. Gentle pressure with the hand 
 over the bladder will often insure complete voiding of the 
 urine. Before the catheter is withdrawn the finger should be 
 placed over its end to prevent the urine flowing out over the 
 surface, and tlie catheter should be withdrawn upward toward 
 the abdomen. All these precautions are essential, as there is 
 great danger of inflammation occurring within the bladder 
 from impurities carried in by the catheter. Except in case of 
 necessity the use of the catheter by the laity is to be dis- 
 couraged. 
 
 When the bladder is overfull it should not be entirely 
 emptied at one time, as in this case also there is danger of 
 causing an inflammation. When in taking the urine it is found that a 
 large quantity has been drawn — say about one pint and a half — the cathe- 
 ter should be withdrawn and the remainder removed several hours after- 
 ward. 
 
 The normal amount of urine secreted by the kidneys of a healthy 
 adult in twenty-four hours is about fifty ounces, or three pints. Some- 
 times it is necessary to send a specimen for examination to the doctor, 
 and this should usually be taken from the accumulation of the twenty- 
 four hours. A simple test by heat is sometimes useful, especially in 
 
 Fig. 16.— a 
 test tcbe. 
 
938 NURSING THE SICK. 
 
 the care of tlie j)it.'gnant WDinan before continenient. A small quan- 
 tity of ui-ine should he placed in a test tul)e, as seen (Fig. lO), or an 
 old iron spoon, and lioated over a Hame hv passing the tube rapidly 
 through it. If the urine becomes cloudy or white, a specimen should 
 be sent at once to the physician. 
 
 CHAPTER IX. 
 
 APPLICATION^ OF HEAT AXD COLD BY POULTICES, STUPES, 
 PACKS, ICE COIL, ETC. 
 
 The immediate etfect of extreme heat or cold n))on the capillaries of 
 the skin is almost identical, the different degrees varying only in eflfect, 
 
 counter-irritation, the relief of pain, ehmination of heat, 
 
 Effect of Heat and i. i x i i i • i.i • r ^i • 
 
 • ,, or control of hsemorrhaoje beino^ tlie occasion for their 
 
 Culd. _ ® _ _ " 
 
 employment. As this article is to deal only with the 
 methods of appHcation, it may be well to give the general caution that 
 heat employed in excess destroys the tissues by burning, and extremes of 
 cold by freezing them. The greatest possible care is necessary when heat 
 is employed that it be not brought too near the skin, as nothing is more 
 distressing than, for instance, a burn on the heel from an unprotected 
 hot-water bottle, or an abdomen blistered by an overapplication of tur- 
 pentine. This danger of burning is greatly increased when the circula- 
 tion of the blood is poor. 
 
 The uses of poultices and materials from which they are made are to 
 be learned from the article in this volume on Medicines and Treatment. 
 
 Of these materials, flaxseed (linseed) meal probably 
 Poultices. . . . . 
 
 possesses the most useful combination of ingredients 
 
 and the power of retaining heat the longest. The proportions are equal 
 
 parts of water and meal. The water should be boiled, if possil)le, in the 
 
 dish in which the poultice is to be made. AYhen boiling it should be 
 
 removed from the lire and the meal stirred in rapidly till the poultice 
 
 is of the consistence of a soft solid, and drops without clinging to the 
 
 spoon. The poultice should then be well l^eaten from three to five 
 
 minutes, to make it light by incorporating the air, and spread upon a piece 
 
 of old muslin of suitable size and shape. The edges of the muslin are 
 
 turned over the poultice material and the face covered by a piece of 
 
 cheese cloth or old mosquito netting. The cheese cloth should be made 
 
 a little larger than the muslin upon wliich the poultice is spread, so that 
 
 it can be folded back over the muslin to keep the contents of the poultice 
 
 in place. If the poultice is to be applied to the throat, the neck, or a 
 
POULTICES AND THEIR APPLICATION. (y.>/,) 
 
 finger, it is well to fold it into one piece of cheese cloth or muslin, 'j'his 
 can be done more quickly, it adapts itself more readily to the part, and 
 there is less danger of the poultice squeezing out. Few poultices should 
 be made over half an inch in thickness. Those used for the chest must be 
 of light weight, otherwise they add to tlie already overburdened efforts of 
 respiration, and those intended for use over the abdominal wall sliould 
 never exceed a quarter of an inch in thickness. A liot newspaper, plate, 
 or tray can be used to carry the poultice to the sick-room, and oiled 
 muslin, a folded towel, or the hot newspaper can be placed over the 
 poultice to keep in the heat and moisture. Poultices should be retained 
 in place by bandages, or a binder made by doubling a piece of muslin 
 and pinning it firmly about the part of the body to which the poultice is 
 applied. Safety pins should be used for this purpose. The poultice tin 
 should be washed immediately, before the meal dries. This can be done 
 very quickly with a little warm water, and saves much future trouble. 
 
 Poultice material should never be used a second time, as it gets soggy 
 and loses its value. Flaxseed meal is inexpensive and can be obtained at 
 any pharmacy. Indian meal and a variety of vegetables are used as sub- 
 stitutes for flaxseed. Stale bread can be soaked in hot water, the water 
 drained ofE, and the bread used in the same way. Milk should never be 
 employed, as it soon becomes sour and objectionable. Starch poultice is 
 made by first mixing the starch with cold water and then adding boiling 
 water till it thickens. This poultice is sometimes used in abdominal cases 
 where very light weight is desirable, the starch being spread very thinly 
 over the cloth. Slippery-elm poultices should be made of one third slip- 
 pery elm to two thirds flaxseed meal ; a little more water is necessary than 
 that used for plain flaxseed poultice, otherwise it is made exactly the same. 
 
 The cotton jacket, or " dry poultice," is made by stitching a layer of 
 absorbent cotton between two pieces of mosquito netting or cheese cloth. 
 This poultice is used for the chest, and is preferable to flaxseed on account 
 of its lightness. It should be cut so as to pin at one shoulder and down 
 one side under the arm. It has to be changed every second or third day, 
 otherwise it becomes foul-smelling from the excretions from the body. 
 
 Mustard plaster should be made in the same way as flaxseed poultice, 
 
 except that tepid should be substituted for boiling water, as the latter 
 
 destroys the eflScacy of the mustard. This plaster can 
 Mustard Plaster. ' ', • p i • i ■ , t r t mi 
 
 be spread upon paper it desired instead of muslin, ihe 
 
 strength of these plasters varies from the pure mustard, when rapid 
 
 counter-irritation is desired, to equal parts of mustard and flour, or one 
 
 to ten or twenty for use upon children. The condition of the skin should 
 
 be watched constantly when mustard is applied, as its liability to blister 
 
 is great ; its action may continue and destroy the structure beneath 
 
 the skin. 
 
940 NURSING THE SICK. 
 
 Hot stupes are best made of two thicknesses of old flannel, preferably 
 
 of blanket, although new cheese cloth or nuislin may be used. The flannel 
 
 should be folded into a towel and placed in a basin 
 
 * while boiling water is j)0ured over it. The dry ends 
 
 of the towel are then used to wring out the stupe, by this means making 
 
 it very hot. A variety of special stupe wringers are made (example 
 
 Fig. 17), but the simplest 
 methods are often the 
 best. Care must be taken 
 to wring the stupe very 
 17.— A sTii'E WRINGER. dry, otherwise it damp- 
 
 ens the clothing and bed, 
 causing great discomfort to the patient. The flannel should be 
 I . shaken out hastily just as it is applied, to incorporate the air, and 
 i* thus aid in the greater retention of heat, and oil muslin or rubber 
 should be used as a cover to keep in the heat and moisture. Hot 
 stupes should be reapplied every ten minutes if a high degree of heat 
 is desirable. The counterirritant eflect can be increased by the use of 
 turpentine. The turpentine is mixed with olive oil, equal parts (a tea- 
 spoonful of each is commonly used), rubbed lightly over the surface, 
 and covered by the hot flannel. This precaution should always be taken, 
 as there is great danger of blistering when turpentine is sprinkled over 
 the surface of the stupe. Severe pain in the stomach or abdomen can 
 be quickly relieved by a hot alcohol stupe, made by saturating a piece of 
 thick flannel in alcohol and placing it between two plates in an oven till 
 hot. It should be carried to the bedside before removing the covering 
 and applied as hot as the skin will bear. 
 
 Heat can also be applied by means of rubber bags or bottles filled 
 
 with hot water, or bags filled with salt or sand and heated in an oven. 
 
 The old-fashioned soapstone or bricks heated are also 
 
 ^^ ''^^ *""! ^-^ most useful. When the hot-water bag is used it should 
 Dry Heat. . . ^ 
 
 be filled half full of boiling water and covered with 
 thick flannel. This bag can be applied to any part of the body, and 
 gives great relief from pain. An electric pad has recently been invented 
 for the same purpose. It is rapidly warmed by attaching the cord to an 
 electric-light fixture, and can be adapted readily to any surface. The 
 advantage of this method of applying heat is found in the lightness of 
 the pad and in the freedom from danger of burning the surface over 
 which it is used. 
 
 In giving the hot pack the mattress should be covered by a rubber 
 sheet and a large dry blanket. The patient is then enveloped completely 
 in another blanket wrung from water as hot as the hands can bear. 
 This blanket is passed quickly under the patient, one side folded over 
 
GIVING THE WET PACK. 
 
 941 
 
 the chest and one leg, wliile tlie other is wrapped cloBely around the 
 arms and the other leg and tucked firmly in at the Bhoulders. Tliis 
 arrangement of the Itlanket prevents two surfaces com- 
 ing in contact at any point, and keeps all parts of the 
 body equally moist. Tlie second blanket is then folded over the patient 
 and the whole surrounded by hot-water bottles or hot bricks and covered 
 
 The Hot Fade. 
 
 Fio. ly. — Wet tack: fu;st stage. 
 
 Fig. 19. — Wet pack: second stage. 
 
 by a rubber sheet or blanket to keep in the heat. An ice cap or cold wet 
 towel should be applied to the head. This pack is usually employed when 
 it becomes necessary to vvithdraw rapidly from the body a certain amount 
 
042 
 
 NURSING THE SICK. 
 
 of fluid, as in severe kidney disease, ete. Its duration should not exceed 
 one hour. 
 
 Fig. 20. — Wet pack : third stage. 
 
 The Void Wd Pack. 
 
 The cold wet pack is given in almost the same way as the hot pack. 
 A long sheet is used instead of the blanket. This sheet is wrung from 
 water varying from 60° to 80° Fahr. The body is 
 enveloped in the sheet and covered in tightly by the 
 dry blanket. Other blankets can be added to exclude the air, and a 
 towel wet in ice water applied to the head. This pack is usually contin- 
 ued from fifteen minutes to an hour. It is commonly used to control 
 nei'vousness and for elimination of heat from the body. 
 
 When the ice pack is given, two sheets are used in place of one, with 
 chopped ice put between them. A large quantity of ice is necessary to 
 produce any appreciable effect in cooling the body, and 
 it has to be constantly replenished. This pack is seldom 
 ke])t up over twenty minutes. 
 
 Cold can be applied to a limited 
 area by means of ice coils made to 
 fit certain parts of 
 the body, as the 
 head, spine, knee, or abdomen (Fig. 
 21). The arrangement of the coil is 
 as follows : A pail or foot tub con- 
 
 The Ice Pack. 
 
 The Ice Coil. 
 
 ^57 ^ST 
 
 i'lci. :^1. — An ice coll.. 
 
 taining water, and a large piece of ice ^i tube conducting ice water to, and B, tube 
 , . , , , conducting; it from, the coil. 
 
 wrapped m cheese cloth to prevent 
 
 the dirt from stopping up the ice coil, is elevated about two feet above 
 the level of the bed, as shown in Fig. 22. The water is siphoned through 
 the coil by means of the Davidson syringe or by excluding the air en- 
 
THE ICE (JOIL AND ICE POULTICE. 
 
 fi4:3 
 
 tirely frotn the tuhe by extciidiiit^ it. The tulx; tlirou^li vvliich tlio coil 
 empties should be fastened to a pail at the opposite side of tlie bed as 
 seen in Fig. 22. Wlieiiever the pail is nearly filled the water ean be 
 emptied into the tub and used again. 
 
 Fig. 22. — An ice coil in opekation. 
 
 Cold is also applied by rubber bags filled with chopped ice and adapted 
 to certain surfaces, or by ice poultices. An ice poultice is made by mix- 
 ing the chopped ice with dry flaxseed and filling it into 
 a bag of oiled muslin made for the purpose. The edges 
 of the bag are held together by binding with adhesive plaster, or they can 
 be turned over and hemmed down. A lapel is left at the top to be fast- 
 
 The Ice Poultice. 
 
1)44 NURSING THE SICK. 
 
 ened down in the same way utter the ice is put in. Those poultices can 
 be made of any size. They are particularly useful for the relief of sore 
 throat, or when it becomes necessary to apply cold to the chest or ab- 
 domen. 
 
 Iced cloths to the forehead give great relief from extreme pain in 
 the head. It is best to have a square of ice provided on which one cloth 
 is cooling while the other is in use. This plan is also 
 valuable when ice compresses liave to be applied to the 
 eyes. An evaporating lotion can be made of alcohol, ice, and water. In 
 applying, two thicknesses of cloth only should be used. They should 
 be changed before dry. 
 
 CHAPTER X. 
 MEDICAL NURSING.— CARE OF THE SICK AT NIGHT. 
 
 It is difficult to give any correct idea of the care of medical cases 
 without going into a lengthy description of the nursing in special dis- 
 eases. It may be said, however, in general, that the constitutional symp- 
 toms in connection with any disease have to be carefully noted and re- 
 ported upon, the condition of the alimentary canal, or digestive tract, the 
 skin, the respiratory organs, and the excreta thrown off by them. When 
 the stomach is irritable it is shown by extreme thirst, nausea, or vomit- 
 ing, and the object of all treatment and care is to overcome this con- 
 dition and make the retention of food possible. 
 
 Care of the mouth is of the lirst importance. The sense of taste may 
 
 be deadened, the teeth injured, the different glands connecting with the 
 
 mouth and even the ear may become infected by im- 
 Care of the Mouth. .. . , . , , , . r^ ■, ' ^ 
 
 purities carried in through the tubes. Swabs made 
 
 by twisting absorbent cotton about a toothpick or small stick, or a piece 
 of cloth wound about the finger, can be used for washing out the mouth, 
 and every particle of impurity must be removed from the roof of the 
 mouth, the teeth, and the tongue. Listerine, much used as a mouth wash, 
 is very cleansing, but a solution of glycerin, lemon juice, and ice is much 
 more agreeable. 
 
 Thirst and nausea probably can be best overcome by giving sips of 
 very hot water at frequent intervals, or "ice pills" — cracked ice sub- 
 jected to hot water to remove the sharp edges — can be 
 
 'j T- •/'■ given. The patient should be instructed to swallow 
 and vomiting. . , 
 
 tlie pills whole, as melted ice becomes warm before it 
 reaches the stomach, and does more harm than good. If cold water is 
 
CAEE OF MEDICAL CASES. 045 
 
 allowed, a small glass one third full will visually satisfy the patient as 
 fully as a large one tilled to the brim, and will do less harm. Vomiting 
 is often controlled by the use of capsicum or mustard ])last(;r over the pit 
 of the stomach, or by giving nourishment or acidulated drinks in very 
 small quantities, with ample rest between. The modern remedy fbut one 
 to be used only in experienced hands) is the stomach tube. The appa- 
 ratus consists of a flexible rubber tube about sixteen inches in length 
 with an opening on either side near one end, and a glass funnel and rubber 
 tube, connected by means of a glass pipe, to the other. (See Medicines 
 mid Treatment, Fig. 10). This apparatus is used both for washing out the 
 stonjach and for feeding. It is important that the tube be kept per- 
 fectly clean, especially when used for feeding. All vomited matter should 
 be examined, and in serious cases saved, as it is often of great diagnostic 
 value to the physician. 
 
 The nature, frequency, appearance, and odour of the movements 
 from the bowels are all important, and such points as the following 
 
 should be reported : The presence of mucus or fresh 
 Fceces and Urine. , i , . t i ,i , ^^, -, 
 
 blood in diarrhoea or other movements ; small round, 
 
 hard pieces, or those flattened into ribbon shape in constipation ; the 
 
 colour, if it be natural or absent, as in " clay-coloured " dejection when 
 
 jaundice is present, or yellow and of the consistence of " pea soup," as in 
 
 some cases of typhoid fever, or black from the presence of some drug, as 
 
 iron ; or it may be black and tarry from blood that has remained for 
 
 some time in the intestine ; the frequency, amount, and condition of the 
 
 urine— if there be difliculty in passing it, or if it be retained altogether. 
 
 If the appearance of blood is present in the urine, make sure that it is 
 
 not due to the monthly period. 
 
 The skin, if acting well, should be moist and soft. When it becomes 
 
 dry, hot, or glazed, or unusually hard, the proper amount of perspiration 
 
 can not pass off, and other organs of the bodv are taxed 
 The Skin. . 
 
 accordingly. It should also be carefully examined for 
 
 any eruption that may be present. 
 
 When the respiratory organs are affected the respiration must be 
 
 carefully counted, the frequency and severitv of cough 
 Respiratory Organs. , , , ^i , . j. ^-, ^ , 
 
 noted, and the expectoration carefully examined. 
 
 Purulent or bad-smelling sputum should always be disinfected, but it 
 is especially to the expectoration in cases of consumption — phthisis, tuber- 
 culosis of the lung — that our greatest attention should be directed. If 
 the sputum containing these poisonous germs be allowed to dry and fly 
 about in the atmosphere the greatest possible harm may be done. Such 
 germs will be sure to flnd lodgment in lung tissue too weak to resist their 
 action, and the disease, once fastened upon a human being, is hard to 
 
 eradicate. Prevention is then our line of action, for it is noio helieved 
 62 
 
946 NURSING THE SICK. 
 
 that if t/u'ne yerms were deistroyed immediately vpon heing coughed up 
 the disease would disappear entirely. Heredity in this case means only 
 the inheritance of a weak and susceptible luno- tissue, and not disease trans- 
 mitted by the blood. AVhen this disease is known to be present, those who 
 realize its infectious nature will surely be conscientious enough to avoid 
 expectoratiiiir u]K>n floors, sidewalks, or even on the ground, or in any 
 way distributing the seeds of a disease so fatal. 
 
 The " sanitary sputa cup " (Fig. i^3), made from paper prepared espe- 
 ciallv for the purpose and impervious to fluids, should be used. The 
 
 paper can be ])rocured cut and folded as 
 seen in Fig. 24, and simply tied about 
 with a bit of string, or the cup with an 
 adjustable frame can be purchased in quan- 
 tities. The special advantage of this cup 
 over one made of china is that it can be 
 burned without risk to a second person, 
 who may be obliged to empty the contents 
 Fig. 23.-SANITARY sputa cup. of the china cup. The cup when in use 
 
 should always be fllled one third with a dis- 
 infectant — bichloride (1 to 1,000), or carbolic (1 to 20). This is done to 
 imprison and kill the germ as soon as it appears. While the germ is 
 moist there is positively no danger of conveying the disease to others. 
 For this reason handkerchiefs, upon which the sputum is likely to dry, 
 should never be used. Use instead small pieces of soft muslin or cheese 
 cloth or Japan paper, and burn them at once. If this is not possible, 
 a hinge can be made in the top of a box cover and the napkins kept 
 closed in the box till they are burned. The china cup or the frame 
 used for the sanitary' cup should be boiled once in twenty-four hours. 
 
 The disinfection and disposal of excreta belong particularly to the 
 person caring for the sick, and it is here that almost her greatest useful- 
 ness can be exercised. In typhoid fever, for example, 
 Excreta. ., . 4: i .• i • .i 
 
 the poisonous germs are found entirely m the evacua- 
 tions from the bowels, and it is necessary to make sure of their destruc- 
 tion, otherwise they readily find their way into the water supply and thus 
 contaminate food and drink. To become active, this special germ must 
 be swallowed. The discharges containing the poison must therefore be 
 thoroughly broken up and w^ell mixed with a solution of bichloride of 
 mercury (corrosive sublimate), one part to five hundred of water, or car- 
 bolic acid (1 to 20). This must always be done before throwing them 
 into the sewer, and in country places, where sewage does not exist, a 
 trench as distant as possible from the water supply should be dug two 
 or three feet deep, and each evacuation, after thorough disinfection, should 
 be thrown into the trench and covered with chloride of lime and fresh 
 
CARE OF THE SICK AT NIGHT. 
 
 047 
 
 eartli. All clothing rcinovcd from the bed should be iintncrsed in car- 
 bolic solution, and the hands, whenever they have come in contact with 
 the typhoid patient, should be disinfected. 
 
 Fifi. 24.— Diagram of sanitary sputa cup. 
 
 Position of 
 the Body. 
 
 In certain diseases the position of the body is of such importance that 
 a word just here may not be out of place. In peritonitis, pneumonia, 
 
 and typhoid fever the strictly recumbent position must 
 
 be kept, and the use of the bedpan and urinal enforced. 
 
 In pneumonia every advantage for the expansion of the 
 diseased lung must be given, and as little work put upon the heart as 
 possible. In typhoid fever and peritonitis the friction of movement or 
 pressure brought upon the abdomen would tend to increase the inflam- 
 matory process and lessen the chance of recovery. The upright position 
 has to be maintained in cases where there is difficulty of breathing, either 
 from heart disease, fluid in the chest or abdomen, or from asthma. 
 
 In caring for the sick at night, preparations should be made so that 
 the patient may not be disturbed unnecessarily. Squeaking doors should 
 
 be oiled and all utensils handled with the utmost care. 
 '* the^Niqht "^^^^ dress and shoes worn by the night nurse must be 
 
 free from rustle and noise, her movements quiet, and 
 her manner soothing. A small tin refrigerator placed just outside the 
 sick-room is useful in saving steps, or one may be improvised bv the em- 
 ployment of a foot tub, large pan, or bowl. The ice should be raised 
 
948 NURSING THE SICK. 
 
 from below by piece? of wood, and the rajnd meltiiiu- of the ice prevented 
 by enveloping it in llannel or news])aper. The ''old doctor's icepick" 
 (a stout pin with a weighted knob), or a hat pin can be used for the crack- 
 ing of small pieces of ice noiselessly, or it can be chojijied in a bag, and 
 kept in the room suspended in cheese cloth tied over a bowl. The coal 
 should be ])i-e}iared as })reviously described, and brought noiselessly, and 
 an extra blanket or two provided. The eyes of the ])atient should be 
 protected from tlie light, and from shadows cast upon the walls and 
 ceilinof, as these are often more disturbin<r than the light itself. A " fairv 
 light," gas, or electric globes, covered by dark cambi-ic shades, or a can- 
 dlestick with reflector, can be used. The shadows can ])e prevented by 
 standing the light Avithin a canojiy made by bending ])astc1)oard into 
 sections, or standing three books on end and covering them by a fourth. 
 The clock has often to be removed, as the constant ticking disturbs 
 many people and prevents sleep. 
 
 Nervousness, sleeplessness, restlessness, and general discomfort of the 
 body can often be overcome by giving a cool light sponge (if allowed) 
 
 either with water or alcohol, or freshening up the bed 
 p 1"^ f '^ and cooling the back of the patient by fanning either 
 
 with the bedclothes or a fan. The application of heat 
 or friction, usually called " rubbing," will often relieve pain and put the 
 patient to sleep. Simple methods of relief should always be tried before 
 drugs are resorted to. The question whether sleep or nourishment is of 
 greater importance is a difficult one to settle, and when the illness is of a 
 critical nature, definite orders from the physician should be obtained. 
 Stupor is often confounded with sleep, and patients in this condition 
 have been allowed to pass away without the proper remedies or nourish- 
 ment being given which might have saved life had the true condition 
 been recognised. The ebb of human life is said to be lowest between 
 the hours of 1 and 5 a. m., and it is during these hours that the greatest 
 watchfulness is necessary. The extra blanket, the nourishment or stimu- 
 lation, should be given at this time. 
 
 The ventilation of the room at night frequently becomes a serious 
 question, as many people are opposed to inhaling what they consider the 
 
 " dangerous night air." They are much more willing 
 „. V, to breathe over ao-ain the air contaminated by the 
 
 poisonous exhalations from their own lungs. It is time 
 that this popular prejudice were overcome. The admission of too large 
 quantities of the air, deprived in part of its oxygen by the absence of the 
 sun, would be objectionable, but the constant admission of a small quan- 
 tity is essential and not hurtful. 
 
CARE OF SURGICAL CASES. 049 
 
 CIIAPTEE XI. 
 SURGICAL NURSING. 
 
 The general principles that apply to the nursing of medical cases may 
 be followed in surgical nursing, and it is only in the technique of the 
 dressing of surgical wounds and in the preparation of those about to 
 undergo a surgical operation that there is any essential difference. 
 
 The subject of injuries, wounds, and the emergencies and diseases 
 entailed by them, has been so ably dealt with in the article in this volume 
 entitled Surgical Injxiries and Surgical Diseases, that further men- 
 tion of the subject is intended only to impress upon the reader the neces- 
 sity of carrying out these general rules. 
 
 Surgical cleanliness, or asepsis, may be simply described by saying 
 
 that the hands, the instruments, the towels, the utensils — in fact, anything 
 
 surrounding the wound that is likely to be touched or 
 
 Cleanliness ^° come in contact with its surface must, as far as pos- 
 sible, be made free from germs. Sterilization by steam- 
 ing, boiling, or subjecting to a strong disinfecting solution is therefore 
 necessary. In dressing a clean wound, even though slight, the same care 
 in detail is necessary as in one of a more serious nature, as the danger of 
 introducing poisonous material is just as great. Whatever is to be used 
 for dressing, whether it be muslin or cheese cloth (unless the antiseptic 
 corrosive-sublimate gauze obtainable at any drug store be used), the 
 towels, and the water to be used upon the surface of the wound, should 
 be boiled, and small wads of absorbent cotton or cheese cloth — prepared 
 also by boiling — for the sponging. The basins or bowls for solutions, 
 and those in which to remove the old dressings, should be perfectly 
 clean. The bed and parts immediately surrounding the wound should 
 be covered by towels and protected underneath by a rubber or large 
 pieces of thick wrapping paper. The assistant's sleeves should be put 
 above the elbows and the hands well scrubbed with a clean nailbrush — 
 especially about the nails — in a lather of hot water and soap, for from 
 five to eight minutes. They are then washed for five minutes in a solu- 
 tion of bichloride of mercury (1 to 1,000). 
 
 The greatest possible care and delicacy should be used in removing 
 old dressings. Those adherent to the wound should be soaked off 
 
 ^ . with antiseptic solution and carefully lifted from either 
 
 Dressings, • i • t ^ i • tit «. 
 
 Side instead of being ruthlessly torn on. Avoid touch- 
 ing the surface of a wound and thus breaking up the newly formed or 
 forming tissue. Remove discharges from the surrounding skin by wash- 
 ing toward, not from, the wound. All soiled dressings, especiallv those 
 
950 
 
 NURSING THE SICK. 
 
 ooiitiiining tlie fatal poisonous discharges from tubercular joints or syph- 
 ilitic ulcers, or those saturated by pus, sliould be burned at once. If such 
 dressings be wrapped in newspaper there is no possible objection to their 
 beine: burned even in a cookine: stove. 
 
 'The Patient. 
 
 PREPARING FOR OPERATION. 
 
 In preparing a patient for operation attiMition sliould be given to the 
 following points : The stomach, the intestinal tract, the bladder, and the 
 surface to be operated upon. The diet two or three 
 days previous to the operation should be somewhat 
 lessened in quantity, but nourishing, and during the day immediately 
 preceding the operation should consist chietiy of fluids, avoiding milk. 
 The intestinal tract should be made free from any 
 accumulation of faecal matter by cathartics, and a 
 thorough enema given on the morning of the opera- 
 tion. The part to be operated upon should be well 
 cleaned, disinfected, and shaved, if necessary. The 
 oily matters of the skin, usually iilled with poison- 
 ous bacteria, can ])e removed by liquid soap, ether, 
 or alcohol, and a disinfecting dressing applied some 
 hours before the operation. But special instruc- 
 tions in these matters will be given by the surgeon 
 in charge. A bath should be given, the hair di- 
 vided and braided firmly on either side close to the 
 ears, if the patient be a woman, and when an anaes- 
 thetic is to be administered, any false teeth should 
 be removed. A loose night-gown and wrapper 
 should be worn, and long, warm stockings, or those 
 made especially for the purpose from pieces of old 
 blankets, as seen in Fig. 25. 
 
