COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX641 46693 RC50 .W99 1913 Minor medicine; a tr CoUege of ^fjj'gicians anb ^urgeong ^itirarp MINOR MEDICINE A Treatise on the Nature and Treatment of Common Ailments By WALTER ESSEX WYNTER M D., B.S. (Lond.), F.R.C.P., F.R.C.S. Physician to the Middlesex Hospital and Lecturer on Medicine in the Medical School. Late Examiner in Medicine to the Royal College of Physicians ; Lecturer in Pharmacology and Therapeutics and Examiner in Pharmacy to the Royal College of Physicians SECOND EDITION. REVISED AND ENLARGED NEW YORK AND LONDON D. APPLETON AND COMPANY MCMXVI 1^ Published Reprinted . Reprinted . Reprinted . Reprinted . Second Edition Reprinted , Sept. 1907 MarchldOS July 1908 Sept. 1909 Feb. 1910 Nov. 1913 Jan. 1916 Copyright, 1907, 1908, 1909, 1910, 1913, 1916 All rights reserved MY HOUSE PHYSICIANS WHOSE LNTEREST AND COLLABORATTON HAVE ENCOURAGED THE DEVELOPMENT AND ARRANGEMENT OP THE MATTER SET FORTH IN THE FOLLOWING PAGES Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/minormedicinetreOOwynt PEEPACE For who hath despised the day of small things. — Zechariah iv. 10. The change in the system of medical education some thirty years ago, whereby the custom of commencing as pupil to a medical man in general practice was abandoned in favour of proceeding straight from the course of general education to a medical school or university, has involved certain deficiencies in the knowledge of those so trained. Since the subjects of what might be regarded as trifling disorders either do not present themselves at a hospital or are intercepted in the casualty department in order to spare the time and energy of the visiting staff, the present-day student has little or no opportunity of familiarising himself with those slighter maladies which are likely to be among the first encountered when he commences practice. This is no doubt accentuated by the natural tendency of students to concentrate their attention on those organic diseases which are mostly inquired about at examinations and to interest themselves in rare diseases, complex or extensive operations, and questions of higher research — matters of the utmost importance in regard to the progress of medicine, but with which those who are occupied in family practice, and who constitute perhaps ninety per cent, of the profession, are comparatively rarely directly concerned, at all events in early years. It is vii viii Preface in the hope of conveying some information, and of arousing interest in the sphere of Minor Medicine, that the present small volume has been written. My grateful acknowledgments are due to Mr. G. S. Hughes for help and suggestions in revising the proofs and preparing the index. W. ESSEX WYNTER. 27, WiMPOLE Steeet, Cavendish Squaee, W. CONTENTS PAGE INTRODUCTION xi CHAPTER I THE DIGESTIVE SYSTEM ... « , , 1 CHAPTER II DISEASES OF THE SKIN ....... 48 CHAPTER III THE RESPIRATORY SYSTEM ....•• 88 CHAPTER IV NERVOUS SYSTEM i • HI CHAPTER V THE CIRCULATORY SYSTEM , . , « • .148 CHAPTER VI THE MUSCULAR SYSTEM . . , . , , .164 iz X Contents PAGE CHAPTER VII SPECIAL SUBJECTS . 174 CHAPTER VIII MAINTENANCE OF INDIVIDUAL HEALTH . . . ,199 CHAPTER IX DIET , . 215 FORMULA , 250 INDEX 268 INTRODUCTION In attempting to deal with such matters as the minor derangements of health, the difficulty at once presents itself of steering a middle course between indispositions too trifling or familiar to deserve mention and those which already receive ample attention in more serious books on medicine, and it is probable that transgressions in both these directions will meet the critical eye. More formidable still is the danger of including among trifling ailments phenomena, which, though apparently of sHght importance, may belong to really serious disease, but it would be practically impossible to define these differences in all cases without expanding these pages into a substantial treatise on medicine. Apart from the risks, medical and surgical, which are associated with occupation, and possibly even more with lack of it, there are inherent or acquired tendencies which assert themselves at different periods of life, and underlie apparently trifling ailments. Thus, in the first twenty-five years tuberculosis is likely to prevail, in the second similar period, syphilis, and in the third, gout or cancer, and it is well to keep these probabilities in mipd in dealmg even with superficial indications. On this account minor disorders must be considered in relation to the state of the general health and in view of probable underlying diathesis. A blister resulting from friction or heat is not a serious matter, though such a manifestation appearing spontaneously, or in the subject of glycosuria or renal xii Introduction disease, might reasonably give rise to grave anxiety. Vomiting after injudicious feeding only brings relief, while spontaneous vomiting may indicate serious brain disease or other vital disorder. Symptoms which represent response to a known and trifling cause of disturbance may be hghtly regarded, whereas such as emanate from an internal or constitu- tional state are of much more serious augury. It is " that which proceedeth from within " which is of the greater moment. This general discrimination is not always easy, but it may be concluded that persistence or increase in any local phenomenon points to some underlying cause, and the occurrence of what is termed bodily illness goes far to confirm the suspicion of actual constitutional disease. No better illustration of this could be found than an outbreak of warts, which in a young robust individual is a matter of small concern, but in an elderly person exhibiting cachexia and pigmentation may indicate that rare form of maUgnant disease, Acanthosis nigricans. It must be insisted, therefore, that none wUl assume the responsibility of dealing even with minor maladies, without that general knowledge of medicine and mental caution which guards against the confusion of great things with small. There are few greater tragedies in medical experience than those involved in the recognition of deadly disease in what a patient has regarded as a trifling ailment. Every now and then in every doctor's experience such a one wiU hghtly ask advice about what appears to him a mere pimple, but which skilled examination proves to be the outpost of malignant disease, involving a mutilating operation and ultimate threatening of life itself. So, also, the persistence of such a common symptom as constipation or mere languor may lead to the recognition of Diabetes or Bright's disease, which proves fatal in a Introduction xiii few months. How many are the consumptives who feel and say that if only they could get rid of their cough they would be quite well. Medical practice is full of such incidents, saddening and indeed tragic in the anticlimax that ensues. These instances, however, are the rare exceptions, which, while they impose the need for wariness in dealing with any marked manifestation, especially such as persist or are associated with general impairment of health, yet leave ample scope in the vast majority for the rehef of discomfort or actual suffering by simple means. Before proceeding to a detailed consideration of departures from the standard of health, it may be well to survey some points in the development, growth, maintenance, and decay of the human organism, which may be regarded as representing natural phases in the course of Kfe. The average weight of the infant at birth is seven and a half pounds for males and seven pounds for females. There is usually a loss of one pound during the first three days which is made up in the next seven, so that by the tenth day the weight is the same as on the first. Con- tinued loss indicates malnutrition, maldevelopment, or disease. At the end of the first year the weight should be three times that at birth. An average gain of four ounces per week for the first six months is usual. During the second year the gain is six pounds, and during the third four and a half. Four pounds per annum should be added in the fourth, fifth, sixth, seventh and eighth years, and six pounds per annum during the ninth, tenth and eleventh. Increase is more marked in the autumn, and girls develop faster between the ages of eleven and thirteen, while the principal period of growth for boys is from fifteen onwards. The height at birth is 20" 61 inches for boys, and 20*47 for girls. Eight inches should be added in the first year. xiv Introduction three and a half in the second, and two or three annually till the eleventh. At twelve and thirteen girls exceed boys, though these from fifteen onwards more than make up the deficiency. Rickets in early life tends to limitation of the ultimate stature. The importance of these weights and measures lies in the fact that in health steady progress in height and weight is the rule, and any check is a sure indication of disease or malnutrition. The circumference of the head is 13' 9 in the male and 13'5 in the female, increasing four inches during the firsl year, one inch in the second, and a further inch and a half betweei:. two and five. The sutures remain open till the sixth month and movable to the ninth. The posterior fontanelle closes at the second month, the anterior remaining incom- pletely closed till the eighteenth. Earlier closure in- dicates arrested growth of the brain. Rickets delays closure even to the end of the third year, and cretinism till the eighth. Compression deformity disappears at the end of the first month, though the head remains mouldable till the end of the first year. The antero-posterior and transverse diameters of the chest are equal in the new born infant, and up to the third year the transverse diameter of the head, chest and abdomen are equal. Subsequently the chest expands more than the other two. At the fourth month voluntary movements occur, especially attempts at grasping, and the head can be held erect. About the seventh month the infant can sit up, and may stand by the ninth, commencmg to walk when a year old, and going without support at fifteen months. The newly born avoid light, the pupils contract and the lids close. The extrinsic muscles of the eye are not co-ordinated till the third month. The cornea is only Introduction xv slightly sensitive, so that care must be exercised in washing, and the eye does not close in the first weeks of life when an object is approximated. In the first few weeks also the iris in all babies is of a uniform slatey blue. Though the eyes may follow a moving object, there is no definite recognition till the sixth month, and no tears appear duriiig the first eight or ten weeks. Hearing is not developed for twenty-four hours after birth, and in some cases not for several days. It is very acute for the first few months, the child starting at sounds and sometimes falling into convulsions at sudden noise. At two to three months the infant turns towards sounds, and within another month apparently recognises the voice. Tactile sensibility is present at birth, but is not acute except m the lips and tongue. After the third month this becomes general, though the mouth remains very sensitive to slight changes of temperature, so that special care is needed in administering food. Speech begins at the end of the first year, girls as a rule advancing quicker than boys. The teeth usually begin to appear at the sixth month, and the first set should be complete by the end of the second year, but in some quite healthy children none appear till the tenth month. Syphilis tends to advance and rickets or creti- nism to delay dentition. During the first six months there is only sufficient secretion from the mucous mem- brane to keep the mouth moist, the salivary glands and^ presumably the pancreas, are not functional, so that starchy food cannot be digested. With the appearance of the teeth, however, salivation is established, and thence forward the addition of starches to the diet is permissible and desirable, albeit the eruption of the teeth may render a return to the simplest food temporarily necessary. Though the constitutional effects of dentition appear to have been much exaggerated and such remedies as gum-lancing have now become practically obsolete, there xvi Introduction can be no doubt that excitation of the nervous system with irritabihty and fractiousness do accompany the appearance of the milk teeth, attended in some cases with stomatitis and skin eruptions, as well as disturbance of the digestive system manifested by vomiting and diarrhoea, and more rarely extension of catarrhal changes to the respiratory tract. It is advisable, therefore, that additions to the dietary at this time should be made with caution and with due consideration for the recurring disabilities of this period. Another feature of infancy is the delay in development and functional activity of the sudoriferous glands, render- ing infants intolerant of external heat and liable to undue rise of the body temperature with comparatively shght internal disturbances. This absence of sweating affords a substantial reason for frequent bathing. At the end of the first year the weight should be nearly three times that at birth, and thenceforward the yearly increase should be from four to six pounds up to the age of eleven. About this time girls develop at a greater rate than boys, and from twelve to fourteen commonly exceed them in weight and height. Thereafter, from fourteen onwards, the male develops at a greater rate, and the female at a less, so that by fifteen the temporary lead of the girl is extinguished. It is interesting to note in this connection that the size and weight of the heart maintains a relative pro- portion to that of the body, weighing one ounce at birth and adding half an ounce each year up to the age of twelve, when it weighs about seven ounces. Owing to the relative narrowness of the thorax in childhood the apex beat usually extends to the nipple line as a normal condition, and in adults who retain this infantile form of cylindrical chest the same relative position in regard to the nipple continues throughout life. The years from twelve to sixteen in girls and from Introduction xvii fifteen to nineteen in boys are those of most rapid growth and expansion, and it is at this time that the heart increases most rapidly, adding an ounce per year to its weight. The apex beat assumes its adult position within the nipple line, and any arrest of development following on inflammatory infiltration of valves becomes in- creasingly apparent. This is especially noticeable in regard to mitral stenosis, which, though occasionally indicated by an accentuated first sound associated with a systolic murmur in childhood, never presents a definite presystohc murmur till about the twelfth year. From this age onwards such a murmur is increasingly prevalent, especially in girls, though signs of faihng compensation are rare before twenty. Indeed, reserve power and compensation are so good during the period of growth, that mechanical failure and dropsy at this period of Ufe must, with confidence, be attributed to adherent peri- cardium, which is found in nearly all fatal cases. A pronounced constriction of the mitral valve is not un- commonly associated with dwarfing in stature and much delayed development, and when combined with cyanosis could scarcely fail to attract notice. The period of second dentition commencing with the eruption of the first permanent molar at the age of six is often associated with impaired health, both in boy& and girls. There is an interregnum while the decay of the first set of teeth tardily replaced by the second leaves the individual in a varying degree edentulous, and exposes him to the discomforts and dangers of local inflammation and infection to an extent that has only recently been taken seriously into account. As this occurs at a time when the demand for nutrition^ and especially animal food, is increasing, special attention, both as regards dietary and the state of the mouth, is needed. It is doubtful whether children ever achieve proper xviii Introduction mastication with the milk teeth, and they are certainly- further handicapped in the interregnum between them and the permanent set up to the age of thirteen. Fortu- nately about this time of life they are under the eye of their parents or in preparatory schools, where these defects can in some measure be counteracted. The first and second seven-year periods of growth are also those in which the exanthemata mostly occur, and these should be foremost in the mind when febrile dis- turbances manifest themselves, both for the welfare of the individual and the added responsibility of guarding others from infection. It has been sometimes suggested that it is well or at least convenient to be through with these complaints in a family of children, and certainly the individual who has safely surmounted the various infective diseases has an enhanced value in freedom from inconvenient checks during adolescence ; but when it is sufficiently realised that the outcome of any form of infectious disease cannot be confidently foretold, involving, as it does, a certain, if small, mortality and the possibility of permanent maiming : this consideration should give pause to the practice of purposely exposing healthy children to the risk of infection and its possible conse- quences, and should be seriously urged when such a procedure is proposed by people unversed in the course of disease. Certainly no experienced medical man would be a party to running a real risk for the sake of con- venience. Passing from the periods of infancy and childhood, the individual enters upon adolescence and is free in general from health disturbances except for belated exanthemata to which he may be exposed at school, and the accidents incidental to sports and pastimes. One exception to this, however, exists in the occurrence of rheumatism, which is a disease especially prevalent in the period of growth and development, but is less com- Introduction xix monly overlooked at this time of life, since it is almost invariably associated with painful arthritis, a feature of the disease not uncommonly lacking in early childhood. The morbid tendencies, however, of this phase of life have been so exhaustively treated of in the publications of school medical officers, that practically nothing remains to be specially noticed. Girls at about the age of sixteen sometimes display a conspicuous enlargement of the thyroid gland unaccom- panied by symptoms, which usually subsides in the course of a year or two without treatment. Some temporary turgescence may recur at the men- strual periods giving a slight fullness to the front of the neck as well as the breasts. The more persistent enlargement at puberty is functional, and of much the same character, so need not give rise to anxiety. Morbid disturbances, especially such as are associated with the distribution of micro-organisms in the blood- stream, are apt to show themselves in those areas where active growth and development are associated with dilatation of the vascular channels, such as the epiphyses of bones and the establishment of functional activity in the organs of generation, leading to local disease in the subjects of tubercle at this period, and in others to functional disturbances. It is in the growing period that the lymphatic glands are most liable to infection, and hyperplasia as evidenced by the prevalence of tonsilitis, adenoids, adenitis of the lymph glands, and susceptibility of Peyer's patches to typhoid and other infections. The period of growth and development calls therefore for a generous supply of sound plain food, ample air space both by night and day, and the avoidance, as far as possible, of exposure to infections such as might be expected in crowded places and in tropical countries, XX Introduction young people being particularly vulnerable under such circumstances. The frequency with which pulmonary tuberculosis asserts itself in adolescents and young adults at the commencement of the working period of life goes far to prove this, especially when contrasted with the relative immunity of the immediately preceding years of school life. As the skeletal system is not completely consolidated till the twenty-fifth year, this should be regarded as the commencement of adult hfe, and successive periods of twenty-five years might mark the young, middle-aged, and old, if human hfe were conducted on ideal fines. As things actually are, for most people it would be more in accord with experience to account them immature till twenty, young till forty, middle-aged till sixty, and thenceforward old. According to this computation only a minority attain old age, though many acquire the characteristics pre- maturely. While growth and development are proceeding, in spite of persistent appetite and ample dietary, the in- dividual tends to be spare, but with completion of these there is a noticeable increase of bulk, due to fat and muscle, and the youth is said to "fill out." This stage usually coincides with a more settled and physically less strenuous mode of life, often with marriage. Most people appear to arrive at a state when for many years they change very little in appearance or bulk, and any decided variation attracts notice. The demands of growth and development are such that much food is required, but assimilation and functional activity are so great that httle remains over for storage, and starvation tells very much more quickly on children than adults. When the growing period is completed and the habit of hberal feeding is continued, unless Introduction xxi balanced by strenuous work, flesh is put on, at first uniformly, but with middle age, when physical activity diminishes and a steady routine takes its place, local accumulation occurs and the individual becomes stout. This may in time react on activity, since more effort is required to support and move a heavy body, and disinclination for exertion results, with danger of in- creasing obesity. The accumulated fat represents only the inconvenience ; the danger to health and long life resides in the nitrogenous suboxidised constituents of the food, which overwork and damage the internal organs, particularly the heart and kidneys. Throughout the insect world it is noticeable that the larval stage is characterised by extraordinary voracity, which contributes to the size and vigour of the perfect insect, but the mature creature eats little, and in some cases not at all. Human beings would do well to follow this example and diminish the amount of nutriment when the body has attained its full development. Hard and continuous work, whether with brain or muscle, necessarily requires sufficient food to repair waste and to supply a reserve during the period of activity, but this does not lead to flesh-forming. It is remarkable that lame people usually have enor- mous appetites but do not get fat, the enhanced muscular effort necessitated by mechanical disadvantage counter- balancing and calling for this exceptional supply. They may be compared with badly designed engines, in which the work co-efficient is low and only maintained by an extravagant combustion of fuel. Apart from the question of defective digestion and assimilation or the presence of wasting disease, it may be concluded that excess of food with deficient output of energy involves the accumulation of fat, and a deficiency of nutriment with disproportionate output of energy xxii Introduction leads to attenuation, hence the efficacy of the rest cure, especially in thin people. Testing the body weight at intervals is a valuable help in controlling the balance, and the maintenance of a steady weight within slight varia- tions dependent on changes in mode of life, is a sure indication of health. The question of balance between food and activity is of the utmost importance throughout life, and needs special adjustment in the different periods. In adolescents the only limit is imposed by the capacity of the digestive organs in volume and efficiency, and the only ill effect of over-feeding is the disturbance of these organs, commonly remedied spontaneously by facile emesis or temporary failure of appetite. In adults excess of food over the needs of the body maintenance results on the one hand in accumulation of fat, and on the other in the surcharge of the blood and tissues with an undue quantity of imperfectly oxidised nitrogenous products, while the undigested surplus under- goes unwholesome fermentation in the digestive tract ; clouding the mental faculties, disturbing the temper, over-stimulating the generative organs, and overworking the emunctories. It is highly probable that excess of food, and especially of animal food, over the natural requirements and assimila- tive capacity of the body is the chief cause, not merely of disorders of the digestive organs, but of degenerative changes in the circulatory and renal system, particularly arterial sclerosis, which accounts for the majority of deaths in the ten years before and after sixty, apart from the effects of syphilis and some other diatheses which operate at an earlier age. Celsus advised an alternation between too little and too much food with a general tendency towards too little, and there is much to be said for the system of fasting on recurring days and periods for its beneficial effects on the Introduction xxiii community, just as a day off once a week in the course of drug treatment prevents cumulative effects or undue tolerance. Feeding is not altogether a question of means, for some who could afford much are abstemious, and many who can afford little eat excessively. Some chronic invalids attain great age, possibly owing in part to the sparseness of their diet, and centenarians are met with more often in the Union or almshouse than in the mansion or palace, and more frequently among those who have worked hard for a scanty living than among those who have spent their lives in ease and luxury. Comparable with the remarkable changes, both psychical and physical, which occur with the advent of adolescence in women, are those which attend involution of the generative organs at the menopause in middle age. The physical variations attending the cessation of menstruation are a tendency to increased bulk and weight, sometimes the appearance of hair on the chin and upper lip and a lowering of the pitch of the voice. Changes in other regions occur, and it is about this time that myxoedema, erythematous lupus, rodent ulcer, rheumatoid arthritis, and other diseases chiefly develop ; indicating special morbid tendencies and diminished resistance. The most common and noticeable features, however, of the menopause are the psychical changes, which, though more pronoimced in some cases than others, are never altogether absent. Every grade is met with, from altera- tion of temper and disposition, or loss of self-control, to marked eccentricity and actual disturbance of mental balance, or fixed delusions requiring restraint in an asylum. Most of the strange behaviour manifested by women of what is called " an uncertain age " is attributable to this cause, which may well be described £is " the roaring xxiv Introduction forties," Family quarrels and estrangements, extrava- gant beliavioiir in public and the adoption of strange cults and views characterise the period in question. Those who have exhibited neurotic tendencies earlier in life are apt to display them in an aggravated form at this time, and may present symptoms, mostly referable to the nervous system, which are confusing and puzzling, unless the age and circumstances are taken into account. Functional affections of all kinds occur, and conditions such as acroneurosis, erythromelalgia, and Raynaud's disease may develop. The importance of keeping in mind this phase of feminiae hfe, which is dependent on natural involution and disturbance of internal secre- tion, lies in the fact that it is temporary, and therefore hopeful as regards prognosis, though due allowance and suitable measures are necessary at the time to prevent permanent damage to the individual's family or social relations, from mistaken interpretation of possible unusual behaviour. The oncoming of old age is marked by a lowering of functional activity associated with degenerative changes in the tissues, involving loss of elasticity and range of action. Perhaps the first change appreciable by the individual is that occurring in the lens, accompanied by the recession of the near point of distinct vision, till convex glasses are required for reading or any close work. This commonly asserts itself at about forty-five, really at the commencement of middle hfe, and delay in its occurrence may be regarded as a promise of long life, for those who have attained great age have usually deferred the need of extraneous aid to vision till a much later period. The presence of myopia, or short sight, necessarily affords a favourable handicap, since till this is exhausted by the decreasing refractive power of the lens no extra converging power is needed, and such individuals may even be enabled to dispense with the Introduction xxv glasses they have formerly used. On the other hand an unusually early or rapid development of presbyopia indicates some additional cause of retrogression, and may connote the onset of diabetes. The appearance of the arcus senihs shows a similar degenerative change in the cornea, and is accompanied by retrogressive changes in cartilage in various parts of the body, especially the joints and thorax, while fibrous structures such as tendons, aponeuroses, and hgaments become indurated and even calcified. The elastic tissue of the lungs disappears, giving place to fibrous tissue, and similar changes sooner or later pervade the arterial system and heart. Thus the earlier and more pronounced degenerations affect mainly the extra-vascular tissues inducing stiffenino- and loss of range of movement. Similar decay of elastic fibres occurs in the skin which becomes loose or wrinkled and easily falls into folds, ceasing to brace the subcutaneous tissues and maintain the regular and sharp outline of youth. At no point does the appearance of age show itself with such certainty as at the side of the neck below the angle of the jaw, where the slack integument fails to adapt itself to the prominences and sulci so apparent there. The sebaceous and sudoriferous glands disappear, so that the surface becomes dry, and sweating is almost or completely abohshed. This change in the skin and its functions together with disappearnce of fat renders the individual more sensitive to cold, which his lowered vitaHty is unable to counteract ; hence elderly people are often troubled about draughts and night air, in a way the more vigorous are unable to appreciate. All the senses become dulled, sight, hearing, and touch, possibly smell and taste less than the others. Reserve power, both in the heart and lungs, is exhausted, so that any extra effort tells unduly. Sense of ec^uilibrium is diminished and falls are more xxvi Introduction serious on account of loss of elasticity, and greater fragility of bones and fibrous structures. The pulse becomes progressively slower from infancy to old age as the blood pressure rises, and febrile reaction becomes less and less marked, particularly the surface temperature, rendering the recognition of acute disease increasingly difficult. The capacity for digesting food and metabolic activity are reduced, so that the maintenance of nutrition is a difficult problem, Not only must the quantity of food taken be small, but the proportion of nitrogen constituents should be dimi- nished and the articles selected should be readily as- similable and really nutritious. An approach to the dietary of early childhood re- presents what is required without the saccharine in- gredients. Owing to the weakened power of digestion, rest before and after meals is very necessary, and the habit of dozing on these occasions appears less injurious to the aged than it often is in earlier years. Stimulants in small quantity and suitable form are generally beneficial especially towards the end of the day. Though elderly people commonly sleep indifferently, they need a good deal of rest, and this is best taken in bed as being more secure from change of temperature, which is all the more dangerous during sleep. A definite routine, so trying to the young, is acceptable to old people, who like to adhere to habits and to know what to expect. Indeed they commonly resent having their customary ways interfered with. But it is the temperamental change in advancing age which is perhaps most general and conspicuous, and / this is characterised in health by a tendency to delibera- tion and placidity, possibly even contentment. I recall once hazarding the statement that no one was really content till he had thoroughly made up his Introduction xxvii mind that he could not have what he wanted. " When I arrived at that stage," replied an eminent physician, "I should regard myself as the subject of calcified cerebral arteries." This probably sums up the situation, for as long as vigour and enterprise exist there will be straining after the unattainable, and the contentment of old age probably represents the accepted inability and even desire for betterment, associated with emotional quietude and dependent on retrogressive changes in the cerebral circulation. In childhood superabundant energy finds sufficient satisfaction in restless and aimless functional activity, later, in adolescence, focussing itself in attempts to excel in competition with others. In middle age sufficient effort is concentrated upon what is useful and necessary in the needs of life, while as age advances effort becomes irksome, and is called forth only by the need of retaining what has been already acquired. The desire of most people is to extend the span of life, or at least the period of active enjoyment and utility. Though the hands of the clock cannot be put back, they may possibly be retarded, and this is most likely to be effected by adapting the dietary to the period of life both as regards quantity and quality, as has been already indicated. It is advisable also to adhere as long as practicable to the mode of life of each phase as it reaches completion. In adult life the exercises and amusements of youth should be continued as far as circumstances and bodily vigour permit, or those more deliberate field- sports adopted which conform to the ability of the individual when the more active games are no longer possible ; these may be continued through life, serving to maintain the freedom of movement of the limbs and body, as well as the health and vigour of the internal organs and the elasticity of the mind. It is a rare relief from xxviii Introduction the pressure of business and obtrusion of various troubles, to turn to the river or the golf green and the fresh associa- tions of the country. The same may be said of more serious occupation, which should not be given up completely, though it may be relieved of many of its more arduous and monoto- nous features, so long as the individual can follow it. Adherence to the ways and habits to which one has be- come accustomed tends to the prolongation of life and the avoidance of ennui, for elderly folk cannot readily find means to employ an indefinite amount of leisure. The alternative to dying in harness is to retire at an age when sufficient energy and initiative remain to apply to some more congenial mode of life or the pursuit of a favourite hobby. What has been said of men in relation to their occupa- tion applies in many cases to women in family life, who have devoted their interest and energy to their children and domestic affairs to the exclusion of everything else. For them a time comes when such cares and occupations cease in the natural course of events, and, without an alternative claim on attention, interest in life is apt to wane. The result in both is likely to be the same — absence of outlook, restless discontent, leading to relative over- exertion, or subsidence into a melancholy quietude. Physically there commonly ensues dilatation of the heart, entailing failure of circulation, associated with dropsy, which a woman may survive, but a man never. This is perhaps to be broken-hearted. " The grief that does not speak Whispers the o'erfraught heart And bids it break." MINOR MEDICINE CHAPTER I THE DIGESTIVE SYSTEM In considering minor disorders of tlie digestive system, it is often extremely difficult to allocate definitely the trouble in any particular organ, subjective symptoms affording very insecure ground for such discrimination, and the several processes involved being so closely inter- woven that irregularity in one may produce even more conspicuous disturbance of another, and some compre- hensive feature, such as portal congestion, may affect several at once. Under the term '* LiveP " are popularly grouped such features as flatulence, dyspepsia, and constipation, due to excesses in diet or stimulants, which really indicate the presence of catarrh, congestion or subacute inflammation in the stomach or intestine ; while the occurrence of slight jaundice, clouded complexion, and mental depression are probably due to constipation or to some interference with the free flow or elimination of bile, resulting from catarrh of the ducts, and the resorption of this fluid with crude or toxic constituents into the general cnoulation. Headache, giddiness, malaise, muscular debility, mental depression, and irritability indicate the effect of 1 Minor Disorders of Digestion e>* such toxines on the nervous system ; while piles, weight in the right hypochondrium, and pain about the right shoulder-blade may be due to congestion of the hver or even slight hepatitis, shoulder pain being referred through the connections of the splanchnics with the lower six dorsal nerves. The activity and reserve power of the liver doubtless vary in different individuals, as do their capacities in other directions. The influence of habit and idiosyncrasy is also marked. Moreover, functions that can be relied on in certain conditions of health, activity, and period of life may prove totally inadequate in others — as when a diet of beef and beer agrees well with a man enjoying a vigorous country life, but will not suit the same individual in the physically Isss active existence of town, or when years have diminished the efficiency of his organs. CHmate and season, too, exert a powerful influence in the balance between the cha^x^acter and quantity of food and the functional capacitj^ of the digestive organs, so that what is necessary and suitable in some circumstances may prove actually injurious in others. A Bilious Attack usually comes on in the morning, often after a disturbed night in which sleep is broken or attended by dreams of a depressing or terrifying nature. This may follow on an extraordinary repast, sometimes a meal which has been accompanied by emotional disturb- ance, or taken hurriedly or when overfatigued. Some- times it occurs in hot or thundery weather, in an east wind, or in connection with a visit to the seaside. In some people even falling asleep soon after eating will bring on an attack ; but to those who are predisposed, any or no cause may be assigned. Such as are admitted, however, point to arrested or disturbed digestion, associated with disordered secretion and probably toxic fermentation. The first symptoms noticed are malaise, headache, and disturbance of temper, the merest trifles causing great A Bilious Attack 3 irritation or unreasonable depression ; there may be also vertigo, muscae volitantes, muscular debility, and entire lack of interest or ability to fix the attention. The healthy colour of the skin is replaced by a muddy pallor, with dark rings round the eyes and dryness of the skin and hair. Appetite is lost, and there is commonly nausea ; if an attempt is made to eat, food tastes bitter and unpalatable, disapprobation being extended to the cook. Even if the morning meal has been restricted to tea and toast, it usually disagrees, giving rise to flatulence and discomfort, and is very commonly