 In preparing the room for a surgical operation 
 
 it should be cleared of all unnecessary articles — i.e., 
 
 ^, ^ pictures, ornaments, upholstered 
 
 The. Room. r •, . r 
 
 furniture — m fact, everything 
 
 upon which dust can lodge. Have the room care- 
 fully swept, well aired, and wiped with a damp 
 cloth, and at the time of the operation heated to a 
 temperature of from 75° to 80° Falir. Lay a drug- 
 get or thick wrapping paper about twelve feet square, or ordinary rugs 
 turned wrong side up, near the best lighted windows, and on this place 
 a firm kitchen table, or boards resting on stands, or barrels of the same 
 height — even an ironing board can be used in some cases. This table 
 should be padded with a thick Ijlanket neatly folded and covered by a 
 
 Fig. 25. — Flannel stook- 
 ing for use duuinq 
 operation. 
 
BEFORE AND AFTER OPERATION. 951 
 
 sheet. A firm, flat-bottpmed chair should be provided for the surgeon, 
 and a stili" cushion or folded blankets furnished in case the chair is not 
 high enough. IJave one or two stands upon which to place instruments, 
 dressings, etc. ; plenty of hot 
 and cold water, ice, hot-water 
 bags, bottles or bricks, brandy 
 and a Davidson syringe in case 
 a stimulating enema is required ; 
 alcohol and ether to clean the 
 
 . Jb 10. -si'j. — A <;j{j:.sent-.si/ai'1.d basin. 
 
 skm, and tablets of bichloride 
 
 of mercury with which to make solution ; three china pitchers, and 
 basins for instruments (preferably hand basins), or the instruments can 
 be placed on a stand covered by towels wrung from carbolic-acid solu- 
 tion ; a toilet soap dish for ligatures ; soap and nail])rush ; two pails or 
 slop jars all scrupulously clean ; eighteen towels (old without fringe 
 preferred) ; rubber sheeting ; boiled water for instruments and sponges. 
 An ether cone can be made by covering a folded newspaper with a 
 towel and twisting it into a cornucopia. A small blanket should also be 
 provided with which to cover the patient on the operating table. Things 
 not obtainable in the house — i. e., gas or oil stoves, basins, table, etc. — 
 can usually be hired temporarily. At the time of operation a second 
 person should be in attendance for any emergency that may arise. The 
 surgeon generally furnishes the sponges, dressings, instruments, and 
 anaesthetics. 
 
 The bed to be occupied after operation should be protected by a rub- 
 ber, and made up firmly with an extra folded sheet to be placed directly 
 under the part operated upon, so that it can be easily 
 removed in case it becomes soiled by discharges or 
 haemorrhage. The bed and blanket in which to envelop the patient on 
 his return should be thoroughly heated by the use of hot-water bags or 
 bottles. 
 
 A crescent-shaped basin (Fig. 26) or toilet soap dish and towels should 
 
 be provided, as there is usually vomiting after the administration of ether. 
 
 This vomiting from ether is sometimes hard to control. 
 After the Operation. ,, ^ -n n ^ i ^ i. • • n i.'x' 
 
 " Ice pills, or Jiot water given in small quantities, or a 
 
 tumblerful of tepid water — used to wash out the stomach by increasing the 
 
 vomiting temporarily — prove useful means of getting rid of the ether. 
 
 The disagreeable taste of the ether can be somewhat removed by washing 
 
 out the mouth and rubbing the tongue thoroughly with ice water. An 
 
 ether chill is frequently seen in people with nervous temperament. It 
 
 means nothing and should cause no alarm. The patient should never be 
 
 left alone while coming out of ether, as choking is liable to occur either 
 
 from the materials vomited or from swallowing the tongue. This is a 
 
\\y2 NURSING THE SICK. 
 
 serious inarter, as it is a (|uesriun oi mimitt's only Avhcn the oxygen is 
 entirely shut uli' from the lungs. In uhnost any of the other emergencies 
 immediately following operation — lubmorrhage, heart failure, etc, — the 
 foot of the bed can be elevated from the tloor by placing a strong chair 
 underneatli the footboard ; external heat can be applied, and a small 
 amount of brandy, or whiskey given in hot water by enema. 
 
 CHAPTER XIL 
 OBSTETRICAL NURSING. 
 
 No inexperienced person would attempt to perform a surgical opera- 
 tion of any magnitude, and no person ignorant of the mechanism of child- 
 birth should wish to carry a woman through such a critical experience, 
 except in an extreme emergency. A physician should be consulted in the 
 early stages of pregnancy and should have the entire direction of the 
 woman during this period. Arrangements to secure a nurse thoroughly 
 trained in obstetrical practice should be made early, as those who follow 
 this branch of nursing successfully are often engaged six or seven months 
 in advance. The nurse will be able to give information about the articles 
 required and arrangements to be made for the confinement, and should, 
 if possible, be shown the topography of the house in which the confine- 
 ment is to take place. 
 
 If medical supervision is impossible, attention should be given to the 
 following points : Daily exercise for an hour or two in the open air, good 
 hygienic surroundings, and at least eight hours' sleep 
 during the twentj'-four are essential ; clothing loose 
 enough to allow of free circulation of blood ; frequent bathing, the sitz 
 bath being employed when the full bath proves too exhausting ; a gen- 
 erous but not too stimulating diet, and rigid regularity in eating should 
 be adhered to. The bowels, if not regulated by food and exercise, should 
 be moved daily either by purgative enema or simple laxative. The urine 
 should, if possible, be examined at intervals during pregnancy, and at 
 least four times during the last two months ; this is of serious import 
 to the patient, and must 7iot be neglected. The nipples require prepara- 
 tion or toughening. A daily application of solution of l)orax — a table- 
 spoon to one pint of water — can be used, and fresh cacao butter or albolene 
 used for lubrication. 
 
 The date at which labour is likely to occur can be 
 calculated in a variety of ways, one of the simplest being to add seven 
 days to the date of the beginning of the last menstrual period and count 
 
OBSTETRICAL NURSING. 953 
 
 forward nine months. This is usually within a week of the correct tiirie, 
 althouijh a difference of three weeks sometimes occurs. 
 
 A large, well-veiitilated room free from sewer connections, having, if 
 possible, a southern exposure, should be chosen. This room and its con- 
 tents should be thoroughly cleansed from dust and other impurities, and if 
 obliged to retain old stuffed furniture and drapei-ies, cover them, if pos- 
 sible, with clean sheets. Ascertain, if possible, that no contagious disease 
 germs have been recently present there. 
 
 Have in readiness two rubber sheets long enough to tuck under the 
 mattress, or the same amount of tar paper ; a large thick " sanitary pad " 
 used to protect the bed ; twelve clean sheets and twelve old soft towels 
 recently laundered ; several small squares of cheese cloth, to be used for 
 sponging ; a large rug that will extend well under the bed can be inverted 
 and made to protect the carpet ; binders and safety pins of different sizes; 
 sanitary napkins ; an earthenware bedpan ; Davidson's bulb or a fountain 
 syringe ; three pitchers for water ; bowls, or preferably hand basins, for 
 solutions, and one in which to receive the placenta ; two new nailbrushes ; 
 a slop jar and pail ; plenty of hot and cold water ; carbolic acid (1 to 20) 
 and bichloride solution (1 to 1,000) ; brandy, whiskey, and a glass and 
 water for administration by mouth ; glycerin for the hands ; a yard of 
 linen bobbin, a sixteenth of an inch wide, for tying the cord ; albolene 
 or sweet oil with which to remove the waxy secretions from the child's 
 body ; a soft blanket in which to wrap the child ; a child's bath-tub and 
 thermometer ; unscented soap — white Castile, the purest form obtainable, 
 preferred ; small pieces of linen or gauze to wash out the eyes ; and a 
 set of baby clothes. 
 
 The square " agate seamless bed or douche pan " and the " agate douche 
 or irrigator," holding from three and a half to five quarts, will answer all 
 purposes and completely take the place of syringes and the ordinary 
 "slipper" or "Eureka" bedpan. This entire outfit can be purchased at 
 any drug store, or the " pan " and " irrigator " can be obtained at less 
 cost at a crockery store where agate ware is kept, and the rubber tubing, 
 " stop-cork," and nozzles at a drug store. While the original cost of these 
 is probably a little higher (about five dollars), they obviate the necessity 
 of having two sets of utensils, and are more durable. 
 
 The materials used for the obstetrical dressings can also be purchased 
 at any drug store, or where surgical supplies are kept. Absorbent cotton 
 or cotton waste, absorbent gauze, oiled paper, bichloride 
 tablets (seven grains and a half to the pint of water 
 make a solution of 1 to 1,000), and carbolic-acid solution (1 to 20) are 
 necessary. Pound packages of the cotton and packages containing five 
 yards of the gauze are most economical. The best substitute for the 
 gauze is a good quality of bleached cheese cloth. 
 
951 
 
 NURSING THE SICK. 
 
 The sanitary pad should be about three feet square. In making it, 
 take a piece of oiled paper of this size and cover with a thick layer of 
 cotton waste, place it between cheese cloth and tack the whole loosely 
 about the edges with long stitches. The sanitary napkins are similarly 
 made. They should be of two sizes, those to be used immediately after 
 delivery being much wider and longer than those used subsequently. 
 The cheese cloth can be cut about twenty -live inches square and tilled 
 one third its width and a little less than its length with cotton waste. 
 The gauze is then folded over and stitched down the centre and across 
 the ends (Fig. ^7). The smaller napkin is made in the same way, except 
 
 h 
 
 ^.^j-^. 
 
 Fig. 27. — Sanitauy napkin. 
 
 that it should be much narrower and the cotton waste should extend only 
 about ten inches of its length, thus leaving the ends free and firm for 
 pinning. These napkins are sold at about fifty cents per dozen, but they 
 can be made at much less expense. Both the pads and napkins can be 
 sterilized by placing them in a covered dish or between two pans in an 
 oven and subjecting them to a slow heat for about four or five hours. 
 Avoid exposing them to the air till ready for use. 
 
 The bed should be made by covering the mattress first by a clean 
 sheet and then by a rubber sheet or tar paper (inexpensive and to be 
 burned after use) put lengthwise across the centre of the bed and 
 tucked firmly in at the sides. Over this spread a second rubber or tar 
 paper and cover with another sheet. Then put in place the " sanitary 
 pad," or, in the absence of tliis, three sheets folded in four thicknesses to 
 absorb the discharge. 
 
 The signs of beginning labour are pains in the lower part of the 
 abdomen and back, occurring at regular intervals about once every half 
 hour, and a discharge of mucus tinged with blood 
 from the vagina. True pains can be distinguished 
 from tliose that are false by placing the hand over the 
 lower part of the abdomen ; in true pains the contractions of the uterus 
 are to be readily felt through the abdominal wall. As the labour ad- 
 vances the pains grow more severe and the intervals shorter. The 
 first stase of labour consists in the dilatation of the uterus and ends when 
 
 True rind False 
 Pains. 
 
BEFORE DELIVERY. O55 
 
 the membranes liave rnptured and the uterus is completely diluted, ^i'he 
 second stage, or stage of expulsion, ends wlien the child is born, ""i'lie 
 third stage ends wlien the placenta is expressed and the uterus contracted 
 to the size of a closed hand. 
 
 The person in charge of the patient should make an entire change of 
 
 her personal clothing, and should always wear while on duty washable 
 
 dresses and aprons, keeping herself scrupulously clean. 
 
 Charge During the puerperal or cJiiIdbearing stage a 
 
 woman is peculiarly susceptible to infection, and it is 
 
 almost criminal to undertake the care of a woman about to be confined 
 
 after being in contact with any disease either contagious or " septic " tljat 
 
 is communicable. 
 
 The diminution of the condition or disease known as "childbed 
 fever " or " sepsis " is due, no doubt, to the aseptic and antiseptic pre- 
 cautions now being enforced. Let it be the motto of every one under- 
 taking such responsibility to carry out implicitly all the aseptic and 
 antiseptic precautions given. 
 
 When the labour pains begin the person in charge should notify the 
 doctor. This is best done by writing a note describing the nature and 
 frequency of the pains and the condition of the patient. 
 
 In the " first stage " of labour the patient should be allowed to walk 
 about and occupy herself, or sleep if inclined to do so. The bladder 
 should be frequently emptied and the large intestine 
 T ^ ^^, made perfectly free of any accumulation of fsecal matter 
 
 by an enema. This makes the labour easier and some- 
 times shortens its duration. Simple fluids should be given, avoiding 
 alcoholic or other stimulants. The patient must be instructed not to 
 bear down during the pains of this stage, and to sit, if walking about, 
 when a pain occurs. This rule should be adhered to, as there is danger 
 of too early rupture of the membranes and protracted and painful labour 
 in consequence. 
 
 Have in readiness for the examination by the doctor hot water, soap, 
 two clean nailbrushes and two bowls, one containing a disinfectant solu- 
 tion for the hands. Before preparing the patient for 
 ,-, j^ , the examination the hands and forearms of the attendant 
 
 should be scrubbed for three minutes in hot soapsuds 
 with a stiff nailbrush and washed again for five minutes in a disinfectant 
 solution. The nails should be kept short and care taken not to roughen 
 them. Use for cleaning a bone or a wood cleaner, and prevent the rough- 
 ening of the skin of the hands by the use of glycerin and by wiping 
 them perfectly dry. 
 
 The patient should be dressed in a loose wrapper and placed on the 
 back at the right side of the bed, with the clothes drawn out of the wav 
 
05G NURSING THE SICK. 
 
 aiul two sheets adjusted, one over each leg, to ]>rotect the body during 
 examination. After dipping the hands in the disinfectant clean carefully 
 the external genitals and surrounding parts Avith soap and water and 
 afterward with sterilized water or disinfectant solution, and remember 
 that the hands should always be held in a disinfectant each time before 
 touching the genitals. Care should also be had not to touch or handle 
 unnecessarily unclean surroundings. 
 
 During the " second stage " the patient must be kept strictly in bed 
 
 and not allowed to leave it for any ])urpose. She should be covered by 
 
 a sheet folded and tied loosely about the waist by a 
 
 ecom age oj ^^^^ passed through the middle and fastened securely 
 
 to the nightgown, which can be gathered in soft folds 
 
 well up under the arms. Strong safety pins should be used to ])in the 
 
 sheet, which is lapped over on the right side so as to cover both legs ; 
 
 the feet should be enveloped in a pair of white cotton stockings. 
 
 Delivery is usually made with the patient lying upon the left side, 
 but some practitioners prefer the patient placed upon the back. Firm 
 pressure made upon the lower part of the back during the pains gives 
 relief (in doing this the hand of the attendant should be kept "clean" by 
 using a disinfected towel), and the patient may be allowed to pull on a 
 sheet firmly secured to the foot of the bed. This greatly increases the 
 expulsive power of the uterus, and must be avoided in rapid delivery, 
 otherwise the parts may be ruptured. 
 
 In the " third stage" the person assisting may be called upon to hold 
 
 the uterus by placing the hand upon the abdominal wall and watching to 
 
 see that it remains properly contracted. Sometimes it 
 '■'■ Third stage" of , j. i • i i. ^.r 
 
 T L becomes necessary to make circular movements over the 
 
 Labour. •' , 
 
 uterus or to grasp it, and pushing firmly downward 
 promote contractions till the placenta, which should always be kept for 
 the doctor's inspection, is delivered. 
 
 In emergency, when no doctor is present, the patient should be placed 
 
 on the left side with the knees fiexed. All antiseptic precautions being 
 
 taken, the perinneum should be carefully watched. 
 
 7«er^e/!Ci'. are -^yj^^j^j ^j^^ head is to be seen, place the fingers against 
 
 of the Mother. . ^ . ^ '^ 
 
 it and hold it l)aek during the pains, to prevent too 
 
 rapid descent and to allow the gradual stretching of the vaginal walls. 
 If this plan be faithfully carried out there is little danger of laceration. 
 AVith the first child the labour is often slow, a half hour or more being 
 required for the passage of the head. In subsequent laliour the time is 
 usually much shorter, allowing little opportunity for proper preparations. 
 If the head is coming too rapidly, tell the patient to open her mouth and 
 avoid bearing down. When the head is delivered insert the finger into 
 the passage to see if the cord be about the neck, and if so pull it carefully 
 
AFTER DELIVERY. 957 
 
 over the head and wi])e the eyes and rnoutli free from secretion. The 
 
 hand should tlicn be placed on the abdomen over the uteruB, moved 
 
 downward till the child is expelled, and still held iirmly till the placenta 
 
 is expressed and the nterus contracted. The placenta shoulrl be twisted 
 
 as it is expelled till all the membranes come away. The uterus should be 
 
 held for at least half an hour after, or until the pulse is below 95. The 
 
 pulse should be taken frequently, and if it becomes very rapid a physician 
 
 should be called at once, as this probably indicates ha3m(jrrlia<^e. 
 
 As soon as the child is delivered the patient can be turned on the back 
 
 and an assistant told how to watch and hold the uterus, so that attention 
 
 . , .V, ., , ^^y ^J6 ffiven the child. The child should first be made 
 Care of the Child. ' " , , . , , « . , i 
 
 to cry out by slapping the face with the wet hand or a 
 
 towel. If it fails to respond to this treatment, and is not- breathing, the 
 cord should be cut at once (it is usual to wait till pulsation has ceased). 
 This is done by tying it with bobbin about two inches from the body, 
 and again two inches from that, and cutting between. Frequent subse- 
 quent examination of the cord is necessary to be sure no haemorrhage is 
 taking place. The child's body should then be immersed in a hot bath at 
 a temperature of 100° to 105° Fahr. The head should be bent back- 
 ward, and a piece of gauze or a handkerchief placed over its mouth so 
 that air can be blown into the lungs by breathing through the covering. 
 This should be done at least twelve or fifteen times, or till the child takes 
 a long breath. 
 
 When the child is successfully delivered, as described, the patient 
 should be cleansed of discharges by bathing all parts either with warm 
 
 water that has been boiled or with a disinfectant solu- 
 after Delivery ^^^^'> sterilized gauze or muslin that has been disinfected 
 
 being used. Be very careful to resterilize the hands 
 always hefore touching the genitals. When all impurities are removed, 
 one of the above-mentioned 
 " sanitary napkins " should 
 be used. If not sterilized, 
 a few layers of gauze satu- 
 rated in disinfectant solution 
 may be placed over it. 
 
 -3^6^ 
 
 The soiled pad and bed- ^^^ 28.-ABDOMmAL BI^'BER. 
 
 ding should be removed and 
 
 replaced by clean. An abdominal binder is then usually applied. This 
 binder should be made of unbleached muslin or bleached twill. It is 
 
 three feet six inches in length and fourteen inches in 
 Abdominal Binder. .,,, ,^. „„^ i i in i • ^ • ^ 
 
 Width (l^ig. 2b), and should, when pinned m place, ex- 
 tend from the border of the ribs in front to below the prominence of the 
 hips. It should be made to fit perfectly the contour of the body by 
 
958 
 
 NURSING THE SICK. 
 
 takin*;; in ilarts both above ami bt'low. To this is fastened the '^'^ani- 
 tarv napkin" held in j)laee by tour large safety pins. 
 
 Fiii. Ji'. — Binder with shoulder stka 
 
 I •. ■'■!'. — Sloane breast bindki: 
 
 Breast Binders. 
 
 Compression is made upon the breasts either by the use of the binder 
 with shoulder straps (Fig. 29), the " Sloane binder," or the '' Y breast 
 bandage.'' The Sloane breast binder (for dimensions 
 and shape of which see Fig. 30) is first pinned firmly 
 together down the front with medium-sized safety pins. Next, the darts 
 are taken in and the bandage attached to the abdominal binder by pinning 
 it about the waist, the whole being completed by fastening it firmly at 
 the shoulders (Fig. 31). 
 
 ^ 
 
 ^/ 
 
 
 Fic. 31. — The Sloane axu abdominal binders applied. 
 
 The Y breast binder, originally used in the Boston Lying-in Hospital,, 
 has the advantage of leaving the ni])ples exposed (Fig. 32), thus saving 
 unpinning at each nursing period. The nice adjustment of this bandage 
 rerpiircs considerable practice. A T bandage is made by folding a towel 
 lengthwise and pinning it at right angles to another towel folded in the 
 same way. The T is then made into a Y by making a diagonal fold in 
 the middle of the cross piece and fastening the corners of the plait with 
 safety pins. In putting the bandages on the long end of the Y is passed 
 under the back and pinned to the other ends as they are brought across, 
 one above and the other below the breasts. Smooth, thin layers of ab- 
 
CLEANLINESS, REST, AND QUIET. 
 
 059 
 
 sorbent cotton sliould be yjlaccd between the bandage and the breasts, at 
 the sides, and also under and between the breasts, to make tlie compres- 
 sion even and prevent chafing. Where the breasts are small it is some- 
 times an advantage to pin the bandage together in the centre. 
 
 Fig. 32. — The upper figure shows the double Y breast bandage in position. The lower left-hand 
 figure shows how the Y bandage is made. The third figure shows how the double Y bandace 
 is completed by fastening the arms of the Y to the tailpiece on the patient's opposite side. 
 
 General Rules. 
 
 Both the abdominal and breast binder should be changed as often as 
 soiled. They are usually worn about seven days, although their use may 
 be continued longer if comfort is derived from them. 
 
 The general rules for the care of medical cases apply to obstetrical 
 nursing as well. During the first week or more visitors should be ex- 
 cluded, as rest and quiet are of so much importance. 
 The patient should be kept on her back for the first six 
 or seven hours, and must not be allowed to sit erect during that time ; 
 afterward the position may be frequently changed. In some cases the 
 freedom of the room is allowed within ten days, and many women who 
 are strong resume their usual routine of life at the end of three weeks. 
 Too great haste in this matter is often regretted afterward when some 
 uterine difiiculty traceable to carelessness at this time appears. 
 
 The bed, the patient, and the room must be kept pei-fectly clean. 
 Some practitioners allow a bath every second day. The greatest possi- 
 ble care is to be used in giving it that the patient is not chilled. The 
 napkin will have to be changed at first every hour and later every three 
 to five hours, the parts being thoroughly cleansed and kept free from 
 
960 - NURSING THE SICK. 
 
 odour. All soiled clothes must be renioveil at once ; the napkin can be 
 wrapped in paper and burned ininiediatelv. 
 
 The diet is usually liquid for the tirst twentj-four hours, and if all 
 symptoms are normal after that a fidl meat diet is often allo^yed. 
 
 The bowels are usually moved on the third day by an enema or glyc- 
 erin suppository or other medication by mouth. 2[edlc'nie or vaginal 
 douches should be given only when ordered by the pliysician. 
 
 If there be retention of urine try the simple methods mentioned in 
 Chapter VIII of this article ; without orders use the catheter only in emer- 
 gency, and not more frequently than every eight hours. 
 
 The breasts also require careful management. The nipples should be 
 cleansed after every nursing with some weak antiseptic — i. e., boric acid 
 or other solution — to prevent cracking and infection. If the breasts be- 
 come too full give fluid sparingly, and apply a bandage for compression, 
 or rub very carefully with the hands from the base toward the centre of 
 the breast, the motion being circular. Rubbing is not advised where 
 inflammation is present. The amount and colour of the discharge — 
 lochia — is important. Normally it should be more or less bloody for 
 the tirst four days, growing gradually thinner and losing its colour till 
 it ceases, sometimes within two and sometimes not for four weeks. It 
 should never have a bad odour. Report carefully all other symptoms — 
 pulse, respiration, temperature, chills, pains, condition of the tongue, 
 stomach, etc. 
 
 CHAPTER XIII. 
 CARE OF THE NEWBORN CHILD. 
 
 The child should be carried into a warm room, 75° Fahr. The face 
 
 should be cleansed and the eyes wiped with a bit of soft linen, care being 
 
 _, . ^ , taken to remove the secretions from the lids before ap- 
 The First Balk. , . ^ • ^ . , . . . 
 
 plying any solution that may carry tn the impurities. 
 
 "Wasli the mouth with lukewarm water, using the little tinger gently so as 
 not to irritate the delicate membrane. If the child be strong, the bathing 
 may be done an hour later, on the lap, in a blanket, to avoid chilling. 
 
 After this the full tub bath can be given daily with safety (tempera- 
 ture of the water 100° Fahr.). The child is lifted into the tub by grasp- 
 
 .„, „ , _ , ing the ankles with one hand, supiiortinir the head and 
 
 The Full Tub Bath. ,^ , , ., , , , , , I , ., '^ , . 
 
 shoulders with the other, and held while bathing by the 
 
 thumb and little finger placed in the armpits, allowing the head to rest 
 
 upon the other fingers spread out like a fan at the back. Keep the body 
 
CAEE OF THE NEWBORN CHILD. 901 
 
 well under the water for alj(jut five minutes. Use a fresh cloth rather 
 
 than a sponge, and avoid too great friction of the skin or scalp. 
 
 Never use a fine-tooth comb on the scalp ; a soft brush is better. 
 
 Avoid powder, or use sparingly. Compound talcum or lycopodium are 
 
 probably the least irritating. The navel cord should be 
 Oeneral Rules. n ' i i i i i • i 11 
 
 well powdered and enveloped m dry absorbent cotton, 
 
 unless otherwise ordered, and held in place by the binder sewed on snugly. 
 
 Avoid making the binder too tight for comfort, or in any way limiting 
 
 the movements of the chest. 
 
 Frail children should be bathed with caution, and some amount of 
 
 medication may be introduced through the skin by the use of sweet oil 
 
 applied daily, instead of the bath. They should have extra heat supplied 
 
 to the body by means of hot- water bottles, and the greatest possible care 
 
 exercised to prevent chilling, which might prove fatal. 
 
 The " Gertrude " suit presents the most useful and hygienic mode of 
 
 clothing an infant. The band gives firm support to the abdominal wall ; 
 
 ^ ^ , ^, , . the slip and skirts, supported at the shoulders, are of 
 
 Infants Clothing. -n ^ • ^ -, ^ ^ . -,. -, r ^ 
 
 uniform thickness throughout, thus avoiding the faults 
 of the old-fashioned method of dressing, with its multiplicity of pins, 
 bands, and uneven distribution of heat and weight. The clothing should 
 be warm, of light texture, and so loosely applied that free movement of 
 the trunk and all extremities is possible, The child is dependent for 
 enjoyment and exercise upon two things — namely, full respirations (cry- 
 ing?) and kicking. 
 
 The napkins should be of " cotton diaper " of two sizes, the large 
 ones to be folded in a triangle, the smaller in a square, one point of 
 which extends well up under the band to prevent its being soiled. 
 
 When soiled or wet, the napkin should be changed at once and placed 
 in a bucket of water in the bath-room till taken to the laundry. Napkins 
 that have been wet should not be dried in the nursery or reapplied till 
 laundered and thoroughly aired, as they add to the impurities of the air, 
 and cause chafing. 
 
 Inflamed buttocks can be treated by washing thoroughly with soap 
 and water whenever the napkin is changed, and dusting with lycopodium 
 powder. If this fails to reduce the inflammation, stearate of zinc may be 
 used. 
 
 The passages of a newborn infant are greenish black, and of the con- 
 sistence of tar, until all the contents of the bowels at birth are evacuated. 
 
 When the mature milk of the mother is taken, about 
 Fcpcp 9 
 
 the fifth day the passages become normally pasty and 
 
 of a yellowish " canary colour." After the child has become accustomed to 
 the milk diet, if the passages show greenish streaks of mucous and undi- 
 gested curdy masses the digestion is not perfect. 
 C3 
 
902 NURSING THE SICK. 
 
 The eyes should at first be directed away from strong light, but the 
 mouth should always be left uncovered for the entrance of oxygen. 
 Fresh air is as necessary for health and growth as proper 
 Fresh Air ami ^_^^^^ .^^^^^ rei,nilation of the bowels ; and it is important 
 that the child should have every opportunity for phys- 
 ical development from the first. It is safe to say that the child may be 
 taken out of doors in fine weather at the end of ten days, and on pleasant 
 days in winter when three months old. 
 
 Regular habits of eating and sleeping must be established from the 
 first. This is very simple, for the child knows only what it is taught. 
 During the first three days the child should be put to 
 "'^" the breast four or five times, beginning after the mother 
 
 has had her first sleep. Although there is little milk secreted at this 
 time, it is a known fact that the nursing aids in the contraction of the 
 uterus, satisfies the cravings of the child, and that the colostrum (first 
 milk) helps the bowels to throw oil their contents. During this time the 
 child should be fed only plain warm water, as the sweetened water so 
 often given causes flatulence. 
 
 The mother's milk comes between the third and fifth day, usually in 
 abundance. The child should be nursed at both breasts every two hours 
 during the day and twice at night, the nursing to be continued fifteen or 
 twenty minutes. This plan is usually carried out for the first month or 
 six weeks, when the interval is lengthened to two and a half hours. No 
 artificial method of feeding will ever take the place of mother's milk, 
 and this fact should be urged upon mothers who wish to escape this tax- 
 ing ordeal. 
 
 It is sometimes a difiicult matter to make the child take hold of a 
 small contracted nipple. A vacuum can be made in a bottle with a large 
 mouth by inverting it in hot water and placing it quickly over the breast. 
 The nipple is thus drawn into the bottle and made more prominent. 
 "Weak children, disinclined to nurse, have often to be held by the assist- 
 ant (the mother has often to allow the breast to liang over a " weak nurs- 
 ling "), and great perseverance is necessary to make them take the requisite 
 amount of nourishment to sustain life. 
 
 Irregularity in nursing often does infinite harm. The digestion is 
 hindered and the mother's milk is changed in character by being irregu- 
 larly secreted. When there is overfeeding the milk is often returned 
 unchanged, or there may be vomiting or indigestion. 
 
 The nipples and the mouth of the child must he kept clean, otherwise 
 both suSer, the child from its sore mouth, the mother from infection 
 carried into the ducts, and the resulting much-dreaded abscess. 
 
 The mother should avoid diet and drinks of a stimulating character, 
 and keep herself as far as possible in a quiescent state during the nursing 
 
FOOD, NATURAL AND ARTIFICIAL. 963 
 
 period. If the child is well nourished the weight kIiouM steadily increase, 
 the week's average being from four to eight ounces. If losing in weight, 
 affected by colic, sleepless, and passing food in an undigested state, the 
 child requires the attention of the physician. 
 
 Weaning is usually begun at the ninth, and completed by the twelfth 
 
 month, unless the heat of summer makes tlie time undesirable. Dr. 
 
 Rotch, of Boston, first put into practice the method of 
 
 ArtificMFood. r"o<iifyi"g cow's milk to proportions of fat, sugar, and 
 
 albuminoids, found by recent analysis to be contained 
 
 in motlier's milk. Cow's milk contains fats four per cent, (cream), sugar 
 
 four per cent, (sugar of milk), albuminoids four per cent, (casein), in 
 
 round numbers, while the mother's milk of a high general average contains 
 
 fats four per cent., sugar seven per cent., albuminoids two per cent. The 
 
 albuminoids, as a curd-forming, element, is the one most apt to cause 
 
 trouble in the child's digestion. 
 
 The best substitute we have for mother's milk, according to recent 
 teaching, is cow's milk modified. The Walker-Gordon laboratories in 
 different cities meet the needs of a food containing the exact required 
 amounts of fats, etc., in a given case — that is, they supply the proportions 
 ordered by physicians on prescription. Dr. E,otch has taught how to 
 think in percentages of the various methods of preparing cow's milk. 
 Among domestic methods of modifying cow's milk to the proportions of 
 mother's milk are the following : " Top-milk " method, spoken of by Dr. 
 Holt in his excellent handbook on The Care and Feeding of CJiildren. 
 From a quart of milk allowed to stand in a cool place for five hours re- 
 move the top third about six ounces carefully by means of a spoon, and 
 avoid agitating; to this add two parts of water and a teaspoonful of 
 sugar (preferably milk sugar). Barley water is advised instead of water, 
 as it prevents the curdling of the milk in large lumps in the stomach. 
 This proportion will keep well for two days in winter, but should be 
 made fresh every day in summer. The milk thus modified can be given 
 simply heated, or it can be " peptonized," " sterilized," or " Pasteurized " 
 (the last method by means of Dr. Freeman's " Pasteurizer "), or it may 
 be set aside for future use after 
 simply heating the milk to 16Y° 
 Fahr. and putting it at once on 
 ice. 
 
 The exclusive use of " proprie- 
 tary foods " has been found to 
 give rise to malnutrition and 
 
 hsemorrhagic disease, known as fig. ss.-a ncesixg bottle. 
 
 scurvy. 
 
 The nursing bottle (Fig. 33) should be free from grooves in which 
 
 \ 
 
964: 
 
 NURSING THE SICK. 
 
 dirt can lodge, and should be provided with a straight black rubber nip- 
 ple (tliose furnished with long tubes can not be made clean). Both the 
 bottle and the nipple should be boiled between each 
 
 The Nursing Bottle. 
 
 feedinff. 
 
 "Modified" and "sterilized" milk can be had in bottles suital)le for 
 one feeding. It is best heated l)y standing the bottle in warm water. 
 
 GENERAL RULES FOR FEEDING INFANTS (Dr. T. M. Rotch). 
 
 First week 
 
 One to six weeks 
 
 Six to twelve weeks, and possibly 
 
 to fifth or sixth month 
 
 At six months 
 
 At ten months 
 
 Intervals of 
 feeding. 
 
 2 hours. 
 2\ hours. 
 
 3 hours. 
 3 hours. 
 3 hours. 
 
 Number of 
 
 feedings in 
 
 24 hours. 
 
 10 
 
 8 
 
 6 
 6 
 5 
 
 Average 
 
 amount at 
 
 each feeding. 
 
 1 oz. 
 
 li to 2 oz. 
 
 3 to 4 oz. 
 6oz. 
 8oz. 
 
 Average 
 amount in 
 34 hours. 
 
 10 OZ. 
 12 to 16 oz, 
 
 18 to 24 oz. 
 36 oz. 
 40 oz. 
 
 CHAPTER XIV. 
 
 NURSING INFECTIOUS AND CONTAGIOUS CASES. 
 
 Responsibility of 
 
 the Person in 
 
 Charge. 
 
 In the care and isolation of those suffering from contagious and in- 
 fectious disease much depends upon the person in immediate charge of 
 the patient. Next to the physician, on her rests the 
 responsibility of preventing the spread of disease germs. 
 She must first understand and believe in the contagious- 
 ness of the germs, and feel the importance of carrying 
 out the measures established for their extinction. Waging daily warfare 
 against these enemies of mankind is as useful, and requires almost as much 
 courage and perseverance, as the " taking of a city." 
 
 Isolation, to be complete, must include the removal of superfluous 
 draperies, furniture, rugs, etc., the shutting off the sick-room or apart- 
 ments from other parts of the house, and the destruction 
 of the germs thrown off froin the body, or means for 
 keeping them under control. This task would be accomplished easily if 
 the germs could be seen, but, as they are invisible, we sometimes forget 
 them. 
 
 If possible, two rooms should be given up to the isolation — one in 
 which to disinfect and make all arrangements for the care and comfort 
 of the patient, and the other for the occupancy of the patient, or one 
 
 Isolation. 
 
CARE OF INFECTIOUS AND CONTAGIOUS CASES. 965 
 
 may be occupied while the other is airing, the exchange being made 
 
 every twenty-four Jiours. This is an admirable plan, but entails extra 
 
 labour. The rooms should be at the top of the liouse. 
 
 Locution and Ar- j j. ,-, ,-, n ■, , , , 
 
 , ,. J, it otlier rooms on the same noor have to be used, a 
 
 ra7h(jement of Rooms. _ _ ' 
 
 sheet kept constantly wet in a mixture of glycerin, one 
 part to six parts of carbolic-acid solution (1 to 80), should be tacked 
 to the outer frame of the door of the sick-room, so that it sweeps to and 
 fro when the door is opened. This tends to catch and imprison the 
 germs, and prevents them from floating out into the surrounding atmos- 
 phere. Two sheets should be kept in constant use, one always soaking 
 in the solution. They should be boiled, if possible,' every third day. 
 
 Communication with others in the house can be established by means 
 of a slate on which the messages are written in a large hand so that they 
 
 can be read at a distance. The children of the family 
 Further Preventive i i j i . - . i i i i j -r ^^ ^ i 
 
 ^ should be sent to otlier households — it possible where 
 
 there are no children. Other preventive measures include 
 thorough cleanliness of all objects and utensils, destruction of all excreta, 
 introduction of a free supply of sunlight, air, and heat, that drive out 
 dampness and foul air. All dust should be removed daily from wood- 
 work, furniture, and floors with a cloth dampened with bichloride, 1 to 
 2,000 (germicide). The floors should be wiped up on hands and knees. 
 Avoid too much moisture, as wetting the germs down instead of remov- 
 ing is objectionable. They are sure to float again in the air as soon 
 as dry. The highly polished floor is the most sanitary. Nothing should 
 be removed from the rooms without being disinfected or protected by 
 coverings saturated in disinfecting fluid. Even imused food should be 
 enveloped in paper ready for burning and sent down in this way. 
 
 An open fire adds greatly to the ventilation of the room, and can be 
 readily used for destruction of unused food and excreta. Old cloth, 
 
 cheese cloth, or soft Japanese paper napkins can be 
 Value of an Open i _<• n j- i <• ^i , . 
 
 Fire ^ discharges tTom the nose, expectoration, 
 
 etc., and for washing from the surface any discharge 
 from the bowels. These should he 'burned at once. 
 
 If fsecal matter mixed with sawdust can not be burned, it should be 
 saturated, thoroughly mixed, and allowed to stand one hour in a solution 
 of chloride of lime, six ounces to the gallon of water, 
 and Urine Urine can be disinfected in the same way. The water- 
 
 closet can be disinfected with the same solution or 
 with simple slaked lime in solution. 
 
 Keep the room as far as possible free from flies. They and other 
 insects have been the means of conveying infection from one person to 
 another. The bed should be kept scrupulously clean, frequent changes 
 of linen being made. The clothing, when not soiled, can be wrapped 
 
966 NURSING THE SICK. 
 
 tifflitlv in a carbolized sheet and sent at once to be boiled, or it can be 
 
 soaked for six hours in a sohition of carbolic acid (1 to 20), and then 
 
 boiled. Clothes that are soiled slu)uld be washed first 
 
 L , , r ■ ' bv the attendant and then subiected to the carbolic solu- 
 Jiea, (iHii Linen. -' _ •' 
 
 tion and aftcrwanl boilud. A washtub or footbath 
 placed on a stool can be used for the disinfectant, and a special boiler 
 kept on the range ready for use. The water in these should be changed 
 every twenty-four lu»urs. 
 
 The patient should be bathed as often as permitted. When oily sub- 
 stances, such as vaseline, etc., are used upon the skin in the eruptive con- 
 tagions to prevent the scales from Hying, they should 
 
 Care of the Patient. ^ -, ^^ j , i . .i ' . , i .• 
 
 not be allowed to accumulate, as they prevent tlie action 
 
 of the skin and too much work is thrown upon other organs in conse- 
 quence, especially upon the kidneys. To guard against chilling is of 
 equal importance for the same reason. 
 
 When the eyes need protection, as in measles, etc., use a screen 
 directly over the eyes or about the bed. Do not in any case shut out 
 the sunlight from the room. 
 
 Dishes and all utensils not injured by heat should be boiled frequently. 
 A large tin pan and gas stove are indispensable for this purpose, and 
 always before returning them to the household supply cleanse and dis- 
 infect them. 
 
 Children's toys, books, and brushes that have come closely in contact 
 with the patient should be burned. 
 
 When convalescent and ready to leave isolation, the patient should be 
 bathed in a solution of bichloride (1 to 5,000), the hair being washed in 
 a solution of 1 to 1,000. The body can then be enveloped in a clean sheet 
 and the patient taken to another room. 
 
 Instruction for disinfection of the rooms and their contents will be 
 found in the articles on Hygiene and Diseases in General. 
 
 It remains only to mention a few points that may be helpful to the 
 
 person in charge of the patient. Simplicity of dress, as few articles as 
 
 possible being worn, is important. Old shoes and 
 Dress and Hygiene ..li. ii jiiii jtj; j 
 
 4-ii. A,i^ t corsets that can be burned should be used, li good 
 of the Attendayit. _ ^ => 
 
 shoes be worn it is necessary at the end of the case to 
 scrape the soles well and subject them to a thorough wetting in bichloride, 
 which does not improve their condition. Shoes can be made noiseless 
 for night use by a bandage of old muslin torn in four-inch strips and 
 wound about them. Cotton clothing should be used — simple fabrics that 
 bear boiling or carbolizing. In cold weather a sack or dressing gown 
 of wool may be necessary. Subjecting wool goods to carbolic for one 
 hour only does not materially injure them, or they may be baked in an 
 oven at moderate heat for a number of hours to disinfect them. 
 
DRESS AND HYGIENE OF THE ATTENDANT. 907 
 
 The hair should be covered by a triangular bandage made of soft 
 muslin and tied about the head (see Surgical Injuries and Surgical Dis- 
 eases^ Figs. 4 and 5) so as Gomjjletely to ewvelop the ha/lr. This point is 
 very important. The hair, being naturally moist and oily, encourages 
 the retention and growth of bacteria, and is almost as fruitful a medium 
 for their transmission as the " finger nail." At least four of these l^and- 
 ages should be provided, and if one of them be worn constantly while in 
 the sick-room it enables the attendant to take outdoor exercise without 
 washing the hair. 
 
 When following out these instructions one can go out with safety 
 while in quarantine, after brushing a solution of bichloride or carbolic 
 rapidly over the hair with the hand, taking a bicliloride bath and chang- 
 ing the clothing. If the patient can not be left, an airing should be taken 
 by protecting the body from cold in winter and sitting for an hour or 
 two at an open window. This is quite as important as the necessity for 
 taking plenty of very nourishing food, gargling the throat two or three 
 times daily, especially in caring for diphtheria, or contagions involving 
 sore throat, and taking a tonic. After the patient is out of quarantine and 
 the disinfection of the room complete, the hair of the attendant should 
 be well washed in bichloride (1 to 1,000), and afterward with strong soap- 
 suds, and the body sponged in a solution of the same strength, followed 
 by a hot bath. 
 
 CHAPTER XY. 
 
 CONVALESCENCE. 
 
 Convalescence, so tedious and irksome to the person recovering 
 from a severe and lengthy illness, can be made both endurable and inter- 
 esting. A variety of occupations of a mild and judicious nature should 
 be planned, and watchfulness exercised that overfatigue or too much 
 excitement does not discourage the patient or cause him to lose self- 
 control. 
 
 When the temperature, pulse, and respiration have reached the normal 
 limit, and the appetite, sleep, and general feelings of activity are returning, 
 the patient may be allowed to sit up in bed supported 
 by a back rest. The time is usually limited to from 
 ten minutes to half an hour on the first day. Gradually the time is in- 
 creased and the interval shortened. Do not wait for the patient to com- 
 plain of fatigue. On showing signs of this he should he put to hed at 
 once. Those who are well and strong little realize the amount of exer- 
 tion and excitement caused by the simple act of sitting up. 
 
968 
 
 NURSING THE SICK. 
 
 The Nightimjale. 
 
 The "nightingale," named for Miss Florence Kightingale, the pioneer 
 nurse, whu, as is well known, did such noble work in the Crimean AVar, 
 and who established the present system of training 
 nurses in hospitals, is a useful wraj) to be worn about 
 the shoulders in bed. It is usually made of eider down or some light- 
 weiijht tiannel, for the dimensions of which see Fig. 34. The corners of 
 
 the cut made at the middle of 
 
 the goods are turned back to 
 
 3-1 ;-^ ^ y, \ form the opening for the neck, 
 
 and the whole piece can be 
 hemmed around with feather 
 stitching. The outer corners 
 at the extreme lower border 
 can be finished with two but- 
 
 Fio. 34.-A Nightingale. j.^^^^ ,^^^^ buttouholes tO gather 
 
 about the wrist, and the '' nightingale " can be held in place by ribbons 
 tied at the neck in front. 
 
 A "bed sack" is recommended by Miss Camp in her Reference 
 Book for Nurses as affording better protection for the arms. " Pic- 
 ture to yourself a white tiannel sack with the usual 
 The Be bac^. g\^Qi^\(\QY seams and arm sizes, the back in one piece 
 about twenty-four inches broad from arm to arm, the front and neck 
 correspondingly large. The neck, left straight, and two inches higher 
 than usual, is faced with soft blue or pink silk, shirred three or four 
 times, and gathered up just to fit the throat and tied with ribbon to match 
 the silk. The sleeves, made full, similarly faced and shirred, make tlie 
 sack quite complete. It is so broad across the back that it is put on 
 without the least effort, and the bit of colour about the throat makes it 
 very attractive." 
 
 When the patient is able to sit out of bed a reclining chair or sofa 
 may be used, but there is an advantage in having a wheel-chair or cot so 
 that the patient can be wheeled or carried into another 
 room. In many cases change of scene, if only for an 
 hour, is very beneficial. Provide warm stockings, bed slippers, and a 
 wrapper for protection and pillows for comfort. The foot of the chair 
 should be placed at right angles with the bed, so that the person lifting 
 can turn and deposit the patient without going around the chair. The 
 pillows should be built into the seat and back and the blankets spread 
 over them. The patient, if not too heavy, can be lifted by one person. 
 The arms of the patient can be locked about the neck of the attendant, 
 who, placing one hand under the thigh and the other under the back, can 
 lift even a very weak patient without mueli upsetting. When two people 
 are required in the lifting they should both stand at the same side of the 
 
 On leaving the Bad. 
 
MANAGEMENT OF CONVALESCENCE. 
 
 969 
 
 bed, placing the hands, one under tlie hlioulderB and buttockH, the other 
 under the thighs and ankles, and, lifting in unison, turn and put the 
 patient into the chair gently. The Ijlankets are then turned up at the 
 foot, folded over from either side and fastened securely by safety pins 
 to insure keeping the feet warrrdy covered. If the patient suffers from 
 cold feet a hot-water bottle can be put to the feet before pinning the 
 blankets. The upper blanket can then be fastened about the neck and 
 shoulders, or a nightingale may be worn (Fig. 35). 
 
 As the patient gains in strength his condition will be greatly benefited 
 by the fresh air, and if not strong enough to bear driving he might be 
 
 Fig. 35. — A convalescent. 
 
 carried into the sunlight on a cot, and, if necessary, an umbrella used 
 to protect the head. The first drive should be made short, increasing 
 daily. 
 
 The diet of a convalescent must be watched carefully, and, if the 
 appetite is failing, or undigested food is vomited, the condition is probably 
 due to overeating or to food that is unsuitable. At this 
 period some patients have to be constantly spurred on 
 and encouraged to use their strength, while others have to be held in 
 check. It is here that the greatest exercise of tact, discernment, and self- 
 control on the part of the attendant are necessary. If confidence be 
 established, and through strong personal influence complete control of 
 
 Diet and Exercise, 
 
970 NURSING THE SICK. 
 
 the will of the patient be gained — this is especially true in nervous affec- 
 tions — rapid recovery should be made. 
 
 Relapse, except in the germ diseases, is probably most often due to 
 overexertion, overfeeding, or nervous excitement. The condition of 
 nervous excitement in certain people often reaches a 
 e apse. high pitch before it becomes visible, or before the patient 
 
 gives any sign. The quick, trained eye should see this condition coming 
 on and should, if possible, prevent it by sending away the visitor, chang- 
 ing the conversation, or making the patient lie down or take a walk in 
 the fresh air. 
 
 In early convalescence the visits of friends have to be limited, and 
 it is often best that the patient be kept in ignorance of their solicitude. 
 Avoid discussion of the matter in the presence of the 
 patient, and thus remain master of the situation. The 
 few callers that are permitted should come at a time when the patient is 
 at the best and their stay should be brief. Preparation for the night 
 should be made early. A sponge bath, gentle rubbing to take the place 
 of exercise, will often insure a good night's sleep. 
 
 CHAPTER XYI. 
 CARE OF THE DYING AND LAYING OUT THE DEAD. 
 
 Disease terminates either in resolution and a return to health or in 
 the alternative, death. When death takes place and there is no physician 
 present, the fact must be established. (See Surgical Injuries and Surgi- 
 cal Diseases., Chapter XIII.) It is thought by those who have investi- 
 gated the subject that death is much less painful than is popularly sup- 
 posed, and long hospital experience justifies this belief. 
 
 There is very little that can be done for the comfort of the dying. 
 
 Unless unconscious, they naturally take the position that gives greatest 
 
 ease, and usually th^v should be allowed to remain in 
 Care of the Dying. , ^ .,. " ^^ "i ^ ^ • . mi 
 
 that position except when extreme dyspnoea exists. I he 
 
 perspiration can he removed from the surface with soft towels or hand- 
 kerchiefs and the face gently fanned. An extra amount of external heat 
 can be applied when the extremities are cold, and the action of the heart 
 is sometimes materially increased by use of a hot poultice or a sponge 
 wrung from hot water and applied directly over the surface. If the pa- 
 tient can swallow, half an ounce of brandy in hot water can be given, or 
 an enema of whiskey, one ounce to three ounces of hot water. Great 
 
THE DYING AND THE DEAD. 97I 
 
 relief also is sometimes given by the introduction of cold air fi-oni tlio 
 top of a window. 
 
 After the fact of death has l)een esta])lish(jd the cliin may Ijo hold in 
 place by a bandage, or supported from below l^y a pillow case folded 
 
 into small compass. The eyelids can be kept closed by 
 
 Bathing and Ar- ■. . ,. . j- .-, • • , , , 
 
 ranging the Body. P^'^^"'f ^ ^"'.y P'««« ^^ *^^^" ''"^^«<^ P^P^^ ""^^^^ the upper 
 
 lid. The hair should be combed and, in case of a 
 
 woman, braided firmly, and a lock of hair taken for the friends. The 
 
 body should then be bathed, the orifices left open, and a large sheet 
 
 folded into a triangle well padded with cotton wadding can be used to 
 
 envelop the loins and receive the discharges from the bowels. Closing 
 
 the orifices, or putting tight bands about the body is objectionable ; the 
 
 gases have then no proper means of escape. The ankles, knees, and 
 
 wrists should at first be tied firmly together. It is quite unnecessary to 
 
 place the head low or in the unnatural position so often seen. One or 
 
 two pillows can be used. 
 
 If no undertaker is in immediate attendance the use of ice upon the 
 
 abdomen (to prevent decomposition) is advised. A 
 
 Belomposition. ^^'^S® ^^* P^^ (probably the best home arrangement 
 
 that can be made) is filled with cracked ice and placed 
 
 upon the abdomen over the first sheet, and the ice kept replenished as it 
 
 melts. 
 
 Avoid using fluids upon the surface, as they only soften the skin. 
 Air should be admitted from the top of the windows, keeping the 
 lower sashes closed. This precaution prevents the entrance of intruders 
 from outside and creates a better circulation of the air. Direct draughts 
 should be avoided. The room should be kept cool — as cold as possible — 
 and if ice is plenty, two or three large pieces standing in tubs about the 
 room would be useful. 
 
 If an examination (autopsy) is to be made, protect the carpet with old 
 
 rugs or paper, provide a firm table or board on barrels, 
 
 ^^^lutopsy! "'^ three pails and basins and pitchers of hot and cold water, 
 
 ice, twine, a large needle, a roll of cotton wadding, 
 
 soap, stiff nailbrushes, and bichloride solution (1-1,000). 
 
 The clothing should be opened through its entire length at the back 
 
 and carefully folded under by turning gently from one 
 
 ^^"'^ClotUnq ^ ^^^® ^° *^® other. A long nightdress should be used 
 
 till the time for placing in the coflin arrives. 
 
 In dressing for the grave a dress formerly worn gives the most 
 
 natural effect, especially in the old ; otherwise, cream, white, or lilac, if the 
 
 casket be of the same colour, can be used. Simplicity of detail, always 
 
 most elegant, is especially suited to the dignity and solemnity of death. 
 
INDEX. 
 
 Abdomen, 61. 
 
 Abscess, 459, 504 ; acute, .471, 472 ; beneath the 
 jaw, 555 ; between the tooth and jaw, 551 ; cold, 
 485, 486 ; deep, of the palm, 580 ; formation of, 
 629, 630 ; of the brain, 789 ; of the breast, 558, 
 659 ; of the eyelids, 883, 884 ; of the fingers, 581, 
 582 ; of the liver, 703, 704 ; of the neck, 554 ; of 
 the prostate gland, 596 ; of the tonsil, 550 ; origi- 
 nating in the lymphatic glands of the armpit, 
 578 ; superficial, in the armpit, 578 ; tubercular, 
 485, 486, 559, 560. 
 
 Absorption, 88, 93, 94. 
 
 Acne, 604, 605. 
 
 Aconite tablets, 836, 837. 
 
 Actions, reflex, 132, 133 ; spontaneous, 101. 
 
 Adam's apple, 69, 672. 
 
 Adipocere, 592. 
 
 After-image, 145 ; negative, 145 ; positive, 145. 
 
 Afterpains, 755. 
 
 Ague, brow, 879 ; cake, 704, 705 ; fever and, see 
 Fevbr, Intermittent. 
 
 Air, 109 ; and pus in the pleural cavity, 671, 672 ; 
 composition of, 318 ; expired, 108, 113 ; ground, 
 336, 338, 339, 355, 356 ; movement of, 334 ; sewer, 
 322, 362, 364 ; stationary, 107 ; tidal, 107 ; viti- 
 ation of, 321. 322, 323, 324. 
 
 Air-cells, 71. 
 
 Air-passages, 68, 674. 
 
 Air-sacs, 106. 
 
 Air-vesicles, 674. 
 
 Albuminoids, 89, 381. 
 
 Albumoses, 381. 
 
 Alcohol, 444, 842 ; abuse of, 783 ; injurious effects 
 of, 611, 612 ; use of, at puberty, 409. 
 
 Alcohohsm, 543, 611, 612, 789, 790, 791, 792, 793, 794, 
 829, 830 ; Keeley gold cure for, 791, 792, 793. 
 
 Ahmentary canal, 59, 88, 89, 135, 568. 
 
 Alimentation, 88, 89. 
 
 Aloin, belladonna and podophyUin tablets, 837, 
 838. 
 
 Alumina sulphate, 372. 
 
 Ammonia, aromatic spirit of, 845, 846 ; water, 
 889. 
 
 Amoeba, 129 ; coli, 699, 703. 
 
 Ampulla, 150, 152. 
 
 Amputations, 440, 504. 
 
 Amylopsin, 91. 
 
 Anabolism, 114, 115. 
 
 Anaemia of the brain, 795 ; of the spinal cord, 
 795 ; pernicious, 767. 
 
 Anaesthesia, 795. 
 
 Anaesthetics, 202. 
 
 Anastomosis, 36. 
 
 Anatomy, 85 ; human, 1. 
 
 Anemometer, 333, 334. 
 
 Aneurism, false, 439, 468 ; of the arch of the 
 aorta, 693 ; traumatic, 439, 468, 583. 
 
 Angina Ludovici, 5.55 ; pectoris, 689, 090, 691. 
 
 Ankle, 15, 16, 17 ; sprain of the, 526, 527. 
 
 Anthrax, 543, 544. 
 
 Antipyrine, 612, 849. 
 
 Antisepsis, 748 ; during the lying-in period, 757 ; 
 in the management of labour, 748, 749, 750, 955, 
 959, 960 ; in the treatment of wounds, 441, 442, 
 443, 444, 445. 
 
 Antiseptics, 429, 443, 452. 
 
 Antiseptic solutions, 461. 
 
 Antrum of Highmore, 75, 551. 
 
 Anus, 59, 89 ; artificial, 570, 573 ; painful fissure 
 of the, 570, 571 ; wounds of the, and rectum, 
 570. 
 
 Anvil, 79. 
 
 Aorta, 24, 27, 29, 31, 61, 99, 100. 
 
 Aphasia, 795, 796. 
 
 Aphthae. See Thrcsh. 
 
 Apnoea, death from, 590. 
 
 Apoplexy, 543, 710, 885. 
 
 Appendicitis, 565, 566, 567, 568, 705. 
 
 Appendix, vermiform, 64, 93. 
 
 Appetite, loss of, 880. 
 