rejected, the vomit including some portion or the whole of the meal taken overnight, accompanied by a good deal of mucus with bile, which may be green or yellow, having an acrid, bitter taste. The act of retching is preceded, accompanied, and followed by nausea and prostration with cold sweats, the patient feeling at this stage as miserable as possible. Diarrhoea or constipation may follow, while the other symptoms continue through the day, totally unfitting the individual for any sort of occupation or amusement, so that he generally chooses to remain in bed or sit in a darkened room, alternately dozing and concerning himself with the exigencies of his disorder. As to the pathology of this condition, only inferences can be drawn, as no ocular demonstration of the state of the viscera is obtainable. Two features, however, appear to be definite, and constantly present. One is that the digestive apparatus is on strike, as may be deduced from the complete anorexia, the arrest of digestive processes, and the absence or inversion of peristalsis, resulting in vomiting and regurgitation of bile through the pylorus. The other is the presence of catarrh, quantities of mucus being thrown up with the undigested food, or independently by retching. In the absence of the normal secretions and functional activity there is undoubtedly a vast increase in micro-organisms associated with morbid 4 Secretion and Reabsorption of Bile fermentation, producing lactic and butyric acids and other unwholesome products, whicli induce tlie nervous and other symptoms attributed to toxic absorption. A bUious attack is therefore to be regarded as a transient catarrh of the gastro-duodenal area, associated with arrest of the digestive function and the development of morbid products of fermentation and perverted digestion, which are absorbed into the circulation unchanged, owing to the protective action of the liver being suspended. It is appropriate to recall in this connection some features of the bile and its circulation. When a biliary fistula is established, it is noticed that there is at first a copious escape of that fluid, but in the course of a few days the quantity diminishes greatly, and moreover the amount secreted varies from day to day, from which it is inferred that the bile secretion and with it the functional activity of the liver is not uniform, and that a condition which has been termed torpidity of the liver may exist. The falling off in the quantity and depth of colour of the bile as a result of continual escape through a fistula is evidence that a large portion of the natural secretion, under normal conditions, is reabsorbed with the products of digestion : in the case of fats it is, indeed, the vehicle by which they are taken up into the circulation, the bile being returned into the intestine again and again. Thus the hver provides afresh perhaps not more than a tenth part of that which is daily passed through the ducts, nine-tenths being old bile returned from the hver to be used again. This aspect of the bile circulation to and fro between the liver and intestine suggests another cause of bilious attacks, which is independent of external influences, such as have been suggested — that is, the cumulative efiect of toxic products of imperfect digestion ; the stale bile becoming more and more deeply charged with them, when the bowels are not acting efficiently, and they are not Portal Circulation 5 eliminated. For it need not be supposed that the protective action of the liver, as exemplified after the in- gestion of snake venom and other poisons, is entirely due to complete destruction of these substances, but rather to their return to the intestine, whence in the course of time they are evacuated. So long as they are prohibited access to the general circulation by the selective if not destructive power of the liver cells, the organism is safe, and the beneficial influence of purgatives, in these and allied circumstances, substantiates this view, as does the elimina- tion by the bowel of such metallic poisons as lead, assisted by the same agency. Another point worthy of consideration in connection with temporary derangements in which the liver is directly or indirectly concerned is the peculiar character of the portal circulation. Nowhere else in the body except in the kidney do we find a double capillary system interposed between the afferent and efferent vessels, and the dis- advantage of the arrangement from a circulatory point of view is demonstrated by the constant failure of these two systems in chronic cardiac disease, resulting in the one case in ascites and in the other in anasarca, while the functions of the organs are seriously disturbed. When the circulation through an ordinary capillary is watched and the variation in rate of flow with the systole and dia- stole of the heart is observed, it must be realised how great is the disadvantage in the portal capillaries with no such vis a tergo behind them, but only thin-coated valveless veins peculiarly liable to variations in calibre, and relatively unsupported by surrounding tissues, while they are ex- posed to gross variations in pressure as exercised by the abdominal muscles and the diaphragm, and to the influence of the nervous system, as in shock or collapse. Dilatation of the portal vein and its tributaries no doubt allows of the accumulation of the products of 6 Treatment digestion in the intervals of meals, and of their gradual subjection to the action of the liver, the portal system acting as a reservoir, thus assisting in converting nutrition from an intermittent into a continuous process. These reflections would lead one to the conclusion that great variations in the rate of the portal circulation are possible, both with and independently of the process of digestion, the nutrition of the liver cells and tissues being independently provided for by the hepatic artery. The usual treatment adopted during these crises and its success are fully in accord with these views. It consists (i) in relieving the system by starvation and purgatives or even emetics, though in acute attacks vomiting occurs spontaneously; (ii) in aiding the elimination of toxic material by diluents ; and (iii) in controUing the local fer- mentation changes by antiseptics. Practically these results are obtained by the use of mercurial and saline purgatives, abstinence from food, and drinking freely of some alkaline aerated water. The mercurial preparations commonly employed are calomel, grey powder, or blue pill in doses of gr. ij-iv, given preferably at night. A very convenient and effective pill is composed as follows : ^. Pil. Hydrarg gr. iij Ext. Aloes . , . . . gr. j Ext. Hyoscyam gr. j or in a mild case a compound rhubarb pill will suffice. It is usual with mercury to administer a saline draught in the morning to ensure active clearance of the bowel. The ordinary black draught, a seidlitz powder, or a sufficient dose of one of the aperient mineral waters such as Condal, Hunyadi, Apenta, or Friedrichsall, or a drachm or two of sulphate of soda or magnesia, answer very well, Besides drug treatment, however, it is well to advise the patient to do without food for Treatment 7 twenty-four hours, or even longer should recovery be delayed. Milk may be given in small quantities, and perhaps a little soup or beef tea, but the less the better., and the inclination is usually entirely wanting, so that abstinence is less difficult. As improvement occurs, the milk may be given hot with arrowroot, Revalenta arabica, or cornflour, and junket and blancmange may be added. In regard to drinking the case is different ; if there is vomiting there will be thirst, and in any case the mouth is uncomfortable. Mineral waters simply aerated, such as Seltzer, Salutaris, or Perrier water, may be taken ; the addition of a little fresh lemon is agreeable and refreshing to the mouth, but it does not consort well with the milk and should not be taken in too close proxi- mity with it. Alkaline waters have the advantage in assisting to liberate the mucus of which there is an excess in the stomach, and of reducing any acidity ; the most popular are Potash or Soda, Apollinaris and Vichy. The addition of sulphate of soda or magnesia in the proportion of a drachm to the pint where the bowels are not loose is useful, though it does not improve the taste. Stimulants are to be avoided, that is to say, alcohol in any form makes matters worse. If there is great prostration and depression, carbonate of ammonia in doses of 10 grains added to nearly a tumblerful of milk is useful. Acute attacks usually pass off in twenty-four hours or so, and may not be so bad as to completely disable the patient from attending to minor affairs ; moreover, if experience has taught him to foretell or expect a paroxysm overnight, he may anticipate the treatment as well as the disorder, and, by taking the remedies prescribed above at once, may prevent the attack or cut it short. Though, in most cases, of infrequent and irregular occurrence, some individuals are subject to bilious attacks at intervals of a few days, scarcely passing 8 '^ The Blues" a wliole week without symptoms, and in such the treat- ment should correspond, being adopted once or twice a week, though possibly in a modified form. For instance, the mercurial may be reduced to one-tenth of a grain of calomel as a lozenge twice or three times in the course of the day, followed by compound liquorice powder; or a pUl, composed of a quarter of a grain each of iridin, euonymin, and podophyllin, may be substituted, with prepared Carlsbad salts, which should be taken several mornings in succession and at such intervals as may correspond with the recurrence of the dis- order, once a month being sometimes sufficient. When very persistent and disabling, a course of treatment at one of the special watering-places is to be recommended, where the routine life, limited diet, and appropriate salts diluted with large quantities of water are combined with moderate exercise and quiet amusement. Besides these acute attacks, which usually provide their own cure by loss of appetite, vomiting, and diarrhoea, there appears to be a subacute and more prolonged con- dition of the same kind, known in the vernacular as the ** Blues." This consists of a group of symptoms including mental depression, irritability, vacillation, and inabihty to fix attention or take any interest in the usual occupa- tions or amusements ; there is generally loss of appetite, but sometimes morbid hunger; the ingestion of food, however, not being attended with satisfaction and being commonly followed by some symptoms of indigestion. It may last two or three days, and either pass off or culminate in a regular bilious attack. Headache, cutane- ous irritation, an unhealthy aspect of the skin and conjunctiva, and constipation with high-coloured urine, often loaded with urates coexist, and appear to depend, as in the former conditions, upon the accumulation of digestive by-products and defective renewal of bile ; there is possibly also some catarrh of the storaach and Chill on the Liver 9 duodenum with retardation of the portal circulation. Drowsiness in the day and unsatisfactory sleep at night are also common features of the complaint, which is apt to supervene on loss of accustomed exercise or too close adhesion to routine life, perhaps combined with relative excess, in eating and drinking. The remedies suggested in the foregoing paragraph are equally effective here, but need not be quite so di'astic. The compound rhubarb pill two or three nights in succession, the blue pill with aloes and hyoscyamus or gr. j-ij of calomel, followed by a saline such as citrate of magnesia in the morning, with a limited farinaceous diet and a more free use of either plain water or one of the mineral waters usually suffice. The plan of drinking a tumblerful of hot water an hour before each meal so as to wash out the stomach and upper part of the intestine is beneficial. A Chill on the Livep. — This is a diagnosis com- monly made by the patient and possibly accepted by the medical man as a doubtful entity. As in most functional derangements, there are no definite objective symptoms, but the subjective ones are numerous and are similar to those already enumerated. The mental depression and loss of physical energy are more marked, and a sense of weight, discomfort, or pain is complained of in the right hypochondrium and epigastrium, and at the back under the shoulder-blade or in the interscapular region. There is a tendency to coldness of the extremities and the face often has an ashy colour and pinched look. The bowels are constipated, the urine scanty and loaded with Hthates, appetite is lacking, and digestion attended with discomfort. Some dilatation of anal veins may occur. The duration of this state when untreated is indefinite unless dispelled by change of atmosphere or climate, continuing two or three weeks or even a month. The onset appears to be determined by cold and inactivity, and is often associated with the prevalence of a north-east wind, sedentary lo Flatulence occupation in a cold room, or a long railway journey. Here, again, tlie pathology is only a matter of inference, but both cause and effect are in accord with the supposi- tion that there is congestion of the portal system with slowing of the circulation through the liver and chronic catarrh of the mucous membrane of the digestive tract. The most effective treatment in addition to measures for unloading the abdominal venous system and adapting nourishment to a diminished digestive capacity, as in the former disorders, is the application of external heat, which is best applied as a hot-water or Turkish bath, prolonged beyond the ordinary time on three or four days in succession, the skin being thoroughly reddened and perspiration encouraged. As a sense of chilliness is a feature of the disorder, this is agreeable, and an immediate sense of relief follows, but repetition is necessary to ensure permanence, and anything in the form of cold douche should be omitted. In spite of the low spirits alcoholic stimulants are to be avoided, except in the form of hot spirit and water at night to promote the action of the skin on going to bed. Carbonate of ammonia or sal volatile in fairly full doses well diluted, as in a glass of milk, may be taken during the day. Flatulence (Tympanites). — ^The condition of gaseous distension in the digestive tract is a very common one, and leads to great discomfort and even danger by disturbance of the respiration and circulation, through upward displacement of the diaphragm and embarrass- ment of the thoracic viscera, but even more by interfering with the propulsion of the intestinal contents and inducing actual obstruction. Kinking and volvulus, or twisting of the gut, has supervened on this distension, and it is often the exciting cause of the onset of the symptoms in patients with obstructive lesions. Mere confinement to bed in those unaccustomed to sickness, or invalid diet, may cause this distressing Treatment 1 1 symptom, which is variously alluded to as tympanites or meteorism. The same may result from the action of purgatives, and it is also found in many diseases, especially typhoid fever, and as an after-effect of abdominal operations. The accumulation of gas may be limited to the stomach or colon, or may be generally distributed throughout the digestive tract. Sometimes it appears to be due rather to paralysis and relaxation of the muscular walls of the gut or abdomen than to the actually increased pressure within, and its rapid occurrence marks the last stage of acute and fatal illness. This is especially the case in unfavourable issues in pneumonia and other acute diseases, or in collapse after severe injury or operation. Observant nurses have been wont to note how in such instances liquids ingested appear to fall direct into the stomach with an audible gurgle or splash instead of being grasped by the gullet and swallowed in the ordinary way, and they correctly anticipate a speedily fatal event. The rapid extension of the area of stomach resonance till it actually reaches the pubes corresponds with the previous observation ; and whether limited to the stomach or involving the intestines, such rapid develop- ment of gaseous distension, associated as it is with pro- found nervous prostration, is of the gravest augury. As a concomitant of acute and chronic intestinal obstruction and peritonitis this symptom is only too familiar, and is one of the chief bars to recovery after operation. In such desperate and critical conditions which com- monly preclude the administration of remedies by the mouth, recourse must be had to the subcutaneous in- jection of strychnine in paralytic or of atropine in spas- modic states. The introduction of an oesophageal tube by the mouth in acute gastric distension or by the rectum in that of the intestines has sometimes secured relief ; other remedies which have been efficacious are the Enem^ 12 Minor Degrees of Flatulence Terebinthinse (5 iv with mucilage or barley water to 5 vj), Enema Asafetidse gr. xxx, and the Enema Rutse TIL XXX (diluted in the same manner). In a thin subject with coils of intestine visible through the abdominal wall, gas has been directly liberated by puncture with a fine trochar and canula, but such a proceeding has obvious risks. In patients confined to bed the warmth and pressure afforded by a rubber or flat metal container filled with hot water are comforting and sometimes curative. The occasions, however, which it is chiefly intended to allude to here are those either of acute attacks resulting from some departure from customary diet, or chronic or recurring attacks associated with the continued ingestion of unsuitable food, or other causes. In the stomach flatulence is due to fermentatioil of carbohydrate or saccharine matters associated with delayed or disordered digestion, or when occurring im- mediately after a meal may result from direct liberation of gas from excess of carbonate of soda employed in the preparation of the food. The effect of gastric distension is a feeling of tightness and fulness with actual bulging in the epigastrium and left hypochondrium, palpitation of the heart, a sense of oppression in the chest, and often flushing and burning in the face, some temporary relief being obtained at intervals by eructation. There is always hyperacidity of the gastric contents, and the regurgitation of acid fluid through the cardiac orifice may add the sensation of heartburn to the other discomforts. When the general mass of the intestines is involved, there is more uniform bulging of the abdomen with c. wider distribution of pain or discomfort, but this is a rare event apart from the more serious condition involved in obstruction and peritonitis. Chronic or recurring inflation of the colon is commonly Enterospasm 13 associated with constipation and generally accompanied by the discharge of flatus per anum. This condition is responsible for the continual development of those " intestinal croakings " known as borborygmi which are excited by the peristalsis of the intestine, and also by the movements of the diaphragm and of the abdominal muscles in respiration. At the hepatic and splenic flexures, and sometimes also in the sigmoid, sharp horseshoe curves attended by kinking and muscular spasm lead to local stasis and distension, which give rise to great discomfort often unrelieved for hours by any escape of the imprisoned gas. These attacks appear to be induced by articles of diet for which the patient has an unfavourable idiosyncrasy, and often result from exposure to external cold or the ingestion of iced beverages or confections ; even fruits such as strawberries or pears may cause an attack. Besides the local distension unrelieved by eructation or escape of flatus, these paroxysms of " Entepospasm," as they have been called, are remarkable for their liability to recur at the same hour on several successive days : six o'clock in the evening is a favourite time, and may be connected with the custom of drinking tea in the afternoon. As already stated, flatulence is usually associated with acidity, and this is specially liable to occur when unconsidered trifles are taken at irregular times, enough to excite gastric secretion while insufficient to absorb and occupy it. It is doubtful also whether on these irregular occasions the alkaline digestive secretions of the pancreas and liver, which should neutralise the contents of the stomach as they traverse the duodenum, are excited in an equivalent degree, the absence of bile being an acknowledged factor in the production of fermentative changes and irregular or insufficient peristalsis. The remedies which have been advocated for flatulence are as numerous as the wide distribution and variations 14 Remedies for Flatulence in the complaint would lead one to expect. Those which exert an immediate local influence are either antacids or aromatics, while those which have a more continuous and extended effect are antiseptic, cholagogue, or purga- tive. As a type of the jBrst class Sal Volatile is a good ex- ample and a very popular remedy ; half a drachm with VI XX of Spirits of Chloroform and vi x of the Tinctura Carminativa in water forms an agreeable and effective dose in an ordinary attack of gastric flatulence, or the combination of sal volatile and spirits of chloroform with bicarbonate of soda and infusion of cloves in appropriate doses is effectual. Immediate relief can often be obtained by taking two or three drops of peppermint or cajeput oil on a piece of sugar, and when the more formal drugs are not at command a very good draught can be extem- porised by pouring boiling water on four or five crushed cloves in a wine-glass, and adding ten to twenty grains of carbonate of soda ; merely drinking hot water will commonly be of benefit, since each time the cardia is relaxed some pent-up gas escapes, and much of the effect of the aromatic substances, alcohol, or ether depends on this. A compound rhubarb pill followed by a draught of hot water exerts a relaxing influence on both the oesophageal and pyloric openings, and acts later as a purgative, so that it is probably the most comprehensive remedy where flatulence and distension are associated with a meal which disagrees, either on account of its chemical or physical characters or the temporarily dis- ordered state of the stomach. Flatulent distension of the colon is more difficult to relieve immediately by drugs. Locally applied pressure and heat exert the most rapid effect, but the spasmodic attacks known as " Enter ospasm " are often rapidly benefited by menthol given in small doses. A pill com- posed of Menthol gr. J, Calomel gr. ^, with sufficient Heartburn 1 5 Powdered Ginger (gr. ij) and Syrup of Glucose to make up a convenient bulk, may be given three times a day, though a single dose ensures relief in a few minutes. Com- pound menthol or soda mint tabloids have a similar effect. Heaptbupn. — This word well expresses the uncom- fortable sensation which occurs behind the lower end of the sternum when the acid contents of the stomach regurgitate through the cardiac orifice into the oesophagus. It may result from active exertion, lying down or stooping just after a meal, but may come on independently when there is flatulent distension of the stomach or irregular secretion of acid with active peristalsis. In the latter class of cases, which are commonly associated with neurasthenia or gout and habitual dyspepsia, there may be such profuse discharge of this acid fluid that it is ejected from the mouth almost as in vomiting. Indeed the contraction of the stomach with dilatation of the cardia only lacks the simultaneous compression by the abdominal muscles to complete this. The discomfort itself may be relieved by drinking a little fluid so as to wash back the acid into the stomach, or corrected with a little alkali, such as sal volatile or soda, the soda lozenge of the Pharmacopoeia being specially useful on such occasions. In one instance the acid eructations referred to above, which had continued off and on for forty years, were relieved by " Live-long tablets," an old-fashioned mixture of soda, ginger, rhubarb, and magnesia made into a sort of confection with sugar. When these occurrences are frequent, the patient should be advised to sit or stand upright for some time after a meal, lying down or stooping tending to bring the gastric contents against the cardia, but the condition often connotes dyspepsia with over-acidity and spasm of the pylorus or laxity of the cardia. The modern view of digestion, aided by gastric surgery, has tended to displace the stomach from its 1 6 Hiccough pre-eminent position as an organ of digestion, regarding it chiefly as a reservoir for food, which exerts some antiseptic power, and continues comminution by dissolv- ing connective tissue and cement substance in animal fibre, rendering ingested matter more easily permeable by the true digestive juices. Long retention of the food by contraction of the pylorus, excess of acid secretion or the occurrence of fermentation, are affairs apart from the normal function of the organ, and indicate something wrong either in the stomach itself or in the chemical or physical quahties of the food. Hieeoug"!!. — This uncomfortable and sometimes dis- tressing phenomenon is produced by intermittent spas- modic contraction of the diaphragm, the resulting in- spiration being checked by falling together of the vocal cords, which are not held open as in inspiration. It is often a terminal symptom in serious abdominal states such as peritonitis and intestinal obstruction, and is sometimes a neurotic manifestation, in such cases being continued in an exaggerated fashion for weeks, though ceasing during sleep and capable of suppression by disciplinary measures. Under more ordinary circumstances it appears to arise in connection with stomach irritation, excited by flatu- lence, over-distension, or indigestible food, and especially by hot condiments such as pepper and curry powder. Active exertion immediately after a meal is also a common cause, and it very frequently occurs in infants from too hurried or excessive ingestion of milk. The attacks are not usually prolonged, and consequently afford little opportunity for trying drugs, but once started are kept up by expectancy, so that often the best way of arresting them is by suddenly diverting the attention. Pressure of the finger-tip on the cricoid cartilage with slight movement is often successful, and is especially useful in infants, hiccough in them often ending in vomiting. Dyspepsia 17 In adults, drawing a deep breath and maintaining contraction of the diaphragm is usually effective ; coutiting up to a hundred without drawing breath, or taking several sips of water with a similar restriction answers nearly as well, and is easier to carry out. Failing relief by these methods, reliance may generally be placed on the effect of a good sneeze excited by tickling the nostril or taking snuff. In really protracted cases apomorphia, morphia, and pilocarpine in full doses have been injected with benefit ; inhalations of chloroform or amyl nitrite have been given, or firm traction on the tongue has proved effectual, tension being kept up while the period of several spasms passes. If any morbid condition such as distension of the stomach or hyperacidity coexists, it should be reheved, and lavage has proved immediately remedial in some cases. Dyspepsia. — Under the term " indigestion" are in- cluded a number of uncomfortable sensations associated with the ingestion and digestion of food, which may be con- sidered under " minor disorders " so long as the objective signs of wasting, hasmorrhage, reaUy severe pain, persistent vomiting, and the serious indications denoting perforation or obstruction in the digestive tract are absent. Apart from these signs of organic disease, the distress caused by disturbance of the process of digestion, even when ex- pressed only by morbid sensations, is serious enough to call for rehef , though it is frequently borne for long periods by the patient, under the impression that it is irremediable or will pass off of its own accord with some change of cir- cumstances ; such an event having, perchance, come within the range of his personal experience. To the medical adviser few things are more unsatisfactory to deal with than subjective symptoms, often intermittent in their occurrence and dependent on a disturbance of balance in the daily life of a patient, who is not sufficiently incapacitated to put himself under complete supervision. It is almost needless to say that dyspepsia occurs at aU 2 1 8 Dyspepsia ages, commencing in infancy with the disagreement of natural food, calling for the hundred-and-one proprie- tary articles which contend with one another for popular favour ; associated in childhood with insufficient masti- cation usually accompanying the temporary dentition and increased by the interregnum prevailing between this and the completion of the permanent set of teeth. In the period of school life, when boys are commonly allowed to bolt their food and regulate the duration of their meals by the exigencies of the playground, the irregular ingestion of articles which are neither particularly wholesome nor nutritious throws a further strain on the function of the stomach. It is a marvel to many adult observers how the average schoolboy does commonly emerge scatheless from these as from other self-imposed risks. The vigour of youth and absence of over-sensitive nerves make hght of gastric remon- strances, if they exist, and the facility of vomiting, which is a feature of the young throughout the animal kingdom, is an effective safety-valve, a timely evacuation of the stomach no doubt often affording escape from more prolonged trouble. A common cause of so-called indigestion is insufficient interval between meals. We start the day later, and introduce more repasts, than did a previous generation, to say nothing of the ancillary refreshment between them. The stomach may be considered to be never empty, it gets no physiological rest, and any morbid fermentation that may be set up is inevitably handed on by the gastric residues from one meal to another, while the organ itself does not contract, and in not a few instances appears rather to dilate and lose its peristaltic power. It is worth considering that in most cases of indigestion dependent on functional causes the only meal which may be unat- tended with subsequent discomfort is breakfast — that is, the one succeeding the relatively long, foodless interval Dyspepsia 1 9 of night. There are, of course, other things which throw an undue strain upon the functions of the stomach, one of the commonest being " eating too fast." It is unneces- sary to go into the many motives for this, but whatever they are, the economy will not keep pace with the volun- tary act of swallowing. Mastication, insalivation, the secretion of the digestive juices, the successive chemical changes the food undergoes and its passage from one portion of the tract to another, can neither be hurried nor dispensed with. To scamp the preliminary phase of the digestive process in the mouth is only to throw extra work on the rest of the tract, the stomach especially, work which it is neither suited nor prepared for, and consequently does not perform ; so that a large portion of the food thus hurriedly taken is passed on practically as foreign matter, not merely to waste, but injuring the delicate mechanism and interfering with such normal processes as may be going on. Eating hurriedly, however, is not alone accountable for this crude interference with diges- tion. Many people are not blessed with what the dentists call " a good bite " : either there are gaps in the teeth due to loss or irregularity, or when the proper complement is present there is not necessarily satisfactory contact between the upper and lower sets. Then there is the character of the food, which may be so tough as to defy the strongest masticatory powers. Those who are prone to indigestion would find it a good rule " never to put into the mouth anything which resists a moderate use of the knife and fork, and never to swallow anything they cannot bite." It is only too common a practice to get rid of tough morsels by " bolting " them, and to persist in eating more of what has already proved refractory from motives of politeness, carelessness, or sheer necessity. Such seK- sacrifice may be commendable socially, but it entails serious and prolonged suffering on the victim of such considerations, and if he is prone to indigestioa will 20 Selection in Diet render him miserable and uncompamonable for horn's and even days. Instances are known in which grape- skins have been found in the stomach three months, and the pulp of an orange six months, after being swallowed, and it is not too much to suppose that tough morsels of meat, doughy substances saturated with fat, ill-made pastry and pudding-crust, and various " strings and stones, skins and bones " will be refused passage by a sensitive pylorus for hours or even days ; in the mean- time preventing the stomach from resting, and becoming the nucleus of fermentative processes, which interfere with the wholesome solution of successive meals and give rise to eructation of gas and the various uncomfortable sensations which constitute dyspepsia. Those who possess irritable and sensitive stomachs may suffer long before they find the remedy or the regimen which reheves them or secures immunity, but they will do wisely in the long run to eschew strange cooks and unaccustomed dishes and to adhere to simple fare. In the preparation of food attention must be paid to the due hanging of meat before it is cooked, and if this cannot be accomplished, it is better to consume New Zealand lamb which is imported aheady well hung, or else to select the inner organs, such as tripe, sweetbread, or Hver, which are easier of digestion than ordinary meat. Though fish and poultry are commonly supphed to invahds as being easier of digestion than meat, this is not always the case. It should be remembered that boiling is better than baking or frying, and that flat fish of all kinds are more tender than others, except, perhaps, whiting or smelts, and, of course, oysters. But the form of animal food which is best tolerated by a hypersensitive stomach is milk in one form or another and egg albumen. They may be diluted in various ways, or con- verted into semi-sohds, such as junket, custard, or blanc- mange, or combined with starchy food, either predigested Remedies 21 or not. When these are rejected or give rise to pain, there remains nothing but absolute starvation for a few days, so as to give the stomach complete rest both in the matter of secretion and peristalsis. Thirst can be alleviated and the comfort and bulk of the patient maintained by enemata of warm water, the quantity being raised by degrees to half a pint every four hours. This, of course, requires the patient to be kept in bed and rather exceeds the limit of minor medicine. The commonest causes of attacks of dyspepsia are the ingestion of unsuitable food, mental disturbance such as worry, annoyance, and haste at meal-times, eating when overfatigued, especially when the patient falls asleep immediately afterwards, and undue activity either immediately before or after eating. In one instance of a busy city man who barely got through his day's work in time for the evening meal, the late Sir Andrew Clark gave but one direction, "Dress for dinner," and this was effectual. For the ordinary solitary instances of food disagreeing and perhaps occasioning a disturbed night, there is no remedy equal to the compound rhubarb piU taken as soon as the disorder is recognised. It will restore peace and comfort, and render the stomach fit for next morning's breakfast. For children the compound rhubarb powder (Gregory's) answers the same purpose, and is useful as a disciplinary measure as well as a therapeutical one. Where the discomfort succeeding meals is habitual, as in nervously excitable individuals over-anxious about studies in youth and about other affairs in later life, all the precautions about taking food at proper intervals and in a proper state of preparation, both as regards the individual and the food, must be observed ; but in ad- dition it will often be found that the constant discomfort has led to the elimination of one thing and another from the diet list, till the patient is restricted almost entirely to carbohydrate food in the form of bread and sweets. 22 Farinaceous Food and Fermentation There is commonly some tenderness of the stomach area with distension and even dilatation of the organ associated with succussion and loss of peristalsis and con- tractile power. These are the very numerous cases which benefit remarkably by the mode of treatment introduced by Dr. Salisbury and named after him, and which consists in the administration of raw meat finely minced and lightly grilled, in increasing quantities up to half a pound to a pound at a time, nothing else being allowed except hot water as a beverage either some time before or after the meal. In the majority of these cases the fermentation of carbohydrates is the root of the evil, and a sustained, purely nitrogenous diet puts an end to this, while supplying a highly nutritious food in a small space, and so encouraging the stomach to contract to normal dimensions. Apart from this special regime, however, persistent flatulent dyspepsia may often be cured by omitting all farinaceous food for a day or two and subsisting on nitrogenous material such as meat, fish, and eggs alone. Sometimes the restriction of each meal to one class of food, such as fruit, cereals, or meat, is found beneficial. Lengthening the intervals between meals so as to ensure the stomach being empty before the next is taken exerts a powerful influence in correcting morbid processes in the digestive tract, and free imbibition of water, pre- ferably hot, an hour or more before or after meals tends to clear and refresh the stomach. Fasting to the verge of actual hunger is a ready cure for many functional derangements of digestion. Such unsuspected articles as bread, coarsely made as it sometimes is in the country with a good deal of potato ; or water, hard with an unusual amount of calcium salts, may be the cause of persistent discomfort. To sum up, it may be affirmed that digestion and fermenta- tion go hand in hand in the moist warmth of the stomach, Fermentation and Digestion 23 and anything which checks the former tends to encourage the latter ; hence food matters which are not readily permeated and broken down by the gastric juice, dilution of the secretions by draughts of fluid immediately as- sociated with eating, fatigue, worry, or sleep on a full stomach, are all likely to result in fermentation getting ahead of digestion, with consequent pyloric spasm, gastric dilatation, hyperacidity due to inorganic acids, and the evolution of gas. Such a meal is spoilt, it is a " bad brew," and the sooner it is got rid of by vomiting or purging the better for the individual. These are nature's methods of cure and the safest and speediest to imitate. Little has been said as to drug treatment in connection with this occasional disorder, for on the one hand, in otherwise healthy subjects, the rational attention to diet and the physiology of digestion should suffice to prevent or correct such errors, and on the other, the habit of taking the numerous nostrums advocated as cures for indigestion has led to Uttle good and much harm, and it is not contemplated here to enter into a consideration of more serious forms of disease. There are, however, some preparations which afford reHef to the temporary discomfort. Mention has already been made of the compound rhubarb pill, which may be considered the most wholesome and effective remedy. Another pill is composed as follows : l^:. Menthol gr. J Calomel gr. f Pulv. Zingeribis . , . . gr. ij Maltine q.s. This affords immediate relief to flatulence and discom- fort and tends to check further fermentation. Three or four may be taken at intervals of a quarter of an hour. Rather less efficient in their effects are the bismuth and soda lozenges of the British Pharmacopoeia. The Mistura Bismuthi Co, recommended by the British 24 Constipation Pharmaceutical Congress ^ is an agreeable and soothing compound, but belongs to a more serious class of remedies, containing as it does morphine and hydro- cyanic acid. Constipation. — Among minor disorders, it would be difficult to select one which is so prevalent, productive of so many complications and remote disturbances, so difficult to remedy in its later stages, and which is so neglected in its beginning when the obstacles to recovery are slight. The periodical evacuation of the residue of the digestive process is absolutely essential to health and comfort, and its inefficient performance results in two groups of symptoms : the one referable to mechanical distension and irritation, both local and reflex ; the other to resorption of poisonous matters developed or surviving in the faeces. The greater part of the large intestine is principally concerned with the absorption of the chyme poured into the ascending part by the ileum, and its contents gradually pass from liquid to solid as they approach the rectum, the numerous pouches tending to delay the transit and increase the surface for absorption, which is normally not complete till this last part of the intestine is reached, and the usual amount of the daily evacuation, some five or six ounces, is no more than the rectum can easily accommodate. Compared with the rest of the large intestine, the rectum is straight, smoothly cylindrical and thick-waUed, adapted to the modelling and expulsion of the final residue of the food, which comes to rest at the internal sphincter and accumulates for a distance above this, according to the infrequency with which the bowel is emptied. This wait in close proximity to a ring of lym- phoid tissue is closely associated with local infections ' Morphine Hydrochloride 8 2:r., Distilled Water 4 3, Compound Tincture of Cardamoms 3 §, Chloroform 70 vii, Liq. Extract of Nux Vomica 135 m, Acid. Hydrocyan. dil. 820 ni ; mix and add concentrated solution of Bismuth 15 §, and water q.s. to one pint. Dose 20-30 tn,. Causes and Consequences 25 resulting in ischio-rectal abscess, fistula, proctitis, and possibly haemorrhoids. The immediate result of omitting to empty the rectum, a matter which is under the control of the will, is the accumulation of faecal matter involving distension of this portion of the gut till it encloses a globular mass instead of a tapering cylinder, the ejection of which through the small though distensible anal orifice becomes increasingly difficult. In addition, the walls of the rectum, thinning as they distend, lose power of con- traction, and the contained matter by continuous ab- sorption of fluid becomes harder, while the concentration causes the phosphate of lime to deposit in rough mortar- like masses of crystals. Fortunately, at first, increasing distension of the rectum excites contraction which is at last irresistible, but by habitual retention this tolerance is encouraged, the muscular walls cease to respond, and particularly as age advances, what is termed " ballooning of the rectum," with deficient contractility, supervenes, and habitual constipation is established. The evils which ensue are : constant and increasing difficulty in emptying the bowels, serious complications from straining at stool, fsecal obstruction and stercoral ulcers, which may perforate. Other causes which tend to difficulty in relieving the bowels are : taking too little fluid, so that, the needs of the economy being stinted, absorption by the colon is carried on to almost complete dryness of its contents ; taking little food, and that of a nature to leave scanty residue ; inactivity, which results in loss of muscular power in the abdomen and probably defective bile secretion ; and the ingestion of astringents, such as lead, hard water, or tea which contains much tannin. Exceptional causes are surgical operations about the perineum, paralysis of the diaphragm or abdominal muscles, and other conditions affecting the power of 26 Remote Effects of Constipation compressing the abdomen. I have known a case of extreme emphysema where great difficulty existed in this respect, and it should never be forgotten that dis- placements or tumours in the pelvis or actual stricture of the lower bowel may for a long time convey no other impression to the patient than difficulty in defsecation. The common effects of constipation are headache, loss of appetite, foul breath, and furred tongue. There is often irritability of temper, lack of power of applica- tion, and general malaise. Inability to sleep soundly and waking unrefreshed are common accompaniments, usually associated with increased vascular tension. Among special disturbances may be mentioned epistaxis, and such paroxysmal affections as asthma, migraine, bilious attacks, and, in children, convulsions. Epileptic fits are encouraged, but can hardly be said to originate in constipation. There are, moreover, many complex and irregular groups of symptoms which might not ordinarily be thought of in this connection, due nevertheless to what has been termed Copraemia, or toxic absorption from the colon. Such cases are often rendered all the more difficult of detection by the faecal accumulation being masked by even a daily motion of the bowels, and it may be only by a pelvic examination or the recog- nition of scybala by palpating the abdomen that a knowledge of the true state of things is arrived at. Complete corroboration is subsequently afforded by the immediate recovery of the patient when effective purga- tive measures have been adopted. For instance, a woman of thirty-five had been ill for five weeks with an eruption of erythema multiforme, the temperature rising to 103° every other day with chills and sweats as in malaria, the bowels were recorded as acting daily, yet a pelvic examination undertaken in the expectation of finding some source of septic infection, Remote Effects of Constipation 27 which had been excluded elsewhere, revealed only a loaded rectum, and the adoption of thorough evacuant measures practically disposed of all symptoms in twenty- four hours. Another young woman had been invahded for a similar term with continual rejection of food and recurring hsematemesis associated with anaemia and remarkable fractiousness, reHeved for a time by careful dieting, but presenting aU the features, including epi- gastric tenderness, of relapsing gastric ulcer. This case made no real progress till resolute purgation was adopted, though the bowels had been apparently acting regularly, and then she recovered at once. Instances of severe neuralgic headache, palpitation, bronchial asthma, and pains referred to the muscles or fasciae, or called lumbago and sciatica, are of frequent occurrence, and often yield at once to an enema or purga- tive. The older generation of practitioners had a higher appreciation of the value of keeping the bowels open than we have now, just as they paid more attention to the characters of the pulse and tongue. Habitual constipation may often be remedied by diet with only the occasional employment of drugs, and to arrange this efiectually the physiology of the colon must be principally considered, the factors of most importance being habit, moisture and bulk of residual matter, and the due activity of the muscles and glands concerned. The evidence of rhythm in the bodily economy is so obvious that it is hardly necessary to refer to it. The disposition to sleep, to wake, and to take food recurs in most individuals with the regularity of the clock, and this periodicity is marked in disease, by the recurrence of paroxysms such as those of ague, asthma, neuralgia, exacerbations of fever, and many neurotic seizures at one particular hour. A similar cycle is observable in the majority of healthy people in connection with the 28 Influence of Habit bowels, and should be imitated by those who aspire to a similar satisfactory condition. There is in addition a re- markable sympathy between the stomach and the colon, shown in many ways, but particularly in the tendency of the ingestion of food to excite activity in the lower bowel. In some diseases and nervous conditions, as well as under the influence of strychnine, this is so irresistible that every meal is interrupted by the necessity for going to stool. It is probably owing to this as well as convenience that the usual time allotted to this necessary function is shortly after breakfast, and such a salutary habit should be seriously insisted on as a primary feature in correcting constipation. In many cases it will be found that a departure from this for one reason or another has marked the commencement of the complaint. As has been already mentioned, the habit of drinking an insufficient quantity of fluid has a tendency to induce constipation by rendering the excreta too dry and hard, as in the condition of fever. Perhaps the facilities of modern life have diminished the necessity for physical exertion, so that those who are exempt from labour and not addicted to athletics have not much real inducement to thirst ; but in addition to this, the inconvenience of normal activity of the skin and kidneys in the course of prolonged amusements, social functions, and journeyings sometimes prompts women more especially to limit the quantity of fluid taken. This is an unwholesome practice, which, in addition to the result here indicated, leads to too great a concentration of the natural fluids of the body, and may scarcely aUow some of the less soluble salts to remain in solution. The amount of fluid dafly required by the body is two pints or more. The kidneys should remove forty ounces and the lungs account for about the same quantity in aqueous vapour, though this may be supplied by the food, which may be considered to consist of 50 Adjuvants 29 per cent, water. There still remain losses to be accounted for by the skin and bowels, so that an allowance of two pints of fluid a day is really a very small one, and yet many people, especially women, do not take the equivalent of five tumblerfuls in the twenty-four hours, -which constitutes this amount. The dejecta consist of the undigested and indiges- tible portions of the food taken and the residues of the digestive secretions, with more or less poisonous matter returned from the liver in the bile, and the various micro-organisms which flourish in the intes- tinal tract. Their bulk necessarily varies with the quantity and degree of solubility of the food. Though absolute abstention does not completely abolish them, as may be seen in starvation and in newly born infants, yet it has an important influence on the frequency and ease with which the rectum empties itself. The addition of such indigestible matter as the seeds and skins of fruits, some of the husk of wheat, as in brown or wholemeal bread, and the cellulose structure of vegetables, with whatever else that is unirritating and sufficiently comminuted to readily pass the pylorus, must be regarded as wholesome in assisting the regular action of the bowels. The effect of subsisting entirely on elaborately selected and prepared food, including fine white bread, from which these coarser elements are ex- cluded, is entirely the opposite. The influence of muscular and glandular activity in assisting the action of the bowels is best fllustrated by the common experience of the effects of sedentary habits, of the exclusion of bile from the intestine in obstructive jaundice, and the indirect effect of extremes of heat and cold, in inducing constipation. From these observations it will be understood that the natural remedy for constipation consists in affording regular opportunity for the bowels to act and so 30 Remedies cultivating the habit ; taking sufficient fluid to satisfy all the needs of the body without carrying the desiccation of the bowel contents too far (a glass of water night and morning being a useful addition to the usual daily con- sumption), taking a due proportion of indigestible matter in a divided form, such as is contained in brown bread, marmalade, oatmeal, and fresh or dried fruits, with such ordinary laxatives as syrup, honey, preserves, and salad oil. The question of exercise must be suited to the age and circumstances of the individual, but is most effective when taken before breakfast, if only as gymnastic move- ments which include the abdominal muscles. It may be considered that no exercise is worthy the name which does not quicken the pulse and respiration and so far in- crease the development of heat as to moisten the skin. Where these measures prove insufficient recourse must be had to drugs, not more than two days being allowed to pass without an action. The mildest laxa- tives that are efficient should be adopted, as the more powerful the drug the greater the reaction, and constipa- tion is relieved not cured by purgatives. The confections of sulphur or senna, manna, castor oil in doses of a drachm or two well shaken with milk, or sulphate of magnesium or sodium in drachm doses with half a pint of water should be taken in the early morning, and are mild enough to be given to children. Calomel as lozenges containing one-eighth or one-tenth of a grain, Colalin in half -grain tablets, or small doses of Cascara may be taken three times a day. A useful pill is that recommended by the late Sir Andrew Clark containing a quarter of a grain each of calomel, euonymin, iridin, and podophyllin, which should be taken at night ; the latter drug is sometimes effective alone, one grain being dissolved in an ounce of glycerine and teaspoonful doses taken at intervals of four hours. These may be regarded as adjuvants to the regime Cracked Lip 31 already recommended, but where accumulation has al- ready taken place the bowel must be cleared by means of enemata either of soap and water alone, or if induration has already taken place, this should be preceded by a drachm or two of glycerine or five ounces of olive oil. A sufficient dose of castor oil should also be given to complete evacuation of the higher reaches of the intestine. In spite of the most active purgation hard scybala con- verted almost to the consistence of stones by phosphate of lime may remain in the pouches of the colon, easily palpable through the abdominal wall and merely tun- nelled or grooved by the passage of more fluid matter. These can scarcely be removed except by croton oil, not given in such drastic doses as one minim, but in one-sixth or one-third of a grain repeated three times a day, either in a pill containing some carminative or with half an ounce of castor oil flavoured with pepper- mint or menthol. Croton oil is not an agreeable remedy for the patient and requires great care in its administration by the practitioner, but there appears to be no other drug which excites sufficient secretion and peristalsis to dislodge these concretions, which seem almost embedded in the mucous membrane. All the more care is needed since they chiefly occur in elderly and feeble individuals. If there is any doubt as to their presence either before or after attempts at treatment, it can easily be dispelled by an X-ray skiagram. Craeked Lip, — It is well known that eczema is specially prone to occur at the junction of mucous membrane and skin, and this petty lesion is a case in point. Either upper or lower lip may be affected, usually in the middle line, the next point of election being the corner of the mouth. Owing to the mobility of the part and its peculiar sensitiveness, even a trifling fissure constantly asserts itself, is slow to heal, bleeds readily, and proves a great source of discomfort. It occurs 32 Local Measures mostly in spring and autumn and in association with catarrh or disturbance of digestive function. Once developed, it may persist or recur for several days, but does not penetrate below the surface of the cutis and is very rarely multiple. The best local application, more effective at night, is an ointment composed of fifteen grains of lead acetate to an ounce of white vaseline or lard. But lotions such as Hebra's — ^. Carbolic Acid . . . , .39 Glycerine gj Ether gj Spir. Vin. Eect g vj or a simple solution of 2-10 grains of Silver Nitrate in Nitrous Ether 5 j, are serviceable and more convenient by day. Intractable fissures may be touched with sulphate of copper or lunar caustic, after moistening the hard edge, at night. A small dose of calomel or blue pill followed by a saline purge is often of service in connection with associated digestive disturbance. A more diffuse dry eczema causing roughening and soreness at the edge of the lip and in patches around the mouth, particularly in children and those with thin clear skin, during the prevalence of dry east wind and cold weather, may be relieved with any simple ointment, but the dilute white precipitate ointment or the glycerine of tannic acid with an equal quantity of eau de Cologne is particularly suitable. Catapphal Herpes. — In the immediate vicinity of the several orifices of the body there not infrequently occurs an outcrop of small vesicles on a reddened base preceded by papules and attended by a sensation of heat and tension. Such outbreaks are usually noticed about the mouth, nostrils, and meatus urinarius, more rarely near the eye, external auditory meatus or anus. The eruption may even attack the mucous membrane in the con- Catarrhal Herpes :i3 junctival sac, buccal cavity, fauces, and urethra or im- mediate neighbourhood. Though it resembles shingles in appearance, it differs in its tendency to recur, affecting the same individual in some cases every few months, and in the absence of neuralgic pain. The onset is often marked by chilliness or actual shivering with slight rise of temperature, and, on the face especially, it is a frequent accompaniment of various specific fevers, particularly coryza, pneumonia, and ague. It sometimes occurs endemically, possibly in connection with defective hygiene, outbreaks being reported from time to time as " herpetic fever." The attack itself is of little importance apart from its symptomatic association, but is productive of some soreness and disfigurement at the time, and sometimes gives rise to anxiety when affecting the genitalia through being mistaken for venereal disease. The treatment consists in protecting the vesicles from the air and drying them by starch and zinc powder : an ointment of zinc oxide or boracic acid being a soothing application if the patient is not going about. When affecting moist surfaces, frequent washing and the separation of contiguous parts with lint soaked in weak boracic acid or lead lotion are more suitable. In the mouth and conjunctiva gargles and collyria can alone be used. On the genitals if superficial suppuration occurs, although this is somewhat exceptional, aristol powder may be employed or lint soaked in a weak solution of peroxide of hydrogen. In regard to recurrence the only preventive measures are daily washing of any part particularly liable to attack, and the special consideration of any diathetic state that predisposes, the most important of which is gout. The arrest of local chronic or recurring discharge in the threa- tened area should not be neglected. Dpy Mouth. — The persistent deficiency of secretion 3 34 Dry Mouth in the mucous membrane of the mouth and of the salivary glands, though consistent with good general health, is productive of serious discomfort, the movements of the tongue and lips being so far interfered with that talking and eating become almost impossible without continually sippiQg fluid. Some half a dozen instances of this distressing affection have been brought to the notice of the profession by Mr. Hutchinson and the late Dr. Hadden, but doubtless many others have existed, and as a temporary condition it is probably more common. It has been regarded as a neurosis of the sympathetic, having in one case at least followed mental shock and been associated with sup- pression of lachrjmaal secretion either on emotional or reflex excitation. Mr. Hutchinson has suggested that it is allied to the physiological state of fear or nervous excitement in which the buccal secretions are commonly suppressed. In the cases described, the lining of the mouth and tongue was much altered, becoming smooth and shining with impairment of taste and diminution of sensibility, the tongue itself becoming fissured, very red, and quite denuded of papillae. As a concomitant of fever, particularly when accom- panied by nervous prostration, desiccation of the mouth is familiar enough, as it is also in severe cases of diabetes, and the same thing is observed in some cases of neurasthenia. So far all the idiopathic cases reported have been in women of from fifty years upwards. Treatment in these has so far been unsatisfactory, the use of glycerine locally and tincture of jaborandi in vf[^ xxx doses three times a day affording only very partial alleviation. In the sympto- matic cases benefit has resulted from the administration of lemon juice, dilute phosphoric acid, pyrethrum and pilocarpine, the latter in the form of tablets (gr. 1/10). Uleep of the Tong-ue and Mouth.— The Ulcers of Mouth 35 irritable ulcer at the side of the tongue commonly situated about the middle, and rather towards the upper than the lower surface, is practically always due to contact with a projecting point, such as a collection of tartar or a broken tooth. Swelling of the tongue is an important factor in the trouble. Variations in the bulk of the organ are very wide, as may be seen in comparing the thin dry tongue of fever or of irritant dyspepsia with the pale swollen teeth-indented tongue of atonic dyspepsia. The pro- jection from the tooth may indeed be persistent, perhaps a natural cusp, and yet ulcer and soreness occur in the same spot only at intervals, generally opposite a bicuspid. This results from the enlargement of the tongue often in association with atonic dyspepsia, causing it to bulge against the teeth, the indentations being obvious along its edges. For some time, though soreness is felt, no definite lesion can be seen, then there appears some redness and irregularity of surface, and finally a shallow soft ulcer, the trouble in one phase or another lasting days or even weeks, sometimes with remissions or recurrences. Treatment consists in removing any sharp projection from the tooth, and in reducing the bulk of the tongue, which can be best accomplished by purgatives and a mixture of mineral acid and strychnine. Some relief may be afforded in the meantime by the use of lozenges of cocaine, borax, and chlorate of potash, and healing may be hastened by applying sulphate of copper in crystal to the surface, or by ordering the patient to frequently paint the surface of the sore with a solution of chromic acid (gr. X to water 5 ])• This treatment is only applicable to the soft, super- ficial, and transient abrasions. An ulcer with definite edge or indurated base may be tuberculous, syphilitic, or cancerous, and requires very serious consideration. Dyspeptic ulcers occur in the front of the mouth either towards the tip of the tongue or on the adjacent 36 Oral Antisepsis mucous membrane beneath it or inside the under-lip. One or more points may be affected, each ulcer appearing as a buff more or less circular or oval patch surrounded by a narrow red margin. The ulcers are painful, smarting especially when food is taken, and commonly last several days. They are usually associated with gastric disturb- ance, either catarrh or dyspepsia, and require both local and general treatment. After drying the surface, lunar caustic may be lightly applied or the crystal of copper sulphate held in contact for a minute, till the buff surface is destroyed and sufficient reaction excited to encourage healing. The ulcers often commence in small cystlike developments of the mucous glands, and are commonly associated with an acid reaction of the secretions of the mouth, so that an alkaline mouth wash or antacid tooth powder is beneficial. A very useful mouth wash in ulcerative or septic conditions of the mouth is composed as follows : Thymol . . . . gr.j Acid. Benzoic . , • gr.j 01. Gaultherii. . . . . mj Eucalyptol . , . mi 01. Menth. Pip. . . . ml Spir. Vin. Eect, . . . 3j Acid. Boric. . . , gr. XXV Glycerin! , , . . . . 3J Tr. Cocci . m XX Aq. dest. . ad 0. j A preparation similar to Odol is produced by dissolving Salol 2-5, Saccharin -004, Peppermint Oil -5 in Alcohol 80 per cent. 97, and adding Clove and Caraway Oils. The general treatment should consist of mineral acid and some vegetable bitter with a laxative. A compound rhubarb pill taken for two or three days before the evening meal is effectual, and small doses of strychnine with nitrohydrochloric acid and sulphate of soda or magnesia answer very well. Pyorrhoea Alveolaris 37 When the mouth affection is very diffuse, as in ulcera- tive stomatitis, aphthous stomatitis and gingivitis, local measures should be restricted to the use of the mouth wash or glycerine of borax at frequent intervals, the caustic being omitted. Sometimes after taking strong cheese and other irritating condiments, there develops a follicular inflam- mation over the hard palate for an inch or so behind the incisor teeth persisting for several days, but which is speedily relieved by the mouth wash above mentioned. As a preventive measure, now that oral sepsis is re- cognised as the source of both local and general disease, the employment at least once a day of an antiseptic mouth wash containing permanganate of potash or dilute formalin, such as the preparation known as " For- molyptol," is to be strongly recommended, as a preserva- tive both of the teeth and the health, and as a preventive of many minor disorders of the mouth and throat. Rig-g-s's OP Fauehapd's Disease (Pyopphcea Alveolapis). — Though anything but a recent discovery in medicine, modern conservative dentistry and the recog- nition of oral sepsis as a fertile source of chronic disturb- ance of health have led to a wide expansion of interest in this complaint. As it is, moreover, a very common one, insidious in onset and not invariably painfully assertive, it is either overlooked by patients or not thought worthy of mention to the medical attendant, though it may be the underlying source of more definitely recognised dis- orders. The etiology of the complaint is not absolutely clear : rheumatism has been suggested, and in this country at least, few can claim to have been wholly free from any taint of that widespread affection. Inefficient brushing of the teeth allowing formation of tartar between them and the gums, and the known profusion of micro-organisms existing in the mouth, offer more reasonable explana- tions. Once established in such inaccessible fissures, the 38 Pyorrhoea Alveolaris cocci are free to develop and extend unchecked, and to run the gauntlet of the digestive tract : perhaps sometimes in disordered states of the secretions escaping destruc- tion and obtaining a lodgment elsewhere, as in the stomach or appendix vermiformis. Locally, various septic and suppurative lesions of the buccal mucous membrane, teeth, and tonsils, recurring at intervals, are traceable to the affection. Souwers in TTie New York and Philadelphia Medical Journal for July 30, 1904, writes : " Recurring tenderness of the teeth, making mastication uncomfortable, accom- panied by some soreness of the gums, is frequently re- ferred to the catching of slight colds, or to the stomach being out of order. The first reason for taking advice is often that the individual has noticed the receding of the gums from certain teeth, or that the use of the tooth- brush, or even slight pressure by the fingers, occasions bleeding. The occurrence of pain, resembling in character that experienced when exposed dental nerves are sub- jected to varying temperatures on taking food or drink, but situated at the lateral surfaces of the teeth, will forcibly notify the sufferer that action of some kind is essential. Even sudden changes in atmospheric temperature, as in going from a warm room into a cold entry, the mouth being open, will start an attack of aching. In other cases there is a sensation of burning and stinging situated along the gingival border in the upper jaw, the feeling being par- ticularly marked in the rugse behind the incisors. On examination the mucous membrane is found red, shining, swollen, and appears to hang in folds ; and to the patient, when impact is made by the tongue, this suggests that pus or fiuid of some kind must be present. When touched by the finger, the feeling of a sodden tissue is given. Slight pressure over the diseased area, when the trouble has progressed sufficiently, will elicit a slight purulent discharge in even very mild cases. In those mouths in Treatment 39 which the morbid condition has been long continued, there will be found, between the gums and teeth, varying quantities of tartar, which, by constant accretions, act as a wedge that slowly but surely causes a recession of the gum, the ultimate result being the loosening and dropping out of the teeth. Even in mild recent attacks, where prompt treatment has caused a halt of the invader, examination of the tooth fangs, by means of a small scaler introduced between the neck of the tooth and the gum, will generally reveal commencing deposits, the presence of which is resented by the gum, as shown by its tenderness, sponginess, and bulging between the teeth, its tendency to ooze blood, and the constantly recurring gumboils which make life a burden to the sufferer." The prognosis was at one time regarded as extremely unfavourable, but under decided, persistent, and patient treatment a cure may be effected, though relapse will follow neglect, or the too early cessation of treatment. The treatment consists first in remedying any systemic diathesis, such as gout or rheumatism, and the removal of such contaminating influence as may be exercised by painting and metal-working. Locally, the gums, adjacent rugae on the palatal surface, and both sides of the teeth must be thoroughly cleaned with hydrogen peroxide, taking care to reach the recesses in the mucous membrane behind the last molar teeth, as it is here the disease lurks when all other parts have apparently returned to a normal condition. The pus having been thoroughly removed even from the fissures between the teeth and gums by this agent, the mouth must be well rinsed out with water. Then, on a morsel of absorbent wool, aromatic sulphuric acid, either pure or diluted with once or twice its bulk of water, according to the severity of the mischief, is applied, care being taken that all recesses, corners, and fistulous passages are searched and that the acid is applied betwoei) 40 Treatment the gums and the necks of the teeth, avoiding as far as possible touching the crowns. The pledget of wool need not be dripping with acid and may be hardly more than thoroughly damp. Fine-pointed forceps must be used, as the application should be effectually inserted between the gum and the teeth, and in the narrow spaces between adjacent teeth. For reaching into a sinus too small to admit the pledget of wool, applicators made of paper or Wood's cotton may be used. Following the acid, a mixture of equal parts of sodium carbonate and borax must be freely applied, being well rubbed in either with a piece of absorbent cotton-wool or with the finger, taking care that it is packed firmly into the dental interspaces, so as to completely neutralise the acid. The mouth is again cleansed by water ; then sulphate of quinine is dusted along the seat of disease and hghtly packed between the teeth ; dipping dry absorbent cotton in the quinine and lightly, but firmly, dabbing this on the diseased parts is the simplest method. One course of treatment of the character described will often suffice, but the progress of the case will indicate if repetition is needed, and if the strength of the acid should be modified. The quinine should be used daily till the gums become and remain normal. As an aid in the relief of the gum congestion, a solution of adrenalin (1-1000) is effective, particularly in the declining stage of the inflammation. The patient should be directed to use a mouth wash two or three times daily of some cleansing antiseptic prepara- tion. In addition, he should at bedtime rinse the mouth with magnesia cream or a solution of magnesia, leaving it adhering to the buccal surface, this being the best preventive of tartar. Many dentists prefer powdered sulphate of copper to the aromatic sulphuric acid, and substitute a saturated solution of tannin in Eau de Cologne for the quinine. Toothache 4^ Teeth which are hopelessly loosened should be removed, this being the readiest means of curing the pyorrhoea. Where the teeth are sensitive on their lateral aspects to changes in temperature, protection may be afforded by drying the surface and applying a paste made of zinc oxide moistened with a few drops of phosphoric acid, or by gently swabbing the exposed roots of the teeth every evening with alcohol. Toothaehe (Odontalg'ia). — The relief of pain is essentially the province of medicine, and though few- medical men extend their practice into the realms of dentistry, there are occasions, when they are called upon in emergencies, where a little knowledge and resource may save a great deal of suffering, and only such occasions and measures will be adverted to here. What is com- monly termed " toothache " may be either odontalgia, in which pain is complained of in a tooth, either from local disease or from distal nerve disturbance, or else neuralgia of the trigeminal, which in many cases, though imperfectly localised, depends on dental trouble. Sometimes exposure of the neck or fang of a tooth from retraction of the gum, when associated with an acid reaction of the mouth secretions, gives rise to pain. Under similar circumstances a carious tooth of old standing may cause suffering. It is useful, therefore, to remember that merely rinsing the mouth with a little warm water and soda or sal volatile will in such instances give relief. The main causes of pain, however, of a more severe type are inflammation of the pulp or periosteum, the one involving caries, and the other redness and swelling of the gum, in either case tenderness on pressure being a prominent symptom. In rarer instances the pain is as- sociated with retrogressive changes in the pulp or nerve of an apparently sound tooth or one that has been filled. Acute inflammation of the pulp involves pain of § 42 Treatment sharp, shooting character, throbbing with the pulsation of the Tcssels, increased in the horizontal position and therefore worse at night, and by changes of temperature. Locally, cold reheves and heat intensifies the pain. There is practically always a cavity in the tooth, and contact with the interior excites acute suffering, as the pulp Is commonly exposed. Temporary relief may be secured by appljdng a particle of cotton-wool steeped in one of the essential oils such as that of cloves, cinnamon, or peppermint, or in pure carbohc acid, and covering with another pellet dipped in gum mastich or sandrac moistened with chloro- form. A favourite remedy in Italy, under the name of Odontodol, is composed of Cocaine Hydrochlorate, gr. xvj, dilute Hydrocyanic Acid -n^xv], Tincture of Arnica 5 ij, and Liquor Ammonia Acetatis to the ounce. Tension in the pulp cavity from a putrescent pulp, usually in a tooth which has been stopped, requires relief by opening the chamber. Periosteal pain — that preceding an alveolar or root abscess — is more constant and gnawing in character. Tenderness is elicited by pressure on either the gum or the tooth, and though biting on it at first gives a sense of satisfaction, this becomes unbearable as the inflamma- tion progresses. Later there is swelling of the face and the pain is mitigated. Appropriate remedies are first a purgative such as a drachm of sulphate of magnesia every four hours for three doses, or a colocynth and calomel pill at night, with local removal of blood by scarification or a leech, and then the painting of the dried gum with a mixture of equal parts of liniment of iodine, tincture of aconite, and chloroform. Maturation of the abscess may be hastened and some rehef afforded by the application of hot fig or raisin poultices or wool steeped in hot water in the sulcus between the gum and the cheek, but poultices over the Fissure of Anus 43 exterior of the face are to be sedulously avoided, as they encourage the bursting of the abscess through the skin, leaving a permanent and unsightly scar. When pain has existed for some hours and the forma- tion of pus is already probable, its escape may be aided and relief afforded by carrying a double thread steeped in carbolic acid deeply between the tooth and edge of the gum by means of a needle with the eye broken so as to leave only a notch sufficient to hold the thread in posi- tion during its insertion, the thread thus acting as a drain. Fissure of Anus. — It is certainly remarkable that whereas slight wounds of mucous membrane in the mouth, stomach, and rectum usually heal with great rapidity, spontaneous lesions of those parts such as small ulcers are extremely persistent, and can often be remedied only by great care and patience. Fissure of the anus is an example of a peculiarly small and apparently unimportant lesion producing great suffering, and which exhibits no disposition to heal of its own accord. The symptoms are very characteristic, but are commonly erroneously referred by the patient to piles. Slight moisture at the anus and itching may be the only thing noticed till the bowels act, when there occurs severe rending pain which may inhibit the contrac- tion of the bowel, induce spasm of the external sphincter, and persist for some hours. These attacks of pain return with increasing severity with each attempt at defsecation, causing the utmost misery and dread. If the patient is taken at her word, an examination, which causes a similar attack of pain, reveals nothing in the nature of piles. Only a very careful scrutiny in a good light wiU enable the observer to appreciate the small crack or ulcer partly within and partly without the anus, and usually at the posterior aspect. It may be concealed by a fold of skin, but is commonly indicated by a small vascular projection in close proximity. The ulcer ig 44 Haemorrhoids quite shallow, the base occupied by a whitish granular slough, and it may not exceed an eighth of an inch in length. Early mild cases are readily cured by the application of nitrate of silver or even sulphate of copper in the solid form : a single application may suffice, but the healing may be further encouraged, if it flags, by applying a solution of the same agents (one grain to the ounce of water) two or three times a day. Should the ulcer have attained greater dimensions and not respond to this treatment, it must be completely exposed, and the base divided by drawing the point of a small knife across it from edge to edge, and the " sentinel pile " if present snipped off. It is as well to endeavour to heal the ulcer in the interval between the action of the bowels, which may be extended by a mild opiate, evacuation being subse- quently encouraged by a laxative. H-asmopphoids in their persistent and aggravated form constitute a definite surgical complaint, and are only to be cured by operation, but occasional engorgement or even inflammation of the hsemorrhoidal veins and con- tiguous tissues about the anus, either just within or without the sphincter, is so common a malady that few escape it, and many people suffer from transitory attacks at repeated intervals till they ultimately require the services of the surgeon, especially if treatment is neglected in the early stage. Usually after a period of constipation, and particularly if this has been overcome by strong purgatives, the development of piles is marked by aching pain in the coccygeal region, increased by def sscation, which is diffi- cult and painful, and attended by protrusion