 Arbor vitse, 49. 
 
 Argon, 319. 
 
 Arm, 10, 189, 280. 
 
 Arrowroot, 930. 
 
 Arterial constriction, 103, 104 ; dilation, 103, 104. 
 
 Arteries, 25, 28, 88, 97, 100, 101, 104 ; bleeding 
 from, 437, 448, 449 ; hsemorrhoidal, 64 ; pulmo- 
 nary, 25, 27, 99 ; wounds of, 98, 99. 
 
 Artery, anterior tibial, 31 ; axillary, 30 ; brachial, 
 30, 577, 578 ; common carotid, 553 ; external 
 carotid, 30 ; external iliac, 31 ; femoral, 31, 
 
 ■ 583 ; hepatic, 65 ; internal carotid, 30 ; inter- 
 nal Uiac, 31 ; left common carotid, 30 ; left 
 common iliac, 29, 31 ; left subclavian, 30 ; pop- 
 liteal, 31 ; posterior tibial, 31, 33 ; radial, 31, 
 99, 578, 579 ; right common carotid, 30 ; right 
 common ihac, 29, 31 ; right subclavian, 30 : rup- 
 ture of an, 468 ; ulnar, 31, 578, 579 ; umbiUcal, 
 161, 162. 
 
 Arthritis, acute serous, 530, 531. 
 
 Articulations, 17, 18. 
 
 Asepsis, 748 ; in the management of labour, 748, 
 749, 750, 955, 959, 960 ; in the treatment of 
 wounds, 441, 442, 443, 444, 445. 
 
974 
 
 INDEX. 
 
 Asparag:us, cream of, 932. 
 
 Asphyxia, deatlj from, 590. 
 
 Asthma, crj, 075, 083, 084. 
 
 Astigmatism, 147. 
 
 Atavism, 105, 7S4, 785. 
 
 Athletics, intercolleRiate, 297 ; track, 248, 249, 
 
 200, SVW ; training for track, 291>. 
 Atmosphere, 332, 340. 
 Atomizers, 854. 
 
 Atrophy. 790, 797 ; muscular, 808. 
 Atteutiou. 140, 211, 218. 219, 220, 221, 227. 
 Auricles, 20, 27. 
 Auriculoveutricular opening, 26, 27 ; valves, 99, 
 
 100. 
 Automatism, 122, 132. 
 Autopsy, preparing for an, 971. 
 
 Bacillus, 623 ; anthrax, 544 ; comma, 631, 032 ; 
 diphtheriiP (KlebsLi>effler), 307, 000, 001, 002 ; 
 of malignant tedema, 3:37 ; of splenic fever, ,337 ; 
 tetani, ;«7, 480 ; tuberculosis, 323, 484, 615, 018, 
 625, 628, 075, 076 ; typhosus, 352, 617, 618, 025, 
 6.56, 946. 
 Back-rest, 911. 
 Backbone, 4. 
 
 Bacteria, 93, 623, 624, 625, 626, 627, 628 ; in ice, 352 ; 
 in relation to food, 386 ; in the air, 322, 323 ; 
 killed by boiling, 352 ; modes of gaining access 
 to the tissues, 479 ; multiplication of, in the 
 blood, 030 ; non-pathogenic, 027 ; of erysipelas, 
 630 ; of putrefaction, 474 ; omnipresence of, 4:^4, 
 435, 436 ; pathogenic, 627, 628, 029, 630 ; poisons 
 produced by, 435, 430 ; propagation of, 624 ; 
 pyogenic, 458, 459, 400, 554, 029 ; react toward 
 the body fluids, 031 ; relation of, to disease, 027, 
 628, 029 ; relation of, to inflammation occurring 
 in wounds, 4.34, 4;i-), 436, 441, 443, 449 ; removal 
 and destruction of, 443, 462 ; total exclusion of 
 impossible, in emergencies, 443, 444 ; ulceration 
 caused by, 440. 
 Badminton, 275. 
 
 Bandage, applied by the flgure-of-eight method, 
 457, 458 ; applied by the spiral method, 457 ; 
 Esmarch's triangular, 455 ; how to apply to a 
 limb, 450, 457 ; oblong, 4.54, 455 ; roller, 454, 455, 
 456 ; spica, 458 : triangular, 454. 
 Barley, cream of, 932 ; gruel. 929. 
 Barometer, 332 ; aneroid, 3.3:1 ; cistern, 332, 3.33 ; 
 
 reading the record of, 333 ; siphon, 3.33. 
 Barometric variations, .3.30. 
 Bars, home parallel, 279, 282 ; horizontal, 278 ; 
 
 parallel, 278, 302 ; vaulting, 278. 
 Baseball, 245, 265, 260, 296, 302; training for, 
 
 299. 
 Basedow's disease, see GoItre, Exophthalmic. 
 Basket ball. 273. 
 Bas.sini"s operation. .575. 
 
 Bath, alcohol, 805 ; bran, 899 ; cold, 3.53, 828, 829, 
 864, 915 ; cold sponge, 3.53, .354 ; cold tub, 804 ; 
 compressed air, 899, 900; cool, 353, 354, 915; 
 daily, for infant, 754, 755 ; foot, 864, 805, 914 ; 
 for newborn child, 7.52, 753, 900 ; full tub. 914 ; 
 full tub, for infant, 900, 961 ; general, .3.53 ; herb, 
 899 ; hip, 805. 915 : hot, 3.53, 3.54 ; hot-air, .353 ; 
 hot tub. 803 : local, 353 ; malt, 899 ; medicated, 
 353 ; milk, 899 ; mud, 899 ; mustard, 805, 800, 
 
 887 : needle, 353, 354, 355 : pine-needle, 899 ; 
 rain, 354, 355 ; Russian, 899 ; sand, 899 ; sea, 
 354 ; shower, 353, 364 ; sitz, 916 ; sponge, 805, 
 913, 914 ; sponge, of alcohol and water, 877 ; 
 tan, 890 ; temperate, 915 ; tepid, 3.53 ; Turkish, 
 881, 898, 899 ; vapour, 3.53 ; very hot, 353 ; warm, 
 353, 364, 804 ; bath-thermometer, 915. 
 
 Bathing, 352, 828, 803 ; during pregnancy, 740 ; in 
 old age, 411 ; sea, 354,897. 
 
 Bathroom, ;te4. 
 
 Bath tub, 364, ;i56. 
 
 Battledoor and shuttlecock, 275. 
 
 Bed, 904 ; changing the, of a helpless patient, 905, 
 900 ; confinement to, 800 ; labour, 743, 964 ; liftr 
 ing patient from one to another, 910, 911. 
 
 Bedroom, 401. 
 
 Bed-sack, 908. 
 
 Bedsores, 910, 917. 
 
 Bed-tray, invalid's, 924. 
 
 Beef, broiled pulp, 931 : broth, nutritious, 927 ; es- 
 sence, bottled, 927 ; juice, 926 ; sandwiches, 931 ; 
 tea, 926, 927. 
 
 Beer, 611. 
 
 Biceps, 11, 22, 23, 280, 281, 282, 286, 286. 
 
 Bicuspids, 00. 
 
 Bicycling, 200, 261, .302, 828; correct position in, 
 255, 250, 204 ; for girls, 205 ; for women, 263, 
 204 ; incorrect position in, 255, 250. 
 
 Bile, 90, 91,92, 119. 
 
 Biliousness, 871, 872. 
 
 Binder, abdominal, 957, 958, 959 ; breast, 598, 599 ; 
 Sloane, 958 ; with shoulder straps, 958 ; Y 
 breast, 958, 959. 
 
 Birth, 162, 823 ; records of, 309, 312. 
 
 Birth-rate, relation of, to death-rate, 313. 
 
 Black eye, 543. 
 
 Black heads, 80, 602. 
 
 Bladder, gall, 61, 65, 60 ; tapping the, 73, 74 ; urin- 
 ary, 15, 01, 73, 74, 112, 930. 
 
 Bleeders, 437. 
 
 Bleeding, application of heat to stop, 448 ; cau- 
 terization to stop, 449 ; from arteries, 4.37, 448, 
 449, 579, 583 ; capillaries, 437 ; large vessels in 
 the neck, .5.53, 554 ; the bowels, 880 ; the lungs, 
 885 ; the nose, 519, 546, 880 ; the stomach, 886 ; 
 veins, 98, 437 ; wounds, 437, 438, 570 ; how to 
 stop, 445, 446, 447, 448, 449, 543, 578, 579, 583. 
 
 Blind area, 3,57 ; spot, 78, 145, 146. 
 
 Blood, 88, 94. 95 ; circulation of, 25, 27, 28, 97, 101, 
 272, 590. 613, 085, 086 : clotting of, 96 ; colour of, 
 108, 109 ; effusion of, beneath the skin. 468 ; 
 embryonic, 102 : equalizes body temperature, 
 119 ; heart, 105 ; lessened amount of, in brain 
 during sleep, 164 ; lesser circulation of the, 27 ; 
 loss of, 4.37, 438, 452 ; maternal, 162 ; passage 
 of, through respiratory organs, 105 ; plates, 
 95, 96 ; poisoning, 479 : potency of, 780 ; quan- 
 tity of, in the body, 437 : regurgitation of. 26, 
 27 ; respiratory changes in the, 108 ; spitting 
 of, 684, 6R5 : supply, 3 ; system, 88, 105 ; varia- 
 tion of local supply, 103. 
 
 Blood-vessels, 3, 83, 674 ; intercommunication of, 
 36, 37. 
 
 Bloody flux, 699. 
 
 Blushing, cause of. 104. 
 
 Boils, 472, 473. 543, 544, 546, 578, 629. 
 
INDEX. 
 
 975 
 
 Bone, 1, 3, 80, 382 ; breast, 4, 9 ; ethmoid, 0, 8, 70 ; 
 frontal, 0, 7, 70 ; hip, 15, 19, 20 ; hyoid, 4, 74 ; 
 mastoid, 7, 8 ; occipital, 0, 7 ; palate, 70 ; tem- 
 poral, 18, 54 ; thigh, 15, 19, 20 ; vomer, 75. 
 
 Bones, 1, 3, 4, 88 ; cheek, 4 ; ear, 149 ; enlarge- 
 ment of turbinated, 8 ; flat, 1, 3, 4 ; inferior 
 maxillary, 8 ; inferior turbinated, 8 ; innomi- 
 nate, 15, 19, 20 ; irregular, 4 ; lachrymal, 8, 70 ; 
 long, 1, 2, 3, 4 ; malar, 8, 70 ; metacarpal, 14 ; 
 nasal, 8 ; of the face, 8 ; of the fingers, 14 ; 
 of the foot, 10 ; of the hand, 14 ; of the leg, 
 15 ; of the shoulder, 10 ; of the toes, 17 ; of 
 the skull, 4, ; of the wrist, 14 ; palate, 8, 76 ; 
 parietal, 0, 7 ; short, 4 ; sphenoid, 0, 8, 76 ; su- 
 perior maxillary, 8, 70 ; temporal, 6, 7, 8 ; tur- 
 binated, 8, 75. 
 
 Boric-acid tablets, 841. 
 
 Bottle, nursing, 903, 964. 
 
 Bottles containing drugs, 921 ; labelling, 921. 
 
 Bouillon, 928. 
 
 Bowels, 15 ; care of the, 754. 831, 936. 
 
 Bowling, 275. 
 
 Boxing, 828. 
 
 Boys, care of, at puberty, 407 ; growth of, 163 ; 
 physical training of, 265, 266, 292. 
 
 Brain, 6, 40, 42, 83, 80, 88, 103, 131, 169, 214 ; com- 
 parative importance, size, and weight of the, 42, 
 134, 135 ; compression of the, 540, 541, 542 ; con- 
 cussion of the, 240, 541 ; convolutions of the 
 human, 43, 44 ; cortex of the, 47, 135, 136, 137, 
 176, 186, 187, 188, 190, 195, 196 ; divisions of the, 
 42 ; functions of the, 179, 188, 590 ; growth of 
 the, 42 ; in the absence of stimulation, 188 ; lat- 
 eral" ventricles of the, 46, 47 ; left hemisphere 
 of the, 140 ; location of the, 42 ; membranous 
 coverings of the, 42 ; motor functions of the, 
 212 ; motor outgo of the, 189 ; motor parts of the, 
 134 ; processes, 187, 188, 225, 226 ; relation of 
 centres to impulses, 44 ; relation of size to in- 
 tellectual capacity, 42 ; retentiveness of the, 
 
 187 ; right hemisphere of the, 140 ; second ven- 
 tricle of the, 46 ; sensitiveness of the cortex, 
 
 188 ; sensory parts of the, 134 ; set of the, 189, 
 190, 191, 192, 194, 195, 212, 214, 223 ; softening of 
 the, 37, 813 ; stem, 135 ; temperament of the, 
 
 189 ; cells, 114, 164 ; centres, 190 ; fatigue, 203 ; 
 habits, 189, 206, 212, 213, 214, 216 ; water on the, 
 802 ; workers, hygiene of, 411, 412, 413. 
 
 Breast, 83, 558, 559 ; caked, 761 ; care of, during 
 pregnancy and lactation, 741, 760, 761, 960. 
 
 Breathing, 69, 108, 319, 320, 590. 
 
 Bright's disease, 707, 708, 715, 716, 717, 718, 719, 720. 
 721 ; acute, 711, 712, 713, 714 ; chronic, 714, 715, 
 716, 717, 718, 719, 720, 721 ; heart disease compli- 
 cating, 709 ; heart disease producing, 709 ; in- 
 flammatory complications of, 710. 
 
 Bronchi, 70, 674 ; diseases of the, 673, 673. 
 
 Bronchitis, 673, 875 ; capillary, 681, 682 ; chronic, 
 673. 
 
 Broncho-pneumonia, 679, 681, 682. 
 
 Brown mixture, 845. 
 
 Bunion, 587, 588. 
 
 Burners, gas, 329. 
 
 Burns, 495, 496, 497. 
 
 Bursa, 588. 
 
 Buttocks, inflamed, of infants, 961. 
 
 C'jecum, 03, CA. 
 
 Caisson disease, 797. 
 
 Callus, 504. 
 
 Calomel, 873, 875, 879 ; tablets, 838, 839, 874. 
 
 Canal, alimentary, 59, 88, 89 ; auditory, 78 ; coch- 
 lear, 1.00, 151 ; lachrymal, 78, 149 ; neural, 83 ; 
 semicircular, 79, 80, 1.00, 1.52, 153 ; spinal, .5. 
 
 Cancer of the face, .544 ; of the gut, .569 ; of the 
 lip in smokers, 544 ; of the liver, 703 ; of the 
 fxjsophagus, 550 ; of the rectum, .573 ; of the 
 stomach, 696, 697 ; of the tongue, 548 ; trans- 
 mission of, 614. 
 
 Canine madness, see Hydrophobia. 
 
 Canker sores, .549, .5.50, 883. 
 
 Capillaries, 25, 30, 88, 97, 98, 100, 101, 104 ; bleeding 
 from, 437 ; lymphatic, 104 ; jjulmonary, 71. 
 
 Capsicum plaster, 945. 
 
 Capsule, 17 ; external, 47 ; internal, 47 ; Mal- 
 pighian, 110, 111 ; suprarenal, 73. 
 
 Carbohydrates, 90, 92, 115. 110, 118, 379, 380, 381, 382. 
 
 Carbolic acid, 430, 444. 
 
 Carbon dioxide, .320. 
 
 Carbonic acid, 98, 105, 109, 110, 114, 323 ; gas. 
 amount given off, .320. 
 
 Carbuncle, 473, 474, 543, 544. 
 
 Carlsbad salts, 851, 852, 872. 
 
 Cartilage, 10, 17, 88 ; arytsenoid, 69 ; cricoid, 69 ; 
 cuneiform, 69 ; thyroid, 69. 
 
 Castor oil, 842, 873, 874, 875. 
 
 Catalepsy, 797. 
 
 Catarrh, suffocative, 681, 682. 
 
 Catgut, hgatures of, 449 ; sterilizing, 449. 
 
 Cathartics, saline, 851, 852, 853. 
 
 Catheterization, 936, 937. 
 
 Cavity, greater peritoneal, 61 ; lesser peritoneal, 
 61 ; nasal, 75, 128, 154 ; pleural, 71 ; resonance, 
 128 ; thoracic, 68. 
 
 Cell, 185, 186 : body, 132 ; germ, 167 ; origin of 
 the human body, 86, 87, 160 ; processes, 188. 
 
 Cells, 86, 113, 169 ; amoeboid, 129 ; cardiac muscle, 
 121 ; cDiated, 129 ; cortical, 1.36. 141 ; differenti- 
 ation of, 87, 161 ; epithelial, 75, 80 ; fat, 114 ; 
 functions of, 86, 87 ; gustatory, 155 ; hepatic 
 (or liver), 66, 114, 120 ; living, 88 ; mastoid, 79 ; 
 motor, 134 ; muscle, 120, 121 ; nerve, 131, 132, 
 133, 144; olfactory, 154 : psychic, 134 : pyramidal, 
 136 ; sensory, 134 ; size of, 86 ; spontaneity of, 
 102 ; stellate, 39 ; structure of, 86 ; white, 630. 
 
 Cellulose, 380. 
 
 Celsius's scale, 331. 
 
 Census, local, 309 ; national, 309 : returns, 309. 
 
 Centre, accelerator, 102 : cardio-inhibitory, 102 ; 
 of hearing, 140 ; of sight, 140 ; respiratory, 108 ; 
 speech, 138, 139, 140. 
 
 Cephalalgia. See Headache. 
 
 Cerebellum, 40, 42, 43, 46, 48 ; falx cerebelli. 42, 
 49 ; function of the, 136 ; hemispheres of the, 
 49 ; inferior peduncle of the. 49 ; lateral hemi- 
 spheres of the, 48, 49 ; median lobe of the. 48, 
 49 ; middle peduncle of the, 49 : results of in- 
 jury to the. 136 ; size of the, 48 ; structure of 
 the, 48, 49 : superior peduncle of the. 49 ; ten- 
 torium cerebelli. 42. 48 ; weight of the. 48. 
 
 Cerebro-spinal fluid, 42. 
 
 Cerebrum, 42, 43. 44, 46. 47 : cortex of the. 134, 
 136 ; crura cerebri, 45, 46, 47 ; divisions of the. 
 
9Y6 
 
 INDEX. 
 
 43 ; falx cerebri, 42 ; frontal lobes of the, HO ; 
 heinisphere.s of the, -Vi, 40. 
 
 Cesspool, 301, 370. 
 
 Chancroid, 595, GOO, 001. 
 
 Change of life, 159, 725, 733. 
 
 Chest, 0, 107 ; register, 128 ; to exercise the mus- 
 cles of the, 285, 280 ; voice, 12S ; wall, 10. 
 
 Chicken broth, 928 ; jelly, 931 ; souffl6, 931, 932. 
 
 Chicken pox, 417. tU.5. 049, 050. 
 
 Chilblains. 499. 500. 
 
 Child, bath for newborn, 752, 753 ; care of new- 
 born, 750, 751, 752. 7.5;}, 754, 7.'V">, 9.57, 900, 901, 902, 
 963, 904 ; resuscitation of apparently stillborn, 
 751, 752. 
 
 Childbeariug, 107, 725. 
 
 Chills, 872 ; and fever, 016. 636, 637 ; ether, 951. 
 
 Chin, 9. 
 
 Chloral, 012. 
 
 Chloroform, 612. 
 
 Choking, 872. 
 
 Cholera, Asiatic, :i52, 417, 419, 420, 421, 420, 631, 
 6:12, 63:3, SXi ; infantum, 314, 873 ; morbus, 872, 
 873. 
 
 Chondrin, 381. 
 
 Chorea, see St. Virus's Dance. 
 
 Chyle, 37, :}8, 39, 97. 
 
 Chyme, 92. 
 
 Cilia, 129, 624. 
 
 Circulation, 40, 88, 94, 95, 172, 173, 186 ; collateral, 
 36, 37 ; general, 39 ; greater, ;i3, 97, 98 ; lesser, 
 27, 33, 97, 98 ; maintenance of the, 36 ; pulmo- 
 nary, 97, 98 ; systemic, 97, 98. 
 
 Circulatory apparatus, 101 ; organs, 97, 110 ; sys- 
 tem, 94, 101, 109. 
 
 Cirrhosis of the Uver, see Liver, Hardening of 
 
 THE. 
 
 Cisterns, 343, 347. 
 
 Clam broth, 928, 929. 
 
 Clavicle, see Collar-bone. 
 
 Cleanliness in the prevention of disease, 828 ; 
 surgical, 443, 446, 748, 949. 
 
 Climate, various kinds of, 334, 335 ; effect of, upon 
 health and disease. 894, 895. 
 
 Closet, earth, 359, 361 ; flushing-rim, long-hopper, 
 360 ; pan, 3.59 ; valve, 350 ; wash-down, 300 ; 
 wash-out, 300 ; water-, 359, 300. 
 
 Clothing, 301, .397 ; changing personal, of a help- 
 less patient, 906, 907 ; choice of, 398 ; during 
 pregnancy, 7:W ; infants', 403, 404, 753, 961 ; in 
 old age, 411 ; in relation to training, 301. 
 
 Clubfoot. 588, ,589. 
 
 Cocaine, 612 ; cataphoresis, 809. 
 
 Coccus, 624 ; of pneumonia, 307. 
 
 Coccyx, 4. 
 
 Cochlea. 79, 80, 1.52. 1.53. 
 
 Coffee. 612, 848. 8.59, 860, 893. 
 
 Cold, 212 ; application of, to contusions, 470 ; to 
 inflamed part, 403, 464 : to prevent the forma- 
 tion of pus, 472 ; to stop bleeding, 448 ; effect of, 
 upon the capillaries. 9:38 ; sense of, 1.56 ; treat- 
 ment of the constitutional effects of, 499, 500 ; 
 pack, 804 ; spots, 156. 
 
 Colic, 873 ; biliary, 702 ; infantile, 760 ; wind, 878. 
 
 Collapse, 888. 
 
 Collar-bone, 10 ; fractures of the, 508, 509. 
 
 Colles's fracture, 511. 
 
 Colon, 6,3, 64 ; ascending, 0-4 ; descending, 04 ; 
 transvei-se, 04. 
 
 Colostrum, 75.3, 902. 
 
 Colour-blindness, 147, 148 ; sensations, 148 ; vi- 
 sion, 147, 148. 
 
 Conja, 512, 543, 590. 
 
 Comedo. See Black Heads. 
 
 Commissure, 40 ; great transverse, 40 ; optic, 
 53. 
 
 Conceptions, 215 ; imperative, 820. 
 
 Condyle, neck of the, 9, 19 ; of the jaw, 9, 18. 
 
 Congestion, 080 ; venous, 686. 
 
 Consciousness. 195, 196, 197, 198, 201, 202 : back- 
 ground of, 197, 210, 211 ; contents of, 196, 197, 
 208 ; organ of, 130 ; relation of feeling to, 198, 
 199 ; seat of, 1.30 ; states of, 190 ; stream of, 190, 
 197, 198, 199, 208. 
 
 Consomme, 928. 
 
 Con.stipation, 509, 570, 571, 572, 767, 873, 874, 878 ; 
 fever of, 774 ; occasional, of infants, 874. 
 
 Constrictor, elastic, 448, 578. 
 
 Consumption, 314 ; pulmonary, 32:5, 075, 070, 077, 
 078, 079 ; transmission of, 166. 
 
 Contagion defined, 615, 616 ; prevention of, 8:i2. 
 
 Contusions, ,57, 4:52, 408, 469, 470 ; of joints, .525 ; 
 of tlie abdomen, 501, .502 ; of tiie breast, .558 ; 
 of tlie ej'eball, 543 ; of the eyeUds, 543 ; of the 
 thorax, 557, 558 ; pain caused by, 468, 469 ; treat- 
 ment of, 470. 
 
 Convalescence, 907, 908, 969, 970. 
 
 Convulsions, 798, 880, 887 ; in adults, 886 ; in chil- 
 dren, 887. 
 
 Cooking, 393 ; for athletes, 299 ; for the sick, 933, 
 924 ; meats, 393, 395 ; vegetables, 395. 
 
 Coraeoid process, 10, 22, 578. 
 
 Cornea, 70, 77. 149. 
 
 Corium, 80. 
 
 Corpus callosum, 4S, 45, 46, 48 ; dentatum, 49 ; 
 striatum, 46, 47, 136. 
 
 Corpuscles, 95 ; red, 95, 90, 109 ; touch, 150 ; white, 
 95, 96. 
 
 Corrosive sublimate, 430, 444, 445 ; gauze, 453, 
 454 ; solution, 450, 451 ; tablets, 450. 
 
 Cotton, absorbent, 450 ; jacket, 939 ; rings, 916, 
 917. 
 
 Cough, 874, 875. 
 
 Cowpox, 641. 
 
 Cramp, 798, 799, 873 ; writer's, 614. 
 
 Cranium, 6. 
 
 Cream sauce, 931. 
 
 Creatinin, 110. 
 
 Cretinism, .5.57, 558. 
 
 Cricket, 245, 247, 205, 266. 
 
 Cristse acusticae, 1.52. 
 
 Croup, 875 ; catarrhal, 875 ; inflammatory, 875 ; 
 membranous, 426, 660 ; spasmodic, 875. 
 
 Croup-kettle, 8.54. 
 
 Cry.stalline lens, 77, 78, 143, 140, 147. 
 
 Cup, sanitary sputa, 946. 
 
 Curare. 460. 
 
 Cures, 900, 901, 902. 
 
 Curtilage, relation of, to superficial area, 356. 
 
 Cushion, invalid, 855. 
 
 Customs, 178. 
 
 Cu^icle, 80. 
 
 Cutis, 80. 
 
INDEX. 
 
 977 
 
 Dandruff, 002. 
 
 lJaylig)ifc, inlluenco of, on healUi, 339. 
 
 Dead, laying out the, i)7l. 
 
 Death, 104, 305, 5i)(), Hiil ; Kif,'iiM of, 590, 501 ; fn- 
 quent causes of, 314 ; registration of, 30!), 3i;i. 
 
 Death-rate, 313, 314. 
 
 Decomposition, to prevent, 971. 
 
 Defects, intellectual, 220, 223 ; in visual apparatus, 
 147 ; of the will, 230, 231. 
 
 D(!goneration, 193 ; cheesy, 48i ; gummy, 599, 000. 
 
 Delsarte system, 292, 295, 303. 
 
 Delirium tremens, 505, 819. 
 
 Delusions, 222, 223, 819. 
 
 Dementia, 220, 81.5, 819 ; paralytic, 815, 821 ; sec- 
 ondary, 815 ; terminal, 815. 
 
 Demulcents, 894. 
 
 Dendrites, 131, 132. 
 
 Dengue, 417. 
 
 Dentals, 128. . 
 
 Deodorants, 439. 
 
 Dermatitis (caused by poison ivy), 603. 
 
 Descent, mechanism of, 167. 
 
 Desires, 182, 202, 236, 227. 
 
 Desks for school children, 329. 
 
 Dextrin, 90. 
 
 Dextrose, 380. 
 
 Diabetes, 721, 722, 723 ; insipidus, 721 ; mellitus, 
 721, 722, 723. 
 
 Diaphragm, 33, 24. 
 
 DiarrhcBa, 352, 697, 698, 699, 767, 875, 876 ; acute, 
 698, 699 ; chronic, 699. 
 
 Diastole, 100. 
 
 Diet, 824, 825 ; carbohydrate, 115 ; during preg- 
 nancy, 740 ; fluid, 934 ; for an average man, 116 ; 
 in convalescence, 969, 970 ; in disease, 858, 859 ; 
 in old age, 409, 410 ; in relation to health, 386 ; 
 milk, 858 ; of brain vsrorkers, 413 ; of children, 
 386 ; of nursing women, 762 ; proteid, 115 ; spe- 
 cial, 934, 925 ; training-table, 299 ; raw meat, 
 298; selection of, 610, 611 ; the most suitable, 
 116 ; vegetarian, 116. 
 
 Dietaries, 305, 386, 387, 388, 389, 390, 391, 392, 405. 
 
 Digestion, 40, 88, 92, 172, 173 ; disorders of the, 693 ; 
 in the large intestine, 93 ; in the mouth and 
 stomach, 92 ; in the small intestine, 92, 
 
 Digestive ferments, 92; fluids, 90, 93, 114, 1.35; 
 glands, 91, 103, 114. 
 