of the distended mucous membrane conveying a sense of obstruction. Inflammation and thrombosis of the dis- tended veins usually ensue, indicated by a burning sensation and often acute tenderness. There may be Enteroptosis 45 irritation and muco-purulent discharge and occasionally slight hsemorrhage which affords some relief. Examina- tion with the finger detects smooth, firm projections at the margin of the anus, which are tender, rendered more prominent by straining, and when seen appear as deep crimson distension of the anal folds or of the mucous membrane above. The aching generally radiates over the perinseum and often extends down the thighs, but is usually relieved by putting the legs up or stUl more by lying down. Treatment consists in applying astringents and anaesthetics locally while relieving the portal circulation and softening the faeces by mild laxatives. A single thrombosed and inflamed pile may be immediately cured by incising the swelling and turning out the clot under a local anaesthetic. The best local astringent is adrenahn ; a preparation of the gland extract made up with lanoline under the name of "renaglandin " is a popular and effective preparation, and may be combined with a small quantity of menthol, cocaine, or eucaine. Supposi- tories of hammamelin, of lead and opium, and galls and opium, may also be used, but should be warmed before insertion, to soften them. Glycerine suppositories are also useful, especially when it is desired to obtain a speedy action of the bowels. The laxatives in most general use are the confections of senna, sulphur, or pepper, taken at night. Ichthyol in pills of three grains three times a day has been recommended, but any of the milder purgatives, except those containing aloes, suffice. Enteroptosis. — Laxity of attachment of the several abdominal organs may occur individually or collectively, the latter condition, associated with flaccidity of the parietes, having been considered exhaustively by Glenard in recent years. The displacement and mobility of the kidney, especially on the right side, have been attributed to tight lacing in women, and the same cause may account for 4^ Enteroptosis other displacements, but the general condition of abdomi' nal laxity, sometimes called Glenard's disease, appears to result in all cases from loss of bulk. It is not uncommon after childbirth, and accompanies rapid wasting from any cause, but especially that which is associated with neurosis or neurasthenia. The patients are women approaching middle age, and they complain chiefly of disability in getting about, fatigue and dragging pains at the waist and loins, and exhibit a tendency to stoop forward in walking or standing. On examining the abdomen, which is lax and thin, the muscles appear unusually flaccid, and in well-marked cases the various organs can be grasped through the loose parietes and moved freely in any direction. It is, of course, out of the question to think of surgical interference in such a widespread condition, and an attempt must be made to restore the natural tone and fat. The Weir Mitchell system com- bined with massage and electrical stimulation will effect this, but many patients recover if supported and enabled to get about. Two pieces of five-pound sheet lead are cut out to fit accurately the front and sides of the abdomen, leaving a gap of two inches in the middle line and half an inch along the bony margin of the thorax and pelvis. These are sewn into brown hoUand covers having a free edge haK an inch wide, by which they may be pinned or sewn inside the corsets. These should be long enough to cover the lead plates, which have to be carefully adjusted and temporarily attached to them by pins while the patient is in the horizontal position. The corsets can then be fastened, the lead plates becoming moulded to the front and sides of the abdomen affording firm and elastic support to the viscera through the medium of the gas-containing intestines. When found to be rightly adjusted, the plates can be stitched to the corsets and put on with theva every day before rising, so as to retain the organs in their proper position. As they Mechanical Support 47 become moulded to the body they are quite comfortable, and their weight does not exceed two or three pounds. After a time they crack with wear, especially on stooping, but if the original pattern is taken in paper and retained they can easily be replaced, being slipped into the old cases. This plan enables the patient to go about in comparative comfort, but should be persisted in for three months while efforts are made to restore the general tone and nutrition, and when these succeed the plates may be dispensed with. A very simple means of applying massage to the abdomen is by rolling a moderately heavy ball over the surface in a circular manner, from right to left across the epigastrium, downwards in the left flank, from left to right across the hypogastrium and upwards in the right flank ; following the course of the colon. This has proved effective in relieving habitual constipation, and in reducing the size of the abdomen by bracing the muscles. The ball should be covered with soft leather, have a diameter of four or five inches, and weigh about six pounds. The most suitable time for employing it is just before getting up in the morning — for about five minutes. Discomfort arising from delayed gastric digestion with atony — a very common condition — may be imme- diately relieved by exciting peristalsis. The patient should lie on the right side and rhythmically stroke the skin directly below the ribs in the left flank at intervals of fifteen seconds. This excites peristaltic contraction in the stomach and the contents can be heard gurgling through the pylorus, the organ being com- pletely emptied in ten to fifteen minutes. CHAPTER II DISEASES OF THE SKIN On account of its extreme sensibility and the disfiguring effect of anything disturbing its surface, but few affec- tions of the skin can be lightly regarded. Affording, as it does, such a ready field for observation and treatment, the subject has been already so minutely dealt with by specialists that practically nothing con- cerning it is omitted from modern medical literature. There are, however, a few familiar ailments which on that very account are rarely brought seriously under the notice of the profession, but which are preventable or remediable, and at the same time sufficiently annoying to be worth considering. Owing to variations in the blood supply and func- tional activity of the skin, with changes of temperature, disturbances of the surface are more prone to occur with the onset of hot or cold weather, so that the spring and autumn are specially productive of them, and from time to time exposure to unaccustomed influences leads to painful reaction. Were it more generally understood how many disorders of the skin are dependent on constipation and deranged digestion on the one hand, and insufficient or impeded cutaneous excretion on the other, both often due to physical inactivity, many of the minor skin troubles would be avoided. The alternation of full functional activity with Baldness 49 physiological rest constitutes the best means of keeping every organ, and the system generally, in good working order, and of maintaining physical health ; and, in the case of the skin, an occasional Turkish bath when per- spiration is not excited by ordinary means, in addition to daily bathing and friction, is very beneficial. General eruptions dependent on constitutional disease or internal derangements will not be touched on here, nor will any allusion be made to the well-known parasites, only such common reactions to external influences as are of familiar occurrence being within the range of this chapter. Baldness. — Falling of the hair — defluvium capillitii —in a slight degree is a normal and continuous process consequent on the natural termination of the life of individual hairs, which then become detached from their follicles and are presently succeeded by new ones. This loss is accentuated at certain times of the year, notably in the spring and autumn, and occurs also in an exaggerated degree at irregular intervals as determined by temporary impairment of health and vigour, such as the catamenial periods in women and in either sex as a concomitant of indigestion, ansemia, acute fevers, and, indeed, any illness which reduces the quality of the blood and force of the circulation or impairs the vigour of the nervous system. The persistence of loss of hair with defective renewal, however, in comparatively young men, sufficient to produce visible baldness, is a matter beyond this natural process, calling for explanation and, if possible, remedy. Actual data are scarcely obtainable, but that there has been of late years a great increase in the number of men, more or less bald, between the ages of twenty-five and fifty-five is a very general and deep-rooted impression. This is especially the case in cities, suggesting the idea that it may be due to the wearing of hard hats, 4 so Effect of Hard Hats prescribed rather for the purpose of ceremony than for service or comfort. It is certainly remarkable that women 7inder similar conditions of life do not so suffer, and that baldness is practically unknown among the young and middle-aged of native races who wear no such headgear, and is very much less common among country- men and sailors. An obvious anatomical explanation is offered in the compression of the nutrient arteries of the scalp between the skull and the rim of the hat, which may not only limit the circulation in the wearing, but may produce such thickening and compression of the arterial walls as may render diminution of their calibre permanent, the effect being the more marked owing to the vertex being the highest point in the circulation, and the vessels terminal. Not only does baldness specially affect those who habitually wear hard hats, but it specially affects that part of the head included in their grip, leaving a healthy fringe of hair below and in no way extending to any part of the face. It may be observed, too, that those with broad or round heads are more frequently affected than those whose heads are narrow or long, presumably be- cause the temporal artery in the latter is less exposed to pressure. This limitation of the loss of hair to the part included in the hat appears quite irreconcilable with the idea of independent disease of the scalp and hair follicles, which would never stop short at such an artificial barrier any more than it would refuse to extend to the face. And it would appear much more probable that the associated phenomena described in this con- nection, such as scurf, thinning of the scalp, and diminish- ing thickness and length of hair, are all due to local anaemia from compression of the vessels, and that the conditions of anaemia, debility, and disordered digestion, when present; are merely the associated effects of town life. Changes in Scalp and Hair 51 The variations in the occurrence, degree, and dis- tribution of baldness are sufficiently accounted for by differences in the course and distribution of the blood- vessels supplying the scalp, and in the shape of the head. The practical solution, according to this view, is to discard hard hats, as some have already done ; or at least so to arrange them that no pressure is exerted on the main arteries passing upwards in front of and behind the ears at the sides of the head ; or, better still, to wear a full- sized hat supported on the head by a leather lining shaped as a skull cap, as was done with helmets in the middle ages. By such means baldness may be prevented or may be arrested when commencing, but it is very doubtful if it can be cured when once completely established. This is doubtless true of premature baldness which often affects men in robust health, and cannot reasonably be attributed to any constitutional taint or even partial failure of health. The local changes in the scalp and hair have been well described by Hebra. The first period is that of seborrhoea, in which the vertex is covered with an im- mense quantity of thin white asbestos-like scales, con- tinually being desquamated and renewed, covering the hair with a fine branlike dust, while the moister part clings to the scalp, and, if neglected, accumulates, and from admixture with dust, forms a yellow or grey crust. Potash or soda soap will remove this, disclosing the sound skin white or reddened. Yolk of egg is an efficient and more soothing application, but whatever the treatment the exudation is renewed in a few hours and persists for months or years. It is sometimes accompanied by slight itching. The condition is sometimes associated with anaemia and evidence of feeble circulation such as cold extremities, with chilblains, congested nose, moist palms and soles, 52 Seborrhoea imperfect digestion, and in women scanty, painful, or too abundant menstruation or other uterine disorders. Seborrhoea commonly begins between the ages of twenty and thirty and persists till after forty. The disorder is very common, and those affected do not usually apply to the physician in this stage, but when the inevitable falling of the hair and baldness supervene in two to six years, their concern is aroused, often too late for remedies to be effective. The frontal region and vertex are first affected, giving rise to two bald patches which may become confluent later. Sometimes the anterior border of hair disappears, so that the patient is bald to the occiput (ophiasis). The scalp, thus denuded, appears white, smooth, and shiny. It is tightly stretched over the skull, thin, and can only be pinched up with difficulty. At first numerous fine short slightly pigmented hairs appear, and this is an indication that recovery under suitable treatment may be hoped for ; later, when these have vanished, nothing can be expected of remedies. The duration of life of any individual hair varies according to its position and with the age and state of health of the person. After persisting for months or years, it normally falls out and is replaced by a fresh one from the same or a neighbouring papilla. The thicker the individual hair the longer it remains attached to its papilla and the greater length it attains. As the physiological term of life shortens, so the length and thickness likewise diminish. There is also an interval between the shedding of a hair and the appearance of its successor amounting to some weeks. When the nutrition of the hair is failing, at first few, then many^ hairs suffer diminution in length and thickness and in their term of life. Seborrhoea causes a disturbance in the reproduction of the hair : it represents a too a'mindant production of cells by the sebaceous glands, associated Treatment 53 with chemical change in the direction of fatty impregna- tion. The cells of the outer root-sheath corresponding with the rete mucosum are continued without inter- ruption into the sebaceous glands, and the same change which occurs in them extends presently to the root- sheath of the hair. In consequence of such an alteration in nutrition and the mechanical separation of its elements, the hair must necessarily be shed. If this numerical hyperplasia of the cells of the root-sheath diminishes, the cells become more stable and a new hair may be formed. They may either then nourish a new hair formed from the old papilla, or they may themselves undergo trans- formation in their central portion into a hair. This return to a regular production of hair actually occurs in very advanced stages of alopecia furfuracea ; but after seborrhcea has persisted for six to ten years or more while the production of new hairs has been in abeyance, a return to the normal condition is not at all probable, and at length is no longer possible, the papilla and vessels having become so changed (atrophied) that they are no longer capable of producing new cells for the formation of a fresh hair bulb. Baldness is then per- manent. Loss of hair occurring in the course of acute or chronio illness may be due either to simple trophoneurosis, or to seborrhcea then commencing and continuing after health has been restored, as an independent affection. Treatment. — The first step in the application of remedies is the removal of the sebaceous crust from the scalp. The accumulation of scales must be softened by carefully rubbing oHve oil or paraffin into the skin of the head and leaving this aU night, protected by a cap. After twelve to twenty-four hours the head is well washed with soap, the most satisfactory preparation being the Spiritus Saponatus Kalinus, prepared by digesting soft 54 Treatment soap in half its bulk of rectified spirit, filtering, and scenting with spirits of lavender. The scalp is washed with a sufficient quantity of the solution, the addition of a little warm water from time to time effecting a lather which is subsequently thoroughly riased away with cold or lukewarm water. Anointing with oil is only necessary for the first few days until the sebaceous crust is entirely removed, but the daily washing with soap solution and water should be continued for months, the hair and scalp being allowed to dry and the fat being replenished with some oil or pomade. Later a spirit lotion without soap may be employed. These are the essentials of treatment, but modern pharmacists have usually added to the pomade or spirit lotion employed in the later phases certain drugs having a reputation for promoting the growth of hair, perhaps from some effect in causing irritation and redness of the skin. There is no objection to their use, and the following are some of the formulae advocated: Erasmus Wilson. 01. Amygdalae, § j Liq. Ammonias, § J Eau de Cologne, g j 01. Eosmarini, 3 iij 01. Myristicse, 3iv Tinct. Jaborandi gj Aq. Rosas, ad. § viij Lotions. Hebea. Tinct. Canthar. 3 ss, or Ac. Tannici, gr. xij Sp. Vin. Eectif. gv Sp. Lavandulas, gj Ether. Sulphurat. 3 ij Glycerini, 3 iv 01. Bergamot, v\ x Qnin. HydrocM. gr. xxiv Acid. Tannici, 3 j Alcohol. (60%), g xss Tinct. Cantharid. 3j Glycerini, 3vj Eau de Cologne, 3 iv Vanilin, gr. ss Lign. Santal, gr. iij Pilocarpin Nitrat. gr. iv «Iix. Macerate 4 days and filter. To be well nibbed into the scalp night and morning. Papules 5S Pomades. DUPUTTEEN. Medullas Ossium, g ij Extract. Cinchonse, 3 ij Tinct. Cantharid. 5 j Succi Citri, 3 j Olei Limonis, tii xs Olei Bergamot, ni x Gemmabum Populi. Eesin. Gem. Populi, § j Adip. prjep., 5 vj Aq. Kosas, tn, 160 ; heat together and add 01. Citri, V!\, X 01. Bergamot, tn, x 01. Eosmarin, v\, x Tanno-Quinine. 01. Theobr, § jss Ung. Emollient, 5 ss 01. Amygdalse, § jss Quinin. Sulph. gr. x diss, with acid in Aq. Rosse, § ss Olei Citri, 3 ss 01. Bergamot, ni xx 01. Lavandulas, ni sx Ac. Tannici, gr. xl Tinct. Canthar. 3 j Eau de Cologne, 3 iij These are used to lubricate the scalp after evaporation of the spirit lotions. It may here be repeated that on scientific grounds alopecia furfuracea is curable during the first few years of its existence, if the seborrhcea causing it be removed by persistent and energetic use of the Spiritus Saponatus Kalinus and of the alcohoHc ethereal fluids with the occasional addition of fatty material to the epidermis, whenever it has become too dry. Recovery will be aided by tonics, especially arsenic and iron, with convalescent diet and surroundings, persisted in for six months. This regime may be followed in chlorosis or after fevers and acute diseases, but apart from these the treatment of incipient baldness will probably be limited to local remedies, and it is not always easy to ensure the efficient appHcation of these for a sufficient time. Papules. — The formation of pimples, particularly about the face and neck, is mostly due to inflammation of hair follicles or the associated sebaceous glands. They may be either pale or red, and sometimes present a yellow point from the formation of a minute quantity of pus. Apart from trifling itching they are chiefly objectionable on account of their appearance, and if rubbed may not disappear for days. Should there be a tendency to the formation of sticcessive crops, it is best to treat the patient 56 Stye constitutionally by some laxative such as sulphur lozenges or salts every morning till they subside, or calcium sulphide in pills (gr. 1/4) may be given internally ; otherwise, touch- ing individual pimples, when they first show themselves, with toilet vinegar or colourless solution of iodine will usually abolish them ; even the ordinary tincture may be used at night, as the colour vanishes in a few hours. When a small yellow head has appeared, pressure with a small key will evacuate pus or sebaceous matter and hasten subsidence. Stye (Hopdeolum) occurring on the margin of the eyelid and due to inflammation of the ciliary follicles is of the same nature and runs much the same course as the preceding, but is even more painful and disfiguring and usually leads to considerable swelling and redness of the lid, owing to looseness of the cellular tissue. Some individuals are specially prone to develop styes, which may succeed one another for some weeks on account either of the con- stitutional state of the subject or owing to auto-infection. Lawson recommends painting the lid with collodion or touching the spot with mitigated nitrate of silver in the very early stage, taking special care that none gets into the eye. Where an eyelash can be seen emerging from the inflamed spot, its removal with forceps often expedites recovery, and, as it is generally already loosened, this is not so painful as might be expected. Should the inflammatory process continue in spite of these measures, recourse must be had to hot fomentations or decoction of poppy-heads applied under oil-silk at night, leaving the pus to find an exit for itself. The lids may subse- quently be bathed with a lotion composed as follows : 5^. Sodae Bicarb. . , , , 5 j Boracis 5j Acid. Hydrocyan, dil. . . . fl. 5] Aquae Sambuci , . . , fl. 3 ij Aquam destill. . . . , ad. § viij the Unguent. Hydrarg. Nitratis, in the proportion of Folliculitis 57 one drachm to seven drachms of white vaseline, being painted on the lid at night. The administration of a laxative followed by a tonic mixture of the mineral acids with bark, or quinine and iron, may be required where there is failure of the general health or a succession of styes. Folliculitis of the Buttocks. — Another form of local though more extensive pimple formation, usually occurring in young men, is the outcrop of papules on the buttocks which sometimes accompanies rowing or riding. It is due to pressure and friction, and is mostly developed at the commencement of the exercise, sub- siding of its own accord with rest, though extending if neglected and sometimes leading to very uncomfortable sores if infected. Those with thick and opaque skins are most liable to suffer. The most convenient remedy is a powder composed of equal parts by weight of zinc oxide and starch applied for two or three days while the particular exercise is desisted from ; and a daily rubbing with alcohol in any form such as whisky, eau de Cologne, or even methylated spirit is a good prophy- lactic in the case of those who are prone to this affection. A closely alUed and still more common trouble is the pimple or small boil which is apt to form at the back of the neck from pressure of the collar, and especially its edge. Owing to persistence of the irritation these sometimes assume quite formidable dimensions, and not only suppurate but infect the neighbouring skin, pro- ducing discomfort of indefinite duration. One essential of treatment is the removal of pressure, and if pus has already formed, the evacuation of this by puncture. Subsequent insertion of a little carbolic acid affords the speediest cure. Bearing in mind the liability of local infection, some weak perchloride of mercury or carbolic lotion may be dabbed on the surrounding skin or a small perforated protective plaister, as that of opium, applied 58 Bites and Stings to the spot itself ; but wearing a loose bandage or hand- kerchief round the neck as is commonly done only increases the trouble. As constitutional remedies, ordi- nary pitch or ichthyol in three-grain pUls, thrice daily, have been given with good effect. The Injuries inflicted by Insects are with few and unimportant exceptions due to the inoculation of venom. They may be bites, stings, or penetrations of the proboscis for the purpose of suction. Ants and spiders inflict minute wounds with the mandibles, simultaneously injecting an acrid fluid, irritant to human beings, though lethal to other insects attacked. The bites of spiders, which are rare, and even questioned in temperate climates, like those inflicted by rats, may be aggravated by the intro- duction of matter derived from putrescent food, the wounds inflicted being actually septic. For the most part, saving the accidental introduction of specific diseases such as malaria, yellow fever, plague, sleeping sickness, anthrax, cholera, typhoid fever, leprosy, beri-beri and filaria sanguinis hominis — aU of which have been attributed to insects, and particularly mosquitoes — the insertion of the proboscis in feeding only produces irritation dependent on the instillation of the secretion of the salivary gland, which assists the flow of blood. This is the case with fleas, bugs, most varieties of flies, and has been experimentally proved in the leech. On the other hand, bites and stings inflicted in defence or anger are immediately painful, and may even prove dangerous by reason of the severity or locaUty of the injury or the constitutional state or idiosyncrasy of the patient. Prolonged disturbance may result from the continuous irritation of creatures which bury themselves in the skin, such as the jigger {Pulex penetrans), the itch insect {Sarcoptes scahiei), or the harvest bug {Leptiis autumnalis), Remedies 59 but even the insertion of the proboscis may lead in some skins to the formation of a papule or vesicle which continues to give rise to itching for several days, par- ticularly on washing the skin or changing the clothing. This is evidently due to an irritant fluid, for if the spot be pricked and pressed with a watch-key, a drop of clear fluid exudes and the irritation at once ceases. The irritant associated with the ant {Formica) is the first acid of the Methylene series, and named, after the insect, formic acid. Its peculiar odour is easily identified emanating from an ant's nest which has been disturbed. The same acid has been identified in the hair-glands of the stinging nettle, which produces an identical injury on the skin. The stings of bees and wasps effected by the modified and envenomed ovipositor of the worker or sterile female are commonly held to owe their malig- nancy to the same agent, deposited more freely and deeply in the tissues. Some mitigation of the more superficial stings may be obtained by the application of water or the alkaline juice of any succulent plant to the injured skin, though a solution of soda or ammonia is more effectual, pro- vided there is no delay, for the essential point is to dilute or neutrahse the acid before reaction in the form of swelling and hyperaemia occurs and closes the minute external orifice of the hurt. The deeper injuries of the hymenoptera are popularly treated on the same principle, the blue-bag, soap, or a spht onion being the immediate agents employed : these all contain free alkali, and their homeliness may be excused on account of their generally being ready to hand, but a fairly strong solution of ammonia, potash, or soda is the more appropriate and effectual remedy if apphed at once. In The Medical Record for February 8, 1890, Dr. Ricord of New Jersey reports an instance of the immediate cure of a hornet's sting by the apphcation of a spray of 6o Severe Stings peroxide of hydrogen to the abeady swollen cutis. Though this is an isolated case, it suggests that this powerful agent may prove of service in the local treatment of envenomed wounds of even a more serious nature, and even the weaker solution which is usually in the surgery as ozonic ether may prove of value in deaUng with the stings of bees and wasps. Exceptional instances are recorded from time to time in which vertigo, syncope, and collapse have ensued on such injuries, not necessarily from a multiplicity of punc- tures or even recurring in the same subject on another occasion, the inference being that these symptoms, which occur immediately, are due to the direct instillation of the poison into a vein, the absence of resistance from sohd tissues possibly encouraging a more liberal dose. This view is supported by the slight local reaction in such cases and by the observation of similar effects associated with the hypodermic injection of morphia under like circum- stances. Appropriate treatment in such an event would be general rather than local, consisting of the administra- tion of stimulants, especially ammonia or sal volatile, or even the subcutaneous injection of ether. Pel-haps the most formidable injuries which have been attributed to bees and wasps are those unfortunate instances reported from time to time of these insects being taken into the mouth or actually swallowed either in fruit or some beverage. The swelling resulting from a sting in the tongue or in the neighbourhood of the larynx then causes great distress from a sense of impending suffocation added to the pain and alarm, and unless this can be rapidly relieved by scarification, or the air passage kept open by mechanical means, laryngotomy must be resorted to, as death has actually occurred under such circumstances. Some relief may be obtained by sucking ice or applying adrenalin, but for some hours such cases give rise to great anxiety. Harvesters 6i For the most part the attacks of gnats and midges, and even of mosquitoes, are too general to admit of individual local treatment. Under some circumstances, especially in the tropics, it may be considered worth while to wear a wide veil at the periods, usually after sundown, when they are most prevalent. It is also as well to avoid exposing the ankles even indoors ; thus open slippers should not be worn, better protection being afiEorded by thin moccasins or the old-fashioned buskins into which the trousers may be tucked, the ankles being a favourite point of attack. Even in hot weather in temperate climates such measures are fortunately hardly worth submitting to, but the less aggressive creatures may be warned off by the use of carbolic soap, inunction with the oils of lemon, citronella, or sassafras or thymol in the proportion of ten grains to the ounce of vaseline, or still more conveniently by a concentrated extract of pyrethrum in eau de Cologne. The Harvest Bug", also known as the Mower's Mite {Leptus autumnalis), practically unknown in towns, but only too familiar in certain parts of the country as the immediate cause of insupportable itching, is itself so small as to be almost invisible. Gilbert White, in The Natural History of Selhorne, writes (Letter xxxiv.) : " There is an insect with us, especially on chalky districts, which is very troublesome and teasing all the latter end of the summer, getting into people's skins, especially those of women and children, and raising tumours which itch intolerably. This animal (which we call a harvest bug) is very minute, scarce dis- cernible to the naked eye ; of a bright scarlet colour, and of the genus Acarus. They are to be met with in gardens on kidney beans, or any legumens, but prevail only in the hot months of summer. Warreners, as some have assured me, are much infested by them on chalky downs, where these insects swarm sometimes to so infinite a degree as 62 Effects of Bites to discolour their nets, and to give them a reddish cast, while the men are so bitten as to be thrown into fevers." This larval acarus is J mm. in diameter, globular in shape, having a fused cephalo-thorax divided by a transverse furrow from the abdomen. The legs are long, six- jointed, with two sickle-like claws on the tarsus, and there are no discoverable sexual organs. The colour has been variously described as orange, scarlet, or brick- red, and the creature resembles as nearly as anything a fine grain of cayenne pepper. For its size, it moves rapidly, and usually invades human beings by crawling over the feet, though it may do so by the hands while picking fruit, or gain direct access to the body of any one reclining on the ground. The eggs are laid in June and July, the larvae hatching out in July and August. They abound on dry soil in hot dry weather, and are most often en- countered in stubble fields, on downs, by the roadside, and in gardens, where they are specially plentiful on French beans, hops, and fruit bushes ; though in the districts they favour their distribution is pretty general. In wet seasons and beside rivers they are not met with. Owing to the development of these pests, which varies with the character of the soil and season, occurring about the period of the annual vacation, the irritation set up hj them usually comes as an unpleasant surprise to hoHday-makers, all the more probably since the agent is not seen, and its effects are commonly delayed for some hours after exposure, generally asserting themselves at night, after a day in the country. The ankles and legs are mostly affected, but always the covered parts of the body or limbs, and principally regions subject to pressure, such as the waist, neck, wrists, or knees. This may be a question of moisture, as the axillse are commonly attacked, or it may represent places where the migrations of the acarus are arrested. Scattered spots may occur on any part of the limbs or trunk, but the hands and Prevention and Remedy 63 face escape, affording a contrast to the injuries inflicted by gnats. Having selected its point of attack the acarus burrows into the skin with the aid of sharp mandibles, burying the cephalo-thorax, but not the abdomen. It evidently secretes some irritant substance to encourage exudation, and by suction swells to four or five times its original size, at the same time causing a weal as large as a threepenny -piece which burns and itches intolerably. The torment is unfortunately not limited to the single occasion, but recurs every time the clothes are changed or a bath taken, and interferes with sleep at night for a week or more, evidences remaining perhaps for a month. In children and persons of nervous excitability, especially where the bites are numerous, a sKght degree of fever may be produced, or general urticaria may result. Preventive measures are obviously the most important in connection with this pest. Those who have the pain of its acquaintance are usually content to avoid its haunts during the larval period in the hot weeks of July and August, and at least endeavour to expose themselves as little as possible to their attacks by delegating garden operations to those less susceptible, and by leaving stubble fields, dry downs, and field-paths severely alone in affected districts. Some protection may be secured by smearing the ankles with oil of citronella or sassafras or a solution of thymol in vaseline (10 grains to the ounce) effected with the aid of heat, or pyrethrum in eau de Cologne. A continuous covering of thin close-textured underclothing is also to be recommended. If the skin be stretched tiU the spot becomes pale, a small orange point can usually be discerned where the creature is buried, and if pressure is exerted here by the approximated finger-nails or with a small key, a drop of fluid can be extracted and the subsequent duration of irritation much abbreviated, but this is a tedious and difficult matter when the bites are very numerous, and 64 Caterpillar Rashes the application of sal volatile, vaseline, or carbolised oil must be resorted to. In worse cases naphthol, weak sulphur, or white precipitate ointment should be employed. Plant and Cateppillap Rashes. — Local derma- titis due to penetration of the skin by the hairs of caterpillars and plants is occasionally met with in those coming in contact with them, usually schoolboys or persons occupied in gardening. It is seldom seen in cities, and so rarely comes under the notice of members of the medical pro- fession that many have no experience of the complaint, though it is famihar enough to those immediately con- cerned. The chief characteristic is the limitation of urticarial or erythematous patches to the hand, and sometimes to the neck and face on the same side, or any other part of the body that is within reach of the affected limb, these secondary lesions being self-inflicted. When recently acquired there is much tinghng and irritation, accompanied by some hyperaemia and swelling, with the appearance of erythematous spots and patches or weals. These subside in a few hours, and are followed in two or three days by limited desquamation. Minute vesicles form which dry and separate with a ragged circular edge, sometimes coalescing to form irregular patches. On very superficial observation they might suggest scarlatina in a late stage, but are usually unsymmetrical, and never involve the feet, or indeed any covered portion of the skin. Moreover, the centre of each patch may be seen with a lens to be marked by a fine point representing the irritant. In the case of caterpiQar rash the usually black hairs, though broken off short, are plainly visible ; the colourless hairs or raphides of plants are less obvious. When questioned, however, with such a possibihty in mind, patients may recall having exposed themselves to this source of irrita- tion either consciously in handling hairy caterpillars or particular plants, or unconsciously in a country excursion, Plant Rashes 65 while pushing through bushes or sitting on the ground, where caterpillars or their discarded skins may not have been noticed. It is only the stiff-haired varieties that give rise to this trouble, particularly those known collo- quially as woolly bears and palmer worms ; but there are many varieties, and the numbers vary widely with locality and season, so that at long intervals or in certain places there may be a veritable epidemic, such as occurred in Hyde Park in 1906. The plants which more especially cause these eruptions are none of them wild in this country, but are encountered in the garden or greenhouse, and as their objectionable qualities are not exactly notorious and do not manifest themselves immediately, unconscious victims are met with from time to time. The principal ones are Primula obconica and Primula sinensis. In The Lancet for April 25, 1891, Dr. S. A. L. Swan recorded two cases which came under his care, in which the effects of handling the former resembled acute eczema or erysipelas as regards local appearance, the absence of any general symptoms being a distinguishing feature. The immediate source of the injury has been traced by Dr. Riehl of Vienna to the minute hairs on the leaves and stalks. The cause and effects are similar in both varieties, but Primula sinensis is the less virulent of the two. A condition resembling eczema of the face and hands has been produced in persons handling and cleaning the bulbs of hyacinths, and especially those of Roman hyacinths (var. albulus), the prime agents being the needle-shaped crystals or raphides composed of oxalate of lime measuring o^o to x^ hich in length, which are arranged in close bundles and are easily dispersed by rubbing the dry scales. The corms of the common arum hly are similarly provided, and it is recorded that the laundresses of 5 66 Plant Rashes Funchal, Madeira, once tried to utilise the starch obtain- able from them, but complained of the irritation in the hands produced by it, which, on examination, was found to result from the presence of numerous needle-shaped raphides. Other plants which have in individual instances exhibited irritating qualities are the common feather few, elder leaves, and buttercups. The common nettle is too well known to require mention, except to point out that its stinging property is due to silicious hairs, crushed by firm handling, but which penetrate the skin coming into light contact with them. The irritation is produced by formic acid as in the ant, conveyed through the hair from a gland at the base, and may be mitigated by the immediate application of moisture, or the alkaUne juice of any plant, the dock leaf being a popular favourite. Other species exerting poisonous effects and of colonial origin are Phebalium Argentum, " the Western Australian Blister plant," which blisters the human skin when handled, its acridity being due to an essential oil ; and Dysoxylon Bichii, locally called " mastenea " in the Polynesian islands, the wood, sap, or sawdust of which causes dermatitis of the hands, inflammation of the eyes, and a burning sensation in the throat. Dysoxylon Muelleri, the Red Bean, and Castanosper- mum australe, the Black Bean, woods of New South Wales, are both credited with producing injurious effects in those working them ; the former giving rise to violent catarrh with vomiting and epistaxis, besides dermatitis and the poisoning of wounds inflicted by it. Cassinea aculeata, " Dogwood," and Eucalyptus macu- lata exert a somewhat similar effect on the skin, the so-called Spotted Gum rash being especially prevalent in Mount Douglas, Paterson, N.S.W. Remedies 67 In North America, the Poison Ivy, Rhus radicans (Toxicodendron), Rhus diversiloba or Poison Oak, and the Rhus vernix or Poison Sumach, exert a like influence, due to the presence of a non- volatile oil. An efficient application to the skin so affected is a saturated solution of lead acetate in proof spirit, which combines the advantages of an evaporating lotion and an astringent. It is a peculiarity of many of these poisonous influ- ences that certain individuals appear more predisposed to them than do others, just as does the liability to hay fever and to the development of nettlerash after sea-bathing differ in different people. And, as in these more familiar cases, the persons affected do not become less prone to attacks by repeated exposure and can only escape suffering by avoidance of the noxious agents. Since the introduction of teak, now so much used in this country for ship-building, fireproof floors, and stair- cases, many small inflamed wounds have arisen from punctures and abrasions in those working it, and those engaged in fret-sawing usually suffer from the irritating character of the dust while using that and other varieties of timber, especially rosewood. Sun Eczema. — Erythema solare is due to exposure to the violet and chemical rays of the sun and not merely to heat. In health such exposure in moderation causes bronzing of a reddish brown tint without any separation of the cuticle, and this colouring in the open may be taken as an indication of vigour and a satisfactory condition of the blood, especially as regards haemoglobin, as it is this which protects the tissues and supplies the pigment in a sunburnt skin. The effect, however, is different in those who are anaemic or cachectic, in such as are accustomed to live indoors or in cities, or where parts of the body, usually covered, are exposed. Under these circumstances, par- 68 Sun Eczema ticularly in fair subjects, when no protection is afforded by perspiration, the skin scorches quickly, and becomes red, swollen, hot and extremely tender, smarting on the application of water or even with its natural moisture. Some degree of fever is excited, producing restlessness at night. In severe cases blebs form by exudation beneath the cuticle ; and in loose cellular tissue, as in the face, the combination of swelling and bullae may quite close the eyes, causing serious inconvenience and discomfort. The worst cases occur on the water or on snow, where both the direct and reflected rays of the sun have free access to the unprotected skin, which, in addition, may be further denuded of moisture by a dry wind. Mountain-climbers above the snow-line, and young men making the most of a few days' holiday from city life, are the most frequent sufferers, but occasionally travellers newly arrived in a tropical climate and neglecting reasonable precautions are the victims. People with dark skins are less prone to sunburn, and in some individuals an outbreak of closely aggregated raised red spots which smart and itch intolerably takes the place of the more diffused redness, especially on the back of the hand. Parts of the skin which have become affected suffer more readily on subsequent exposure, and in the course of twenty-four or forty-eight hours the cuticle is shed in ragged patches as after scarlet fever, the surface remaining sore till the process is complete. Apart from securing protection from the direct rays of the sun, especially when first exposed, the skin should be kept moist either by encouraging some perspiration or applying a solution of glycerine, as it is only a dry skin that burns. Bad sunburn may require the application of Goulard lotion, and even the pricking of blisters ; the less severe forms are relieved by diluted glycerine or grease, to protect the skin from the air. Freckles 69 Freckles (Ephelides).