 Diphtheria, 307, 314, .3.38, 417, 436, 616, 617, 6.59, 600, 
 661, 663 ; autitoxine, 833. 
 
 Disease, 100 ; causes of, 306, 609, 610, 611, 612, 613, 
 614, 015 ; germ theory of, 415 ; habits as causes 
 of, 834 ; hereditary, 165, 166, 614 ; hip-joint, 493, 
 584 ; kidney, 767 ; posture in, 860, 947 ; preven- 
 tion of, 305, 823, 834 ; treatment of, 833, 834 ; 
 utero-ovarian, 407. 
 
 Diseases, 415, 615, 616, 617 ; causes of mental, 780, 
 788 ; choleriform, 426 ; communicable, 415, 416, 
 417, 418, 419, 430, 431, 422, 433, 434, 435, 426, 437, 
 428, 429, 430, 616, 617 ; contagious, 415, 615, 616, 
 617 ; endemic, 415 ; epidemic, 415 ; infectious, 
 415, 615, 616 ; malarial, 633, 634, 635, 636 ; nerv- 
 ous, 166, 178, 779, 780, 788, 789 ; non-contagious, 
 616 ; of old age, 411 ; of pregnancy, 766, 767, 
 768 ; of the liver, 701, 702, 703, 704 ; of the pan- 
 creas, 704 ; of the skin, 601, 602, 603, 604, 605. 
 606, 607, 608 ; of the spleen, 704, 705 ; of the 
 64 
 
 stomach, 693, 694, 69.5, 600, 697; specific, 415; 
 sporadic, 415 ; surgical, 431 ; zymotic, 415. 
 
 Disinfectants, 300, 429, 430. 
 
 l)isii]f(!ction. 425, 426, 427, 428, 429, 430. 
 
 i.)isl(jcation8, 19, 2f) ; congenital. .527 ; mechanism 
 of, .537, .528; reduction of, 529. .530; rcjiixir of, 
 527, .528; spontaneous, .537; sympt/nns of, .538, 
 .529. 
 
 Dizziness, 213. 
 
 DobelPs solution, 848, 874. 
 
 Douche, 3.53, 807, 808 ; rectal, 9.% ; vaginal, 93(;. 
 
 Douching, 470. 
 
 Dover's-powder taV)let8, 838. 
 
 Drainage, subsoil, 338. 
 
 Drains, house, 362, 303 ; superficial, 358. 
 
 Draw-sheet, 905. 
 
 Dreams, 164, 231. 
 
 Dress, common .sense in, 399 ; influence of, on the 
 developing woman, 408 ; women's, 399. 
 
 Dressings, surgical, 949, 950 ; Sayre's, for frac- 
 tured clavicle, 509 ; temporary, for fractures, 
 .506, 507. 
 
 Dropped foot, 812 ; vn-ist, 812. 
 
 Dropper, glass, 855, 856. 
 
 Drowning, 590, 809, 887, 888. 
 
 Drug habit, 8.34. 
 
 Drugs, purchase and care of, 921. 
 
 Drum of the ear, 78, 7'9. 
 
 Drumhead, rupture of the, 546. 
 
 Drunkenness. See Alcoholism. 
 
 Duct, common bile, 63, 06 ; cystic. 66 ; hepatic, 
 65, 66 ; left lymphatic, 38 ; nasal, 78 ; pancre- 
 atic, 63, 66, 67 ; right lymphatic, .38, 39, 104 ; 
 thoracic, 38, 39, 61, 104. 
 
 Dumb-bells, 265, 270, 279, 281, 283, 284, 287, 288. 289, 
 302 ; for women, 390. 
 
 Duodenum, 63, 66, 92. 
 
 Dura mater, 43, 43, 52. 
 
 Dust, inhalation of, 322, 333. 
 
 Dying, care of the, 970, 971. 
 
 Dysentery, 352, 430, 699, 700 ; acute. 699, 700 : 
 chronic, 700. 
 
 Dysmenorrhoea. membranous, 730. 
 
 Dyspepsia, 93, 693, 694. 
 
 Ear. 74. 78, 83, 88. 149, 189, 546. 547 ; drum of the. 78. 
 79 ; external, 78, 149 ; internal. 78, 79. 149. 150 ; 
 membranous labyrinth of the internal. 80. 149. 
 150 ; middle, 78, 149, 150 ; physiological anatomy 
 of the, 149. 
 
 Earache, 876. 
 
 Eating, hasty. 613. 836 : regularity in. 613, 825. 
 
 Eccentricity. 333, 224, 225. 
 
 Eclampsia, 767, 768. 
 
 Eczema, 604 ; acute, 604 ; chronic, 604 ; moist. 
 586, 587. 604 : of the leg. 586. 587. 
 
 Education, early. 406 ; systems of. 167. 
 
 Egg, 81 : attachment of. to uterine wall. 160. 161 : 
 human, 158. 1.59 ; of the fowl. 158 ; segmenta- 
 tion of the. 167. 
 
 Eggs. 89. 116 ; shirred. 932 ; value of. as diet. 115. 
 
 Elbow, 17 : fracture of the tip of the. 511. 
 
 Electricity, 86 ; animal, 122 ; for artificial illu- 
 mination, 339. 330. 
 
 Embolism, fatty, of the lungs. 505. 
 
 Embryo, 82 ; development of the, 161. 
 
978 
 
 INDEX. 
 
 F.iiierffeni-ies, 441. 
 
 Kinotional expression, 134; states. ISO. 182. 204; 
 tones, 'Mi ; uiulertoue, '.J04, A>5, asi ; variability, 
 304. 
 
 Emotions, 19S, 3tv.i, 303, 204 ; abnormal. 3a3. 20!>, 
 307 ; permanent set of, 300 ; religious, 300 ; 
 sexual. 3tHi. 
 
 Kmpliysenia of the lungs, 074, 075, 710. 
 
 Kmpyeiim. 070, 671. 
 
 Kmulsirteation, '.W. 
 
 Kncephalon, see Brain. 
 
 Kiuloeaniitis, 0,S7 ; acute, 687 ; chronic, 6fC, 088, 
 08SI ; infectious, 687, 68i) ; malignant. 687. 68!) ; 
 resulting from rheumatism, 00,") ; ulcerative, 
 t>87, 689. 
 
 Kndocardium, 38. 080 ; diseases of the, 087. 
 
 Kudolymph. LW. l.-)!, l,'-,3. 
 
 Kriema, SOS. 80<t ; larger, 9*J, 935 ; nutritive. 808, 
 809. 935 ; purgative, 808 ; soapsuds, 868. 874. 
 
 Knergy, 85, 95, 383 ; nervous, 134, 141 ; of mechan- 
 ical work, 118 ; universal, 80 ; vital, SO. 
 
 Enteritis, chronic, 699. 
 
 Environment, 100, 107, 184, 195, 20;J, 305, 310, 320, 
 334. 
 
 Enzymes, 90. 
 
 Ei)iblast, 82, 83. 
 
 Epidermis, 80, 83. 
 
 Epididymis, inflammation of the. ;)90. 
 
 Epiglottis, 09. 
 
 Epilepsy, 407, 408, 78:3, 799, 800, 801, 812 ; psychic, 
 799. 
 
 Epithelium, 7.'j. 
 
 ICpsom salt. 851. 852. 
 
 Equilibrium, bodily. 152, 153. 
 
 Erysipelas. 420. 476, 477, 478, 630. 
 
 Erysipeloid, .')82. 
 
 Ether. 612 ; chill. 951 ; vomiting from. 951, 952. 
 
 Evaporation. ;J41. 343, 3-13. 
 
 Evolution. 85 ; of mind, 135. 
 
 Excreta, 946, 947 ; removal of, 3.59, 300, 301. 
 
 Excretion, 88 ; organs of, 110, 111. 
 
 E.xercise, 408, 827. 874. 895 ; age, condition, and 
 sex in relation to. 301 ; home. 270. 289 ; in con- 
 valescence, 909, 970; indoor, 201, 207. 270. 271 ; 
 in old age, 410 ; in the daytime. 238 ; in the 
 form of games, 338 ; in the gymnasium, 261, 
 278 ; lack of. 351, 2.52. 013 ; objects of. 2.39, 259 ; 
 out-of-door, 2.37 ; regularity in, 2.36 ; sabre, 274 ; 
 for an infant, 963 ; for boys, 265 ; for children, 
 :W3, 304 ; for girls, 265 ; for women, 303. 732 ; 
 (luring pregnancy. 740 ; special, for the ab- 
 dominal muscles, 2.57, 358 ; for the back mus- 
 cles, 2.58. 259 ; for the muscles of the arm, 3.59 ; 
 for the chest muscles, 3.58, 3.59 ; for the legs, 
 3.57 ; for the shoulders, 258, 259. 
 
 Exposure, 3.39, a31. R33. 
 
 Extension, 22 ; in fractures, 513, 514, 517. 
 
 Extensors, 123. 
 
 Eye, 74, 83, 88, 189, 545, 546 ; accommodation of the, 
 140 ; choroid coat of the, 77 ; focusing the, 140 ; 
 foreign bodies in the, 545. .546 ; inflammations 
 of the, 540 ; shortcomings of the, 147. 
 
 Eyeball, 76, 14.3, 144, 149 ; contusions of the, .543 ; 
 muscles of the, 148 ; tunics of the, 76, 77 ; 
 wounds of the, 546. 
 
 Eyelids, 149 ; contusions of the, 543. 
 
 Eyes, 75, 143 ; innammatiou of the, 876 ; move- 
 ments of the, 1-35. 
 
 Face, anatomical peculiarities of the, 124; ma- 
 lignant pustule of the, 543. 544 ; most sensitive 
 to temperature, 156 ; movements of the, 135 ; 
 wounds of the, .543. 
 
 Faeces, 945 ; disposal of, in infectious anti conta- 
 gious cases, 9l>5 ; infants', 901. 
 
 Fahrenheit "s scale, 331. 
 
 Fainting, 103, 103, 133, 876, 877. 
 
 Falling sickness, see Erii.EPSY. 
 
 Farsight, 147. 
 
 Fat, 90. 116, 118, 379, 380, 381 ; cells, 114; tissue, 
 80 ; value of, as diet. 115. 
 
 Fatigue, 157 ; nmscular, 303 ; nervous, 303, 308. 
 
 Fatty acid, 90. 
 
 Fauces, anterior pillars of the, 155. 
 
 Features, 134. 
 
 Feeble-mindedness. 814. 
 
 Feeders for invalids, 924. 
 
 Feeding, excessive, of infants, 7.59, 700 ; infants, 
 404, 405, 902, 903, 904 ; insuflflcient, of infants, 
 7.59. 
 
 Feeling, contents of, 196, 198, 217 ; definition of, 
 202 ; expression of, 203 ; in relation to pleasure 
 and pain, 301 ; relation of, to consciousness, 
 198, 199 ; signs of, 183, 183, 184. 
 
 Feelings, 140. 197. 198, 199, 200, 201, 205, 208 ; ab- 
 normal, 205 ; intellectual, 217 ; of interest, 217 ; 
 physical basis of the, 203. 203 ; practical aspect 
 of the, 305 ; practical estimate of the, 307, 208 ; 
 theory of the, 200. 
 
 Feet, sore, 882, 883. 
 
 Female, 81, 1.58. 
 
 Femur (thigh bone), 15, 19 ; fractures of the shaft 
 of the, 513, 514, 515 ; neck of the, 15, 20 ; shaft 
 of the, 15. 
 
 Fencing, 374 ; for girls, 274 ; for women, 274, 291 ; 
 of the German duellist, 274. 
 
 Fenestra ovalis, 150. 
 
 Ferments, digestive, 92 ; unorganized, 90. 
 
 Fertilization, 100. 
 
 Fever, African, see Fets'er, I.vtermittf.nt and Re- 
 mittent ; and ague, see Fever, Intermittent ; 
 autumnal, see Typhoid Fever ; bilious remit- 
 tent, see Fever, Remittent ; camp, see Fever, 
 Typhus ; cerebro-spinal, GIG ; Chagres, see 
 Fever. Intermittent and Remittent ; child- 
 bed. 9.55 ; chills and, see Fever. Intermittent ; 
 coast, see Fever, Intermittent and Remit- 
 tent ; continued. 420; enteric, see Typhoid 
 P'evkr ; from the breasts, 758, 774, 775, 776 ; 
 hospital, see Fever, Typhus ; intermittent, 610, 
 030, 037, 638 ; jail, see Fever, Typhus ; jungle, 
 see Fever. Intermittent and Remittent; lungi 
 see Pneumonia ; malarial, see Fever, Remit- 
 tent: marsh, see Fever. Intermittent ; milk, 
 see Fever fro.m the Breasts ; of constipation. 
 77); Panama, see Fever, Intermittent and 
 Remittent ; periodic, 6.3(i : pernicious intermit- 
 tent, 037; puerperal. 748. 774; relapsing, 417, 
 426 ; remittent, 314, 616, 636. 637, 6.38. 639 ; rheu- 
 matic. 664. 665 ; scarlet, 307, 314. 333, 417, 420, 
 016. 617, 646, 647, 048, 049 ; ship, see Fever, Ty- 
 phus ; spotted, 808 ; swamp, see Fever, Inter- 
 
INDEX. 
 
 07'J 
 
 MiTTENT ; treatment of, 877, 878 ; typhoid, see 
 Typuoid Feveii ; typho-iiialat-ial, see Fevku, 
 Remittent ; typhus, 4SM, 4;i(J, 010 ; water-drink- 
 iiif>f beneficial in. 85!) ; yellow, 352, 417, 421, 422, 
 423, 424, 420, 039, 040, 041. 
 
 Fibres, 20, 188 ; afferent nerve, 13'3 ; association, 
 140 ; cardiac muscle, 121 ; contraction of mus- 
 cular, 20 ; efferent nerve, 133 ; motor, 134 ; 
 nerve, 141 ; of the basilar membrane, 152 ; of 
 tlie optic nerve, 180 ; sensory nerve, 134, 142, 
 IdU ; smooth muscle, 121 ; striated muscle. 121 ; 
 striped muscle, 121 ; uustriped muscle, 121. 
 
 Fibrillffi, 20. 
 
 Fibrin, 90. 
 
 Fibrinogen, 90. 
 
 Fibula, see Splint-bone. 
 
 I'ilter, Berlvefeld, 351 ; domestic, 3i50, 351 ; Maig- 
 nen's rapid, 351 ; Pasteur- Cliamberland, 350, 
 351 ; sewage, 372, 373. 
 
 Filtration of drinlfing water, 350, 351 ; of rain 
 water, 343, 344 ; processes, 372, 373 ; sand, 350. 
 
 Finger, 14 ; pressure to stop bleeding, 445, 543, 
 5.53, 554, 579, 583 ; ring, 14. 
 
 Fireplace, open, .324, 320, .327. 
 
 Fissure, 43 ; ante'rior median, of the medulla ob- 
 longata, 49; anterior median, of the spinal cord, 
 51, 52 ; antero-lateral, of the spinal cord, 51, 52 ; 
 great longitudinal, 43. 44 ; great transverse, 43 ; 
 incomplete external, 572 ; of Rolando, 44, 1-38 ; 
 of Sylvius, 44 ; of the breast during lactation, 
 558 ; of the liver, 65 ; painful, of the anus, 570, 
 .571 ; parieto-oecipital, 44 ; posterior median, of 
 the medulla oblongata, 49, 50 ; posterior median, 
 of the spinal cord, 51, .52 ; postero-lateral, of the 
 spinal cord, 52 ; sphenoidal, 54. 
 
 Fistula, blind external, 57'2 ; blind internal, 572 ; 
 complete, 572 ; incomplete external, 572 ; incom- 
 plete internal, 572 ; in ano, 572, 573 ; tubercular, 
 .572, 573. 
 
 Five senses, 212. 
 
 Flatfoot, .587. 
 
 Flatulence, 878. 
 
 Flesh, SO, 121. 
 
 Flexion, 22. 
 
 Flexors, 123. 
 
 Fluctuation, 471. 
 
 FcBtus, death of, 768. 769. 
 
 Follicles, 63 ; hair, 80. 
 
 Food, 88, 89, 94, 95, 98, 113, 114 : administration of, 
 to the sick, 923, 924 ; adulteration of, 336 ; amount 
 required for different individuals, 386 ; artificial, 
 for infants, 763, 764, 765, 963 ; average amounj; 
 consumed daily, 379, 380 ; composition of mate- 
 rials. 383, 384. 385 ; definition of, 379 ; digesti- 
 bility of, 116, 299, 386, 393 ; excess of, 395 ; forms 
 of, 824 ; functions of, 379, 381 ; growth promoted 
 by means of. 379 ; improper, 610 ; influence of, 
 on health, 395 ; in health, 923 ; in sickness, 923 ; 
 mastication of, 92 ; organic nitrogenous mat. 
 ter an essential ingredient of, 381 ; pecuniary 
 economy of. 394 ; pecuniary value of, 393 ; prepa- 
 ration of, 116, 393. 394 : quantity and quality of, 
 395, 396 ; relation of, to work, 386. 387. 388 : saline 
 substances essential to. 382 ; water an essential 
 element of, 382. 
 
 Foods, chart showing composition of animal, 117 ; 
 
 fried, 209 ; noxious, 390 ; nutrients of, 370 : pre- 
 digested, for rectal feeding, 935 ; predigestion 
 of, 925 ; proprietary, 903 ; relative digestibility 
 of, 385 ; Richefs classification of. 379 ; solid, 
 924 ; vegetable, chart showing composition of, 
 117. 
 
 Food-stuffs, 89, 90 ; inspection of, ''M ; nutritive 
 value of, 382, 385. 
 
 Foolishness, 220. 
 
 Foot, 15, 16 : bones of the, 16 ; to exercise the, 28.3. 
 
 Football, 242, 243, 250, 205, 260, 290 ; training for, 
 298, 299. 
 
 Foramen, jugular, 55 ; magnum, 7 ; of Monro, 47, 
 50 ; optic, 53, 76. 
 
 Force, 382 ; unit of, .3^2. 
 
 Forearm, 10, 280 ; fractures of the bones of the, 
 511 ; outward rotation of the, 23 ; supination of 
 the, 23 ; to exercise the, 282 ; wounds of the, 
 578, 579. 
 
 Forehead, 156. 
 
 Foreign bodies in accidental wounds, 4.50 ; in the 
 alimentaiy canal, 508 ; in the ear, 540 ; in the 
 eye, 545, .540 ; in the gullet, 556 ; in the gut, 508 ; 
 in the larynx, .5.55, 5.50 ; in the no.se, 544, .545 : in 
 the rectum, 570 ; in the vermiform appendix, 
 565. • 
 
 Fornix, 46, 48. 
 
 Fossa navicularis. 74. 
 
 Fractures, 500, 501, 502, 503, 504, 505, 500, 507, .503, 
 509, 510, 511, 512, 513, 514, 515, 510, 517, 518, 519, 
 
 520, 521, 522. 
 
 Different kinds of : Colles's. .511 ; comminuted, 
 501 ; complicated, 501 ; compound, 501, bOi. 504 ; 
 green-stick, 3, 501 ; impacted, 502 ; incomplete, 
 501, 502 ; longitudinal, 501 ; obUque, 501 ; of the 
 base of the skull, 519, 540 ; of the bone of the 
 upper arm, 510 ; of the bones of the fingers, 
 512 ; of the bones of the forearm. 511 ; of the 
 bones of the hand nearest the wi-ist. 512 : of the 
 collar-bone, 508, 509 ; of the femur. 512 : of the 
 humerus. 11. 510. 511 : of the knee-pan. 515, 516, 
 517 ; of the leg, 517. 518. 519 ; of the lower jaw. 
 520 ; of the nose, 519 ; of the olecranon process 
 of the ulna, 511 ; of the radius. 14 ; of the ribs, 
 509 ; of the shaft of the femur. 513. 514. 515 : of 
 the skull, 540, 541. .542. 543 ; of the spine. 521. .522 : 
 of the thigh bone. 512. 513 : of the tibia. 517. 518 ; 
 of the tip of the elbow. 511 : of the vertebrae, 
 
 521, 522 ; of the vertex of the skull. 540 : Potfs, 
 518. 519 ; simple. .501 : toothed. .501 ; transverse, 
 
 501 ; T-shaped. .501 : Y-shaped. 501. 
 
 Causes of, .500, 501 ; by direct violence. 500 ; 
 by external violence. 500 : by indirect violence, 
 500. 501 ; by muscular action. .500. 501. 
 
 Signs of, 502, 503, ,504 ; abnormal mobility, 
 
 502 ; crepitus or grating, 502 : deformity, 503 ; 
 loss of function. 4.39, 502. 503 : pain and tender- 
 ness. 502 ; swelling and discoloration of the 
 skin. 503. 
 
 Treatment of. .506. 507. .508 : coaptation in. 514 ; 
 counter-extension in. .514. 517 ; extension in. 513, 
 514. 517 : setting of. .507. 
 
 Complications of. 505 : examination of. 506 ; 
 gangrene following. 505 : repair of. 504. 505 ; 
 stiffness of the joints following, 505 ; temporary 
 dressings for. 506. 507. 
 
980 
 
 INDEX. 
 
 Frostbite. 407. -10^.499. 
 Kruit, dried, soup. dH. 
 Funotions, associative, 213 ; expressive, 174, 170 : 
 
 instinctive, ItCJ ; lanRiinge, 21'.l ; localized, 189 ; 
 
 motor, 180 ; sensory, 18(1 ; variation of, \(Xi. 
 Funnel, glass, for adiuinistering euemata, 934. 
 Furnaces, 324, 320, 327, 828. 
 
 (Jail bladder, 61, 6.5, 66. 
 
 (Jallstoiie. passage of a. 702. 
 
 (iaiues, ice. 2tki ; iniportance of organized, 20.5; 
 indoor, 271, 275 ; object of, involving sides, 205 ; 
 outdoor, 239, 240, 20.5. 270, 408 ; personal-contact. 
 200, 2'.10 ; preferable to special exercises, 2i)l ; 
 violent, 201. 
 
 Ganglia. 54, .55, .50, 130, 131, .580. ,581. 
 
 tiaugrene, 474, 47.5, 470 ; dry, 475 ; following frac- 
 ture, .505 ; from frostbite, 499 ; ga.seous, 400 ; 
 moist, 474, 475 ; prevention of, 470 ; progressive 
 gaseous. 474 ; symptoms of, 475, 470 ; treatment 
 of, 470 ; true, 474, 475. 
 
 Garbage. 305, 375 ; cremation of kitchen, 375, .370, 
 ;J77 : disposal of, 305, 370. 377, 378. 
 
 Garments, outer. 399. 
 
 (ias as fui'l, 327, 329 ; carbonic-acid, 320 ; for arti- 
 ficial illumination, 329 ; nuiins, ;W9. 
 
 Gajstric follicles, 0.3 ; glands, 92 ; juice, 63, 90, 91, 
 92 ; plexus, 58. 
 
 Gastritis, 094, 095 ; acute, 094, 095 ; chronic, 695, 
 090. 
 
 Gaslro-duodenitis. 702. 
 
 Gastro-intestinal tract. 83. 
 
 Gauze, 450 ; antisej)tic (corrosive sublimate), 445, 
 4.53. 4.54 ; value of a firm pad of, 447. 
 
 Gelatin. 89. .381. 
 
 (ielatinoids, .381. 
 
 Gemmules. 107. ICS. 109. 
 
 (Jennan measles. 417, 054. 
 
 Germ-cells, 1.58. 107. 
 
 Germinal area. 83. 83 ; substance, 108. 
 
 Germ-plasm, 107. 108, 109. 170. 
 
 (Jerms in the earth, 330, 337 ; in subsoil water, 337, 
 .3:«. 
 
 Gestation, see Preinancy. 
 
 Gestures. 174. 175. 170. 
 
 Gin-drinker"s liver. 702. 703. 
 
 Ginger, tincture of. 848. 878. 
 
 Girls, care of. at puberty. 407. 408. 737, 728 ; growth 
 of, 163 ; outdoor exercises for, 205 ; special in- 
 door exercises for. 295. 290. 
 
 Gland extracts. 92 : lachrymal, 78, 149 ; parotid, 
 00 : pituitarj-. 45 : prostate, 74 ; secretions, 181 ; 
 th>Toid. 71. 72. 5.50. .5.57. 
 
 Glands. 80. 91, 92, 109. 180 ; digestive, 91, 103, 114 ; 
 gastric. 92 : intestinal. 91 : lymphatic. 38. 61, 88, 
 104 : mammary. lf>3 ; of Bartholin, 598 ; parotid, 
 00. no, 6.58 ; peptic, 63 : pyloric, 6:} ; salivary, 00, 
 89, 91. 93: sebaceous, 80, 112, 113; sublingual, 
 on. 90; submaxillarj'. 00. 90: sudoriferous, 112, 
 119 : sweat. 80. 113 : thymus. 71, 72, 120. 
 
 Glauber's salt, 851. 8.52. 
 
 Gleet, see Gonorrhcea, Chronic. 
 
 Olomemlns. 111. 
 
 Glottis. 09. 120 
 
 Glucose. 380. 721. 
 
 Glycerin, 90. 
 
 Glycogen. 114. 380. 
 
 Goitre, 72, 557 ; exophthalmic, 092, 797, 801. 
 
 Golf, 247, 248, 201, 302 ; for girls, 205 ; for old 
 men, 201 ; for women, 201, 202, 203, 303. 
 
 Qonoooccus, 595, 597. 
 
 Gonorrhcea, .595, 590, 597, 598 ; chronic, .590, .597. 
 
 Gout, 000, 007 ; acute, 007 ; chronic, 007, OOK ; ir- 
 regular, 007, 008 ; suppres.sed, 007, 008 ; trans- 
 mission of, 014, 015. 
 
 Grand mal, see Epilepsy. 
 
 Grave.s's disease, see GoItre, Exiii'irni.\i.Mic. 
 
 Gray matter, 10, 43, 44, 47, 49, 51. l.il, i;i.), 170, 188. 
 
 Grea.se trap, 359. 
 
 Grippe, la, see Infu'enza. 
 
 Growth. KW, 101, 103, 108, 109 ; promoted by 
 means of food, 379. 
 
 Gruel, flour, with milk, 929 ; Indian meal, 929 ; 
 rice. 929. 
 
 Gullet, 24, 59. 61, 88, 89, 556. 
 
 Gymnasium, 270, 275 ; exercises, 201 ; home, 279, 
 280, :W2, 303 ; membership, 279, 303. 
 
 Gyua'cology, 725. 
 
 Habit, 188 ; drug, 834 ; fixed, 190 ; laws of, 188, 
 180. 
 
 Habits, 170, 213 ; acquired, 203 ; as causes of dis- 
 ease, 824 ; formation of, 103, 189 ; injurious, 
 012, 013 ; intellectual, 224 ; of attentive observa- 
 tion, 219 ; of inhibition. 193. 
 
 Ha?moglobin, 95. 90, 109, 319, .320 ; reduced, 109. 
 
 HEemoptysis, see Blood. Spitting of. 
 
 Hiiemorrhage after labour. 773, 773 ; internal. 408. 
 
 Hasmorrhoids (or piles), 64, 571, 572; external, 
 .571 ; internal, 572. 
 
 Hair. 80 ; follicles, 80 : roots of the, 80. 
 
 Hallucinations, 221, 222, 819, 820. 
 
 Hammer-throwing, 248, 2.57. 
 
 Hand. 10, 14 ; fractures of the bones of the, near- 
 est the wrist, 512 ; superiority of tiie human, 
 14 : to exercise the, 282. 
 
 Handball. 272, 273, 302 ; courts, 272 ; for women, 
 273. 
 
 Hands, how to wash the, 444, 445. 
 
 Harelip, 544, 549. 
 
 Head, 0. 
 
 Headache, 801, 802, 808. 878, 879; bilious, 879; 
 malarial, 879 ; nervous, 878 ; sick, 878, 879. 
 
 Healing by first intention, 434 ; by granulation. 
 434 ; by second intention, 4.30 ; interference of 
 bacteria with, 430 ; of wounds. 432, 4;i;3. 
 
 Health, maintenance of, 318 ; the object of physi- 
 cal training, 207 ; training for, 290, 299, .300. 
 