— Fair skins are most com- monly affected, and especially those associated with auburn hair. The buff, brown, or greenish pigment spots occur in adolescents on exposed portions of the skin, usually the hands and face. They may be sparse, abundant, or confluent, and individually are circular or irregular in outline. They appear round the orifices of ducts or hairs, principally in the summer, but only partially disappear in winter. They seem to take the place of the more usual bronzing, diminishing in middle life and disappearing in old age. Colin has demonstrated true melanin in circumscribed portions of the basal layer of cells of the rete Malpighii with a few pigment granules in the papillary layer. Sometimes more extensive patches of pigment occur in place of the freckles, but they both come under the de- finition Actinic Melanoses — that is, pigmentary disorder due to the chemically active rays of the sun unassociated with heat or inflammation, but dependent on personal and family susceptibility and equally common in both sexes. Very similar pigmentation in the first two years of life may be the precursor of the grave disorder xerodermia pigmentosa, and when affecting covered parts (lentigines of Crocker) in elderly people, they may be part of general degenerative changes. When few in number, freckles or pigmented patches may be touched with carbolic acid or treated by galvano- puncture, but more extensive areas should be covered with dilute peroxide of hydrogen solution or oxychloride of bismuth ; the following is Unna's formula : ^. Bismuthi Oxycliloridi . , • § j Calomel gi'- u Hydrogen. Peroxidi (10 vol. solution) . fl. § j Adipis lanss et Vaselini . . aa 5 iv The wearing of a red or brown veil has been suggested, 70 Chilblains to cut off the violet and ultra-violet rays in some degree. Other formulae are : Aqua Cossietica Orienialis. ^. Bismuth. Trinitratis, 5ij ^. Hydrargyri Perchloridi, §j Hydrargyri Ammoniati, 3ij Aquse destillate, §iv Adipis prEeparatse, 5] Ovorum sxiv albumen To be spread on lint and laid Succi citri (i.e. Malse Medicae), on the patches at night. § iij Sacchari aibi, § viij Chilblains (Erythema Pernio). — It is reckoned one of the beneficent properties of memory that pleasant impressions are retained longer and with greater vividness than those of a disagreeable nature. Perhaps it is on this account that the suffering caused by this common complaint is apt to be underrated, for it occurs with less frequency and severity in adults than in children ; even those who have suffered most severely in youth finding it more tolerable as they attain maturity. In children, however, the frequency and severity of the affection deserve more attention than they commonly receive. Four phases may be recognised. Intense itching accompanies the evening rise of temperature between six and nine p.m., which may be so exasperating as to produce a state of continuous nervous rigor and totally prevent application of any kind, with the common sequel during school-days of punishment for deficient preparation of the morrow's tasks. At the same time injury is done to the ill-nourished skin by rubbing and scratching, or the still more heroic measures of beating with brushes or holly leaves, or the application of irritant or bhstering agents, not uncommon among schoolboys. With the subsidence of the itching there follows a period of acute tenderness due to congestion and swelling of the affected parts, so that where the feet are affected, as is commonly the case, walking is almost impossible, and the patient is unable to resume his discarded shoes, Chilblains 71 Relief occurs in the horizontal position, and with the more general distribution of the blood as the child gets warm in bed, though for a time at least pain or itching may prevent sleep. Another period of tenderness rather less acute attends first setting the feet to the ground in the morning, and the putting on of boots is sometimes a tearful proceeding. Dull aching with frequent reminders of local tenderness persist through the day, making active exertion distasteful and converting to a painful ordeal " the sports and pleasures of the child." Thus a vicious circle is created — chilblains leading to inactivity, and inactivity in turn leading to the per- sistence and extension of chilblains — which may continue for weeks, till a change of atmosphere or surroundings brings temporary or permanent relief. Unfortunately, the immediate suffering does not represent the full extent of the damage, for not only are the affected areas extremely liable to subsequent attacks, when circumstances favour them, but their recurrence and persistence induce thickening of deeper structures, such as the bones and ligaments, particularly about the knuckles, which permanently affect the symmetry of the fingers. This indicates that the complaint is not merely a cutaneous affection, and there are other considerations which show that it is not an absolutely local disease. Sir A. E. Wright in The Lancet, January 30, 1897, associates local serous exudation with defective blood coagulability, including under this state urticaria and chilblains. In ten of the latter class of cases investigated, the time required for blood coagulation averaged 9 instead of the normal 3-5 minutes ; and the administration of calcium chloride in 10-30 grain doses three times a day was attended with definite improvement, in some witlj §liortening of the blood coagulation tirae. 72 Chilblains In early life other forms of exudation are common, including the hsemophilic constitution, epistaxis, and the lymphatic state with water-logged tissues, which are amenable to the same treatment. But the essential cause of chilblains is the contraction of the terminal arteries under the direct influence of cold in those whose vasomotor system is active and susceptible, and occurs especially in those who display this vaso- motor excitability in other ways, such as ready blushing and sweating — the nervous-sanguine temperament of older writers. The majority of people do not display this peculiar susceptibility, and it undoubtedly diminishes with age. The effect of vasomotor contraction is to cut off the blood supply, and in a proportionate degree the vis a tergo, from the periphery of the circulatory area, which then cools down under the influence of low temperature, while the corresponding capillary areas, where most exposed or subjected to extra cold or pressure, become exsanguine. These are the patches which under the restored pressure of the circulation undergo capillary dilatation and blood-stasis with the accompanying phenomena of inflammation — heat, redness, swelling and pain, or itching, and which are extremely prone to relapse after recovery if again exposed to a low temperature. Such patches commonly occur over the inner and outer sides of the hands and feet, on the knuckles, heels, and ball of the foot, and even on the nose and ears. A more unusual spot is the vertex of the bald head, and in the days of our grandmothers and the thin Empire costume it was not unknown for chilblains to extend beyond the feet some way up the front of the shins. The effect of low temperature on the vasomotor system is much enhanced by extremes of humidity and dryness of the air, and most people are familiar with th^ Prevention of Chilblains 73 striking penetration of cold associated with the dryness of an east wind or the wet of a partial thaw. The effect of local pressure is sufficiently illustrated by the prominent spots which chilblains select, and by the experience of wearing tight and thin gloves or boots in cold weather. Erythema pernio has affinities with erythema nodo- sum and Raynaud's disease and is defined by Galloway in AUbutt's System of Medicine as a " subacute variety of erythema of the angioneurotic kind," and is specially associated with the susceptible arteries of youth, and sometimes with feeble circulation, as evidenced by an over-slow or over-rapid pulse. The local changes are, first, contraction of the capillary areas through the effect of cold on the over-active neuro-muscular vascular system, manifested by pallor, shrinking, and numbness ; second, vascular reaction or erythema ; and third, if the depressing influence has been sufficiently severe, paralysis with persistent dilatation of the venous capillaries and venules of the part, with escape of serum and even blood from the vessels, causing oedematous swelling of the cutis and loosening of the epidermis, which is easily injured or removed, though the formation of bullae is rare. Abrasion of the surface causes shallow ulceration which is slow to heal on account of the poorly nourished state of the tissues, while further septic infection may involve extension in depth and area. The prevention of chilblains in those who are sus- ceptible is in short the avoidance of cold. Such subjects must be warmly clad throughout — the body, to secure the main sources of heat ; the limbs, to ensure sufficient supply of heat and blood to the extremities, for it is chiefly in the wrists and ankles that the main vessels are most exposed to the contracting influence of cold ; and the extremities themselves, as the most vulnerable parts. In addition to the clothing usually worn, long worsted 74 Remedies sleeves and cloth or leather gaiters or high boots should form part of the costume in cold weather. Gloves and boots should be large so as to fit loosely and allow of linings or thicker hose. Some people find worsted next the skin provocative of the malady, and in such it should be worn over a smoother material, or two pairs of socks may be employed, provided they do not involve any pressure on the feet. The now prevalent and wholesome custom of per- forming certain muscular evolutions and exercises on rising or after the morning bath is to be encouraged. In any casfe, it is essential to begin the day warm and vigorous. To draw cold garments over cold hmbs and descend without energy to breakfast in an ill-warmed room, and then perhaps to start on a cold journey without any definite effort to rouse the circulation, is to court not only chilblains, but more serious maladies. It is this chilly and sedentary beginning, so foreign to youthful nature, which makes so many victims in school-days, when children should either enjoy proper warmth or be free to rouse their energies in their own turbulent fashion. When chilblains have once become eatabhshed, their cure is not an easy matter ; even relief is difficult to secure, as witnessed by the number and variety of remedies recommended. As is the case in many similar instances, these are mostly objectionable or ineffective. Anything which involves rubbing the affected skin or which causes it to become sodden tends to make matters worse by injuring the already damaged epidermis, while a continuous application of any kind to the extremities is more inconvenient and disabling than the complaint itself, so that few remedies get a fair trial, and the effect of intermittent applications is usually discounted by fresh exposure to cold during the day. Taking: these considerations into account, the most practical means of dealing with the situation is first to Treatment of Chilblains 75 secure proper warmth by suitable clothing and exercise, taking care to change or dry moist garments, especially foot covering, in the evening ; and to reserve for the night the application of more definite remedies. For the relief of the intolerable itching which usually occurs in the evening nothing is so immediately effective as heat. Roasting the chilblain before the fire to the limit of endurance and repeating the process several times will allay the itching at the moment, and if per- severed with will ultimately effect a cure. Another plan is to steep the hand or foot in very hot water, removing it when the scalding can no longer be borne, and either letting it cool in the air or plunging it momentarily into cold water, repeating the hot immersion several times. If the skin is then carefully dried without rubbing, the cuticle does not suffer, but this method is not suited to broken chilblains. Afterwards, or when going to bed, a solution of lead acetate in spirit or eau de Cologne may be applied, or an ointment composed of two drachms of wintergreen oil in an ounce of lanoline. In either case the addition of menthol in the proportion of 15 grains to the ounce will be soothing, if there is much tenderness or itching ; or, a dusting pov/der composed of Boric Acid 50, powdered Talc 25, Starch 25, with a Httle Camphor or Menthol ; or Calamine 7, Menthol 1, may be used. Relief has followed steeping the chilblains for five minutes in a solution of alum, one teaspoonful to a gallon of hot water. Many other applications have been recom- mended, such as castor oil, tincture of iodine, and a lotion containing an ounce each of hquor plumbi, tincture of opium, and glycerine in eight ounces of water; but these applications may be considered to come under the criticism previously expressed ; even wintergreen oil is distinguished by an odour which is so penetrating and enduring as to render frequent repetition undesirable, but if used as an ointment and either lightly rubbed i^ 76 General Measures or covered with socks or gloves, this is less developed, and its beneficial influence compensates for the disad- vantage, otherwise Mesotan or Kasemol may be substi- tuted. Whatever preparation is employed, it is probable that the uniform warmth derived from the bathing, and covering for several hours at a time, has much to do with the improvement. For cleanliness and efficiency probably no remedy can vie with the Faradic current, applied either by pads or the water bath, according to the amount of surface involved, the best effect being produced when both poles are applied to the chilblain, but this is not a method that is generally available. As in applying treatment for a cold in the head, the course of the malady is so variable in different subjects, and in the same one on different occasions, besides being powerfully modified by changes in the atmospheric conditions, that its effect is difficult to estimate. Apart, however, from local treatment, it appears that the adoption of more liberal diet with some stimulant and tonic, such as phosphate of iron, to meet the depressing influence of the cold, damp, and darkness of the winter, is decidedly beneficial. In Raynaud's disease great benefit results from the administration of vascular dilators such as nitroglycerine or the nitrites of soda or ether, and by analogy these might be expected to prove beneficial where contraction of the peripheral circulation occurs from exposure to cold, combined where necessary with a cardiac tonic. In the case of broken chilblains great cleanliness should be observed, and an omtment applied consisting of 5 per cent, carbolic acid in vaseline or the more complex one recommended by Unna : Resorcin 5 or Ichthyol 5, Salicyhc Acid 3, Soft White Paraffin to 100. Where the skin is only threatening to give way, 9, covering of flexible coUodjon may save it, Whitlow 77 Whitlow (Paronychia). — Suppurative inflamma- tion of the finger ends has, under this term, included disease spreading to various structures, including the synovial sl'ieaths and the deep tissues of the arm, involving loss of use or actual sacrifice of the limb. Only the superficial forms, however, will be considered here, such indeed as are limited to the region immediately beneath the epidermis or nail. The most obvious characteristic is the presence of a white central patch due to a small collection of pus beneath the cuticle, either alongside or beneath the nail or at a little distance from it on the terminal phalanx of the finger or toe, with an area of redness round it. A focus of this kind resulting from the inoculation of septic matter by scratch or puncture is usually single, limited in area, and attended by severe throbbing pain. It will extend if left alone, but immediately the pus is released, relief occurs and recovery is rapid. There is always an antecedent period of twenty-four hours or perhaps more before pus can be detected, during which pain may be increasingly acute and is best treated by a hot or cold compress with a few drops of laudanum, the hand being elevated. This treatment may be continued after pricking or snipping the raised cuticle, but the separated portion should be completely removed, the underlying surface thoroughly cleansed and then protected by an emollient ointment till sound. When the inflam- mation extends beneath the nail to any extent, recovery will not be complete till this has either separated by itself or been removed, but while only at the edge, the nail may be saved if the pus can find an exit, and the part be soaked with an effective antiseptic such as corrosive sublimate solution 1 to 1000, having been previously anaesthetised with eucaine, as much pain is excited. When paronychia develops in children who are 78 Warts debilitated, and not infrequently suffering from pustules, the affection is more widespread, involving more than one finger and generally both hands. The pain is not so great and the affection runs a more chronic course. It is best treated then, as part of the pustular eczema, with white precipitate ointment and tonics, not neglecting to evacuate pus and expose the diseased part to the antiseptic. Warts (Veppuea) are small, rough, and compara- tively insensitive projections from the skin occurring prin- cipally on the hands and face or scalp — that is, on parts unprotected by clothing — in young people ; though later in life they are more often met with on covered parts, especially the back. When very numerous, flattened and pigmented, in persons past middle life they are sometimes associated with or appear to be the forerunners of mahgnant disease of the viscera, as in the disease known as acanthosis nigricans, though they may ac- company other complaints such as eczema or leuco- cythsemia. The sporadic form, occurring commonly enough singly or in groups, may assume various individual shapes, being flat, irregularly peaked, or filiform. Warts are unsightly, particularly when discoloured by the accumulation of dirt in their interstices, and are apt to bleed or become painful from time to time owing to slight injury. They persist for months or years, grow- ing in size as well as becoming more numerous by the development of fresh ones in the vicinity, though they may at any time disappear spontaneously. A wart consists of either a papilla or projecting core of the skin containing a small artery and overlaid with a rugged accumulation of corneous cells derived from overgrowth of the epidermis. Colrat of Lyons has reported cases in which the warts have dropped off under general treatment by Remedies for Warts 79 sulphate of magnesia, two or three grains in children and haK a drachm in adults being given three times a day. Crocker confirms this, and also suggests full doses of nitro-hydrochloric acid or thirty to sixty minims of the tincture of thuya occidentalis (arbor vitas) two or three times a day. One or other of these drugs may be em- ployed where the warts are very numerous, or tend to recur, but where there are only a few, local measures suffice and are more speedy. Perhaps the most powerful escharotics are either nitric acid or the acid nitrate of mercury, applied very sparingly to the rugged surface with a glass rod or the end of a wooden match. The fluid permeates the cuticle and gradually affects the core of true skin, completely and permanently destroying the growth. Both these remedies have, however, the disadvantages of discolouring the surface temporarily, causing pain in proportion to the freedom with which they are applied, and leaving a perceptible scar, which may be objectionable on the scalp or face. Less drastic remedies, which are nevertheless effective if less speedy, are Hquefied carbolic acid, ethylate of sodium, caustic potash or soda, chromic acid, glacial acetic acid, per- chloride of iron, liquor plumbi subacetatis, and a saturated solution of salicyhc acid in alcohol. If the caustic alkahs are used, it is well to protect the surrounding skin with wax or paraffin, as they are liable to spread, and while applying the remedy a piece of blotting-paper should be held ready to mop up any excess. Chromic acid is best employed on the bare face of the papilla after removing the horny layer by the previous applica- tion of sahcyLic acid in solution or plaister. Sodium ethylate is prepared by dissolving one part of metallic sodium in twenty parts of absolute alcohol, the vessel being cooled by immersion in a stream of water, and should be applied once daily for three or four days in succession. It causes no pain, and the eschar drops off 8o Corns and Callosities of itself. The preparation recommended by Kaposi consists of Sulphur 5 v, Glycerine 5 i|, and Acetic Acid 5 ii|. It should be applied daily. Filiform warts occurring on the face, and especially the eyelids, are most speedily obliterated by snipping off flush with the skin and applying the nitrate of silver point to the base. Thin flat ones may be accounted for by frequent application of the alcoholic solution of salicylic acid alone, while the larger pedunculated forms are best disposed of by the galvanic ecraseur or they may be snipped off and the bleeding stopped with pressure and styptics or the cautery. Corns and Callosities. — It was one of the axioms of John Hunter that pressure from within caused atrophy and pressure from without hjrpertrophy, and the develop- ment of corns and callosities was regarded as a famiUar example of the latter. The modern interpretation is broader, regarding constant pressure as the cause of atrophy and intermittent as that of hypertrophy. In the subject under consideration, intermittent pressure associated with the expansion of the arches of the foot as it receives the weight of the body at each step, and the limitation of the boot, accounts for these develop- ments ; hard corns over bony projections, callosities of a more diffuse form over yielding parts, and soft corns in moist places, as between the toes, being the rule. In places not specially exposed to pressure an ac- cumulation of the epidermis closely resembling a corn is sometimes due to a foreign body, such as a splinter of wood or glass or a thorn, lodged below the surface. The development of corns may be prevented by wearing properly fitting boots which aUow space for the normal expansion of the plantar arches in walking or standing, and the natural enlargement of the foot in warm weather. Merely loose boots are not necessarily satisfactory, since they are apt to exert pressure nowhere but on the pro- Corn Cures 8i jecting points where corns especially form. The practice of not wearing the same pair on consecutive days, leaving them on boot-trees in the interval, is a good one, and those who suffer would do well to avoid keeping boots on unnecessarily. The spontaneous cure of corns when boots are dispensed with, as during a sea voyage or illness of two or three weeks' duration, is very striking. The pain associated with the presence of a corn is increased in very dry or with the onset of wet weather, owing to the increased hardness of the epidermis exerting more concentrated pressure on the underlying nerves in the one case, and the increased vascularity of the superficial tissues in the other. But in addition to exacerbations with atmospheric changes, increase of pain may result from inflammation, or effusion or suppuration in a small bursa formed beneath the hardened skin. Immediate relief from pain can usually be secured by the removal of pressure, and this is most easily effected by surrounding the projection with a ring of wool attached by gum : the corn-plaisters commonly supplied are too clumsy, and a more satisfactory ring can be made by cutting it out of the raw material, and if necessary reducing it in thick- ness. This method is quite physiological, equally adapted for hard or soft corns, and if persisted with will effect a complete cure. Subsequent recurrence may be prevented by the application of soap, or diachylon plaister. The removal of the thickened epidermis may be more speedily effected by careful cutting after soaking in hot water, or by painting twice a day with a solution of salicylic acid, the formula recommended by Vigier being a very good one : Acid. Salicylic. . , . . gr. XV Ext. Cannab. Ind. . gr. viij Alcohol. . , , . . Til XV Etheris . . Til xl Collodion, Flexil. . . ni Ixxv 82 Bunion If this be continued for a week, the corn will faU off of itself, but may leave the underlying skin pink, thin, and tender for a day or two. An inflamed corn, whether suppurating or not, must be treated with a cold wet compress for twelve hours at least, preferably through the night, to reduce the tenderness before it can be removed, or the lotion of lead acetate and opium may be used instead. It is not usually difficult or very painful to loosen the periphery, which is softer and generally more raised than the harder centre, but the final separation demands more fortitude. When suppuration has occurred, the difficulty is rathw diminished, as there is a cavity beneath the corn com- municating with the surface usually at the edge, and by extending this with fine-pointed scissors a radical cure can be effected, though the tender area needs pro- tection from pressure for some days. The essential point in the cure of soft corns is relief from pressure and moisture, the former by a small felt ring, and the latter if necessary by the use of oxide of zinc powder or alum, but the mere separation of contiguous surfaces is generally sufficient. Bathing the feet in cold water in the evening, and putting on dry hose after exertion, is not only refreshing, but an excellent preventive of both soft corns and blisters. Bunion. — This is commonly regarded by the laity as an exaggerated corn, though it is of course much more, but finished off with much thickening of the cuticle over the most prominent part. It is, in fact, a subluxation outwards of the metatarso-phalangeal joint of the hallux, with overgrowth of the base of the phalanx, this being overlaid by a bursa which inflames at intervals, capped by thickened epidermis. There is always a large branch of the long saphenous nerve involved in the bursa, and the vascular supply is generous. As this particular joint is freely exposed to injury, and is moreover the favourite Ingrowing Toenail 83 seat of acute and chronic gout, besides having powerful muscles attached to the movable part, the arrangements from the point of view of torture are as complete as possible. The radical cure of such a condition, when fully developed, involves operation, and will not be entered into here, but in an incipient state something may be done short of this to delay or prevent further develop- ment and relieve pain. In the first place it must be understood that an important, if not the sole cause of the condition, is eversion of the great toe due to wearing pointed shoes with high heels, and the first step must be to secure reasonably shaped boots with straight inner border instead of those usually selected with unlimited latitude across the ball of the foot, leaving the malposition of the hallux un- corrected. If necessary, the great toe may be brought into its proper line by means of a toe-post or brace. Temporary inflammation may be reduced by a cold compress or evaporating lotion, and the corn on the inner aspect removed. Wearing a cap of fairly thick diachylon plaister over the projecting part of the joint will afford some comfort and protection, and when the patient has acquired confidence by walking under the corrected conditions and becomes used to them she will be in a fair way to recovery. Ing-powin^ Toenail. — The pressure on the inner side of the great toe has another effect in pushing up the skin on this aspect while doubling up the nail longi- tudinally ; the inner edge then buries itself in the con- tiguous sulcus, and before long causes painful pressure and ulceration. The remedy for this disabling state of affairs is to relieve the lateral pressure by allowing sufficient space in the boot for the toes to spread naturally in walking, while softening and thinning the convex portion of the nail by soaking it in hot water and gradually scraping 84 Finger Cracks — Blisters with glass or a penknife. When this has been done sufficiently to allow the nail to yield to manipulation, a thin strip of oiled lint should be gently packed between the buried edge and the skin with the flat end of a probe. The parts having been sufficiently separated by this device, it may be possible to insert a strip of thin sheet lead beneath the border of the nail and by carrying it round below the toe to gradually reduce the prominent inner border of skin to its proper limits. It is sometimes necessary to suppress a fungous outgrowth of granulation tissue by zinc oxide, red oxide of mercury or lunar caustic, or to adopt the more heroic method of avulsing the nail, and if it continues to grow in a deformed shape to destroy the matrix with carbolic acid or by erasion. Fing'er Cpaeks are really a limited form of eczema rimosum. They occur most commonly across the top of the thumb, and recur with painful regularity in the same place each winter or spring, generally during the prevalence of cold dry east wind. At these times the use of a drop or two of glycerine rubbed over the hands while drying them after washing will keep the skin moist and supple and prevent their formation. The application of pumice stone to the thickened cuticle at the top of the thumb by reducing its thickness will also prevent cracking. The hands should not be washed more frequently than really necessary ; very cold water and soap containing much free alkali should be avoided, and the skin should be completely dried with a soft towel, subsequent evapora- tion having much to do with the trouble. Besides reducing the hard edges of cuticle with pumice, zalicylic acid plaister or the same drug in collodion may be employed, and later those applications recommended in Cracked Lip. Constantly wearing a rubber cap on the affected part is very beneficial. Blisters result from separation of the outer corneous layers from the newer and moister epidermal strata of Treatment of Blisters 85 the outer skin by effusion of serous fluid. Apart from those caused by burns or the application of vesicants, they commonly occur in consequence of unaccustomed pressure or friction associated with moisture, derived in most cases from perspiration. It is only in the palms and soles that the outer layers of the skin are sufficiently thick and coherent to furnish material for the dome of a blister, pressure and friction in other parts leading to thinning and abrasion instead. The development of a blister is accompanied with soreness, which may set a limit to the particular occupation inducing it, and in such case the formation is arrested by subsidence of hyperaemia and absorption of exuded fluid, but the active process is speedily renewed if pressure and friction are repeated within twenty-four hours. On the other hand, if sufficient rest is allowed, a thickening of the epidermis results, which is protective, so that by gradually inuring the skin to unaccustomed pressure, whether in the use of the hands or feet, the formation of blisters may be avoided, and such graduated use affords the best preparation for any continued effort. Should the irritation be continued without regard to the soreness which attends the raising of the cuticle, the blister will extend in area as well as in height and tension, until it gives way at the margin, discharging the contained fluid, which continues to ooze from the rent for some hours. The worst feature, however, in a broken blister is the admission of air, which dries the new and tender layers beneath, causing them to stiffen and crack on movement, thus prolonging the duration of the sore and affording opportunity for the ingress of septic matter, which may still further increase the injury and retard recovery. The main object, then, in dealing with blisters is to prevent if possible their extension when they threaten to form, or at all events to anticipate their rupture, and 86 Staining of Feet the exposure of the young skin beneath, either by pre- serving the natural epidermal covering or by keeping the part from drying and cracking by the application of some emollient such as vaseline or simple ointment. As a precautionary measure in prolonged marching, some form of woollen covering for the feet is preferable to cotton, and old campaigners recommend soaping the inside of socks or dispensing with them altogether. At the end of the day bathing the feet in cold water is both refreshing and preservative of the skin, and, failing a complete change, the shifting of the right sock to the left foot, after drying, is a useful expedient. Walking with wet feet is to court blisters, and it is worth some delay and inconvenience to avoid this, especially when walking day after day. Rubbing the skin of the palms and soles with any form of spirit tends to toughen it, and too frequent ablution with soap and water, especially hot water and alkaline soap, has a reverse effect. If time cannot be given to allow a blister to subside of itself, or if it is already too far advanced to permit of this occurring, a convenient plan is to pass a needle and white thread through one edge and then cut the thread close to the skin, so that the ends just project and supply a wick by which the contained fluid may slowly drain away. This allows the cuticle to fall back on the soft skin beneath without admitting air, and supplies a practical cure even if further effort is resumed. A bhster is in itself a small matter, but if neglected, leads to much discomfort, and may involve further trouble through local infection and inflammation of glands. Blue Staining" of the Feet. — During the hot weeks of summer numerous instances have occurred in London, and no doubt elsewhere, of greenish blue indel- ible patches on the feet of young women. The iden- tification of the colouring matter as indigo has led to Removal of Stains 87 some speculation as to its possible source, either in the action of some microbe on the sweat, or to the actual secretion of the colouring matter in this product of the skin, as in that of the kidneys. There is, however, no need to seek so far for the cause of this trifling inconvenience. Black stockings, so much in vogue, owe their colour to a process in which indigo is the basis, and the cheaper materials undoubtedly contain a large amount of cotton as well as wool. It is more than likely, therefore, that these blue stains, so difficult to get rid of, are produced by the sweat in very hot weather, aided perhaps by some decomposition, removing the dye from the material of the stockings and conveying it to the adjacent cuticle. Though unaffected by ordinary solvents, the stains are readily removed by chlorine water or a solution of chlori- nated lime or soda in water. They are only met with on the soles and sides of the feet and toes, more rarely