 Hearing, 55, 74. 142, 151 : centre of, 140 ; false, 
 820 ; organs of. .55 ; sensations of, 142, 212. 
 
 Heart. 25. 08. 88, 97, 109 ; acceleration of the, 103 ; 
 acute dilatation of the, 089, 090 ; amount of 
 work performed by different iioitions of the, 
 27. 28 : anatomy of the. 085. 080 ; apex of the, 
 25, 20: ba.se of the, 25; beat of the, 100, 101, 
 7-37; blood, 105; chordiP tendincfc of the, see 
 Heart Strino.s ; circidation through the, 20, 
 27 ; compensatory hypertrophy of the, 687 ; 
 dilatation of the, 087 ; diseases of the, 100, 314, 
 685. 686, 687, 688, 689, 690, 091, 093, 093. 709 ; em- 
 bryonic. 101 : evolution of the. 99 ; fatty, 089, 
 090 ; function of the, 25, 99 ; hypertrophy of 
 
INDEX. 
 
 981 
 
 the, 087 ; movements of the, 28, 135 ; nervouB 
 control of the, 102; neuralgia of the, O'Jl; 
 openings of the, 20 ; palpitation of the, 087, 091, 
 092 ; physiological anatomy of the, 99 ; position 
 of the, 25 ; rapid, 0!)2 ; size of the, 25 ; slowing 
 of the, 102, 103 ; sounds, 100 ; stopping of the, 
 102 ; strings, 20 ; structure of the, 25, !I9 ; ten- 
 dinous cords of the, see IIbaet Strings ; throb- 
 bing of the, 25 ; valves of the, 20, 080 ; valvular 
 disease of the, OSO, 087 ; weight of the, 20 ; 
 wounds of the, 558. 
 
 Heat, 86, 118, 119, 159, 212, 330, 382 ; dissemination 
 of, 320 ; dry, 429, 940 ; effect of, upon the capil. 
 laries, 938; loss of, 119; moist, 429; produc- 
 tion of , 119; prostration, 890; regulation, 119; 
 source of, 118 ; unit of, 382. 
 
 Heating, methods of, 322, 320, 328. 
 
 Hemiehorea, 813. 
 
 Heredity, 104,. 105, 160, 167, 168, 109, 170. 189, 205, 
 014, 780, 781, 782, 783, 784, 785, 780, 787, 788 ; nerv- 
 ous mechanism at the basis of, 779 ; psychic, 
 786, 787. 
 
 Hernia, 509, 573, 574, 575, 576 ; femoral, 573 ; in- 
 guinal, 573 ; irreducible, .575, .576 ; reducible, 
 57'5 ; strangulated, 574; .575 ; umbilical, 574. 
 
 Herpes, 603 ; zoster, 603. 
 
 Hiccough, 879, 880. 
 
 Hip, 15 ; bone, 15, 19, 20. 
 
 Hip-joint. 17, 19 ; disease, 492, .584 ; dislocation of 
 the, 20 ; movement of the, 20 ; tuberculosis of 
 the, 584. 
 
 Hives, 602, 603. 
 
 Hoarseness, 874, 875. 
 
 Hospitals for communicable diseases, 425, 426 ; 
 multiplication of, 308 ; statistics of, 308. 
 
 Hot- water bag, 844, 854 ; heating, ,328. 
 
 Hou.se, 184 ; arrangement of the interior of, 358 ; 
 drains, 362, 363 ; gutters, 358 ; height of, 356 ; 
 location of, 355, 356 ; roofs, 358 ; sanitary ne- 
 cessity of the dwelling, 355 ; structure of, 355. 
 
 Housemaid's knee, 585. 
 
 Human body, 81, 85 ; as a machine. 118, 235. 2.36 ; 
 origin of the, 86, 87 ; structure of, 169 ; tempera- 
 ture, 118, 119 ; weight of the, 135 ; plasm, 169 ; 
 protoplasm, 169. 
 
 Humerus (bone of the upper arm), 10, 11 ; frac- 
 ture of the, 11 ; head of the, 11 ; malignant sar- 
 comata of the, 577 ; radial head of the, 12 ; sur- 
 gical neck of the, 11. 
 
 Humidity, 330 ; degree of absolute, 334, 335 ; de- 
 termination of, 33S. 
 
 Humour, 77, 78, 143 ; aqueous,77, 78, 143 ; refract- 
 ing, 77 ; vitreous, 78. 143. 
 
 Humpback, 6, 492, 559. 
 
 Hunger, 1,57. 
 
 Hunyadi water, 874. 
 
 Hydrocele, 576. 
 
 Hydrocephalus, see Water on the Braiv. 
 
 Hydrophobia, 482, 483, 484. 
 
 Hygiene, definition of, 305 ; object of. 305. 366 : of 
 brain workers, 411, 412, 413 ; of childhood, 401 ; 
 of infancy, 401 ; of old age, 409, 410, 411. 
 
 Hygrometer, hair, 3,32. 
 
 Hyoid bone, 4, 74. 
 
 Hypersemia of the brain, 802 ; of the spinal cord. 
 802. 
 
 Hyperscsthesia, 802. 
 
 Hypnotism, 802. 803, 89G. 
 
 Hypoblast, 82, 83. 
 
 Hypophosphites, syrup of the. with iron, 884. 
 
 Hysteria, 408, 729, 803, 804. 
 
 Ice cap, 8.54, 855, 879, 880, 887 ; coil, 912, 943 ; 
 games, 200 ; pills, 944, 951 ; poultice, 943, 044 ; 
 sports, 2<18. 
 
 Iced cloths, 944. 
 
 lehthyol ointment, 850. 
 
 Ichthyosis, 548, 549. 
 
 Ideas, 197, 198 ; abstract, 215, 216 ; associations of, 
 180, 210, 212 ; general, 215 ; pure, 198. 
 
 Idiocy, 814. 
 
 Ileum, 03, 04. 
 
 Ilium, .500 ; anterior superior spine of the, .500. 
 
 Illusions, 820. 
 
 Images, 197 ; formation of inverted, 140 ; forma- 
 tion of retinal, 140 ; intellectual value of, 316. 
 
 Imagination, 213, 214 ; perversion of .se.xua!, 200. 
 
 Imbecility, 814. 
 
 Immaturity, 193. 
 
 Immunity, 019; acquired, 019. 020. 621. 622, 623; 
 antidote theory of, 620 ; exhaustion theory of, 
 020 ; inherited, 019. 
 
 Impulses, 142, 107, 227 ; afferent, 1-33 ; auditory, 
 140 ; efferent, 1.33 ; hereditaiy, 782. 78:3 ; motor, 
 135. 140 ; nerve, 141 ; sensory, 140 : visual, 140. 
 
 Incisors, 00 ; central, 00 ; lateral, 00. 
 
 Incus. See Axvil. 
 
 Indian clubs, 270, 277, 389, 302 ; for women, 290, 
 291. 
 
 Individuality, 787, 788. 
 
 Inebriety, alcoholic. See Aixoholism. 
 
 Infants, hygiene of, 401 : excessive and insuffi- 
 cient feeding of, 759, 760 : feeding of. 404. 405. 
 962, 963, 964 ; sleeping arrangements for, 40.5, 
 406 ; washing, 402, 403. 
 
 Infection defined, 015, 016 : germ theory of, 415, 
 618, 619 : immunity from. 307, 619 ; septic, 4-3.5, 
 436 ; susceptibility to, 307. 
 
 Infiltration, 535, 536. 
 
 Inflammation, 202 ; acute catarrhal, of the middle 
 ear, 547 ; acute, of the tongue. 547. 548 ; acute 
 suppurative, of the bone, 522. .523. 524. of the 
 middle ear, 547, of the parotid gland, .554. 5,55 ; 
 catarrhal, of the gums and mucous Uning of 
 the cheeks, 549 ; of joints. ,530. 531. .532, .533 : of 
 Peyer's patches in typhoid fever. 63 : of the 
 brain, 879 ; of the epididymis, 596 ; of the eye. 
 546. 876 ; of tlie facial nerve, 54, 55 ; of the jaw, 
 551 ; of the kidneys. 596 ; of the lungs, 679. 680, 
 681, 682 : of the peritonseum, 62 ; of the prostate 
 gland, 596 ; of the seventh cranial nerve. 54. 55 ; 
 of the skin (caused by poison ivy). 603 ; of the 
 temporal bone, .54 ; of the vermiform appendix, 
 93. 565, 566. ,567. .568 ; suppurative, of the pulp of 
 a tooth. 551 ; tubercular, 484, 485. of the lym- 
 phatic glands cf the armpit. 578 ; ulcerative, of 
 the gums and mucous Uning of the cheeks, 549, 
 550. 
 
 Influenza (Fr.. Jn gvippe\ 673. 681. 682. 683. 
 
 Ingrowing toe nail. 588. 
 
 Inhibition. 141. 190. 191. 192. 193. 194. 
 
 Injured, lifting and transporting the. .592. 59.3, 595. 
 
982 
 
 INDEX. 
 
 Injuries of the neck. 5."i2, ."iM, ."i-M, ."VkS ; of the 
 scalp, XiS. 5.S9 : resulting from sport, 'Mii ; of 
 muscles, 4158 ; of nerves, -ttxS. 
 
 Insanity, iW, -107, 4tW, 7S4, 8I-J. 81.5, 816, 817, 818, 
 819, 8-^\ 821. >iii; adolescent. 818; alcoholic. 
 818, 819 ; amenorrhreal. 819 ; asylum treatment 
 of, 815, 81t>, 817 ; choreic, S19 ; chronic alco- 
 holic, 819; circular. 8:9; climacteric, ,si'.) ; tie- 
 lusional, 8>',' ; home treatment of. Sl.">. 81(i, 817 ; 
 plienomena of, 178. ii-i ; pretlisposilioii to, lliO ; 
 puer|X'ral, S'i'.J ; senile. S"i3 ; transmission of. 
 Oil. 
 
 Insects in the ear, ,'Jl(i. 
 
 Insomnia, see Sleeplessness ; cheerful, 208. 
 
 Instincts. 18:}, •,>29 ; inherited. 18:^. 203, 2»). 
 
 Intellect, 199. 2(t8. 21."). 21ti ; basis of. 209 ; contents 
 of, 19G. 198,208; laws of. 211 ; life of the, 208 ; 
 practical aspect of, 219 ; pure, 21G ; signs of, 
 182. 18:j, 184. 
 
 Intelligence. 181, 182. 183. 211 ; organ of, 136. 
 
 Intercostal spaces. 10. 
 
 Interesl, feelings of, 217; intellectual, 218; na- 
 ture of, 217. 
 
 Intervertebrjil substance. .'). 0. 
 
 Intestine. 9;M ; diseases of the, 697. 608, 609, 700, 
 701 : large, .lO, 61, m, 88. 89, 93 ; small. .50, 61, 63, 
 88, 89, 93. 
 
 Intestinal, glands. 01 ; juice, 00, 91, 92; obstruc- 
 tion. .568. 500, .570 ; parasites, 701 ; worms, 701. 
 
 Intoxication, septic. 435. 
 
 Introspection, 177, 179. 
 
 Intubation. .5.56. 
 
 luinssusception, 569. 
 
 Iiivertin. 380. 
 
 Involution. .505. 
 
 Iodine, tincture of, 847. 
 
 Ipecac, 875 ; syrup of. 815, K75, 884, 887 ; tablets, 
 
 mr. 
 
 Iris, 77, 143, 146, 1 17. 
 
 Iron protosulphate. 372; tonic application of, 
 
 8i50. a51 : .salts, 382. 
 Irrigation, 373. .374 : farm. 374 ; field, soil suitable 
 
 for. :M0 ; subsoil. .374 ; surface, .373, .374. 
 Irritation, utero-ovarian. 407. 
 Irritability, 122. 
 Island of Reil. 44. 
 Isolation in communicable diseases, 305, 425, 426, 
 
 064. 
 Itch, 605, 606. 
 
 .Jaundice, 701, 702 ; catarrhal. 702. 
 
 .law, 18. 19 ; articidation of the, 18 ; dislocation 
 
 of the, 19 ; lower, 4, 8, ; upper, 8. 
 .Jawbone, 0, 18. 
 .Jejunum. 63. 
 Joint, "ball-and-socket." 17, 10; hinge, 17; hip, 
 
 17,19; immovable, 17; movable, 17; sensations, 
 
 212; shoulder. 17; stiff. .5:W. 
 Joints, 17 ; stiffness of, following fracture, 505. 
 Judgment. 140, 216. 
 Jumping, 2.56. 2^7. :W2; broad, 248, 257; high, 248, 
 
 2.57, 274, 273, 302. 
 
 Katabolism. 114. 
 Keratin, 381. 
 Kernels. 489. 
 
 Kicking, high, 257, 274, 2.83, 284, 288. 
 
 Kidney disease, 767 ; large, 714, 715, 711;; pelvis of 
 
 the, 73; si/e of the, 73; small, 717, 718, 719, 'l^d, 
 
 721 ; weight of the. 73. 
 Kidneys, 61, 73, a3, 88, 98, 110. 120 ; function of the. 
 
 110, 111, 112; position of the, 73; structure of 
 
 the, 73, 1U». 111. 
 Klebs-Loetlier bacillus, 660, 661, 062. 
 Knee, 15, 17; cap. 15; housemaid's, 585 ; joint, 15; 
 
 knock-. 585 : pan. fractm-e of the, 515, 516, 517. 
 Knee-t-hest positiiMi. 935. 
 Koumiss. 9'.;ti. 
 Kyphosis, see Ilr.MPnACK. 
 
 Labour. 734, 744, 745. 746, 747, 748. 749, 7.50, 0.52. 
 9.53 ; antisepsis in the management of. 748. 749. 
 7.50, 9.55, 9.59, 960 ; asejisis in the management 
 of, 748. 740. 7.50, 955, 950, 960 ; bed. 743. 054 : 
 complications of, 771, 773 ; date of. 953, 9.54 ; 
 luemorrliage after, 772, 773 ; mechanism of. 
 714. 745. 746 ; pains. 162, 745, 9.54. 9.55 ; prepara- 
 tion for, 741,742.743,744. 9.53, 0.54; prolonged. 
 771 ; room. 743. 053 ; stages of, 744, 745, 740. 
 747, 748. 054. 955, 9.56 ; variation of, 194. 
 
 Labyrinth. 70. 80, 149, 150. 
 
 Laceration of the brain. 540, .541, 542 ; of the geni- 
 tal canal, 772. 778. 
 
 Lachrymal bones. 8. 76 ; canals. 78. 149 ; fluid, 
 78 ; gland. 78. 149. 
 
 Lacrosse, 243. 244. 266. 209. 
 
 Lactation, 734. 7.58, 750, 760, 761, 702, 703. 
 
 Lacteals. 37. 38. 97. 
 
 Lakes. 340 ; fresh-water, 342 ; pollution of, 34.5. 
 
 Laminne. 5. 
 
 Language. 130, 17S ; functions. 210 ; growth fif. 
 229, 230. 
 
 Laparotomy, 706. 
 
 Laryngoscope, 128. 
 
 Laryngo-tracheitis, 672. 673. 
 
 Larynx, 68, 69. 123. 129, 672 ; cornicula laryngis, 
 60 ; physiological anatomy of the, 126. 
 
 Latency, 784. 785. 
 
 Lead and opium lotion, 847 ; poisoning. 805. 800. 
 
 Leeching. 867. 
 
 Leg, 15. 180. 283 : milk. 35. 770. 
 
 Lemonade, use of. in fever. 8.50. 
 
 Lens, curvature of the, 140; crystalline, 77. 78. 
 143. 140, 147 ; spectacle, 147. 
 
 Leucin. 381. 
 
 Leucoma. 548. .540. 
 
 Leukapmia. 704. 
 
 Levulo.se. .380. 
 
 Libertinism, 206. 
 
 Lice, body. 607 ; crab. 007 ; head. 006. 
 
 Life. 305 ; abnormities of the intellectual, 219. 
 220 ; athletic, of a comnnmity, 296 ; change of. 
 1.50, 725, 733 ; continuance of, 500 ; mental, 172. 
 173. 17.5. 189, 10.5, 100. 213 ; of the intellect. 182. 
 208. 211. 213. 214. 219 : of the will. 184 ; phy.sical. 
 114. 10.3, 172 : plan for daily. 301 : sexual. 1.59. 
 
 Ligaments. 17 ; capsular, 17 : of the liver. 05 : 
 round. 20. 
 
 Ligatures of catgut, 449. 
 
 Light. 74. 86. 145. .355. 3.58 ; disinfecting power of, 
 426 ; refraction of. 140 ; white. 148. 
 
 Lighting. .320 ; modern methods of, 322. 
 
INDEX. 
 
 9S3 
 
 Lime, 372 ; chloride of, 430. 
 
 Liinewater, 947. 
 
 Limitation of families, 312. 
 
 Liniment, stimulating, 844, 845, 87.'J, 880. 
 
 Lips, 5'.}, ia7. 
 
 Listening, 174, l'.)2. 
 
 Listerine, diluted, as a mouth wash, 4(J7. 
 
 Liver, CI, 0.5, 88, 89, 91, 38<J ; an organ of excre- 
 tion, 119 ; cells, GO ; complaints, VZO ; functions 
 of the, C"), 119 ; Hardening of the, 70a, 703, 710 ; 
 torpid, 872. 
 
 Lobe, central, 44 ; frontal, 44, 45 ; occipital, 44 ; 
 parietal, 44 ; temporo-sphenoitlal, 44. 
 
 Lochia, 755, 750, 900. 
 
 Lock-jaw, 123, 480, 481, 482, 504,800,814; acute, 
 481 ; chronic, 481. 
 
 Locomotion, 123. 
 
 Locomotor ataxia, 800, 807. 
 
 Lungs, 08, 70, 71, 88, 110 ; air surface of the, 100 ; 
 anatomy of the, 074 ; capacity of the, 321 ; em- 
 physema of the, 710 ; fatty embolism of the, 
 505 ; function of the, 70, 105 ; opening the, 285 ; 
 position of the, 107 ; structure of the, 71, 105, IOC. 
 
 Lupus, 487. 
 
 Lying-in period, 755, 756, 757, 758, 773, 774. 
 
 Lymph, 37, 38, 88, 95, 96, 104, 109 ; composition of, 
 96 ; corpuscles of, 104 ; distribution of, 96 ; 
 function of, in tissue respiration, 109 ; hearts, 
 104, 105 ; movement of the, 105 ; plasma of the, 
 104. 
 
 Lymphatic capillaries, 104 ; glands. 38, 01, 88, 104 ; 
 system, 88, 104, 105 ; vessels, 61, 05, 88, 96. 
 
 Lymphatics, 37, 38, 104, 105. 
 
 Maculfe acusticse, 153. 
 
 Maggots in the ear, 546. 
 
 Magnesia, citrate of, 851, 852. 
 
 Malaria, 338, 352. 833. 
 
 Malarial poisoning, 610. 
 
 Male, 81. 158. 
 
 Mallet, 79. 
 
 I\Ialpighian bodies, 73 ; capsule, 110, 111. 
 
 Malleus, see Mallet. 
 
 Maltose, 90, 380. 
 
 Mammary glands. 163. 
 
 Man, 85, 134, 135, 148. 
 
 Mania, 203, 815, 820 ; a potu, 818. 
 
 Marriage, of cousins, 786 ; rate, 312. 
 
 Marrow, 3. 
 
 Massage. 291, 470, 570, 895 ; for sprains, 526 ; of 
 sea bathing, 354 ; to hasten absorption of blood- 
 clot. 539 : to prevent stiffness in joints, 533. 
 
 Mattress, changing the, of a helpless patient, 907. 
 
 Maxilla, inferior, see Jaw, Lower ; superior, see 
 Jaw, Upper. 
 
 Measles, 417, 420, 651, 652, 653. 654. 
 
 Meats. 20, 89, 110. 121 ; value of, as diet, 115. 
 
 Meatus, external auditory. 149 ; urinarius, 74. 
 
 Medication, various methods of, 920, 921. 
 
 Medicine, administration of, 921, 922 ; chest. 834, 
 835 ; measuring. 921 ; not in use, 921 ; prepara- 
 tion of, 920. 921 ; preventive. 305. 823. 824. 
 
 Medulla oblongata. 42. 45. 40, 47. 49. 102, 135 ; an- 
 terior pyramid of the. 50 ; lateral tract of the. 50. 
 
 Medullary sheath. 41, 131. 
 
 Melancholia, 203. 815, 820. 
 
 Membrane, ara<.-hnoid, 42, 43, .52 ; basilar, l.V). 151. 
 1.52 ; blastodermic, 82, 83 ; lining nasal cavities. 
 154 ; lining mouth cavity, 1.55 ; lining the uteruH, 
 1.59, 160, 161 ; nnicouH, of the tongue, 75 ; pleu- 
 ral, 68 ; reticulate, 15<J ; synovial, 17 ; tectorial, 
 150 ; tympanic, 149 ; vitelline, HI, 82. 
 Memory, 140, 141, 213, 214, 221. 
 Meningitis, 663, 807, 8<J8, 879 ; cerebrospinal. Wi;. 
 
 808 ; simple, 808 ; tubercular, 808. 
 Menopause, see CHA.NfJE of Life. 
 Menstruation, 81, 159, 103, 407, 408, 726, 727, 72«. 
 729, 730, 731, 732, 733; absence of, 730, 731; 
 change of colour in, 730 ; disorders of, 730. 731. 
 732, 733 ; excessive, 731 ; first, 727 ; painful. 7;-i0, 
 881, 882 ; relation of, to pregnancy, 1.59, IWI : 
 scanty, 730, 731 ; vicarious, 731. 
 
 Mental anguish, 208 ; development, 169 ; experi- 
 ences, 174, 190, 197 ; facts, 175 ; fatigue, 412 : 
 images, 216 ; life, lU, 172, 173, 175, 170, 177, 178, 
 180, 181, 189, 195, 190, 213 ; overstrain, 204 ; phe- 
 nomena, 1.30 : processes, 174 ; states. 173, 174, 
 175, 170, 186, 195. 217; training, 408; work, 609. 
 
 Menu, preparation of a, 116. 
 
 Mercuric chloride, 430. 
 
 Mesmerism, 808. 
 
 Mesoblast, 82, 83. 
 
 Metabolism, 88. 113, 114, 103, 382. 
 
 Meteorology, 330. 
 
 Micrococcus, 624. 
 
 Micro-organisms, .329. 336, 337 ; in the air. .323 ; 
 non-pathogenic, 300 ; of chicken-pox, 323 ; of 
 measles, 323 ; of scarlet fever. 323 ; of small- 
 pox, 323; of typhus fever, 323; of whooping- 
 cough, 323 ; pathogenic, .300, 307, 308. 
 
 Micturition, '112. 
 
 IMidwifery, 725. 
 
 Midwives, 741. 
 
 Migraine, see Headache. 
 
 Milk, amount of. for nursing babies. 7.59 ; char- 
 acteristics of human. 103 : cow's, modified. 963: 
 cure, 900 ; diet. 115, 858 ; peptonized. 926 ; ster- 
 ilized, 925, 926. 
 
 Mind and matter. 184 : contents of, 197. 198. 199 : 
 evolution of. 135 ; habits of, 212 ; physical re- 
 lations of. 175 ; reading. 215 ; signs of. 181, 182. 
 183, 187. 188. 189 ; study of the human. 171. 
 
 Mineral salts, 379 ; waters. 896. 897. 898. 
 
 Moisture. 330 ; necessary amount of, in air. 319. 
 320; variations in amount of, 321. 
 
 Molars, 60 ; anterior, 60 ; first. 60 : permanent, 
 00 ; posterior, 00 ; second, 60 ; six-year. 60 : 
 third. 60. 
 
 Monomania, 821. 
 
 Moral training. 408. 
 
 Morbid con.'^cientiousness, 207 ; perversion, 205. 
 207. 231, 2.33 : will-lessness, 2-31. 
 
 Morphine, 407, 012. 873, 879, 886, 893 ; tablets. aSo. 
 830, 885. 
 
 Mortahty of large cities, 315 ; statistics, 312, 313. 
 
 Motion. 40. 88. 120. Vii. 382. 
 
 Motor area. 137. 1.38 ; cells; 1-34 : centres, 1.34 : 
 fibres. 134 ; functions, 186 : impulses, 135, 140 : 
 nerve-fibres, 134 : oculi, 53 ; processes, 186, 187, 
 188, 215, 216 ; tendencies, 214, 
 
 Jloulds, 323. 
 
 Mountain climbing, 901. 
 
DSi 
 
 INDEX. 
 
 Mouth, 59. 8S. 89. 127 ; care of the, 403. -167. STT, 
 9+1 ; roof of the, 8, 59 ; sore, 8S3 ; wiish. aW. 
 .">47, 877. 
 
 Movements, liX ; expressive, 17C ; oE muscles of 
 respiration, 107. laS ; of the alimentary canal, 
 va ; of the arteries, 135 ; of the eyes, IM'i ; of 
 the face, 135 ; of the heart, 133 ; of tlie larynx 
 in spealiing, i;i"j ; of thetesophaKUS in sHallow- 
 inji, l.'io ; of the pharynx in swallowing. 135 ; of 
 the tongue, 135. 
 
 Mucin, 90. 
 
 .Mucus, 159. 
 
 ^lumuiitlcatioD, 475. !i'.\-i. 
 
 Mumps. IK), 417, 05S. Ii59. 
 
 .^lurnmr, respiratory, .VJO. 
 
 .^luscle, -.X), 121, 120: biceps. 11 ; cardiac. r,M, 122 ; 
 cells, 120, 121; ciUary, 140, 147; contractility of, 
 122; sterno-cleiilo-niastoid, 553; temporal, 9; 
 voluut^u-y, 20, 83, 122, 123, 137. 
 
 Muscle-libres, 120, 121 ; cardiac, 121 ; smooth, 
 121; striped, 121 : luistriped, 121. 
 
 Muscles, 20, 8(5. 88, 103, 114, 120, 169, 180 ; action of, 
 22; death of, 104; electrical stimulation of, 124; 
 functions of, 20; hand, 280; increasing the size 
 or', 207; involuntarj-, 20, .57, 8:3; of the eyeballs, 
 148; physical education of, 235 ; respiratory, 
 108. 127; striped, 20, 121, 122 : voluntary, 20, .57, 
 s:j, 135, 137; wrist, 280; yield heat, 118. 119. 
 
 .^luscular fatigue, 202; sense, 156, 1.57; tone, 123. 
 
 Mustard bath, 865, 887; leaves, 844; paste, 8(52, 
 873, 880, 884 ; plaster, 802, 875, 939, 945. 
 
 JIutton broth, 928. 
 
 :\lyelitis, 808. 809; acute transverse, 808, 809. 
 
 Myxtedema, 72, 557, 558. 
 
 Nails, 80. 
 
 Xapkins, infants". 901 ; sanitary, 953, 954, 9,57. 
 
 Xares, anterior, 75 ; posterior, 75. 
 
 Nasal cavities. 8, 75, 128, 129; duct, 78 ; fos.sae, 75. 
 
 Nativity, influence of, on the death-rate, 313. 
 
 Nausea, 157, 914, 945. 
 
 Navel, 161. 
 
 Near-sight, 147. 
 
 Neck, 4; breaking the, 108; wounds of the, 552, 
 553, 5.54, .555. 
 
 Necrosis, 474, 475, 476. 
 
 Nerve, abducens. .53, 54 ; anterior crural. 57 ; au- 
 ditory, 55, 79, 186 ; coccygeal, 50 ; conductors, 
 133; eighth cranial, 55; eleventh cranial, 55; 
 facial. 54: fifth cranial, .54: lir.st cervical, 56; 
 (irst cranial, 53; fourth cranial. 46, 53, 54; g^reat 
 sciatic, 57: hypoglossal. 56; impulses, 141; in- 
 ferior maxillary. 54; left abducens. 53: left au- 
 ditory, .53 ; left facial, .53 ; left glosso-phar3-n- 
 geal, .53 ; left hypoglossal. .53 ; left motor oculi, 
 .53 ; left olfactory, 53 ; left optic, 53 ; left pa- 
 thetic, 53 ; left pneumogastric, 53, 55 ; left spi- 
 nal accessory, 53 ; left trifacial, .53 ; left vagus, 
 .55 ; median, .57 ; musculo-spiral, .57 ; olfactory, 
 41. 45, 53, 75 ; ophthalmic, .54 ; optic, 45, .53. 77, 
 7S, 143, 144, 145, 147 ; paralysis of the facial, .54, 
 •55 ; paralysis of the seventh cranial, 54, .55 ; 
 pathetic, 53, .54 ; phrenic, .56 ; radial, 57 ; right 
 abducens. .53 : right auditory, .53 ; right facial,- 
 .53 ; right glosso-pharyngeal, .53 ; right hypo- 
 glossal, 53 ; right motor oculi, .53 ; right olfac- 
 
 tory, .53; right optic, 53; right pathetic, 53; 
 right pneumogastric, .53, 55; right spinal acces- 
 sory, 53 ; right trifacial, 53 ; right vagus, 55 ; 
 second cranial, 53 ; seventh cranial, 54 ; sixth 
 cranial 53, 54 ; spinal accessory, 55 ; superior 
 maxillary, 54 ; third <;ranial, 40, ,53 ; trifacial, 
 54 ; twelfth, 50 ; ulnar, .57 ; vagus, 141. 
 Nerve-cells, 39, 40, 131, i:32, 13:3, 144, 184. 
 Nerve-centres, 40, 133, 141. 
 Nerve-cords, 40. 
 
 Nerve-corpuscle, 39, 40. 
 
 Nerve-fibres, 39, 40, 131, 132, 141, 184, 185 ; afTerent, 
 133 ; centrifugal, 133 ; centripetal, 133 ; effer- 
 ent, 133; medullated, 40, 11 ; non-nirdulUited, 
 40, 41 ; .sensory, 134, 142. 
 
 Nerves, 42, 8t), 88. i:M, 131 ; cervical, 56 ; cranial, 
 40, 53, .55, 50 : division of the, .579 ; dorsal, .56, 
 57 ; fifth cranial. 40 ; glo.sso-pharyngeal, .55 ; 
 injuries of, 46S ; intercostal, 57 ; lumbar, 50, .57 ; 
 of communication, 5S ; of distribution, .58 ; op- 
 tic, 45 : sacral, 50 ; secretory, 119 ; sensory, 1.37, 
 i;W, 202 ; sixth cranial, 40, .53, 54 ; spinal, 52, 66, 
 133, 135 ; sj-mpathetic, 102 ; vaso-motor, 103, 
 119; vagus. 102, 141. 
 
 Nervous action, 184 ; api>,aratiis, cardiac, 104 ; 
 centres, 176, 190, 192. 203 ; disorder, 193 ; en- 
 ergy, 1.34, 141 ; exhaustion, 203, 204, 220, 221, 
 232, 233,811, 812; fatigue, 202, 208; functions, 
 132, 137, 140, 170, 177, 182; ganglia, 131; im- 
 pulses, 141 ; physiology, 176 ; prostration, 809, 
 811, 812 ; structure, 131 ; tissues, death of the, 
 164. 
 
 Nervous system, 39, 92, 102, 119, 125, 129, 130, 131, 
 140, 163, 176, 184, 209, 779 ; central, 130, VU, 142, 
 143, 148, 163, 185, 187, 194 ; eerebro-spinal, 40, 
 42, 58 ; correlation of functions of the, 134 ; ele- 
 ments of the, 39, 184, 185 ; functions of the, 130, 
 176, 181, 185 ; in relation to psychology, 184 ; 
 of children, 779 ; peripheral, 130 ; structure 
 of, 184, 185 ; sympathetic, 40, 57, 88. 
 
 Nettlerash, see Hives. 
 
 Neuralgia, 809, 810, 811, 812 : intercostal, 810 ; of 
 the heart, 691 ; trigeminal, 809, 810. 
 
 Neurasthenia, see Nervous Prostr.vtion. 
 
 Neurilemma, 41. 
 
 Neuritis, 812 ; multiple. 812. 
 
 Neurons. 131, 132; psychic, 132. 
 
 Nightingale, invalid's, 968. 
 
 Nipple shield, 761. 
 
 Nitrogen, 115, 318, 319. 
 
 Nitrogenous compounds, .381. 
 
 Noises, 153 ; in the sick-room, 907 ; disagreeable, 
 196. 
 
 Noma, .550. 
 
 Normality, the test of, 205. 224. 
 
 Nose, 74, 75, 83, 127, 149, 544, 545 ; bridge of the, 
 8 ; septum of the, 8, 75. 
 
 Nozzle of syringe, boiling the, 9.35 ; glass, 9.36 ; 
 insertion of, 934 ; lubrication of, 9.34 ; vaginal, 
 936. 
 
 Nubia, 335. 
 
 Nur.se, choice of obstetrical, 741, 952 ; wet, 703, 704. 
 
 Nursery, essentials of an ideal, 401, 402. 
 
 Nur.sing, first, 753 ; frequency of, 759 ; infectious 
 and contagious cases, 964, 965, 966, 967 ; med- 
 ical, 944, 945 940, 947,948; night, 947, 918; ob- 
 
INDEX. 
 
 985 
 
 stctrical, 053, 053, 054, 055, 950, 057, 05H, 050, OliO ; 
 
 surgical, 040, 050, 051, 0552. 
 Nutrients, albuminous, 970 ; nitrogenous, 370 ; 
 
 non-nitrogenous, 370; of i'oods, 370; protoid, 370. 
 Nutriment, transfer of, 04. 
 Nuti'itiun, 88. 
 
 Oatmeal gruel, 920 ; water, 874. 
 
 Obesity, 881. 
 
 Obstetrics, see Midwifery. 
 
 ( Jccipital lobe, 44. 
 
 Occupations, injurious, 013, 014 ; ofTensive, 413. 
 
 Odours, classification of, 1.55 ; perception of, 1.54. 
 
 Oertel's treatment by mountain climbing, 001. 
 
 Otlsophagus, see Gullet. 
 
 Oil, coal, 3a0 ; colza, 320 ; enema of, 934 ; for 
 artificial illumination, 320. 
 
 Oiled silk, 453. 
 
 Old age, 103 ; hygiene of, 409, 410, 411. 
 
 Old sight, 147. 
 
 Olfactory bulb, 45; cells, 154; nerve, 41, 45, 53, 
 75 ; organs, 154. 
 
 Olivaiy body, 50. 
 
 Omentum, great, 02. 
 
 Ophthalmia neonatorum, 426. 
 
 Opisthotonos, 481. 
 
 Opium, 012 ; poisoning, 542, 869. 
 
 Optic commissure, 45, 53 ; foramen, 53, 76 ; nerve, 
 45, ,53, 77, 78, 143, 144, 145, 147 ; thalamus, 46, 47, 
 136 ; tracts, 45. 
 
 Orange, 148 ; jelly, 9.30. 
 
 Orbicularis, 123. 
 
 Orbits, 75, 76. 
 
 Organ of consciousness, 130 ; of Corti, 1.50, 151 ; 
 of equilibrium, 153 ; of intelligence, 130. 
 
 Organs, 86, 169 ; development of the, 83 ; limita- 
 tions of the sense, 173 ; of circulation, 94, 97, 
 110; of cold, 156; of excretion, 110; of hear- 
 ing, 55 ; of involuntary movement, 186 ; of 
 muscular movement, 184 ; of muscular sensa- 
 tions, 88 ; of smell, 88, 154 ; of special senses, 
 74, 130, 134, 137, 138 ; of speech, 138, 139 ; of 
 taste, 88, 155 ; of temperature, 88 ; of the blood 
 system, 07 ; of touch, 88, 150 ; of voluntary 
 movement, 180 ; of warmth, 156 ; olfactory, 
 154 ; reproductive, 158, 100 ; respiratory, 83, 105, 
 109, 945 ; rudimentary, 782 ; sense, 184, 186 ; vo- 
 cal, 55, 140 ; yield heat, 118, 119. 
 
 Osmosis, 108, 319. 
 
 Otoliths, 153. 
 
 Ovaries, 15, 01, 81, 88, 109. 
 
 Overdrinking, Oil. 
 
 Overeating, 611, 013, 825, 826. 
 
 Overtones, 152. 
 
 Overtraining, 299. 
 
 Overwork, 609. 
 
 Ovulation, 81. 
 
 Ovum, 81, 82, 1.58, 159, 160, 168. 
 
 Oxalic acid, 444. 
 
 O.xidation, 114, 115. 
 
 Oxygen, 98, 105, 318, 310. 320 ; inhalation, 853, 854. 
 
 Oxyhaemoglobin, 109, 319. 
 
 Ozone, 321. 
 
 Pack, cold, 864, 942 ; hot, 940. 941, 942 ; ice, 942. 
 Pads, sanitary, 953, 954, 957. 
 
 Pain, 157, 173, 198, 109, 200, 201, SOSJ ; a constant 
 •symptom of fracture, 502 ; expi'ession of, 174 ; 
 intellectual value of, 209, 210 ; of labour, 102, 
 745,054, 055; results fi'om conipression of the 
 nerves, 461, 402; signs of, 181, 182; varies di- 
 rectly as the nerve su]jply, 408, 469. 
 
 Palate, 127; bones, 8, 70; cleft, .541, .549; liard, 
 59 ; soft, 59, 155. 
 
 Paleness, cause of, lfJ4. 
 
 Palm, deep ab.scesses of the, 580. 
 
 Palsy, Bell's, 797 ; birth, 797. 
 
 Panada, 032, 033. 
 
 Pancreas, 61, 63, 60, 07, 88, 89, 91 ; di.sf^ases of the, 
 704. 
 
 Pancreatic duct, 63, 00, 07 ; juice, 07, 90, 91, 92. 
 
 Pangenesis, Darwin's theory of, 107. 
 
 Papilla;, 75. 
 
 Paralysis, 407, 408, 812; alcoholic, 795; facial, 
 801 ; infantile spinal. 804. 
 
 Paranoia, 785, 780, 815, 821, 822. 
 
 Parasites, intestinal, 701. 
 
 Paregoric, 840. 
 
 Paresis, 812, 822 ; general, 815. 
 
 Parotid gland, 60, 90, 058. 
 
 Parotitis, 658, 059. 
 
 Parturition, see Labour. 
 
 Pasteurizing process, 705, 700. 
 
 Patches of Peyer, 055. 
 
 Patella, see Knee-pan. 
 
 Patient, care of, 909, 910, 911, 912, 913, 948 ; care 
 of, after operation. 951, 9.52 ; care of, in infec- 
 tious and contagious cases, 900 ; lifting and 
 handling the, 909, 910, 911 ; preparing for op- 
 eration, 950, 951. 
 
 Pedicles, 5. 
 
 Pelvis, 6, 15, 01. 
 
 Peppermint water, 847, 878. 
 
 Pepsin, 91. 
 
 Peptic glands, 63. 
 
 Peptones, 90, 92, 381. 
 
 Perceptions. 197, 213, 214, 215, 221. 
 
 Perflation. 324. 
 
 Pericarditis, 665, 092. 
 
 Pericardium. 28. 08. 686. 
 
 Perilymph, 150. 151. 
 
 Periosteum, 2, 504, ,522, 523. 
 
 Peritonasum. 61, 62. 
 
 Peritonitis, 563, 564, 565, 506, 507. 568, 705, 706 ; 
 acute, 705 ; acute general suppurative. 501 ; 
 chronic, 705 ; diffuse purulent, 564, 505, 500, 567, 
 508; localized, .598 ; septic, 504, 505 ; symptoms 
 of, 504, 505 : tubercular, 705, 700. 
 
 Peroxide of hj'drogen, solution of, as a mouth 
 wash, 467. 
 
 Perspiration, 112, 113. 
 
 Pertussis, see Whooping Cough. 
 
 Petit mal, see Epilepsy. 
 
 Peyer's patches (or plaques). 63, 655. 
 
 Phagocytosis. 621. 622.. 
 
 Pharyngitis, chronic. 550. 551. 
 
 Pharynx, .59. 60. 61. 89. 127, 128. 149. 
 
 Phenacetine. 877, 878, 879, 880 ; powders. 849 : tab- 
 lets, 849. &50. 
 
 Phlegmon. 4.59. 460. 477. 5.54. 
 
 Phthisis, pulmonary, see Consumption. Pulmo- 
 nary. 
 
9S6 
 
 INDEX. 
 
 Physical training. 235. 230. 237, 238, 265, 266, -JOS ; 
 health the object of, 207 ; of boys, 265 ; of 
 wiuueu. 264, 'MS. 
 
 I'hysiolosicai processes. 172, 173 ; units. 167. 
 
 Piiysiology, 85. 86 ; nervous, 176 ; of the senses, 
 171» ; relation of, to functions of the human 
 btHly, 172. 
 
 Pia mater. 42, 43. 52. 
 
 Pile.-^. 64. 571, 572 ; external, 571 ; internal. 572. 
 
 Pills, Blaud's, 850, 851 ; coiupounil cathartic, 840, 
 874 ; ice, 914, 951. 
 
 Pinna, 78, 149. 
 
 Pitch, 151, 1.52. 
 
 Pituitary body. 45 ; gland. 45. 
 
 Placenta. 161 ; delivery of the, 162. 746 ; pncvia, 
 769. 770 ; retained. 771, 772. 
 
 Plague, 426. 
 
 Plant!J. l.m 
 
 Plasma, 95. 96. 
 
 Plasmodium malaria^. 6:«. 634, 6:i5, 636, 637, 6;}9. 
 
 Plajiter, 862 ; sticking, 453. 
 
 Pleasure. 199. 2lX). 201. 2t12; signs of, 181. 
 
 Pleura, 71, 669, 670, 674 ; diseases of the, 6(i9. 
 
 Pleural cavity, 71 ; membranes, tiS ; sac, 71. 
 
 Pleurisy, 71, 669 : simple, 669, 670 ; subacute. 670 : 
 with adhesions, 670 ; with effusion, 670. 
 
 Pleuritis, 669 ; acute, 669. 670. 
 
 Plexus, abdominal. 58 : brachial. .57 ; cardiac. .58 ; 
 cervical, 56 : choroid, 46 ; gastric, 58 ; hepatic, 
 58 ; hypogastric, 58 ; lumbar, 57 ; pelvic, 58 : 
 prostatic, 58 ; renal, 58 ; sacral, 57 ; solar, 58 ; 
 thoracic. 58 ; uterine, .58 ; vesical, 58. 
 
 Plumbing, 326, 328, U7, 356, 358, 359, 362, 363, 364, 
 365. 
 
 Pneumonia, pneumonitis, 314, 338, "679, 680, 681, 
 682; chronic interstitial, 679 ; double. 680 ; germs 
 of, 079, 080 ; lobar. 079 : lobular. 081. 082 ; of 
 heart disease, 679 ; secon(lar3-, 079 ; symptoms 
 of, 680, 681 ; treatmeir. of. 681. 
 
 Pneumothorax, 671. 
 
 Poisoning and its treatment. 890. SO]. 893. 894. 
 
 Poisons and their antidotes. 801, 892, 893. 
 
 Poliomyelitis. 812. 
 
 Polo, 240, 24;j, 250, 260, 200. 
 
 Polyuria. 721. 
 
 Pons Varolii. 42, 45, 46. ."50. 51. 
 
 Population. 309. 310, 311. 315. 316. 
 
 Portal system. 35. .380. 
 
 Posture, faulty, 408 ; in di.sease. 800, 947. 
 
 Potash (or potassium), chlorate of, 848, 819 ; per- 
 manganate of, 430. 444. 
 
 Potatoes, creamed, 032. 
 
 Pott's fracture. 518, 519. 
 
 Poultices. 4.5.3. 401. 402. 403. 801. 802; dry, 939; 
 how to make. 938, 939 ; use of, 403, 801 ; use of, 
 discouraged. .581, .582. 
 
 Powder for infants. 901. 
 
 Precipitation process. 371, 372. 
 
 Pregnancy. 7.34, 7-^5. 730. 737. 7.38, 7.39. 740, 741, 
 9.52 ; duration of. 102, 737, 7.38 ; extra-uterine, 
 769 ; hygiene during. 738, 7.39. 740. 741 ; in 
 chronic disea-ses, 770. 771 ; " longings ■' of. 7-35 ; 
 molar, 709 ; signs of, 7.34, 745, 7.30. 7.37 ; strain 
 on the organs during. 7-38. 7.39 ; taking of drugs 
 during. 741 : vomiting of, 700. 
 
 Prepotency, 785. 
 
 Prescriptions, 921. 
 
 Pressure, 212 ; to stt)p bleeding, 445. 448, .543. 553, 
 554, 579, 583 ; points, 156 ; sense of, 156. 
 
 Primitive trace, 82, 83. 
 
 Privies. 358, 361. 362, 369, 370. 
 
 Processes. 184, 185 ; axis-cylinder, 131. 1.32, 133. 
 1S5 ; brain, 187, 188 ; cell, 188 ; central, 188 ; 
 ciliary, 77; functional, 195 ; higher intellectual, 
 191. 192 ; imitative. 219 ; intlamnuitory, resolu- 
 tion of, 462; intellectual. 213; mental. 174; 
 motor. 180, 187. 188. 215, 210 ; of computation. 
 180 ; of memory, 180 ; piiysiological, 172, 173 ; 
 protoplasmic, 131 ; psychical, 140 ; time of 
 cerebral, 142. 
 
 Prophylaxis, see JIedicine, Preventive. 
 
 Prostate gland. 74. 
 
 Proteids, 89, 90, 115, 110, 118, 381. 
 
 Protein, ;^S1. 
 
 Protoplasm. 86, 95, 144, 158, 164, 107, 169; con- 
 tractility of. 120; generates heat, 118; irrita- 
 bility of, 87 ; muscle, 122 ; of nerve centres. 
 141 ; structure of, 114 ; the physical basis c)f 
 life, 86. 
 
 Pseudo-angina pectoris, 001. 
 
 Psoriasis. 604. 
 
 Psychic activity not wholly eliminated in sleep. 
 164 ; cells, 134 ; facts, 172 ; neurons, 132 ; proc- 
 esses. 140. 
 
 Psychology, 171. 172, 174, 175 ; experimental. 1R0; 
 function of. 173 ; methods of, 177, 178, 179. 1K(i ; 
 practical importance of, 233, 234. 
 
 Psychrometer, 332. 
 
 Ptyalin, 90. 
 
 Puberty. 159, 407, 725, 727, 728. 
 
 Pubes, 15. 
 
 Puerperal fever. 748. 774 ; infections, 426 ; insanity. 
 822 ; sepsis, 775. 77(i, 777. 
 
 Pulley weights. 270, 279, 281. 289. 
 
 Pulmonary tuberculosis, see Consvmption, Pul- 
 monary. 
 
 Pulse, 100 ; coimting the. 31, 918 : daily variation 
 in rate of, 103 ; rapid, present in fever, 103. 
 
 Punching bag, 270. 289, 302. 
 
 Pui)il of the eye, 77, 143. 
 
 Pus, a free outlet for, 460, 401, 403, 471, 472, .523, 
 .524 ; application of cold to prevent the forma- 
 tion of, 472 ; formation of. 402 : in the che.st. 670. 
 671 ; microbes. 402, 463, 479, 480 ; signs of the 
 presence of. 471. 
 
 Pustule, malignant, of the face, 543, 544. 
 
 Putrefaction, .502. 
 
 Pyjcmia, 430. 504. .501) ; cause of, 479 ; historj- of, 
 480 ; symptoms of, 480. 
 
 Pyloric glands, 03 ; opening of the stomach, 62 ; 
 valve, 62. 
 
 Pylorus. 92. 
 
 Pyopneumothorax, 071. 
 
 Quickening (in pregnancy), 7.37. 
 
 Quinine, 879 ; in malarial diseases, 034 ; pills. 8.39, 
 
 840. 
 Quin.sy sore throat, 5.50. 
 
 Rabies, see HvnnoPHonTA. 
 
 Racial characteristics, 781, 782 ; continuance. 1.57. 
 
 Rackets, 272, 273, 302. 
 
INDEX. 
 
 987 
 
 Radius, 14 ; fraoturo of the, U. 
 
 Kain, 3;iO, :540, ;5i;5. 
 
 Ranula, 548. 
 
 Bapier, 274. 
 
 Reaction, control of emotional, 20G ; time, M2. 
 
 Reading, V.)2 ; mind, 215 ; unwholesome, 205. 
 
 Rr-aumur's scale, 331. 
 
 Rectum, GI, O:), 04, 9:3, 933, 934. 
 
 Refuse, 3G5 ; disposal of, 3(;5, 377, 3;-8 ; dry, 370 ; 
 liquid, 375 ; manufactory, 375 ; market, 375 ; 
 moist, 370 ; separation and removal of kitchen, 
 37G ; solid, 3?'5. 
 
 Register, chest, 128 ; head, 128 ; vocal, 127, 128. 
 
 Ranuin, 91. 
 
 Repose, 412. 
 
 Reproduction, 88, 157, 158, 109, 781. 
 
 Reservoirs, .340, 347. 
 
 Respiration, 88, 105, 154, G74 ; abdominal, 107 ; ac- 
 tion of the • diaphragm iu, 24; amount of air 
 consumed in one, 321 ; artificial, 751, 7.52, 869, 
 870, 871, 888; by the skin, 109; carbonic acid 
 given off in, 319, 320 ; costal, 107 ; diaphrag- 
 matic, 107 ; in children, 107 ; internal, 109 ; in 
 the adult, 107 ; nervous control of, 108 ; oxygen 
 consumed in, 319, 320 ; primary, 751 ; rate of, in 
 a healthy adult, 107, .321 ; sexual differences in, 
 107 ; Sylvester's method of artificial, 751, 7.52, 
 809, 870, 871 ; taking the, 918, 920 ; tissue, 109 ; 
 variation in the depth and rate of, 163, 164, 321. 
 
 Respiratory changes in air, 108 ; changes in the 
 blood, 108. 
 
 Rest cure, 901, 902 ; of mind and body, 912, 913 ; 
 value of, 236. 
 
 Restiform body, 50. 
 
 Resuscitation of apparently stillborn ch ild, 751, 752. 
 
 Retina, 53, 77, 78, 143, 144, 140, 148, 186 ; cones of 
 the, 144, 145, 146, 148, 150 ; inertia of the, 196 ; 
 mechanical stimulation of the, 145 ; origin of 
 the, 144 ; rods of the, 144, 145, 146, 148, 150. 
 
 Revaccinatiou, 642, 643. 
 
 Reversion, 165, 784, 785. 
 
 Rheumatic hyperpyrexia, 665 ; pains, 882. 
 
 Rheumatism, 338, 664, 665, 666, 637 ; acute, 532, 
 664, 665 ; acute articular, 664, 665 ; chronic, 665, 
 066 ; inSammatory, 664, 665 ; muscular, 880 ; 
 transmission of, 614. 
 
 Rhinitis tablets, 836. 
 
 Rhubai-b and soda mixture, 853, 880, 883. 
 
 Rhythm, 122. 
 
 Ribs, 4, 9, 10 ; false, floating, true, 9. 
 
 Rickets, 524, 559. 
 
 Riding, 253, 254, 256, 261, 303, 828, 872 ; for girls, 
 265 ; for women, 263, 264. 
 
 Right-handedness, 140. 
 
 Rigor mortis, 591. 
 
 Rings, flying, 278. 
 
 Ringworm, 605. 
 
 Rivers, 340, 341 ; contamination of, 341, 315. 
 
 Rochelle salt, 851. 852. 
 
 Rod, glass, for preparing medicines, 855. 
 
 Rods of Corti, 150. 151. 
 
 Room, size of habitable. 3.58. 
 
 Rcitheln, see German Measles. 
 
 Rowing, 240, 250, 259, 260, 266, 838 : for women, 
 263, 264, 303 : machine, 277, 279, 281, 284, 289, 302 : 
 training for, 299. 
 
 Rublx.T rings, 915, 910. 
 
 Rubeola. See Mkasi.es. 
 
 Ruiming, 123, 124, 248, 249, 2.57, 2«'>, 302, 828 : a 
 
 horse, 250 ; in the gymna.sium. 277 ; long-din- 
 
 tarice, 248, 240 ; short-distance, 248. 
 Rijiiround, .582. 
 
 Rupture, 573, 574, 575, 570 ; of the drmnli.-,-i.l .'it. 
 Rutherford's thermomet«r, 331, 832. 
 
 Sabre exorcise, 27'4. 
 
 Sac, hernial, 573 ; jjleural, 71. 
 
 Saccule, 1.50, 153. 
 
 Sacnim, 4, 15. 
 
 Saddle, bicycle, for women, 20^1 ; three-pommel, 
 for women, 203. 
 
 Saliva, 00, 90, 92 ; secretion of, 135. 
 
 Salts, 90, 110, 110, 851, 852. ^53. 
 
 Sarcomata, malignant, of the humerus, .577 ; of 
 the thigh bone, .584, 585. 
 
 Sarcopeptones, Rudisch's, 93.5. 
 
 Scabies, 605, 000. 
 
 Scalp, 80 ; injuries of the, 538, 5.39, 540. 
 
 Scapula, see Shoulder-blade. 
 
 Scar, 4.33, 4-34. 
 
 Scarf skin, 80. 
 
 Scarlatina, see Fever, Scarlet. 
 
 Sciatica, 810, 811, 812. 
 
 Sclerosis, 812, 813 ; multiple, 812, 813. 
 
 Sclerotic coat, 77. 
 
 Scoliosis, see Spine, Lateral Ci'Rvatcre of the. 
 
 Screen for bedclothing in fractures, 514, 515. 
 
 Sea bathing, 354, 897. 
 
 Seborrhcea, 002. 
 
 Secretion, 91, 180; infantile mammary, 755; of 
 digestive fluids, 135. 
 
 Segmentation, 160, 167. 
 
 Seidlitz powder, 851, 852. 
 
 Self-control, 193, 260 : distrust. 207. 
 
 Seminal fluid. 81, 160 ; vesicles, 160. 
 
 Sensations, 40, .55, 133, 134, 137, 142. 1*^.. 211. 212. 
 213, 214 ; colour, 148 ; elimination of painful. 
 202; joint, 212; muscular, 142, 156, 157, 202. 
 272 ; of bodily equilibrium, 212 ; of hearing. 
 142, 212 ; of movement, 212 : of sight, 142, 212 : 
 of smell, 142, 154, 155, 212 : of taste, 142. 212 ; of 
 temperature, 142 : of touch, 142 : painful. 202 : 
 relative importance of various, 154 ; seat of 
 the, 134, 143 ; value of, as experiences. 212. 
 
 Sense of cold, 156 ; muscular. 156. 1.57 : of humour. 
 201 ; of pressure, 156 ; of smell. 1.54 : of taste. 
 155 ; of temperature, 156 ; of touch. 156, 212 ; of 
 warmth. 156 ; organs, 173, 1S4, 186, 202. 
 
 Sensibility. 157, 212. 
 
 Sensitiveness, 181 ; animal, 182 : discriminating, 
 181. 184. 187; general. 181. 
 
 Sensory area, 137 : cells, 1-34 ; centres. 1.34 ; dis- 
 turbances, 188 : fibres. 134. 186 ; functions. 180 : 
 impression. 187 ; impulses, 135, 140 : nerves, 
 137, 138. 202. 
 
 Sepsis, puerperal. 775. 776. 777. 
 
 Septicemia. 435. 430. 479, 480, 504, 590, 775, 776. 
 777 : progressive. 479. 
 
 Sequestrum, 523. 524. 
 
 Sei-um, 96. 
 
 Sewage. 365, 366 : disposal of. ^45. .365. -367. -371. 
 373, 374 ; farms, 373, 374 ; filters, 372, 3r3 ; in- 
 
OSS 
 
 INDEX. 
 
 fluence of. on river water, 3-11 ; purifloat ion of, 
 871, STi, 373. 
 
 Si'wers, 3U(J, 307, 3GS, 300 ; Berlier system of, 300 ; 
 closed, 301 ; combined system of, 307 ; tUisbiug, 
 .■103 ; Liernur's system of, 368, 3()0 ; separate 
 system of, 360, 307 ; Shone system of, StiO ; ven- 
 tilation of, 307 ; Waring system of, 309.; water- 
 carriage system of,-300. 
 
 •Sex, barrier of, in psychological study, 17?^ ; in 
 relation to exercise, 301. 
 
 Shell, l.->8. 
 
 Shinbone, 15, 10, 517. 
 
 Shingles, 003. 
 
 Shivering, 157. 
 
 Shock, 138, -tJO, -JOS, 888. 
 