on the dorsum, but always within the area included in the shoes, and might scarcely be considered worth troubling about, except that those affected are often very anxious to get rid of them, and the cause and remedy are not exactly obvious. Other dyes come off on the feet even more readily, especially red aniline, and may not be so innocuous, causing irritant poisoning of abrasions produced by chafing of the boots in hot weather. These stains, however, are removed by prolonged soaking in water, which is also the best remedy for the superficial inflammation. And it is well not to resume such foot-covering till the skin is sound. Neglect leads to the formation of a chronic and painful sore, with inflammation of the lymphatic vessels and glands. The employment of arsenic in dyeing with red aniline may have something to do with the irritation. CHAPTER III THE RESPIRATORY SYSTEM Sope Throat. — This very common affection is due to many causes, but whether it be the initial symptom or be discovered in the cause of a routine examination, it must not be at once concluded to constitute the entire complaint. Indeed in the majority of cases it is only part of some general affection and not, properly speaking, local at all. As it is often a very important, and in some cases a by no means easy, matter to obtain a good view of a child's throat, it may not be deemed out of place to suggest the following method : The nurse should hold the child in her lap facing a good light, steadying the head against her right shoulder by embracing it with her right arm with the hand on the forehead, while controlling the hands and legs with her left. Sitting opposite to her, and at the same level, with his back to the light, the observer further steadies and directs the child's head by grasping the nape of the neck in his left hand with the thumb in the right ear. While inserting a small spatula with the right hand, the ring finger carries the lower lip near the left corner of the mouth inwards over the lower gum or teeth, effectually opening the mouth. The spatula should not be inserted too far and should touch nothing but the tongue. All movements should be gentle and deliberate. It may be premised at the outset, particularly in 88 Exanthemata 89 children, that all the acute specific fevers are accompanied at the onset by inflammatory affections of the tonsils and fauces. To give instances would be practically to cite the whole list, but fortunately for diagnosis, other and more characteristic features accompany or speedily follow the occurrence of sore throat, and if the practi- tioner has been reasonably guarded in his first expression of opinion and has adopted the usual antifebrile remedies, the case will not have been prejudiced provided further careful watch is kept on developments. There is, however, one exanthematic sore throat which it is important to recognise at once, both on the patient's account and to avoid the spread of infection. That is diphtheria. The disease, in spite of advances in bacteriology and serum therapeutics, remains something of a bugbear on account of the difficulty of diagnosis and the irregularity and uncertainty of its course. There are, doubtless, characteristic features which are only too obvious in a proportion of cases, but they are so variable in occurrence and often delayed so long, that the patient may lose the advantage of serum treat- ment, which is beneficial mainly when administered within twenty-four hours of the onset, and may even communicate the disease to others before its nature is appreciated. The indications specially relating to diph- theria, some of which are pretty sure to develop in the course of the attack, are : The presence of diphtheritic membrane on the fauces or in the expectoration, loss of knee-jerks, and occurrence of albumen in the urine. Early involvement of the nares or larynx is also strongly indicative of diphtheria. More particularly in those in whom dyspnoea manifests itself early, in the absence of the foregoing indications, partial or complete suppression of respiratory murmur on one side of the chest or in one lobe of the lung is very significant, and is 90 Diphtheria a point to be very seriously considered, when meditatiag relief by tracheotomy, indicating, as it does, deep penetra- tion of the morbid process in certain bronchi, which might render the operation useless. The other general features which characterise diphtheria are pallor, prostration, and an appearance of profound illness out of all proportion to local manifestations, and generally associated with but slight degree of fever or even normal temperature. One or other of these features will probably manifest itself within twenty-four hours, but even that is too long to wait, and there are only too many instances in which no help to diagnosis is afforded other than the finding of the Klebs-Loeffler bacillus or the late development of paralysis either of the heart, respiration, palate, or groups of voluntary muscles. Recognising the existence of such cases, beyond the limits of immediate certain diagnosis, and the im- portance of taking definite therapeutic and protective measures at once, many physicians adopt the practice of isolation and the administration of efficient doses of anti-diphtheritic serum, while awaiting the report of the bacteriologist ; and as neither of these measures involves any serious drawback, should the case not prove diph- theritic, comparable to those resulting from their omission if the reverse is the case, it is no doubt a good and safe policy, employed with reasonable discrimination. It is not intended to discuss here the details and treatment of so serious a malady as diphtheria, but no reference to sore throat should be made without laying stress on this important aspect of the matter. When pain or discomfort in the throat is complained of, particularly in swallowing, inflammatory changes can usually be recognised in the soft palate, pharynx, or tonsils. Relaxed Throat. — Dull aching with a sensation of stiffness and actual pain in swallowing, and the sensation of a "lump in the throat," which repeatedly excites that Relaxed Throat 91 function together with a dry, harsh, and painful cough, usually indicate this condition. On investigation the smooth portion of the fauces, including mainly the soft palate, uvula, anterior and posterior pillars, but to some extent -also adjacent parts of the mucous membrane, are found to be unusually red, tense, and shining, though in a later stage they may look dull, flabby, or actually cedematous. The uvula, especially, becomes elongated, limp, and irresponsive to the semi-voluntary movements involved in deep inspiration. There is no fever. Much has been asserted in regard to the causation of cough by the contact of such an elongated uvula with the epiglottis or larjmx, but when it is remembered that in the sucking infant the uvula normally lies against the posterior aspect of the epiglottis, thus providing a median channel for respiration, while the flow of milk in suck- ing proceeds on either side ; and, further, that in marine mammals this arrangement persists through life ; con- tact between the uvula and epiglottis can scarcely be looked upon as an unnatural or disturbing condition. Hence the partial or complete removal of the uvula is not warranted as a cure for this temporary state ; while, on the other hand, when over-strenuously performed, it has led to subsequent escape of fluids and air by the posterior nares, and so to interference with swallowing and speaking. Though occasionally revived, this mis- taken practice has fortunately become nearly as obsolete as that of lancing the gums to aid the eruption of the teeth. In either case, when definite tension or oedema exists, superficial scarification, to release a little blood or serum, secures all the benefit that can be obtained by the use of a cutting instrument, and it is extremely rarely that this is needed at all. The condition of faucial injection is commonly attri- buted to exposure to cold moist air, particularly when 92 Rheumatic Sore Throat breathing by the mouth, and is more Likely to occur as a local affection in debilitated subjects. It is then best treated by local astringents combined with tonics. Gargles and sprays of various kinds are used, but of these, gargling with hot water alone gives immediate relief, and subsequently painting the reddened and swollen parts with glycerine of tannin is usually effective. A very satisfactory astringent is the lozenge of Krameria or of Australian red gum, which should be allowed to dissolve slowly between the cheek and the teeth, pre- cautions being taken against its being inadvertently inhaled while coughing or sleeping. Rheumatic Sore Tiipoat.— If the fauces be examined in any case of incipient rheumatism, they will be found injected, the mucous membrane appearing bright red. Not infrequently inflammation extends to the tonsils, resulting in follicular or parenchymatous tonsillitis, either of which may be a rheumatic mani- festation. Where arthritis occurs at the same time, little diffi- culty may be experienced in diagnosis, and under such circumstances the condition of the throat may even be overlooked, or left to take care of itself, provided salicylates are administered internally. In the absence of arthritis, however — and this is especially the case in children — the change in the throat may be the first indication except the general condition of fever which is usually definite and may be severe (105° F.). Indeed, a rapid onset with high fever and tendency to sweating in a young child, sometimes attended by delirium in the evening, are the principal characteristics of the rheumatic state. It is very important, therefore, in these cases to examine the heart at once and repeatedly, and to give salicylates in effi- cient doses, as either pericarditis or endocarditis may develop. Septic Throat 93 The application of a hot fomentation sprinkled with half a drachm of Olei Gaultherii, extending round the front of the neck to the mastoid region on each side, is at once a comforting and curative measure. Septie Throat. — The distribution of inflammatory changes in the throat is very similar to the preceding, but follicular tonsillitis is the prevailing lesion ; there is also a greater tendency to exudation. The initial fever is not 80 high, the temperature ascending more gradually, but may attain to 103° F. or more on the second or third day. Occasional rigors, general depression, and, locally, some ulceration are the leading features. What is termed " an ulcerated throat " is septic, though the loss of tissue is quite superficial and rarely leaves any permanent traces. The circumstances in which such a sore throat occurs may be some guide to its nature. Many instances seen among students in a hospital or medical school are of this kind, and recurring attacks among domestic servants working, and sometimes sleeping, in a basement near sinks and gullies belong to the same category. Most practitioners can recall instances where a recurrence of sore throats in a house has led to investigation and attention to drains, resulting in complete abolition of the attacks. It may not be out of place here to remark that drains require regular attention and cleansing as much as chimneys, though they do not always receive them, and an enormous amount, not only of definite disease, but general failure of health, as evidenced by loss of energy and appetite, anaemia and headache, attacks of diarrhoea, etc., are really due to sewer-gas poisoning from foul drains, enhanced by insufficient ventilation, both of the house and the drains themselves. It would be well if such evidence of general septic 94 Treatment influences were notified in the same way as is now compulsory in other specific diseases. The treatment of septic sore throat requires anti- septics locally, and tonics and stimulants generally. The following solution — ^. Hydrarg. Perchloridi . , • gr- ij Acid. Hydrochlorici dil. . , 5 iJ Glycerini . . . . . g j Aquam destillatam . . • . ad § x may be used every two hours, either as gargle, spray, or for swabbing the throat, which should be first cleared of secretion by gargling with a little hot water. Care must be taken not to swallow the solution, and if any misgiving exists in regard to this, it is better to use the Gargarisma Chlori. — ^. Potass. Chloratis . , . . 3] Acidi Hydrochlorici , . . ni sij Aquam ad § x The acid and chlorate are first introduced and allowed to react, till the chlorine gas displaces the air in the bottle, water is then added in small quantities at a time tUl the gas is dissolved ; the bottle being corked and shaken with each addition. One of the following solutions may be used : Potass. Permanganatis, gr. iv to water 0. j ; Formalin solution (40 per cent.), tti^j to water ^ j ; Acetozone, gr. ij to water 5 j- The best remedies, internally, are quinine, perchloride of iron, or biniodide of mercury — which may be given as follows : Mistura Chlori. cum Quinina {Burney Yeo). To Potassium Chlorate, in powder, 30 grains in a 12- ounce bottle, add Hydrochloric Acid 60 minims ; cork and shake well to liberate Chlorine ; absorb this by gradually adding, and shaking after each addition, distilled water to 11 ounces ; add Quinine Sulphate Treatment 95 24 or 36 grains, and Syrup of Orange ^ ]'• Dose : ^ j every two, three, or four hours. Other formulae are : — '^. Liq. Ferri Percblor. it], xv ^. Liq. Hydrarg. Perchlor. 3j Sp. Chloroformi, tn, x Potassii lodidi, gr. v Glyccrini, ui xx Sp. Am. Arom., int xx Aquam destill. ad § j Decoct. Cinch, ad gj Three times a day. Three times a day. In the acute stage, when there is much fever, the following complex mixture is advocated : '^. Liq. Ferri Perchloridi . in XV Liq. Hydrarg. Perchloridi . . m XV Liq. Strychninse .... HI V Tinct. Aconiti .... . tniij Potass. Chloratis . , , . gr. V Glycerini 3i Aquam destillatam . . adSj Three times a day. This is powerfully antiseptic and may be gargled or held in the back of the mouth for a moment before being swallowed. It should not be continued for more than two days, by which time the fever will usually have declined. In all these prescriptions glycerine is introduced to prolong the local effect in the throat. Owing to pain and difficulty in swallowing, nourish- ment must be given in liquid or semi-liquid form. Milk, beef -tea, arrowroot with milk, and jelly are the most convenient. Fluids taken hot are comforting. All applications to the throat should be made subsequent to taking food, so as to prolong their local effect as much as possible. In a later stage, when the fever and more acute symptoms have declined, the diet must be liberal, and a mixture of quinine, strychnine, and ammonia, such as the following, should be ordered before meals : ^. Tinct. Nucis Vomicae . . ni v Tincturae Cinch. Co. . . . 5ss Sp. Ammon. Aromat. , • . tti xx Aqaam Chloroformi . . . ad. gj 96 Follicular Pharyngitis This does not make a clear mixture, but it is a good bitter aromatic, and tonic. At this time an allowance of port, brief rest and change of air are old remedies ; and even if the patient had not already been in declining health when the attack occurred, he would certainly be enfeebled by it, and will need such restoratives for a week or ten days before resuming work and risking fresh exposure to the cir- cumstances inducing infection, if those cannot be avoided. It is not pretended that the distinction between these three forms of sore throat is obvious or at all easily made. Rheumatic sore throat, perhaps, is marked by the more abrupt accession of fever, and the local appearances are cleaner and more definitely hypersemic. Moreover, recurrence of the affection in the same individual under different circumstances, the persistent enlargement of the tonsils as a legacy of previous attacks, and the early response to salicylates aid in the diagnosis. Even greater is the difficulty of discrimination between the septic and diphtheritic cases. It might even be said that both are septic and that the latter differs only in having the specific organism of diphtheria super- imposed upon the common infection. In the absence of bacteriological investigation, the distinction will depend on the tendency of diphtheria to extend early to adjacent areas, and to give rise to distinctive symptoms, though, as has been previously stated, these may develop too late to aid the initial diagnosis. With the exception, however, of the use of anti- diphtheritic serum, the remedies that have been suggested are alike beneficial in the simple septic throat and that affected by diphtheria, being as strongly antiseptic as is compatible with safety. Folliculap Pharyngitis. — A sensation of prick- ing-soreness or stiffness in the throat, with cough and, Catarrhal Sore Throat 97 sometimes, alteration in the quality of the voice, usually indicate this complaint, which commonly follows the inhalation of some irritant. By far the most common cause is tobacco-smoking, but it may result from dust, or the fumes in a chemical laboratory. The malady afiEects the back of the pharynx and is characterised by a dry glazed condition of the mucous membrane with raised red spots representing the inflamed lymph follicles. With avoidance of the cause, the condition usually subsides, but it is readily excited again. Local remedies are not easy to apply, as the region is scarcely to be touched without exciting swallowing or retching. Some relief may be obtained by sucking marsh mallow, black currant or glycerine jujubes, or the compound benzoic acid lozenges of the London Throat Hospital (Ac. Benzoic! gr. | in red-currant basis). In this and other forms of vascular injection, a spray of adrenahn solution (1-1000) has an immediate re- medial effect, but requires to be repeated in two or three hours. Catapphal Sore Throat. — It occasionally happens, and in some individuals with greater frequency than in others, that an ordinary catarrh commences in the neighbourhood of the soft palate, constituting for some hours a sore throat. The infection soon spreads to the nares or trachea, or both, so that the nature of the attack is soon evident, and it is only worth while referring to it here to suggest that full development may be some- times prevented by applying to the palate and fauces the remedies suggested farther on as curative when the complaint commences in the nostrils. Catapph. — What is commonly called a " cold " in the head, chest, or throat is really an infective inflamma- tion of the mucous membrane. Though it is fully accepted that such an affection is transferable from one person to another — and instances are in every one's 7 98 Catarrh experience where the malady, once introduced, has passed from one member to another throughout a house- hold — people still cling to the notion that catarrh arises de novo from exposure to cold. Ill consequences result, no doubt, from sudden or prolonged exposure to cold, but catarrh is not one of them, as witness the absence of such troubles in the many arctic expeditions and their rarity in open-air life under any circumstances, to say nothing of the fact that some of the worst attacks of the kind occur in the hot weather. This much may be conceded, that pro- longed exposure to a low temperature when inactive, or sudden chill when overheated, lessen resistance and predispose to microbic invasion. Furthermore, cold, and inclement weather compel many to lead an indoor life, which is the reverse of invigorating, and commonly tend to a limitation of ventilation ; but the most usual source of infection is a crowded gathering under cover, which supplies an overheated, vitiated atmosphere, and is seldom wanting in the elements of infection. The onset of nasal catarrh is usually marked by irritation within one nostril, which may be expressed by slight soreness or tickling, sneezing or thin watery dis- charge, accompanied by slight fever manifested by " chilliness." It is in this stage that the attack m.a>j be aborted by appropriate treatment, though it will not be denied that subsidence may occur spontaneously. The remedies that have been advocated are all either antiseptics or astringents. The most convenient formula is a liquid which may be sprinkled on the handkerchief and inhaled : ^. Terebene "| 01. Eucalypti I .. Camphor j Menthol J Eau de Cologne may be added if desired, but the Nasal Douche 99 combination as it stands makes a very powerful aromatic germicide. If kept in readiness and freely inhaled as soon as the early irritation is experienced, subsequent development of catarrh is often avoided. Another convenient remedy is menthol snuff, but it is neither so cleanly nor efficient as the fluid. Those who have been initiated into the use of the nasal douche may apply a weak antiseptic solution, but a special contrivance is necessary and the knack has to be acquired. The douche consists of a glass vessel with a capacity of an ounce or more having an opening at the top which can be closed by the finger, and a nozzle below to fit the nostril. Its use is perfectly simple but requires a little confidence. Having filled the douche- while the lower opening is closed by the thumb, a finger is placed over the upper opening, thus retaining the contents by atmospheric pressure. The nozzle is then inserted into one nostril, the head being thrown back and slightly inclined to the opposite side over a basin. On releasing the finger capping the upper orifice, the fluid is delivered steadily, and provided the user breathes boldly through the mouth, it will run round the back of the soft palate and out at the other nostril. Should, however, the breath be held, or an inspiration be taken through the nose, the fluid will pass into the throat or even into the larynx, and a bad fit of choking result. The coUunaria mentioned may be used in a simpler manner by sniffing them into the nostrils from the palm of the hand, but this is not so satisfactory. Whatever ingredients be used, the fluid should approximate to the " normal saline solution," otherwise uncomfortable smarting will occur. As the mucous membrane is highly sensitive, any reagents employed must be well diluted. In addition the fluid should be loo Collunaria slightly alkaline and of the same temperature as the blood. Glycothymoline, though expensive, is satisfactory, otherwise a solution of Bicarbonate of Soda or Borax, 4 grains of either to the ounce of water, may be employed as a basis, to which may be added vi xx of Hazeline or a minute quantity {-^^ grain) of Menthol. Alum gr. v ad 5 3 ; Liq. Potass. Permanganate tii vj ad 5 j ; Sulphate of Quinine or Zinc gr. | ad ^ J 5 ^^id. DobeH's Solution '^. Glycerini Acidi Carbolic! . . . . m x Sodii Biboratis ... , . gr vj Sodii Bicarbonatis . . . . . gr vj Aquam ad . • • • ■ 5j are also employed. When a catarrh has passed the initial stage of infection and irritation, it is beyond the influence of nasal douches, sprays, or inhalations, and may be expected to run its course with but little modification by remedies. The entire thickness of the mucous membrane is then involved ; active congestion, swelling, and soon increased secretion, passing through the stages of mucus and mucopus, marking its progress. The air passages are more or less obstructed and there is either sneezing or cough, and some degree of fever. Recourse must then be had to general principles, in order to diminish the severity and shorten the course of the affection while relieving the discomfort of the more prominent symptoms. A hot bath and some hot wine negus or spirit and water, with perhaps the addition of half a drachm of sweet spirits of nitre, are homely remedies. The patient should retire early and have an extra blanket or two on the bed, which should be warmed so as not to check the action of the skin, started by the hot bath. A saline purge in the morning is useful both as re- Treatment ' loi lieving the fever generally and diminishing the degree of swelling or secretion in the mucous membrane. These measures are not incompatible with the usual routine of life, for it is not every one who will seclude himself on account of an attack of catarrh. Nevertheless, for the sake of avoiding conveyance of infection to others, as well as to ensure speedy recovery and the avoidance of more serious developments, con- finement to one room or even to bed is strongly recom- mended. To " feed a cold and starve a fever " is an old adage, but perhaps it would be more practical to suggest that solid food for the one and liquid for the other should be the rule. Reducing the amount of liquid taken to the smallest possible minimum has a decided effect in reducing the nasal discharge, which constitutes the leading feature in a " cold in the head." The only medicine likely to be of service in the course of the complaint is quinine, which may be taken as the ammoniated tincture in drachm doses every four hours before meals for three or four days, or the following mixture may be substituted : ^. Tinct. Nucis Vom m v Tinct. Cinchon, Co 5 S3 Sp. Am. Arom. . , , . tii xx Aq. Chlorof Ormi . . , . ad § j Every four hours. At the outset it is not always evident whether the chief manifestations will be in the head or in the chest. If the initial change is in the throat, it commonly extends to both, and a cold in the head not infrequently spreads later to the trachea and larger tubes, especially if no precautions have been taken. Provided there are no constitutional conditions or idiosyncrasy to prohibit it, a lO-grain dose of Dover's powder at night is one of the best remedies for a feverish cold in an adult. Salol in lO-graiu 102 Tracheitis doses in cachet twice or three times a day will mitigate the feverish and catarrhal symptoms in the early stage. For laryngeal catarrh, characterised by loss of voice and painful brassy cough, chloride of ammonium in 10 or 15-grain doses every four hours is a suitable remedy. It can be given in solution with compound tincture of camphor and sjTup of tolu. Adrenalin spray or local application of Gaultherium Oil, 5 j in a hot fomentation or as an ointment 5 ij to Lanoline 3 j over the front of the neck at night will do much to restore the voice, often within twelve hours. When there is much irritation, with cough and op- pression of breathing, the inhalation of vapour from 5 j of Tincture of Benzoin and a pint of boiling water, gives much relief. The readiest method is to place about a pint of boiling water with the tincture in a jug, and then wind a folded towel round it, so that this projects three or four inches above the top ; serving the double purpose of retaining the heat, and providing a close soft face-piece. Traeheitis. — Catarrh of the mucous membrane of the windpipe, which constitutes a " cold in the chest," may either occur primarily from exposure to infection, or may be due to extension from the nose or larynx. Neglect and exposure to cold and moist, or extremely dry, air, especially when coming out of a warm room, may lead to further involvement of the bronchi and serious illness. Whatever risks are taken in connection with nasal catarrh, it is certainly perilous to keep about and go out of doors with either laryngitis or tracheitis. The symptoms are very definite — a scalding or burning sensation behind the sternum, rough breathing, and a hoarse frequent and painful cough with definite rise of temperature. There is at first complete dryness, then a thin irritating and scanty expectoration followed by more copious mucus and muco-pus as the acute stage Treatment 103 subsides. The voice is always hoarse in some degree, and attempts at speaking provoke cough. The ex- pectoration may be tinged or streaked with blood. Household remedies are the application of a mustard poultice to the upper part of the chest for ten minutes and sipping simple linctus or a mixture of equal parts of lemon juice and either honey or glycerine, or equal parts of Tinct. Camph. Co., Oxymel scillse, and lemon juice. A milder, but still effectual, modification of the poultice may be made by rubbing about a teaspoonful of dry mustard flour into a piece of wadding, placing this on the chest and covering with a sufficiently large piece of wet oil-silk or protective to extend an inch beyond it all round. When this is pressed down, the free edge adheres to the skin and the warmth of the body liberates the essential oil, producing a mild irritation which can be borne, without fear of blistering, all night. The counter- irritant effect is thus prolonged and the chance of marking a delicate skin diminished. The general treat- ment should be the same as that employed for nasal catarrh, but some demulcent is acceptable such as rum and warm milk, thin gruel or milk arrowroot with brandy or whisky on going to bed ; the same principles in regard to diaphoresis and purgation being observed. If the complaint does not yield to these measures, and especially if there is a tendency for inflammation to extend into the bronchi with increase in fever and dyspnoea, the following prescription, the type of the sedative expectorant, should be ordered : Vin. Antimon HI X Vin. Ipecac HI X Sp. ^th. Nitros, 3ss Liq, Am. Acet 5ij Syrup. Limon . 3j Mist. Amygdal .... . acT§i Jlvery four hours. I04 Treatment And later, when secretion is established and fever declines : Ammon. Carb. . • • • . gr. V Tinct, Camph. Co. • • • . ni XX Syr. Scillae . oss Syr. Tolu . . 53 Inf. Senegse . . adgj Every four hours. this being the type of the stimulant expectorant. These remedies are suitable for otherwise healthy adults, but it is as well to state that ipecacuanha and antimony are too depressing to be used when the heart is not sound, either in the presence of valvular disease or the more obscure condition of myocardial degeneration with weak and irregular pulse. Squill and carbonate of ammonia are both irritants, and they must be eliminated should nausea or vomiting ensue. To infants or children opium, even as the camphorated tincture, should not be given, owing to their peculiar susceptibility. Though carbonate of ammonium acts as an irritant in concentrated solution, it may be given in much larger doses properly diluted. Dissolved in a tumblerful of milk, 10, 15 and even 30 grains can thus be administered without discomfort, acting as a reliable stimulant, especially in those cases where an expectorant is required. In all cases of tracheitis and bronchitis, one of the most important matters to observe is the maintenance of a uniformly moist and warm atmosphere. This assists greatly in allaying irritation and spasm, and is especially necessary during a dry, cold north-east or east wind. The object is best attained by a steam jet which not only moistens the air, but raises the temperature rapidly and is an efficient deodoriser. For children the following mixture is generally useful, half the quantity being given to infants ; Cough 105 ^. Vin, Ipecac 3 ss Tinct. ScillEe . . . • . 3 ss Sp. Am. Arom. . . . . 3 ss Glycerini 3j Aq. destill. . . . . adgjss Dose : 3 j-ij every four hours. Cough. — Dwellers in towns, particularly during the winter, are prone to habitual cough with slight greyish expectoration, which is particularly noticeable in the mornings. This is only the natural reaction of the bronchial tubes to the irritation of inhaled soot, usual under such circumstances, and does not call for any treatment, nor need it give rise to any anxiety, but must be looked upon as one of the penalties of modern civilisation. Apart from pulmonary disease, cough may be a source of annoyance both to the individual affected and perhaps still more to his neighbours. Absence of ex- pectoration and the accompanying rattle in the throat usually characterise cough dependent on causes remote from the respiratory system, which, being dependent on less urgent stimulation, is usually absent during sleep. Dryness or inflammation of the fauces or pharynx commonly causes sudden and impulsive cough, with watering of the eyes and often retching. Some persons even suffer in this way on cleaning the teeth. Gargles or demulcent pastilles are the appropriate remedies, and as the symptom prevails most when getting up or going to bed, the use of these agents may be limited to those occasions. A more frequently repeated dry cough is sometimes associated, especially in children and young adults, with the irritation associated with nasal obstruction, foreign matter in the external auditory meatus, or bad teeth, and these causes of disturbance should be looked for and remedied, rather than having recourse to drugs. Another group of causes is subdiaphragmatic, ii> io6 Treatment eluding morbid conditions of the liver and kidneys, but especially disorders of the stomach and colon. The loud barking cough of boys and girls — more often the latter — from eight to twelve or fourteen years of age — which from its long persistence sometimes leads to fears of grave thoracic disorder — will generally be found to yield to rhubarb and soda and proper supervision of diet. It is generally associated with a furred tongue, capricious appetite for plain food, and recurrence of " bilious attacks"; the tendency at this age to hurry over meals without proper mastication, and to supplement them with more attractive and less wholesome articles of diet, being largely responsible, though defective teeth may have a share in the disorder. The condition is indeed one of chronic catarrh, and oftentimes dilatation, of the stomach, which yields to a proper regimen and occasional dose of Gregory's powder, the Pulvis Rhei Co. of the Pharmacopoeia. In young women and girls from fourteen years upwards, such cough may be due to the same condition, but perhaps more often to constipation, and is more conveniently treated with the Compound Rhubarb pill or Cascara Sagrada, which may be administered in capsules repre- senting half a drachm of the liquid extract, or more agreeably as the Aromatic Syrup of Cascara 5 ss-ij . These are by far the commonest forms of dry cough, and the most assertive, being particularly in evidence in schooldays. There is, however, one variety even more noisy, frequent, and demonstrative, and that is the hysterical cough of young women. I was once consulted in such a case, the paroxysms being so violent that the buttons flew off the patient's dress in all directions, and had it not been for the persistence and recurrence of the attacks and the general characteristics of the individual, the diagnosis would have been whooping cough. In such Pleurodynia 107 cases bromide and valerian combined with some dis- ciplinary supervision are required. One word of warning may perhaps be necessary before leaving the subject of dry and paroxysmal cough, and that is to insist on a careful examination of the chest, so as to exclude any local physical conditions before attributing the cough to remoter causes. In rare cases, mediastinal growth or aneurysm may be present, or the irritation may proceed from adherent pleura or enlarged bronchial glands, or be due to whooping cough itself. Indeed, the frequency with which the latter com- plaint is said to follow measles may be accounted for by the presence of adenitis of the bronchial glands. Dry, irritant cough, due to remote causes which cannot be directly remedied, is best checked by some preparation of opium ; morphia, codeia or heroin. Pleurodynia. — Pain in the side is commonly re- garded as coming into the category of the respiratory system, though with the exception of that due to pleurisy this is not exactly correct. The pain, usually referred to the infra-axillary region, may have one of three sources of origin, which may be discriminated by the effect of pressure with the hand. If there is hypersesthesia, excited by the lightest stroking or pinching the skin, the complaint is probably Neuralgia, either associated with anaemia or with herpes, preceding or following the appearance of the characteristic rash. The anaemic form may be relieved by the admin- istration of Quinine and Iron (5-10 grains of the combined citrates), the Syrupus Ferri Phosphatis cum Quinina et Strychnina (s^-j), or a mixture of Iron and Arsenic as follows : "^i. Tinct. Ferri Perchlor iti x Liq. Arsenic. Hydrochlor. , . . tii v Glycerini 5ss Aq. Chloroformi . . . . . ad § j Tbree times a day after food, io8 Myalgia Locally some relief may be obtained by the locaJ application of Anodyne Colloid covered with moist spongiopiline, Linimentum Belladonnse or Linimentum Chloroformi 5 j with Menthol 5 3, the Belladonna plaister, or the recently introduced compound of saUcylates and menthol known as Kasemol. For herpetic pain the same local remedies may be applied, but constitutional ones are less efficacious. If antip3n:'ine fails, one must have recourse to morphine when the suffering is very severe. The following prescription may benefit : ^. Sodje Salicylatis Sodse Bromidi . Antipyrin. Aq. CamphorEe |- aa gr. x 5j Three times a day. When there is not superficial hypersesthesia, but deep tenderness of an aching character is elicited by pressure, the condition is most likely Myalgia. The best remedies then are sahcylates both internally and externally. Aceto-salicylic acid (aspirin) may be given in 10-grain doses in cachet or tabloid, and oil of wintergreen may be applied locally, either 3 3 in a hot fomentation or 5 ij to 5 j of wool fat. This may either be gently rubbed into the skin or may be applied on a strip of linen or lint. If the patient is in bed, a hot rubber water bottle placed against the painful region affords rapid relief. The third variety of pain is a combination of soreness or aching, -^dth acute stabbing paroxysms on coughing or taking a deep breath. There may be a slight rise of temperature and the patient usually holds the side with the hand when coughing or moving, or involuncarily sus- pends respiratory movement in some degree on the affected side. Flicking or percussing excites tenderness, but gentle and firm comprehensive pressure with the whole hand, sufficient to restrain the movement of Pleurisy 109 the ribs, gives ease. This is Pleurisy. In many cases friction may be heard with the stethoscope, but not in all. The most efficient treatment consists in strapping the side (Dr. Fred. Roberts). It is an advantage to soften the surface of the plaister with turpentine instead of heat, as this acts as a counter-irritant besides ensuring a good grip. Two strips, two inches wide and long enough to cross the middle line in front and behind, should be applied diagonally in an X shape, crossing at the seat of pain. Each strip, held firmly over the spine, should be carried round the chest and fixed at the end of expiration. After a day or two the strapping may need re-adjusting, as it is apt to loosen with the movements of the chest. Temporarily holding the affected side of the thorax with the hand is of value in estimating the probable effect of fixation on the pain and also on respiration, for in those cases where this is already much embarrassed by existing pulmonary disease, fixation is not tolerated. Recourse must then be had to leeches or counter-irritation, such as painting with a preparation of iodine or applying mustard or emplastrum calefaciens. Dry pleurisy is an occasional accompaniment of bron- chitis and emphysema, or may occur from exposure to cold or trauma, but is more often associated with constitutional disease such as gout, rheumatism, renal disease, and pulmonary tubercle, which should be carefully sought for. Stiteh in the Side. — This common phenomenon, familiar to every one, generally accompanies unusual exertion, particularly after a meal, or in those unac- customed to violent exercise. The pain is nearly always referred to the hypochondrium on either side, though it may ascend as high as the nipple, and has all the characters of the pleuritic stab. no Stitch in the Side It is due to desiccation of the serous membrane not necessarily of the pleura, the peritoneum being sometimes involved, but always in the region of the diaphragm, and appears often to be associated with turgescence of the liver or spleen during digestion. This desiccating effect of movement on the serous mem- brane is fully recognised and has been made use of in hastening the absorption of chronic pleural effusion. The pain is so sharp and so closely bound up with respiratory movement that it effects its own cure, by bringing the patient to a standstill, and causing him to support the affected area with his hand. After subsiding, it is very apt to recur with renewed exertion, but ceases to give trouble as the subject becomes inured to exercise, especially if he avoids taking it immediatelj^ after a meal. A stitch in the side is so transient, and the circum- stances in which it occurs do not afford opportunity for auscultation, or a friction rub might be heard. In the course of disease affecting the liver or spleen, such as infarcts, new growths, and passive congestion or inflammatory hypersemia, a similar but more persistent pain occurs, increased by respiratory movement or cough and accompanied by audible friction. This is amenable to the same remedies as pleurisy. CHAPTER IV NERVOUS SYSTEM Insomnia. — Except in the treatment of definite and acute affections and on special occasions the use of drugs should be entered upon very guardedly in dealing with insomnia. In otherwise healthy people in whom a bad night or two may be looked upon in the Hght of a minor disorder, the correction of some physiological error may be all that is needed to guard against a recurrence. Over- fatigue, especially when associated with a late and un- digested meal, is a common cause of failure of much- wanted sleep, even in those who are young and active. On such occasions a warm bath following a light and digestible meal with more than the usual quantity of fluid, preferably hot, makes the best preparation for retiring. Otherwise the inclination to sleep should be combated till sufficient time (three hours) has been allowed for the primary stages of digestion and the elimination of some of the waste products of the muscles. On the other hand, an empty stomach is a watchful companion, so that in seeking rest five hours or more after the last meal, sleep is best secured by some light nourishment such as soup, milk, gruel, arrowroot, chocolate, or warm milk alone. Sometimes on waking during the night from a similar cause a biscuit or piece of chocolate is sufficient to restore repose. A loaded colon, a stomach dilated with gas, often from drinking aerated waters late at night, or intestinal flatulence will prevent or disturb sleep. 1 1 1 Insomnia Undue excitement of the brain up to the time of going to bed, excess of tobacco or taking tea or coffee late in the evening may have the same effect, and it is sometimes overlooked in the treatment of invalids that such drugs as strychnine, caffeine, and theobromine given for other purposes may exert a similar influence. Conditions less obvious to the patient are variations from the normal in the circulation. Perhaps the most persistent cause of sleeplessness is high arterial tension, which may be asso- ciated with chronic renal disease and arterio-sclerosis, or may occur occasionally from some disturbance in the digestive tract. Port wine exercises such an influence in some individuals, especially if taken in the evening. This is best remedied by a warm bath before retiring. AlUed to this state is the presence of rigid arteries in the brain, chiefly in old age, which interferes with the adjust- ment of the cerebral circulation. In the opposite direc- tion, the enfeebled vaso-constrictor action in anaemia and debility, convalescence after acute disease, especially typhoid fever and influenza, and in Grave's disease, allows of dilatation of the cerebral arteries automatically on lying down, so that such subjects often fall asleep more easily when sitting up if sufficiently supported, as in a " grandfather's chair." It need hardly be mentioned that undue cold or heat, noise and light, or the attempt to maintain a position incompatible with complete mus- cular relaxation, are all opposed to satisfactory rest. In dealing with insomnia, as with other prominent symptoms of disturbed function, it is therefore obvious that very nice discrimination is needed both to attain a satisfactory result and to avoid needless injury. It is just as unreasonable to apply soporiflcs without judgment in the relief of sleeplessness as it is to employ analgesics unthinkingly in subduing pain. Each in its way is an indication of a pathological condition which should be carefully investigated and suitably dealt with, the Treatment 113 objectionable symptom in each case disappearing with the correction of the underlying cause. As an expedient in either case, some remedies may be applied to the direct relief of the symptoms while the cause is removed or when this cannot be discovered or corrected. In its serious and persistent form, such as precedes or accompanies acute attacks of insanity or is associated with serious organic disease, no symptom is more dis- tressing and damaging, or more difficult to control, than the inability to sleep. Such powerful remedies as are called into requisition on these occasions can only bi administered with the utmost precaution and watched with the most anxious care ; these are morphine and hyoscyamine, chloral and even chloroform. In the restlessness of pneumonia, pleurisy or pericarditis especially when pain or dry cough is present, in the early stages, small doses of morphine (^ or J gr.) give great relief, and delirium may entirely disappear under its influence, or after the sleep it induces, but it should of course not be administered when cyanosis is present, as it would dangerously deepen the stupor of asphyxia. In cardiac disease, too, where restlessness and sleeplessness are prominent features leading on to delirium, the timely exhibition of this drug affords much benefit. It is best administered hypodermically in combination with strych- nine and atropine, a good formula being Morphine gr. J, Atropine gr. ^Ijj, and Strychnine gr. -^^ in 6 minims of water ; half this dosage, viz. 3 minims, usually suffices, especially after the first administration. In all instances, in which there is pain, morphine is the best hypnotic, but in neurosis and mental restlessness the bromides alone or in combination with chloral are better and safer. The bromides of Potassium, Sodium, and Ammonium (gr. X of each) with ii\xx of Sal Volatile and Chloric Eiher and 1)1^ iij of dilute Hydrocyanic Acid in 5 3 of Pepj srmint water make a good combination. 8 114 Treatment The peculiar watchfulness, apprehension, and intrusion of unwelcome ideas associated with the restlessness from high arterial tension should be distinguished from the persistence of grief, worry, or anxiety which may be a direct preventive of sleep, and call for such a nerve seda- tive as that just mentioned, whereas the other does not. A review of the numerous hypnotic preparations with their special uses would be a more elaborate matter than is here contemplated, but it may be suggested that when sleeplessness is associated with neuralgic pain, Antipyrin, Butyl Chloral, or Chloretone in 5-15-grain doses is indicated. In neurasthenic conditions, Chloralamide, Sulphonal, Trional or Tetronal in doses of about 20 grains should be given in cachet, or dissolved in spirit and hot water. The combination of equal quantities of sulphonal and bromide of potassium is specially effective. Hedonal in cachet of 8-15 grains is useful under similar circum- stances, and Urethane, which is readily soluble, may be given in 5-15-grain doses to children or subjects of mania, being specially devoid of danger. As general hypnotics which are free from disagreeable effects, Proponal and Veronal in doses of 7 grains or more are to be recommended, and Dormiol in gelatine capsules containing a similar amount is effective. As a substitute for opium and morphine. Codeine or Heroine can be used ; they are specially useful where there is irritable cough, and the last need be given only in very smaU quantities such as -^j grain. Paraldehyde is almost the only soporific, if we except alcohol, which can be regarded as rather stimulant in its action, and is safe and specially useful in organic heart and kidney disease, often promoting diuresis, and in asthma and arterio-sclerosis tending to diminish spasm. Prepara- tions of lettuce and hops, not omitting the " hop- pillow," may be suggested in what may be termed fanciful insomnia, and in weaning patients from the habitual Narcolepsy 115 use of hypnotic drugs sugar of milk increasingly sub- stituted is a convenient agent. Nareolepsy. — This state may be regarded as the antithesis of insomnia, one term indicating inability to sleep, the other inability to keep awake. The feeling of drowsiness is irresistible, continuing day and night, so that the subject may even sleep standing or walking, and it requires considerable physical disturb- ance to rouse the patient : in this resembling the condition produced by narcotic poisons. The affection is uncommon and usually temporary, occurring for the most part in young women, apparently as a result of auto-intoxication from the defective meta- bolism of proteids associated with constipation. The remedy consists in abstinence from meat and reduction in nitrogenous food generally, while securing regular action of the bowels and suitable exercise. Cephalalg^ia. — Headache is often a prominent feature in febrile states, anaemia, renal disease and arterio- sclerosis, and is specially severe in intra-cranial diseases such as meningitis, cerebral softening, tumour, or abscess. Under these circumstances it is persistent and associated with other manifestations which incapacitate the patient, and render the underlying state evident on careful investigation. Perhaps the least obvious of these causes is chronic Bright's disease, in which the headache is commonly of a dull heavy character, located especially in the occipital region extending to the back of the neck. It occurs on waking in the morning, and is often accompanied by vertigo, and in advanced cases temporary aphasia and failing sight. A persistent headache with these char- acteristics, particularly in an individual at or past middle life, should always suggest an examination of the urine. Excluding serious disease, in which headache is merely a painful incident, there are a number of causes producing this trouble in persons of all ages who are otherwise in 1 1 6 Cephalalgia relatively sound health. It is only necessary to mention among these the effect of a close atmosphere with over- crowding, a frequent cause of headache associated with attending places of worship or amusement, or resulting from sitting or sleeping in small ill-ventilated rooms — a common practice in towns of closing windows and even chimneys to exclude dust and soot contributing very materially to this. Wearing a heavy, hot, or ill-fitting hat for hours at a time, in men, and a close arrangement of super-abundant hair in women, are provocative of this symptom, and on the other hand with insufficient covering, exposure of the scalp either to heat or cold, as in sitting under a lamp or in a draught, has a similar effect. Habitual breathing by the mouth instead of by the nose is also productive of headache, as is seen constantly in cases of adenoid growths, obstructed nostrils, and en- larged tonsils. Besides the inhalation of products of respiration, or coal gas, emanations from drains and such vapours as nitrite of amyl, ammonium sulphide, sul- phuretted hydrogen, and other chemical or putrefactive vapours are similarly productive of pain referred to the head with giddiness and nausea. In a state of health the brain appears to be insensitive ; but as in the case of ligaments and tendons, acute sensibility may develop in connection with inflammation or tension. Pain in the head may therefore reasonably be ascribed directly to the brain when intra-cranial tension is increased by undue vascularity or exudation with ventricular distension. Inflammatory states of the membranes, as in menin- gitis, areproductive of acute suffering, and vascular disease, whether acute as in syphilitic arteritis, or degenerative as in senile atheroma, is also usually accompanied by aching in the head, which may precede apoplexy or thrombosis. In addition to intra-cranial changes, disturbances in Persistent Headache 117 the nerves of the scalp also lead to pain and tenderness referred to the head, either in actual fibrositis or neuritis with soreness along the course of the nerves or in neuralgia with intermittent pain referred to their areas of distribu- tion, and tender spots at points of emergence through bone or fascia. In addition to these sources of headache, others of more general, vague, or transitory occurrence are attri- buted to " toxaemia " and vascular spasm, associated probably with irregular blood supply causing anaemia or flushing of particular areas. Pain, with more restricted distribution, and greater intensity and persistence, may be associated with abscess, aneurysm, new growth, or nodes. From the practical pointof viewof diagnosis, prognosis, and treatment, headache may be considered as persistent, periodically recurring, and occasional : its causation being more or less definitely established in this order. That is to say, a persistent headache is usually due to organic disease, either within the cranium or in some important organ elsewhere. Within the cranium such conditions as meningitis, concussion, abscess, tumour, and arterial degeneration or thrombosis may be instanced, the pain being in many instances localised either about the ear or occiput, usually very severe and subject to exacerbations. The consideration of severe and persistent headache due to organic disease within the cranium will not be entered upon here, except to point out the great import- ance of its early recognition, which may be aided by the occurrence of impromptu vomiting, altered reflexes, constant vertigo, and the presence of optic neuritis, paralysis of cranial nerves, marked increase of pain on coughing, stooping, or lying down, and other evidence of intra-cranial pressure. The opportunity must be taken also of pointing out the imperative duty of applying such anti-syphilitio ii8 Organic Causes remedies as mercury, the green iodide especially, and iodide of potassium in large doses, since a considerable proportion of such cases prove amenable to this treatment. Where no relief follows and the presence of syphilis is excluded, recourse must be had to such drugs as Acetani- lid in doses from 2 to 15 grains, Exalgine 2 to 5 grains, or Morphine in adequate amount to subdue the pain ; while considering the advisabihty of surgical measures. Causes outside the cranium are for the most part changes in the blood-stream, either in the direction of variations in quality, quantity, or pressure, or the presence of injurious matters resulting from morbid processes within the body, or introduced from without ; to v/hich may perhaps be added impressions conveyed through the nervous system in chronic disease of the pelvic organs from which the former cannot be traced. Persistent headache should therefore lead to a sys- tematic examination with a view to the discovery of such organic disease, and the reUef of the headache should be looked for in the remedy of the primary malady, rather than in the apphcation of anodyne measures ad hoc. The discrimination of these various causes of headache is no easy matter, and when decided upon alleviation is not always readily obtained. To consider first ab- normalities of the circulation. These include excess or diminution in the quantity of blood distributed to the head, which is commonly apparent in the colour of the face and neck, and is further characterised by suffusion of the conjunctiva and a sense of throbbing, with exacerba- tion of pain on stooping or in the horizontal position when due to overfulness of the vessels. This form of headache accompanies plethora, fever, alcoholic stimulation, and the effect of drugs which excite circulatory activity in more than a moderate degree, such as the vascular dilators and tonics, and commonly accom- Treatment 119 panies palpitation of the heart from excitement, exertion, or disturbance of digestion. The vascular dilatation and tension may be either active and arterial or passive and venous. The former rules in Grave's disease, fever, plethora, and stimulation, and the latter in mediastinal pulmonary or cardiac disease — chiefly of the mitral valve — associated with obstruction to the circulation and dilatation of the right cavities of the heart ; though undue constriction of the neck or waist by tight clothing may have a similar effect. Headache occurs in both conditions, but is more definitely throbbing, accompanied by visible pulsation of the temporal and other superficial arteries and fiushing of the face in the active form, while a dull aching and tendency to cyanosis with fulness if not actual puffiness of the face characterises the passive. In either, lowering the head, whether in lying down or stooping, and cough increase the pain, and may be accompanied by vertigo and a sense of fulness. The treatment of headache associated with congestion is necessarily bound up with that of the more general condition. Purgatives are valuable in both the active and passive forms, particularly sahnes and the aperient mineral waters in combination with small doses of calomel or mercury. In arterial hyperaemia and over-activity of the heart it may be advisable to give small doses of such depressants as antimony, aconite, and iodide of potassium, the latter especially in gouty conditions. In the passive form of venous congestion, benefit is more likely to be obtained by digitalis or strophanthus. But in either, opium and its derivatives are contra, indicated, and strychnine usually increases the headache, as do the vascular dilators, though either may be needed for their general effects. In febrile affections and vascular excitement associated 1 20 Treatment with, headache, great relief is often afforded by cold to the head — which is most effectually applied in the form of an indiarubber bottle filled with iced water or shaved ice, wrapped in a towel and placed under the nape of the neck. It is more constant in its effect than either eva- porating lotion or an icebag, acting as a sedative to the circulation and reducing fever. When the pain in the head is very acute, especially when inflammatory in origin, the application of one or two leeches below or behind the ear has often the speediest effect in relieving it, while for milder cases the hot mustard and water footbath is beneficial. There are instances in plethoric and gouty subjects where headache is so intense that the patient loses control of himself, and in such, the removal of 20 to 30 ounces of blood by venesection is necessary, and affords the most rapid means of relief. This, combined with full doses of iodide of potassium and saline purgatives, sub- dues the pain at the time, but subsequent attacks will occur unless restraint in food and stimulants is practised. In the opposite direction of anaemia, whether primary or secondary, headache is of very much more frequent occurrence, and the altered conditions of the blood make it practically impossible to decide whether the deficiency in the normal constituents or the presence of abnormal ones is the more important factor. But undoubtedly the most constant complaints of headache come from young women suffering from chlorosis with gastric sym- ptoms and constipation, where these states are combined ; though simple oligsemia from recent haemorrhage is also productive of the symptom, sometimes in an acute degree. In the latter instances, the preparations of opium, especially morphia, so generally given to combat the circulatory and nervous excitement attending serious haemorrhage, appear to control the headache also, or at Recurring Headache 121 least to produce a state of quiescence which mitigates the suffering. For the most part in anaemia the physician is chiefly concerned in restoring the blood to a normal condition, and the remedies applied for this purpose, principally arsenic and iron in one form or another, with suitable laxatives and graduated diet, ultimately remove the headache. Temporary exacerbations are often benefited by light nourishment or reheving the bowels or by one of the drugs recommended in the paroxysmal form of headache, to be presently considered. In those too-common in- stances where gastric disturbance with vomiting, and even hsematemesis, render the administration of most drugs by the mouth unsatisfactory, chloretone in 5-grain doses, in cachet or petroleum emulsion, may prove of service, but this failing a hypodermic injection of morphine is the most effective remedy. Periodically recurring headache is apparently func- tional — that is, associated rather with physiological than anatomical changes. The most familiar examples are migraine, clavus,brow ague, tic douloureux, andneuralgia. It cannot be said that there is any marked regularity in this periodicity except in the case of brow ague and neuralgia, which may keep time by the clock ; but the recurrence, though irregular in time, is marked by close similarity in the site and character of the pain though there may be variations in severity, and subsidence between the attacks is complete. Hemiepania. — This paroxysmal complaint, the leading feature of which is one-sided headache, whence it derives this name or the abbreviated one of migraine or megrim, is essentially a functional disease. There is no ascertained morbid anatomy, it arises and subsides in an otherwise healthy subject, and in the intervals of the attacks there is usually perfect health. In these respects 1 22 Hemicrania the analogy is very close with epilepsy, the one being a sensory and the other a motor disturbance. Either complaint is most apt to commence soon after puberty, the paroxysms acquiring a regular periodicity or being determined by some unusual strain or excitement. The degrees of migraine attacks in respect of frequency and severity have a close parallel with those of epilepsy, in which the haut mat and 'petit mal are commonly dis- tinct, the one being characterised by severity, and the other by frequency of occurrence, while each remains for the most part habitual in the same individual. There is a further similarity in that either paroxysm is usually inaugurated by minor nervous disturbances termed the " aura," and often preceded by an altered disposition or diffuse sensation appreciable by the patient and referable possibly to altered vascular tension due to the presence of some toxic material in the blood. Ex- ceptional cases have been met with in which motor and sensory attacks have occurred alternately or where one has supervened on the other, but these are so rare as to suggest coincidence rather than consequence, and do not excite any anxiety that the subject of migraine may become epUeptic. It has been suggested that spasmodic contraction of a cerebral artery might account for an epileptic attack, which is sometimes unilateral or at least unequally deve- loped on the two sides, the motor manifestations in this pointing to the middle cerebral artery as the seat of dis- turbance. The region concerned in the manifestations of migraine, particularly the evidence of disturbed function in the abdominal viscera, points to the distribution of the anterior cerebral artery to the inner surface of the hemi- sphere forming the sides of the longitudinal fissure, the terminal portion corresponding to the visual area, in which the change usually commences. Both in epilepsy and migraine the onset is attended with pallor of the face, Hemicrania 123 suggesting contraction of the arterioles, which is appar- ently of brief duration, being followed by dilatation and flushing of the corresponding areas. It may be this restoration of the circulation, rather than the initial contraction of arteries, which brings about the severe headache and visceral disturbance which quickly succeed the inaugural symptoms, very much as the restoration of circulation in the nerves and tissues of the extremities after prolonged exposure to cold or pressure is associated with acute aching. An attack of migraine is preceded in many individuals by a feeHng of vigour and mental activity due to rising arterial tension, lasting an hour or two, and then giving way 'to the recognised aura. This, which corresponds to commencing arterial spasm and anaemia of the affected portion of the cortex, takes the form of a central scotoma in the visual field, so that the patient is unable to see the point of his pen, the words he is reading, or the face of the person he may be talking to, though surrounding objects not exactly in the central point of vision may be as clear as usual. Peripheral vision, however, is interfered with by the appearance of " zig-zags " or " Hues of forti- fication," as they have been called, plain or coloured, and black spots. These phenomena are quite transitory, and as they subside in the course of a few minutes to half an hour, the characteristic one-sided headache develops, rapidly acquiring great intensity and concentrating on the eyeball and corresponding mastoid region, though extending vaguely to the brow, temple, and occiput. Meanwhile the countenance becomes pale, the temporal arteries hard and small, and the intelligence clouded, the patient feeling bewildered, prostrated, and often faint, so that he is compelled to lie down. Considerable variations occur in different people, the visual aura being sometimes more complex and ideational, or other special sense being concerned such as the auditory. 1 24 Hemicrania but commonly the aura assumes very much the same character in the same person with subsequent attacks, though producing less impression as f amiharity is acquired. The growing intensity of the hemicrania is attended with a condition allied to collapse with moist skin, chilliness, muscular and nervous prostration, and soon a sensation of nausea attended in most cases by actual retching. Any food which has been recently taken is ejected prac- tically unchanged, but the vomited matter consists mainly of mucus, bile, and watery fluid containing organic acids. Though the act of vomiting is distressing, some relief usually follows, but the headache continues, the patient becomes more apathetic, resents any disturbance, avoids light and noise, dozing and then sleeping except when roused by the profuse secretion of pale limpid urine which occurs for some hours in the later phase of the attack. During the early part of the paroxysms the mouth is dry, there is complete anorexia, the stomach rejecting any food or even Kquid that may be taken, and there is arrest of bile secretion judging by the occurrence of flatulence and pale faeces. These indications of marked nervous disturbances in the secretory organs are accom- panied also by partial suppression of urine, though diuresis is the first function to be re-established. The entire attack usually lasts six to twelve hours, but as it commonly commences in the early part of the day the patient is unfit for anything till after a night's rest and the re-estabhshment of the digestive functions next morn- ing. Curiously, in this complaint, though the malady is distressing and incapacitating while it lasts and the subject of it quite unable to take or digest any food for twenty-four hours, the usual or even an improved feehng of health is immediately restored when it subsides. As far as can be judged the incidence and recurrence of migraine are associated with exhaustion of the nerve centres. The disorder commences most often in connec- Hemicrania 125 tion with severe study, deprivation of sleep, anxieties or excessive social excitement, and recurs with a kind of periodicity which may nevertheless have some relation to causes of nerve exhaustion, disturbance of digestion, or menstruation. The attacks usually become less frequent towards middle life, the intervals becoming longer and the seizures themselves less severe, but it is difficult to esti- mate when they cease, and in some instances they con- tinue into old age, this being itself an indication that they exert no influence in shortening life or introducing other complaints, being indeed quite compatible with sound health and long life. All do not suffer to the extent indicated in the above description, and for the most part, after the first few seizures, there is some mitigation and shortening of them, also the attacks appear to be less severe as they are more frequent, so that many who experience them once or twice a week escape with merely a headache and loss of appetite for a few hours, and are often capable of carrying on routine work. In the most typical cases the tendency to migraine appears to be hereditary and spontaneous ; though per- haps accentuated by some general interference with robust health, such as sometimes accompanies the adop- tion of serious studies, or the responsible duties of life particularly in cities : for it has been noted that the bucoUc temperament is seldom associated with the com- plaint, and a free open-air Kfe is often enough to effect a cure in those who are subject to it. In more pronounced cases the attacks, like those of asthma, commence in late childhood or soon after puberty, and may be more fre- quent or severe and less amenable to treatment. It is necessary, however, to state that a very consider- able number of individuals apparently become subject to attacks of migraine without hereditary predisposition. 126 Treatment and, maybe, at a later period of life, as a result of some local injury or disorder, the attacks being generally very similar, but wanting in some particulars. These have been aUuded to as " reflex migraine." Such are com- monly associated in women with menstruation and chronic disease of the pelvic organs, and have in both sexes followed on head injuries, chronic inflammatory conditions of the appendix, gaU bladder, stomach and other abdominal viscera. The attacks associated with organs of special sense such as errors of refraction may also be regarded in this Hght. The importance of being on the alert to recognise this aspect of the case Hes in the fact that the cure of the local lesion, where possible, is the most direct road to recovery, and may be the more wilHngly undertaken, even by surgical means, since the migraine is often not the only manifestation, though the most obvious to the patient, and may lead to the discovery of chronic or progressive disease which undermines the patient's health generally, and may even prove ultimately fatal. The great difficulty in the treatment of migraine hes in the uncertainty of its periodicity, so that it is almost impossible to be beforehand with remedies, while on the other hand when once the attack is estabhshed, absorption from the stomach ceases and internal remedies then have Httle or no effect. At the very commencement, during the stage of vascular contraction, and before the headache has definitely commenced, the following mixture may arrest the attack ; ^. Liq. Trinitrini . • . . ni i] Acid. Hydrobrom. dil. . . , nt xx Aquam ... ad § ss Twice, with one hour interval. If taken as early as possible when the onset is threat- ened or recognised, there are three drugs which may Treatment 127 mitigate the severity of the paroxysm. These are phenacetin, phenazone, and chloretone. On account of their depressing effect the two former drugs are usually combined with caffeine citrate. ^. PheDacetin . . gr. x I '^. Phenacetin . . gr. x Caffein. cit. . . gr. v I Butyl Chloral. . . gr. z ^. Antipyrin . . gr. x Caffein. cit. . . gr. v In cachet or as a powder. Half as much again may be taken as a single dose on a subsequent occasion if this does not prove effective in the first attack, but it should not be repeated. Migra- nin (Antipyrin Caffeino-citricum) in 8 to 15-grain doses may prove of service if this fails and has the advantage of being freely soluble and consequently more readily absorbed. Phenacetin may also be conveniently given as tho granulated effervescent salt containing 5 grains in the drachm. Chloretone, which is a comparatively new drug and not very soluble in water, may be taken in doses of 10 to 15 grains in powder or cachet under similar circumstances. The effect of these remedies may be to add to the prostration which naturally accompanies the complaint and may in addition induce diaphoresis and sometimes vertigo, so the patient should remain quiet and preferably recumbent while under their influence. No food should be taken while the attack lasts. Usually there is no inchnation for it, but sohcitous re- latives have often a mistaken idea about maintaining the strength in any illness. It is a pecuharity of this complaint that exhaustion does not follow the short abstinence, and when the seizure has passed off the appetite and power of digestion and assimilation are restored at once. The only thing at all acceptable is tea, which may be taken at intervals according to inclination 128 Treatment and in stronger infusion than usual. At the end of the attack, a cup of soup or of milk arrowroot or gruel with a Httle spirit may be taken before retiring for the night, if the patient feels equal to it. In the more frequently repeated but less severe attacks in which prolonged headache is the leading symptom the following combination of drugs is often beneficial : 1^. rhenazoni e . "j Ammon. Broraidi . . r aa gr. x Sod. fc^alicylatis . . J Aq. Camphorse . . . ad § j Every two hours till four doses have been taken. When the intervals between the attacks are long, three to six months or more, it is hardly to be expected that patients will adhere to irksome precautionary mea- sures, beyond partial relaxation of mental application, paying attention to the regularity of the bowels, and perhaps increasing somewhat the daily allowance of fluid ; but when seizures occur at shorter intervals — and they may do so more than once in a week — it is essential to secure mental rest for a time and a more open-air life while taking regularly fractional doses of calomel followed by saline laxatives. A generous diet is advocated with sufficient vegetables and fruits, and for a few weeks at all events such nerve tonics as quinine and guarana. 5i. Quinin. Muriat . . gr. ij Tinftt. GuarauEe . . 5ss Acid. Hydrobrom. dil. . ill xx Aq. Chlorof ormi . . ad § j Three times a day before meals. It is advisable also to look for and if necessary correct any local source of nerve-strain or irritation such as error of refraction or disease in the teeth or nose ; though this does not necessarily at once abolish the attacks. These appear to be precipitated by some special cause of nervous Clavus Hystericus 119 exhaustion associated with general depression of health, and it is this which so often determines a seizure at some critical and most inconvenient time, such as the period of an examination, of some particular social engagements, or perhaps the eve of a journey, when extra demand is made on the nervous system. Clavus Hysterieus. — This is usually described as an intense boring pain in one temple, the vertex, or occiput, occurring from time to time in women who are the subjects of other hysterical manifestations such as the globus hystericus, emotional attacks, and hysteroid convulsions, one or other of which paroxysms it usually succeeds. From the written descriptions in most of the older text-books, it would appear that this particular form of headache and the more active hysterical com- plaints with which it was associated were of commoner occurrence in former generations than at present, when the passive form of neurasthenia prevails. Such a local headache must be regarded and treated as part of the general complaint. It is transitory and is best met by a mixture containing Bromide of Potassium gr. XX, and Ammoniated Tincture of Valerian 5 j in camphor-water, though the combination of Phenacetin gr. X and Citrate of Caffeine gr. v has a more imme- diate effect. Seclusion and quiet are of chief importance until the pain subsides, and it is well to be on guard against hasty recourse to opiates, as in such cases the opium habit is peculiarly liable to be acquired, and, at the best, frequent repetitions of the sedative are likely to be called for. The pill of Butyl Chloral Hydrate gr. iij made up with Glycerine of Tragacanth and perhaps with 2W gr. of Gelseminine Hydrochloride is also useful. Bpow Ag'ue, which, as its name implies, affects the supra-orbital nerve in those who are the subjects of malaria, is a very intense form of neuralgia recurring at 9 130 Tic Douloureux definite intervals for a number of successive days at the same hour. It may be either intermittent or remittent, and at its worst is so severe as to exceed the Hmits of seK-control which can be exercised by the patient ; and raises suspicion of tic douloureux or organic disease. The patients are commonly anaemic and debilitated, and the complaint may be identified by its periodicity and the history of exposure in malarial districts. -The two drugs most efiective as remedies are quinine and arsenic, which must be quickly raised to full dosage and given for some days, till the pain entirely ceases to recur. Instances in Great Britain are exclusively met with in foreigners or those who have resided abroad, and being of rare occurrence, are hable to be overlooked. I can recaU a good example in a Pole who on account of tne great severity of the attacks, which resisted the ordina-iy remedies, was about to be trephined as a case of central tumour, but who was at once relieved by Liq. Arsenicalia in 10-minim doses. TMien the attacks recurred eighteen months later, they were allayed by the same drug. Tie Douloureux. — This, the most intense form of neuralsia. is fortunately very rare. It has been dhserved in elderly people and has been associated with the taint of insanity. It is remarkable for the suddenness and intensity of the paroxysms, lasting from a few seconds to a minute at a time, but recurring often at short inter- vals . The pain is accompanied in many cases with muscular contractions, lachrymation, and flushing or pallor on the affected side of the face or scalp. It quite overcomes the self-control of the patient, and when it subsides leaves him in a shaken and apprehensive state, which has culminated in some instances in suicide. The causation of the malady is obscure, but those cases in which foreign bodies, scars, and neuromata have Tic Douloureux 131 been discovered in association with the fifth or other nerves, and whose removal has been attended with rehef, would suggest a very careful search for any lesion of the kind. The condition of the patient is so pitiable that he will submit to the most complex, dangerous, and extensive operations in the hope that either death or cure may terminate his sufferings and terrible apprehension. Many have submitted to excision of nerves and to removal of Meckel's or the Gasserian ganglion in the hope of obtaining relief. jMany years ago an elderly man under the care of Mr. Henry IMorris underwent an operation for division of the infra-orbital nerve at the back of the orbit, without avail ; subsequently in the course of an examination of the mouth prehminary to excision of the superior maxilla a small shotlike body beneath the mucous membrane of the cheek was touched, bringing on a severe paroxysm. The removal of this put an end to the attacks. Other cases have been recorded in which the excision of cicatrices or foreign bodies has been attended with a hke result, but unfortunately these are a minority, and in most instances the attacks recur in spite of surgical treatment. Recently cases have been benefited by the injection of osmic acid or alcohol into the affected nerve. The drugs which can be suggested as likely to be of service here are few. Where no local lesion can be dis- covered, and particularly where the pain is not limited to the distribution of a single branch of nerve, arsenic in full doses should be tried, the amount being raised by degrees to 15 or even 20 minims of the liquor given after meals and washed down with a good quantity of fluid. The drugs employed in the more ordinary forms of neuralgia may be given in full doses, especially exalgin, acetanilid, and chloretone, but pending more definite measures recourse must be had to the hypodermic injection of morphine. 