 Shoes, 400. 
 
 Shot-putting, 2-18, 257, 258. 
 
 Shoulder, 10 ; blade, 4. 10. 22 ; point of the, 10. 
 
 Shoidders, to exercise the, 284, 285, 280. 
 
 Sieltness, records of, 309. 
 
 Sick-room, 903, 904 ; cleaning the, 90S; heating and 
 ventilating of the, 008, 909 ; in infectious and 
 contagious cases, 901, 905, 900 ; management of 
 light in the, 913. 
 
 Sighs, 174. 
 
 Sight, 142, 14-3. 
 
 Sigmoid flexure, 04. 
 
 Sinews, 21. 
 
 Single sticks, 274, 275. 
 
 Sinks, 359. 
 
 Sinus, tubercular, 400. 
 
 Skating, 200 ; for girls, 205 ; for women, 263, 303. 
 
 Skeleton, 1, 2, 4. 
 
 Skin, 74. 80, SO, 88, 98. 110, 945 ; functions of the. 
 8<). 112 ; loss of heat through the, 119 ; pores of 
 the, 112 ; scarf, 80 ; true, 80, 83. 
 
 Skirt-dancing, 291. 
 
 Skull, 4, ; base of the, 8. 
 
 Sleep, 163, 164, 297. 298, 299, 300, 830, 831 ; in old 
 age, 411 ; regularity in. 012, 613. 
 
 Sleeplessness, 804, 805, 813, 882. 
 
 Sling, triangular, 506. 
 
 Smallpox, 416, 417, 418, 426, 616, 617, 019, Oil, 014, 
 015, 040 ; confluent, 045. 
 
 Smell, 74, 75. 
 
 Smoking, a30. 
 
 Snake bites, 404, 405, 466. 
 
 Soap, 90 ; and water, value of. 452 ; Castile, sup- 
 pository. 874, 887 ; for infants, 403 ; potash (or 
 soft or green). 444. 
 
 Soapsuds enema, 808, 874, 887, 934. 
 
 Socks, 390, 400. 
 
 Sodium bicarbonate tablets, 810,841 : bromide, 878, 
 803 ; bromide tablets, 841. 842 ; chloride, 382. 
 
 Softening of the brain, 37, 813. 
 
 " Soft spot," the. 6. 
 
 Soil, 336, 338, 330, 340. 
 
 Soma!. 926. 
 
 Somatoplasm. 160. 
 
 Sorghum, .380. 
 
 Sounds, 1.53 : musical, 1.53. 
 
 Sparring, 271. 272. .302. 
 
 Speakers, left-brained, 140. 
 
 Special senses. 40, 74. 88, 137, 138, 157. 
 
 Species, origin of, 167. 
 
 Spectroscope, 148. 
 
 Speech, 128 : centre, 138, 130, 140 ; internal, 215 ; 
 organs of, 138, 130. 
 
 Spermatozoon, 81, 82, ir>8, 100, 108. 
 
 Sphincters, external, 04 ; internal. 0-1. 
 
 Spinal canal, 5 ; colunm, 4, 5, ; nerves, 52, .50, 
 133, 135. 
 
 Spinal cord, 5, 40, 40, 40, 51. K), 68. 131, 1.35 ; ante- 
 rior columns of the, .52 : central canal of the, 
 .52 ; hypcncmia of the, 802 ; lateral columns of 
 the, 52 ; membranes of the, 52 ; posterior col- 
 umns of the, 52. 
 
 Spina ventosa, 490, 491. 
 
 Spine, 4, 550, 500, .51)1 ; angular deformity of the, 
 see lU'MPUACK ; lateral curvature of the, 500, 
 501 ; tuberculosis of the, 550, .500. 
 
 Spirilla, 024. 
 
 Spleen, 01,07. 120; enlargement of the, 07. 030, 
 704, 705. 
 
 Sphnt-boue, 1,5. 16, 517. 
 
 Splints, .500, 507, 508 ; interdental, 520 ; plaster-of- 
 Paris. 517, 518. 
 
 Spontaneity, 176, 177. 
 
 Sports, evils of desultory. 207 : ice, 218 ; outdoor, 
 250, 251, 408 ; roughness of, 290, 297. 
 
 Spots, cold, 1.50 ; warm, 150. 
 
 Sprains, 525, 520, 527. 
 
 Spray, 353. 
 
 Sprue, 549, 5.50, 883. 
 
 Stapes, see Stirrvp. 
 
 Staphylococcus, 624. 
 
 Starch, 90. 
 
 Starvation, R«8. 
 
 Statistics, comparison of vital, 310 ; mortality, 
 312. 313 ; vital. .308, 309. 
 
 Stature, diminution of. 103. 
 
 Steam heating, 324, 328 ; inhalation of, 875. 
 
 Steapsin, 91. 
 
 Sternum, 9. 
 
 Stinmlants, 829, 893 : at the training table, 209 ; 
 excess in the use of, 611, 612 ; for the wounded, 
 467. 
 
 Stings of bees. 400 ; of hornets, 406 : of wasps, 
 466. 
 
 Stirrup. 79. 
 
 Stomach, .59. 61, 02, 03, 88, 89 ; cardiac opening of 
 the. 62 ; coats of the, 62, 63 ; dilatation of the. 
 607 ; emptying the, 890 ; pyloric opening of the 
 62 : tube, 856. 8.57, 045 ; ulcer of the. 696 : wash- 
 ing out, 884, 885. 
 
 Stoves, 320, 327. 
 
 Strangulation, 5.52. 
 
 Street cleaning, 378 ; Ri)riiil<ling, 378 ; sweepings, 
 375 : widtli of. 356. 
 
 Streptococcus, 024. 
 
 Stretcher, improvising and carrying, 503. 
 
 Stricture of the urethra. 596, 598. 
 
 Strophanthus. 406. 
 
 Stupes, 803 ; hot, 040. 
 
 Stupe-wringers, 040. 
 
 St. Vitua"s dance. 813. 
 
 Styes, 8&3, 884. 
 
 Styptics, 440. 
 
 Subarachnoid space, 42, 46. 
 
 Subdural space, 43. 
 
 Suffocation. 888, 889. 
 
 Sugar, 00, 380 ; cane, 360 ; invert, 380. 
 
INDEX. 
 
 989 
 
 Suggestion, 103. 
 
 Suicide, predisposition to, lOn. 
 
 Sulci, 43, 44. 
 
 Sulphurous-acid gas, 480. 
 
 " Sun " cholera mixture, 873 ; tablets, 8.38. 87."). 
 
 Sunstroke, 889, 800. 
 
 Suprarenal bodies, 120 ; capsules, 73. 
 
 Suppositories, 93.'). 
 
 Suppuration, .'504, 027, G30. 
 
 Surgery, common sense in, 433 ; definition of, 
 
 431 ; element of time in, 007, 008. 
 Surgical cleanliness, 443, 440. 
 Survival of the unfit, 308. 
 Sutures, 17. 
 
 Swallowina;, 55, .59, 09, 92. 
 Sweat, 112, 113, 800, 875; compo.sition of, 112, 
 
 113 ; glands, 80, 112 ; secretion of, 113. 
 Sweating, excessive, 001. 
 Swedish system, 291, 292, 295, 296, 303. 
 Sweetbreads, 07 ; broiled, 931. 
 Swimming, 2.54, 255, 2,50. 
 Sylvester's method of artificial respiration, 751, 
 
 753, 809, 870, 871, 888. 
 Sympa,thetic system, 130. 
 Syncope, death from, 590. 
 Synovia, 17. 
 
 Synovial fluid, 17, .533, 534. 
 Synovitis, 530, 531, 532, 533; acute purulent, 531, 
 
 533, 533 ; acute serous, 530, 531 ; catarrhal, 532 ; 
 
 sero-flbrinous, 530, 531. 
 Syntonin, 381. 
 
 Syphilis, 595, 598, 599, 000, 614, 015, 016, 618. 
 Syringe, care of the, 935 ; Davidson bulb, 9.34 ; 
 
 fountain. 934, 936 ; hand-bulb, 808. 
 Systemic circulatory system, 109 ; circulation, 
 
 97, 98. 
 Systole, 100. 
 
 Tablets, various kinds of, 835, 836, 837, 838. 839, 
 840, 841, 842. 
 
 Tachycardia, 692. 
 
 Tampon, how to apply, to a wound, 445. 
 
 Tarantula bite, 400. 
 
 Tartar, removal of, from the teeth, 551. 
 
 Taste, 55, 74, 1.55 ; assisted by smell, 155, 156 ; 
 buds, 155 ; goblets, 75. 
 
 Tea, 012 ; drinking, 839 ; use of, in fever, 859, 800. 
 
 Teacher, art of the, 219. 
 
 Tears, 149, 174. 
 
 Teeth, 59, GO ; canine, GO ; care of infants', 403 ; 
 care of the, during pregnancy, 741 ; cleaning 
 the, 520 ; decay of the, 551 ; defeneration of 
 the, in man, 117 ; lower, 9 ; milk, 00 ; perma- 
 nent, 00 ; temporary, 60 ; upper, 8 ; wisdom, 60. 
 
 Temperature, 330 ; body, 118, 119 ; chart, 919 ; 
 daily variation in, 163 ; determination of, 330 ; 
 in acute diseases, 877 ; in chronic diseases, 877 ; 
 mean, 331, 332; methods of taking, 843, 844, 
 918 ; normal, 118, 877 ; object of taking bodily, 
 917 ; regulation of the body's, 119, 181 ; sensa- 
 tions of, 142 ; ssnse of, localized in the skin, 
 150 ; to reduce, 877, 878. 
 
 Temple, 8. 
 
 Tendo Achillis, 25. 
 
 Tendon, 21 ; division of, .579 : long, of the biceps, 
 23 ; short, of the biceps, 22, 23. 
 
 Tennis, 200, 273, 290, 302 ; court, 2<'2, 302 ; for girls, 
 2(i5 ; for women, 262, 2<j3, 303 ; lawn, 244, a^in, 
 260, 361, 272 ; training for, 21)9. 
 Tenor, 127. 
 
 Tenosynovitis crepitans, 580. 
 Tentorium cerebelli, 42, 48. 
 Testes, 88. 160, 109. 
 Tetanus, see Look.iaw ; acute, 481 ; bacilli of, 
 
 3.37; chronic, 481. 
 Thermograjjhs, 3:i2. 
 
 Thermometer, 330 ; bath, 915 ; clinical, 917 : 
 Iliclcs's clinical, 843, 918 ; mercurial, 3JV), Kil ; 
 Rutherford's, 331, 332 ; maximum and mini- 
 nmm. .331, 332 ; metallic, 332. 
 Thigh, 15. 
 
 Thinking, 215, 210 ; of deaf-mutes, 215. 
 Thirst, 157, 944, 945. 
 Thorax, see Chest. 
 Thought, 214, 219 ; expression of, 210. 
 Throat, sore, 883. 
 Throwing the hammer, 258. 
 Thrush, 549, 5.50, 883. 
 
 Thumb, 14 ; approximation of the, to other fin- 
 gers, 14. 
 Thyroid body, 120; cartilage, 69; gland, 71, 73. 
 
 556, .557. 
 Tibia, see Shin-bone ; fractm-es of the, 517, 518. 
 Tic douloureux, 814. 
 Tickhng, 157. 
 Tiles, 3.57. 
 Time for special exercises, 287, 288 ; reaction, 
 
 143 ; relations, 180. 
 Tinea. See Ringworm. 
 
 Tissue, 86, 88, 97, 103, 169 ; cancellous, 1 ; con- 
 nective, 86, 88 ; fat, 80 ; muscle, 80, 101, 130. 
 131 ; nerve, 101 ; physical education of, 235 ; 
 spontaneity of, 102 ; yields heat, 118. 
 Tobacco, 612 ; use of, at puberty, 400. 
 Toes, bones of the, 17. 
 Tone, emotional, 203 ; fundamental. 152. 
 Tongue, 74, 127, 155 ; motor impulses of the, 56 : 
 
 stings of the, 547 ; tie, 549. 
 Tonsil, 00 ; enlargement of the, 550, 551. 
 Toothache, 199, 200. 551. 884. 
 Torticollis, see Wryneck. 
 Touch, 74, 142, 212 ; temperature, and muscular 
 
 sense rarely separated, 157. 
 Tourniquet to stop bleeding, 447, 448, 578, 583. 
 Trachea, see Windpipe. 
 Tracheotomy, 552, 555, 556. 
 Trades, offensive, 413. 
 
 Training, physical, 2:55, 230, 2-37 ; for contests. 
 290. 297', 298 : for health, 296, 299. 300 : for wo- 
 men, 264 ; for boys. 205 ; for men. 360 : value 
 of military. 267 : clothing: in relation to, 301. 
 Traits, acquired and congenital, 786. 
 Trance. 407, 408. 
 
 Transportation of the injured, 592, 593, 595. 
 Traps, 359, 303, 304. 
 Tremor, 814. 
 
 Triceps, 280 ; to exercise the, 281, 282, 285. 286. 
 Trichina spiralis, 396. 
 Trochlea. 13. 
 Trypsin. 91, 381. 
 
 Tube, glass, for taking medicine, 856, 934 ; stom- 
 ach, 850, 8.57, 945. 
 
090 
 
 INDEX. 
 
 Tubercle bacilli, 323, 484, 615. C18. 075, G7C ; gmu- 
 ule. 485. 
 
 Tubercular inHainniations. 484, 48;), 578 : .sinus, 4!X). 
 
 TulH-roulosis. 314. 4'Jii, Clti ; eonununioaiioii of, 
 I>I8 ; iuoculaiioii, 4S(J, 487; in relation to the 
 ilainpiiess of the soil. 3;J8 ; limitation anil cure 
 of. 48tJ ; of the bones, 481), 4SW, I'.U : of t he joints, 
 4!ll. 493, 49;i, 494, .584 : of the lyn)i)liatic glands, 
 48S, 48!1 : of the skin, 487, 488 ; of the si)iue, 4iW, 
 .V>'.i. SCO ; pulmonary,, see Consumption. Pvl- 
 Mo.N.\RY : surgical, 484, 485, 486, 487 ; trausuiis- 
 sion of. 615. 
 
 Tubes, bronchial, 71, 106, 120 ; Eustachian. 61, 79 ; 
 KairchiUrs peptonizing, 930 : Fallopian, 81, l."iU, 
 \M ; MacKiiuiels. 3i"), 336 ; Tobius, 335. 
 
 Tubules, uriniferous, 110, 111, 113. 
 
 Tumbling, 274, 377. 
 
 Tumours, 534, 5.35, 5:JG, 5-37, 538 ; benign. 545 ; 
 malignant, 545, 5:}6 ; of the breast, 559 ; of the 
 face. 544 : of the female organs, 778 ; of the 
 thyroid gland. 557 ; of the tongue, 548 ; prog- 
 nosis of, .536, .5.37 : treatment of, 537, 538. 
 
 Turpentine. 843, 935, 938, 940. 
 
 Twins, 105. 
 
 Tying of the umbilical cord. 750, 751. 
 
 Tympanum, 78. 
 
 Typhoid fever, 314, 3.53. 436. 616, 617, 618. 654. 8:33, 
 916 ; Brand treatment for, 864, 914. 915 ; com- 
 plications of. 6.")6 ; geographical distribution of, 
 6.">5 ; in relation to the depth of water, 337 ; out- 
 look of. 6.56 : period of incubation, 417 ; .symp- 
 toms of, 6.55, 6.56 : treatment of, 650. 
 
 Typhus fever, 417, 434. 436, 619. 
 
 Ty rosin, 381. 
 
 Ulcer of the breast during lactation, 5.58 ; of tlie 
 stomach, 696. 
 
 Ulceration, tubercular, of the tongue. 548. 
 
 Ulna, 13. 
 
 Umbilical cord, 161. 163; care of the, 753, 754; 
 tying of the, 750. 751. 
 
 Unconsciousness. 880. 
 
 Underclothing. 301, 398. 
 
 Undertone, cheerful. 204, 305 ; emotional. 304, 305. 
 207, 231 ; gloomy, 204, 205. 
 
 Urachus, 74. 
 
 Uraemia, 710, 711 ; acute, 710, 711 ; chronic, 710. 
 
 Urea, 110. 120 ; composition of, 115. 
 
 Ureters, 61, 7.3. 111. 
 
 Urethra. 74, 112 ; stricture of the, 596, .597. 
 
 Uric acid, 110. 
 
 Urine, 110, 112. 9.37, 945 ; disposal of. in infectious 
 and contagious cases, 965 ; examination of, 733, 
 734., 937, 948. 
 
 Uriniferous tubules, 110. 111. 113. 
 
 Urticaria, see Hives. 
 
 Uterine wall, 1.59. 160, 101, 103. 
 
 Utero-ovarian disease. 407 ; irritation, 407. 
 
 Uterus, see "SVomb ; healing of the, 163 ; involu- 
 tion of the. 750. 
 
 Utricle. 1.50, 153. 
 
 Uvula, 59. 
 
 Vaccination. 30.5. 410, 418, 419, 43.5, 641, 013,043, 
 
 644. 833. 833. 
 Vaccinia, 041. 
 
 Vagina, 15, 61, 159, 160. 
 
 Valve, ileo-cn?cal. 04; aortic, 37 ; mitral, 37; pul- 
 monary, 37 ; pyloric. 63 ; tricuspid. 37. 
 Valves, auriciilo-ventricular. 99, 100 ; of the 
 
 heart. 36. tWO ; of the lymphatics, 104. 105 : of 
 
 the veins. .33. 99 ; scmilunai'. 100. 
 Vapour, aqueous. ;J30. ;J33. 
 Variation. 170 ; of functions in juriodic activity. 
 
 163 ; of labour, 191. 
 Varicella, see Chicken Pox. 
 Varicocele, 576. 577. 
 Variola, see Smai-lpox. 
 Varioloid, 646. 
 Vaseline. 850. 
 Vttso-conslrictors, 103. 
 Vaso-dilalors, 103. 
 
 Vaso-motor centre. 103; nervous api)aratus. 104. 
 Vegetable acids. 379, 381 ; foods, chart showing 
 
 composition of, 117. 
 Vegetables, 399. 
 Vegetarianism. 110, 117. 
 Vein, anterior tibial. 34 ; axillary. 34 : basilic. 34 ; 
 
 cephalic. 34 ; external iliac. 31. 35 ; iimominale, 
 
 .34 ; internal iliac. 35 ; internal jugular. 33, 34 ; 
 
 left common iliac. 35 ; left innominate. .33 ; left 
 
 renal, 35 ; long sajilienous, 35 ; median, 34 ; poj)- 
 
 liteal, 34 ; portal, 35. 05 ; posterior tibial, :M ; 
 
 right common iliac, 35 ; right innominate, 33 ; 
 
 right renal, 35 ; subclavian. 34 ; uniliilical, 1(!3. 
 Veins. 35, 88. 97 ; deep. 33, 34 : hiemorrhoidal. (54 ; 
 
 hepatic. 35. 30. 65 ; of the greater circulation. 
 
 ;W ; of the lower extremity. 34 ; of the upi)er 
 
 extremity. 34 : position of. 99 ; pulmonaiy. 25. 
 
 37, 33. ;«. 99 ; radial. 34 ; structure of the, 33 ; 
 
 superficial. 33. 34 ; ulnar, 34 ; varicose, 35, 585. 
 
 .580, 587 ; walls of the. 98. 
 Velum interpositum, 46. 
 Vena cava, inferior. 34, 26. 27, 35. 61. 99 ; superior. 
 
 26. 27, 34, 99. 
 Venous system. 104. 
 Ventilation, 324, 3.55. 3.58; arlilieial, 320; Dr. 
 
 Hinckes Bird's method of, 325 ; to determine 
 
 adequacy of, 320. 
 Ventricle, 20 ; fifth, 40, 47 ; first, of the brain, 40 ; 
 
 fourth. 47, .50 ; lateral, of the brain, 40, 47 ; left, 
 
 27 ; right, 27 ; second, of the brain, 46 ; third, 
 
 47. 
 Vermiform appendix. 64, 93. 505, GOO, 507, 508. 
 Vertebi-is>, 4 : dorsal, 9 ; siiiiie of the, 5. 
 Vertebrate animals, 134, 135. 
 Vertigo, 814. 
 Vessels, chyliferous, 37 ; function of the, 98, 99 ; 
 
 lymphatic. 61, 05, 88 ; of the liver, 05 ; structure 
 
 of the. 98, 99. 
 Vision, binocular, 1 18 ; colom-. 147, 148 ; field of, 
 
 148. 
 Visual impulses. 140. 
 Vital energy, 85. 80 ; processes, 382 : spot, 108 ; 
 
 statistics, 308. .309, 310. 
 Vitelline membrane, 81, 82 ; spheres, 82. 
 Vitellus. 81. 
 
 Vitreous body, 77. 78 ; humour, 143. 
 Vocal cords, 68. 69. 70. 130, 137, 128 ; mechanism, 
 
 137 ; registers. 137, 128. 
 Voice. 151 ; average range of human. 127 ; break- 
 ing of the, 128 ; chest, 128 ; conditions of, 120 ; 
 
INDISX. 
 
 991 
 
 control of the, 127 ; falsetto, 128 ; head, 128 ; 
 
 loudness of the 12G, 127 ; pitch of the, 12(i ; 
 
 production of the, 12G ; quality of the, 120, 127; 
 
 range of the human, 127 ; training of the, 127. 
 Vomer, 8, 9 ; bone, 75. 
 Vomiting, 91."); from ether, 0.51, 9.52; of i)reg- 
 
 iiancy, 7G(j ; severe, 885 ; to cause, 884 ; to strjp, 
 
 881, 885. 
 
 Walker-riordon laboratories, 9G3. 
 
 Walking, 123, 12), 103, 10-1, 193, 252, 25;J, 250, 201, 
 827, 828 ; for women, 203, 303. 
 
 Walls, external, 3.57 ; foundation, .350, 3.57 ; inte- 
 rior, 357 ; party, 3.57 ; thickness of, 357. 
 
 Warts, 582. 
 
 Wash basins, different kinds considered, 303. 
 
 Washtubs, 303. 
 
 Wasps, 183. 
 
 Waste products, 110. 
 
 Wastes, 113, 114. 
 
 Water, 90, 110, 110, .379 ; a necessity of man, 110, 
 340, 382 ; boiled, for dressing wounds, 4.50 ; care 
 of filtered, 351 ; characteristics of, 340 ; chem- 
 ical and bacteriological examination of, 342, 348, 
 349, 350, 352 ; composition of, 114, 115, 340; deep 
 well, 344, 345 ; distillation of, .351 ; drinking, 820, 
 827, 859, 874 ; enemas of, 800, 809 ; factors which 
 influence the number of micro-organisms in, 
 350 ; filtration of, 348, 350, 351 ; ground, 330, 339, 
 3.55. 350 ; hard, 344, 350 ; hot, 878 ; mains, 347 ; 
 municipal supply, 305, 347 ; pipes, 347 ; pota- 
 bility of, 348, 349, 3.50, 827 ; purification of, 348 ; 
 quantity consumed daily per head of popula- 
 tion, 345, 340 ; rain, 343, 344, 345 ; river, .341, 345 ; 
 shallow well, 345 ; soft, 344 ; spring, 344, 345 ; 
 sterilized by boiling, 351, .352 ; subsoil, .337 ; sur- 
 face, .340, 341. 345 ; turbid, settled by alum, 350 ; 
 warm, to cause vomiting, 875 ; waste of, 340, 
 348. 
 
 Water supply, contamination of, 339, 340 ; insuf- 
 ficient, 310 ; intermittent, 347 ; need of a liberal. 
 345 ; of a dwelling, 358, 359 ; sources of, 340, 341 ; 
 to calculate the required number of days', 346. 
 
 Wax, masses of, in the ear, 546. 
 
 Weaning, 702, 703, 963. 
 
 Weathercocks, 333. 
 
 Weeping sinew, 580, 581 . 
 
 Weight, decrease of, 115, 163 ; increase of, 115, 163 ; 
 lifting, 285. 
 
 Wells, 340, 341, 342. 
 
 Wens, 80. 
 
 Whiskey, 842, 843. 
 
 White matter, 40, 43, 49, 51, 131, 138 ; swelling, 492. 
 
 Whooping cough, 307, 323, 417, 057, 058. 
 
 Will, 140, 227; act of, 227, 228; basis of the, 229; 
 chaotic, 231 ; contents of, 196 ; defects of the, 
 230, 231 ; defined, 225 ; disorders of the, 230, 231 ; 
 disorganization of, 232, 233 ; evolution of the, 
 
 229 ; in tlie wider sen.se, 227 ; life of the, 184 ; 
 not original, 228, 229 ; power, dependence of, 
 upon digijstion, 298 ; segmented, 2:il, 2.32 ; KignH 
 of, 183, 184 ; training the, 230 ; weakneBS of, 231. 
 
 Window areas, 329, 358. 
 
 Windpipe, 08, 70, 88, 100, 129, 072. 
 
 Winds, 330, ^M. 
 
 Wine jelly, 0.:iO. 
 
 Wines, Oil. 
 
 Winking, 132, i:«, M9. 
 
 Winter cough, 073. 
 
 Woman, care of, after delivery, 7.50, 7.57, 7.58, 9.57 ; 
 care of, in labour, 740, 7'47, 748, 9.50, 957; diseases 
 of the non-pregnant, 777. 778; simple rules for 
 menstruant, 731, 7.32, 733; special indoor exer- 
 cises for, 290 ; special outdoor exercises, 201, 262. 
 
 Womb, 15, 61, 81, 82, 1.59, 100. 
 
 Work, mechanical. 80, 118, 120: mental, fX)9 : 
 physical, 013 ; regularity in, 012 ; to measure 
 amount perffjrmed, 118. 
 
 Worms, intestinal, 701. 
 
 Worry, 194, 195, 009, 013. 
 
 Wounded, general treatment of the, 407. 
 
 Wounds, 432; bacteria in relation to, 441, 443, 
 029 ; bleeding of, 4.37 ; cleaning of fresh, 449, 
 4.50, 451 ; contused and lacerated, 440 ; dress- 
 ing, 450, 451, 4.53 ; gaping of, 4-37 ; gunshot, 440, 
 441, 563 ; healing of, 432, 433 ; how to apply a 
 tampon to, 445 ; incised, 4.36, 5.52, .553, 554 ; in- 
 fected, of the neck, 5.54, 555 ; of the scalp, 
 .539, .540 ; inflamed, 4.58, 4.59, 460 ; inflamed, 
 of the palm, 580 ; of joints, 533, 534 : of the ab- 
 domen, 561, .502, .563 : of the anus and rectum, 
 570 ; of the breast, 5.58 ; of the eyeball, .540 : of 
 the face, 543 ; of the forearm, 578, 579 ; of the 
 great blood-vessels of the chest. 558 ; of the 
 heart, 558 ; of the lung, 558 ; of the neck, .552, 
 5.53, 554, 5.55; of the palm, 579, 580; of the 
 thorax, 558 ; of the tongue. 547 : open, 432 ; 
 of veins, 98, 99 ; penetrating, of the abdomen, 
 .562, 503 ; poisoned, 464, 465, 400. 467 ; poisoned 
 arrow, 460 ; preparations for the treatment of, 
 4.50, 451 ; punctured, 4.39 ; punctured, of the 
 femoral artery, 583 ; sources of infection of, 
 443 ; subcutaneous, 432, 408, 409, 470 ; symptoms 
 of, 436 ; treatment of, 441. 442, 44.3, 444, 445, 446, 
 447, 448, 449, 450, 451, 452, 453. 4.54, 455, 456, 457, 
 458, 459, 460, 461, 462, 403, 464, 465, 466, 467, 468, 
 469, 470. 
 
 Wrestling, 271, 272, 277, 302. 
 
 W>ist, 14. 
 
 Wri'^er's cramp, 614. 
 
 Writing, 192. 
 
 Wryneck, 814. 
 
 Yellow spot, 78. 
 
 Yolk, 81, 1.58. 
 
 Young-Helmholtz theory of colour vision, 148. 
 
Those who regard popular domestic medi- 
 cine and the allied sciences and arts as either 
 entertaining or serviceable will be gratified 
 with ' In Sickness and in Health, ' by the late 
 J. West Koosevelt, M.D.,anda group of 
 C^-lahor»'^g C^- 
 
 
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