13^ Neuralgia Neuralgia. — The pain arising in connection with the cranial nerves differs from headache in general in its strict limitation to particular branches, more especially to those of the fifth, being almost always limited to one side. There is also a pecuhar periodicity in the attacks, which tend to recur at the same hour each day. The character of the pain is less dull aching than penetrating and varied by sudden darting or shooting pangs, which may be so sudden and severe as to cause involuntary jerking of the head. Another characteristic feature is the presence of painful points, apparently located in the regions where the nerve in its course perforates resisting structures such as bone or fascia, these points being tender on pressure. Neuralgia is very much more frequently asso- ciated with anasmia and debihty than with plethora or even a normal state of the blood, though in these latter it may occur as a result of inflammation of the nerve sheath and fibrous stroma or in consequence of peripheral irritation. In treating neuralgia, therefore, these possibihties should be borne in mind. An otherwise healthy indivi- dual may develop neuralgia in consequence of continued irritation from a diseased tooth, sometimes even when this does not give rise to local trouble, and may not reveal abnormality on a cursory inspection. Another fruitful source is eye-strain from refractive error, when the vision is closely applied to fine work or in reading. Such errors may go unnoticed for a time when the eyes are not so used or while the young cihary muscle is competent to overcome the defect, so that the difficulty may not assert itself till study or the requirements of application bring them into pro- minence, and the compensatory powers of accommodation fail. Such sources of nerve irritation and exhaustion are quite competent to give rise to neuralgia and still more to Neuralgia 133 attacks of migraine, but they are more frequently determining causes in the presence of more general failure of health attended by anaemia and loss of vigour from chronic maladies or undue confinement within doors. In women, leucorrhcea and constipation are often additional factors, and chronic poisoning by sewer gas should not be overlooked. Peripheral irritation, unsatisfactory blood-states, and rheumatic or gouty inflammation of the nerve sheaths and stroma constitute the chief factors in the causation of this painful malady. The treatment must necessarily correspond, and consists in discovering and remedying any of the above- mentioned recognised causes of the disorder, while apply- ing those drugs which have been found to alleviate the pain. The most important of these are butyl chloral, phenazone, caffeine, Cannabis indica, gel- semium, quinine, theobromine, acetanilid, pyramidon, and exalgin. As many of these are insoluble, they are mostly given in cachet or tablet, and may advan- tageously be combined. The following are convenient formulae : ]^. Butyl Chloral Hydrati « » gv. iij Gelseminini .... gr. -^ Glycerini Tragacanthoa . . . q.s. (To make one pill.) Two such pills to be taken at first, and one hourly till six have been taken or the pain subsides. Antipyrine or Phenazone is usually prescribed alone, or as a definite compound such as Antipyrin Caffeino- citricum (]\Iigranin) 5 to 15 gr. or as Aceto-pyrine in com- bination with acetic and salicyHc acids, either in powder or cachet ; but being soluble in water it is often employed in mixture. The following is particularly useful in influenza and the headache associated with it ; 134 Anti'Neuralgics ^. Antipyrin. . . . "| Sod. Salicyl. . . J- aa gr. x Pot. Bromid. . . J Aq. Cinnamomi . . , ad 3 j Cannabis Indica is best given in pill, J to f grain of the extract being administered alone or in combination with a similar quantity of the extract of Nux Vomica. It has been employed in supra-orbital neuralgia and in headache associated with mental worry and sleep- lessness. Gelsemium in 5 to 15-minim doses of the tincture is prescribed with Bromide of Ammonium or Potassium for facial neuralgia, especially in connection with carious teeth, and may be repeated every six hours. As above stated, Gelseminine, the alkaloid, is also combined with Butyl Chloral in the proportion of 2^ grain to 3 grains in pill or tablet. Theobromine, Caffeine, and Guaranine are closely allied in constitution and therapeutic effect. In addition to their influence in reducing the pain of neuralgia, they exert a stimulant influence on the heart, and it is usual to employ them on this account in combination with such remedies as Phenazone, Acetanilid, and Phenacetin. They, however, belong to a class, akin to xanthin and uric acid, known as purin bodies, which are associated with gout, and are productive of arterial tension and sleeplessness, so should be prescribed only in view of these limitations. The coal-tar products Phenazone, Pyramidon, Phenacetin, Acetanilid, and Exalgin, with some others, are usually given in combination with the preceding. If given alone they are most conveniently taken as the effervescent granular preparations, in which a suitable dose is contained in one drachm. These preparations are, if anything, too alluring, and in those who are frequently liable to headache are Anti'Neuralgics 135 commonly taken too often and with detriment to health. One of the best is the combination of Phenacetin and Caffeine Citrate containing 5 and 2| grains respectively in the drachm. These drugs, valuable as they are in ordinary neuralgia, are specially apphcable to those cases in which pain is dependent on recognisable organic disease, such as cerebral or spinal tumours, locomotor ataxy and neuritis in its various distribution, such as sciatic, cervico-brachial, musculo-spiral, and intercostal. Where a rheumatic factor is present the combinations with Salicylic Acid, such as Diuretin (Theobromine Sahcylate), Salipyrin, (Antipyrin Salicylate), and Salicylate of Quinine or Aspirin (Salicyl Acetic acid) are specially suitable. Satisfactory as one or other of these remedies may prove in an actual attack of neuralgia, none of them exerts a permanent influence in removing the disorder or preventing recurrence. Furthermore, in most instances the beneficial effect is lessened with repetition, so that larger doses have to be employed, and such may produce undesirable collateral symptoms and exercise a harmful influence on health. On this account recourse must needs be had to an alternative, and this no doubt accounts for the number of such drugs which are recommended in common affec- tions like neuralgia and insomnia. It may indeed be pretty generally concluded that when a plurality of remedies are advocated for the same complaint, none are really effective ; and one might even argue that the curability of any malady is in inverse proportion to the number of so-called cures. Perhaps no disorder offers such a striking example of this as sciatica, in which remedies are so numerous and instance* of speedy recovery so few. Jt is, therefore, extremely undesirable that the treat- 136 Treatment ment of neuralgia should be limited to the administra- tion of analgesics, though these are of value in subduing pain while more radical treatment is carried out. For the most part this consists in eliminating some faulty state of the system by correcting constipation, indigestion, malarial taint, or local disease of teeth, nose, eyes, or ears, or, most common of all, the blood. In a very large proportion of cases anaemia and debility are responsible for neuralgia, particularly in women. Losses by haemorrhage or discharges must be arrested and the waste made good by ample diet, change of air, and tonics. Many are the emasculated forms of iron which have been recommended and laboriously produced, with the idea that they are unirritating or more closely allied to the organic combinations in which the metal is disposed in the organism. Modern analysis and research have done much to dissipate the notion that ferruginous preparations are beneficial on account only of being directly assimilated. More iron is prescribed in a day, if not in a dose, than would be normally contained in the entire body of a healthy person ; and it has been shown not only that such large doses appear beneficial in chlorosis, but that most if not all the metal is recoverable in the fseces, indicating that apart from absorption the presence of the iron in the digestive tract effects some beneficial change, partly at all events by counteracting other chemical bodies by producing insoluble combinations. This may be the case with ammonium sulphide and sulphuretted hydrogen, since the iron is disposed of as sulphide and these compounds are capable of entering into undesirable combination with haemoglobin. The administration of iron should be associated with moderate purgation, free dilution, and efficient dosage. It is this which no doubt accounts for the favourable effect of ferruginous mineral waters when Treatment 137 other metliods have failed, combined as it usually is with a regulated diet, open-air exercise, and early hours. In the treatment of neuralgia in young anaemic women the following formula will often be found effectual, especially when rheumatism occurs : ]^. SodtB Salicylatis Ferri et Ammon. Cit. . , Sp. Am. Aromat. . Aquam Chloroformi Three times a day gr. XX gr. V ni XXX adgj Recent experience has also shown that the combina- tion of arsenic with iron is usually more effectual in curing anaemia than either taken alone. The following rather crude formula has the merit of having proved its efficiency in a number of cases : ^. Tinct. Ferri Perchloridi . # . . IH, x Liq. Arsenici Hydrochlor. . . . • ni v Glycerin! . 3ss Aquani destill . ad § j Three times a day after food. The scale preparations of Citrate of Iron with Quinine or Strychnine or both are very suitable. Quinine and Iron may be given in doses of 5 to 10 grains, but the introduction of Strychnine requires caution as to dose, that of Strychnine and Iron being 1 to 2 grains and that of Quinine, Strychnine, and Iron 2 to 6 grains. Sufficient dilution is obtained by giving these drugs directly after meals and washing down the medicine with a tumblerful of water. A saline purgative may be added, but it is usually more convenient to order a sufficient quantity of aperient mineral water to be taken the first thing in the morning. Bearing in minq the observation tha,t haemoglobin 138 Diet is broken up in the day and built up at night, during the period of rest, it is an important adjuvant to the treatment to enjoin a prolonged period of rest, say a night of twelve hours, while this is being carried out ; at the same time securing efficient ventilation in the bedroom and a due proportion of outdoor exercise or exposure without fatigue during the day. The diet must be adjusted to the digestive capacity. In many instances pain or discomfort after food is a prominent symptom, and if sufficient nutriment cannot be comfortably assimilated, the patient should be kept in bed, or at all events free from fatiguing exertion, till the supply of food can be raised to fairly normal pro- portion. After milk and eggs, animal food may be given in the form of sheep's brains, tripe, sweetbread, or calf's head, such things being easier of mastication and digestion than actual meat. Flat fish, similarly, is more suitable than other kinds. The coarser sorts of fish and poultry, unless boiled almost to a pulp, are really less digestible than meat, and it is certainly a mistake to regard them as " invalid diet " in cases of gastric disturbance or inefficiency. Green vegetables, especially lettuce and spinach, and fruit are valuable additions to the meal. But the main object is to get the patient on a liberal and nutritious regime as speedily as possible, discouraging merely tempting and fancy confections which are no substitute for food, though they may be taken in addition by healthy folk, perhaps without hurt. As a result of bad teeth and defective appetite young women not infrequently forsake simple wholesome food in proper quantities for what are considered delicacies, and a dietary of tea and confectionery will often be found a precursor of the ultimate attack. The question of change of air constantly arises in these cases, and when other matters have been set right, i? Occasional Headaches 139 generally beneficial. Besides climatic change, residence away from the usual surroundings generally means freedom from business worries or harassing domestic affairs and makes for rest ; but precautions should be taken, as far as possible, against the indifferent cooldng and defective food arrangements often experienced in primitive country places or at the seaside. For the most part in debilitated, anasmic subjects a dry and relatively cool atmosphere is to be selected, such as is found on the East Coast of England or at an elevation of some 500 feet. In older people with high arterial tension, a warm and moist atmosphere, such as that of the South and West Coasts and river valleys, is preferable, and this also suits the excitable and so-called neurotic subjects best, but in either case the patient should not go till convalescence is fairly established. Oeeasional Headaches depend on a variety of causes, vary greatly in character and intensity, are more diffuse or difficult to localise, and do not, so far as we can determine, involve any particular structure — that is, are not traceable to the area of distribution of any special nerve or artery as in the previous group. They have more the character of what have been termed " massive pains " and are not usually to be compared in acuteness with those in either of the preceding groups. For the most part " occasional " headaches are not associated with serious organic disease, they occur at long intervals, are of brief duration, constituting the minor ailments of otherwise healthy people, and so come more particularly into the domain of minor medicine. The presence of deleterious substances in the blood as a result of disturbed functions would appear to be the commonest factor, though this may have a direct in- fluence in producing altered distribution of blood by disturbing heart action or altering peripheral resistance, locally or generally. It is certainly noticeable that such 140 Occasional Headaches headaches are associated with flushing or pallor of the face, alteration of the complexion and suffusion of the eyes with either fulness or depression around them, and change from the normal size of the pupil. The lids look heavy, and altogether there is an altered appearance in the face that does not escape an observant person who is familiar with the patient. The commonest source of such toxins is the digestive tract, especially indigestion, constipation, and interference with the action of the liver. These disturbances have already been sufficiently dealt with in a preceding chapter, and there is no need to consider them further here except to suggest in per- sistent cases such remedies as the effervescing citrate of magnesia, artificial Carlsbad Salts (Kutnow's Powder), or a mixture containing laxative and stomachic drugs such as the following : ^. Succi TaraxFici . , . . . . . 5s3 Sodii Sulphatis . . . . . . . 5 ss T. Nucis Vomicse vi v Sp. Am. Arom tti xx Aquam Chloroformi ad 5 j Three times a day before food. Taraxacum is not officially regarded as a potent remedy, but the above combination has proved of service in many cases. What may be termed " toxic headache " results from the action of poisons introduced from without or generated in the body often complicated by secondary effects such as direct irritation of nerves or contraction of blood-vessels, which are very difficult to distinguish. Poisons from without which are productive of head- ache include carbon dioxide, carbonic oxide, and acety- lene derived from deficient ventilation, overcrowding, and the combustion of coke or gas in stoves with defective draught, or in the latter case which " light back," The Remedies 1 4 ^ inhalation of fumes in a chemical laboratory, in some manufacturing processes, or from defective drains may produce headache in a few minutes which may last a considerable time. Perhaps the only remedy is a sojourn in fresh air, but such experience should be avoided or the circumstances corrected. Toxic headache is also produced by alcohol and lead. The autogenetic poisons, apart from those associated with recognisable digestive disturbances and constipation, are derived from faulty or excessive metabolism, being in most cases due either to excessive production or defective ehmination ; such are the causes of headache in fatigue, in fever, and in gout. In fever, headache is best relieved by reducing the temperature and giving fluids ; one of the most striking features of cold bathing for typhoid fever when in vogue was the subsidence of this symptom. Cold applications to the head are still employed, either as some form of ice-cap or as evaporating lotion, but the most comfortable and effective arrangement is the ordinary rubber water-bottle, filled with cold water or shaved ice and placed under the nape of the neck, wrapped in a smooth towel. Most of the antipyretic drugs exert a definite influence on headache, and this is true not only of the coal-tar products, but also of such diaphoretics as acetate of ammonia and nitrous ether. Fatigue headache is a common experience of over- exertion, whether physical or mental; less familiar per- haps, as a recognised cause, is the over-use of the special senses, but excessive stimulation of the eyes, of the ears, and sense of smell are certainly productive of fatigue associated with headache, which appears to be seated, so far as it can be localised, in the forehead. The sense of fatigue is often closely bound up with want of food, and the headaches so common in visitors to large cities 142 Remedies are usually the result of this complex causation and are generally to be remedied by rest and food with nerve stimulants such as tea, coffee, or alcohol. The headache from active study often associated with cold feet, and perhaps produced largely by stooping over a book in a close atmosphere, calls for exercise and fresh air, and is best remedied by a short brisk walk. This is a common experience in student life. Perhaps the best remedy for such headaches in modern times has been the bicycle. Chloride of ammonium has frequently proved of great value in various forms of headache, when given in adequate doses (10 to 30 grains). For headache in gouty subjects which is liable to be persistent and recurring, and usually associated with high arterial tension, iodide of potassium appears the most reliable drug. It should be given in moderately large doses, 10 grains being generally sufiicient, but it must be continued regularly for some days, and ac- companied by saline purgatives and a reduced amount of animal food. Some individuals are prone to headache from climatic conditions, whether due to variation in the direction of the wind or to change of locahty — such headache is either referred to a cold dry air, described as bracmg, or to the opposite state of moist warmth, known as relaxing. The first may be met by a combination of Iodide and Bromide of Potassium or by a mixture containing Potas- sium Citrate, Acetate of Ammonium, and Nitrous Ether ; whUe the other is in a measure counteracted by Nux Vomica combined with Quinine and Ammonia. Unless, however, headache is really severe and per- sistent, it is scarcely necessary to have recourse to drug?, since the symptom subsides after a while as the system becomes adjusted to the altered conditions. Wind and fog also induce headache in many in- Sea-Sickness i43 dividuals, but scarcely to the extent of requiring medica- tion, even if such could be beneficially applied, and the same may be said of headache following prolonged cold bathing, since this usually subsides as the surface tem- perature is restored. Sea-Siekness. — Nausea withdepression, amounting in severe cases to collapse, and actual vomiting is only too well known as an accompaniment of sea voyages. The disturbance is commonly associated with the un- accustomed movement and may affect those who are susceptible in a train journey, while swinging, even in a rowing-boat on still water, or under the influence of any varied and unusual motion, such even as riding in a carriage ; and the motion of a camel, which has a peculiar side-to-side gait, is especially obnoxious in this respect to novices. The causation of the malady is not so obscure as com- plex. Many persons on commencing a descent, as in a lift, are conscious of a peculiar sensation of sinking in the epigastric region, which when frequently repeated, as in the pitching of a vessel, appears to induce nausea culminating in vomiting — besides this, the confused visual sensations due to the complex motion of a boat pitching and rolling, and the effect of these movements on the semi-circular canals, induce giddiness and vertigo through their repeated and alternating impressions on the equilibrium centres in the cerebellum and corpora quadrigemina, adding headache and collapse attended with faintness and chilliness, so that a condition ul- timately results similar to that of concussion of the brain or nervous shock. The patient becomes pale with clammy cold skin and suffers from deadly nausea, vomiting of reflex char- acter with voiding of the contents of the stomach and duodenum and sometimes diarrhoea. Attacks of hemi- crania often occur in those who are subject to it, and 1 44 Sea^SicknesS complete nervous prostration with muscular relaxation ensues, sometimes with loss of consciousness, so that the similarity to the effects of a blow on the head is very close. People are not all affected in this way, though cer- tainly the majority suffer to some degree. A few for- tunate individuals even of a highly developed nervous type do not know what sea-sickness means, others suffer only slightly or for a brief period and perhaps not on every voyage, the disturbance depending on the state of health or the degree of movement. Custom has an educating effect and the symptoms diminish with use, but this is not always the case, and even some seamen suffer at the commencement of each voyage ; and in continuous rough weather, though actual vomiting does not afflict a hardened crew, there is a disturbance of appetite, temper, and equanimity which is attributable to the persistent turmoil. In recent times the increase in size of ocean-going steamers has greatly improved their steadiness, and the frequency of sea-sickness has correspondingly di- minished, so that we no longer hear, as formerly, of per- sistently sea-sick persons being put ashore on the voyage to the East, as the only means of preserving life. The most constant scene of the malady now is pro- bably the Channel crossing, where the boats are relatively small, the sea choppy, and the travellers inexperienced. It may be also that Continental people, who form a large proportion of the passengers, are more susceptible than ourselves, but whatever the cause there is certainly no lack of sea-sick folk on these short journeys. Many people appreciate on going on board that all their senses are assailed at once. The rattle and din of machinery, the waving spars, apparently rising and falhng horizon, and the close atmosphere of the saloon laden with odours of cooking and machine oil, to which Sea^Sickness 145 are soon added the sight and sound of those who are already overcome, added to previous apprehension and often an empty stomach, render them speedy victims. and once estabhshed the symptoms are certain to con- tinue and increase during the continuance of the brief voyage. In most instances the attack passes off in the course of two or three days even on a long voyage unless bad weather is encountered, and there are those who aver that it is worth while to go through the preliminary discomforts for the sake of the renewed health and vigour that usually succeed. On the other hand, those who land after an incomplete experience commonly suffer from gastro-intestinal derangement with headache, vertigo, and malaise for some days ; so that any treat- ment that can be adopted is best directed to entire prevention, or such mitigation of the symptoms as circumstances permit. The remedy which has been hitherto most popular is bromide of potassium, though the corresponding salts of ammonium or sodium might be even better, and a combination of the three best of all. The important conditions are that a full dose (5 j ) should be taken sufhciently diluted in half a pint of mineral water about an hour or at least haff an hour before commencing the voyage, so as to give time for absorption before this necessary function is disturbed. The patient should lie down, selecting a position as near the centre of the vessel as possible, keeping the head low and taking precautions against cold, especially if remaining on deck, as is gener- ally advisable, and it is better to lie lengthways rather than across the vessel since the lateral motion is commonly the more extensive, and rolling from side to side is less upsetting than the alternate tipping up of the head and feet. Moderate pressure on the abdomen by a pad and firm bandage is a comfort to some. A full meal 10 H^ A Specific should be taken two hours before starting, as the stomach is less impressionable in mid-digestion. Many who feel uncomfortable during a short voyage are really suffering from fatigue and lack of food imposed by restlessness and the apprehension of being ill, and not from mal-de-mer at all. In any case retching is more likely to occur and is more distressing with an empty stomach, and the at- tempt to make the deficiency good while on the vo^^^age is a doubtful experiment. A more modern and still more efficient preventive is chloretone. This camphor-like substance, triclilor- tertiary-butyl alcohol, is nearly insoluble in water and volatilises easily at comparatively low temperatures. It should therefore be kept in a stoppered bottle, or, if made up in powders, should be enclosed in paraffin paper, but is most conveniently taken in gelatine cachets ; 5 grains is usually a sufficient dose, the sedative effects lasting five or six hours. Ample experience of its value has already been obtained not only in single doses for short voyages, but when repeated twice a day for longer voyages, and it may be considered quite reliable. The ultimate remedy to fall back upon in obstinate and protracted cases is morphine, which has the advantage of being administered subcutaneously and so acts in spite of vomiting. A quarter of a grain is usually suffi- cient, and as it may need repetition the dose is best kept within small limits. For the general regimen in those who suffer in spite, or in the absence, of remedies ; recumbency, fresh air, and abstention from food must be adhered to ; cold drinks such as lemon juice with effervescing mineral water, whisky or brandy with aerated water, and later diluted milk or perhaps bottled stout or ale with a few biscuits, can be taken ; but for the most part it is as well to take nothing but water to wash out the stomach and ease the Palliatives 147 vomiting until recovery ensues spontaneously, as it usually does in twenty-four to forty-eight hours. If the voyage lasts a week or longer, the restored health and appetite speedily make amends for the wastage of the first days. Curiously enough, invalids and convalescents, who form a considerable proportion of those crossing the Channel on the way to health resorts, suffer less in this respect than many in robust health, so the dread of sea- sickness, especially with the aid of chloretone, need be no deterrent in such cases. It might be added that in this as in most other phy- siological disturbances the young commonly get over their discomfort more quickly than those in a later period of life, in whom the general disturbance is more profound, and there have been instances in which the headache, vertigo, and nausea have persisted for days or weeks after landing and have been the forerunners of serious lesions of the cerebral vessels resulting in apoplexy and hemiplegia, in those suffering from degeneration of the cerebral arteries. CHAPTER V THE CIRCULATORY SYSTEM It is a pretty constant experience in practice that patients complain of weakness and of being readily fatigued, without mentioning anything more definite, or alluding to any local distress. Examination often fails to discover any organic lesion adequate to explain the loss of vigour. There are, however, certain obscure complaints to which such symptoms may be assignable and which should be considered before concluding that the condition is functional. Chief among these are diseases of the heart and kidneys. Long before dropsy develops, or any other sign which attracts attention to either of these organs, a con- sciousness of failing power and of inability to perform ordinary avocations, or of greater effort in doing so, impresses itself on the patient's mind. Every now and then careful examination of the urine will reveal the presence of albumen, pus, or tube-casts, or perhaps only a constant deficit in the output of solids, so that there is persistent low specific gravity. La connection with the heart, apart from definite valvular mischief, which however may first be recognised, especially in elderly people, in consequence of complaint of languor leading to examination, there may be found weakness of the heart's action from defective contractility associated with myocardial disease or degeneration, which is a very obscure matter, sometimes dependent on alcoholism or syphilis which may not be avowed. Such myocardial disease may not give rise to any 148 Obscure Organic Diseases 149 obtrusive murraur, but the weakness of the heart sounds and impulse with some displacement of the apex beat may be all that can be discovered. Sometimes there is a mitral systolic murmur from dilatation associated with a flipping first sound, and occasional irregularity of a weak, pulse. Further evidence may be found in con- gestion and oedema of the bases of the lungs, and closer questioning may elicit a confession of sensations of faintness, palpitation and muscular cramps, or of vertigo on rising and loss of breath on slight exertion. These indications in a patient past middle life may be the precursors of acute cardiac failure or of a cerebral attack from embolism, thrombosis, or haemorrhage. It may be assumed that aneurysm of the arch of the aorta in any part would reveal itself comparatively early, but there is one region — namely, the descending thoracic aorta — in which such disease has been hitherto almost invariably overlooked. Rarely reaching the surface, and not interfering greatly with any important organ, such aneurysms often attain the size of a cocoa- nut or larger without attracting attention ; the only indications being pain referred to the left side of the thorax, varying in intensity and often more noticeable at night ; this feeling of fatigue and want of energy being associated with low arterial tension. There must be in every one's experience instances in which a sudden profuse and fatal hsemoptysis has been the first, last, and only recognised indication of this disease, and whatever may be the opinion as regards the cura- bility of this disorder and the wisdom of allowing the patient for his own peace of mind to remain in ignor- ance of it as long as possible ; no medical man would feel easy should such an accident occur to one of his patients whom he had recently passed as sound, or would forgo the manifest advantages of correct prognosis as affecting his patient's affairs and his own credit. 1 50 Debility When any suspicion of the kind arises, practical certainty can be attained by the use of the X-rays either by a radiogram or the use of the screen. Other obscure causes of general weakness are diabetes and Addison's disease, the manifestations of which are familiar enough, but it is important to bear them in mind in this connection, since patients more often complain of weakness and fatigue than of the more characteristic features of these disorders, and these may only appear at a later stage and require special investigation. In all cases then in which weakness, languor, and fatigue are complained of, these obscure diseases, for the most part productive of low blood-pressure, should be borne in mind, particularly when they are persistent and perhaps associated with actual loss of weight. Having excluded these obscure and somewhat rare organic diseases, there still remains a very large residue of cases in which weakness and fatigue are persistently complained of, and which are usually regarded either as cases of " anaemia and debility " or else as neuroses. The subjects of ansemia and debility exhibit de- partures from the normal standard of health rather on the negative side, such as defective nervous and muscular power, loss of appetite, unsatisfactory digestion, and con- stipation associated with some pallor and possibly lessened force of the heart's action ; resembling in many respects the features of convalescence from acute disease but without any such history. Instances of this kind occur at all periods of life from childhood to old age, and appear to be associated mainly with indoor and town life and a deficiency of sunlight, fresh air, and healthy exercise. The best remedy, as in the case of convalescents, is a change to the country or seaside, preferably where the air is bracing — that is, cool and dry. Prugs are of secondary importance, but where circum- Neurosis 151 stances do not permit of change of air, a bitter stomachic with ammonia or mineral acid, the combination of iron, arsenic and strychnine, or such a preparation as Easton's s;/rup, is usually prescribed, with such emendations in the matter of food, rest, recreation, etc., as the circum- stances permit, for it must be admitted that " res angusta domi " have often much to do with this condition. The cases of neuposis, in which fatigue and weakness are the main complaint, are generally recognisable both by their persistence and their peculiar psychical features. They are characterised by introspection and the tendency to pay as much or more attention to subjective sensations as to objective impressions. They can always be relied on to undertake the handling of their own case with conspicuous lack of success, but their assumed better knowledge, objections to the remedies advised and fore- casts of failure, are serious stumbling-blocks to the practitioner, unless he is one of those who can subordinate rational therapeutics to the arts of the psychological conjurer. For the most part the bromides and valerian have chiefly proved of service, outside the special cures advocated in such cases, but the subject has been fully dealt with in Goodhart's Common Neuroses. Perhaps there is no expression so frequently employed in regard to a somewhat vague condition of ill-health as that of being "pun down." The phrase appears to cover a condition of asthenia which is unassociated with definite physical signs of disease in any particular organ or system. The term has no doubt taken its origin from analogy with the feeble action of clockwork at the end of its spring, and connotes a general reduction of activity of most of the bodily functions, though the most prominent features may be associated with the nervous system. The daily life of most people involves the performance of duties which are not associated with immediate pleasure or profit, and even where these are involved there may 152 On being ^*Run Down^' be an output of energy which is not always adequately balanced by corresponding rest and nutrition. This results in the exhaustion of a latent store of energy and energy-supplying material, together with an accumulation of effete matters which tend to silt up the machine. The functions of nutrition and elimination fail at times as the result of over-action or want of sufficient stimulus in motive or occupation. Such may be the result of con- tinuous monotonous drudgery, or special application which has interfered with the reasonable distribution of the energies in other directions. It is commonly met with in those who have been in attendance on sick rela- tives, where constant watching is associated with keen anxiety and the exercise of continuous self-control, or may result from the undue expenditure of nervous energy associated with too active social life, much excite- ment, and insufficient rest. The condition of being " run down " shows itself in failing energy, loss of appetite, and deficient action of the various secretory organs. The complexion becomes pale and clouded, there is a want of animation, and often actual mental depression, the organism ceasing to re-act satisfactorily to accus- tomed stimuli. Desire fails, and often the sufferer is so enthralled in worries and anxieties that it appears impossible for him to free his mind of them, depute his affairs or suspend his attention even for a time. The chief remedy for this state of things is entire change of occupation and surroundings. For a few days at least the individual must shake off the routine which has consumed his energies in one particular channel. Not merely rest is required, but rest in association with such enjoyment as may be within reach, and in most instances in an atmosphere different from that in which the patient usually lives. Relaxation for a time from the strain of watching, from the monotony of simple duties, from the contemplation of matters incapable of Remedies 153 satisfactory solution, and from uphill work in general, are essential for the mind to recover its elasticity, so as to regard affairs in a proper light, to restore the sense of proportion, and to re-awaken the energies which are in abeyance. Atmospheric conditions may have some share in the development of this state, and it more commonly occurs in the spring or late winter, when warm weather succeeds to cold, after a prolonged imprisonment within doors, and perhaps a greater lack of variety of life than is possible under more favourable climatic conditions. The alteration of health is not limited to mental disturb- ance, but shows itself in lowered arterial tension, dilated pupils, loss of muscular tone, and deficient force of the heart beat, with some loss of fat and often a tendency to lymph stasis and loss of elasticity in the skin, manifested by fiabbiness of the tissues, especially noticeable in the face. It is generally believed that in addition to what has already been mentioned there is a further constitutional weakness leading to a greater tendency either to contract contagious disorders or to develop others to which the patient may be subject or exposed. The absence of efficiency in work and loss of power of enjoyment, with disturbance of the usual mental characteristics, together with the tendency to develop or acquire definite maladies, render it important to restore the proper state of health without delay. As has already been suggested, the most effective remedy is a complete change of locality and occupation. Some new interest should be encouraged for a time, and if the patient can healthily indulge in a favourite hobby, so much the better. In the absence of this, residence with friends or in an hotel or hydropathic establishment would be useful, unless the patient is really unable to free himself from the daily routine ; in which case some definite change must be effected in favour of relaxation, exercise in the open air, change of diet, and early hours. In regard 154 The Rest Cure to drugs the most useful are mineral acids and combina- tions of strj^chnine, quinine, or other preparations of cinchona. Some stimulant may be needed, and at first mild mercurial purgatives followed by salines. Extreme cases of this kind, particularly in women, are constantly treated by a modification of the Weir jMitchell system which has been termed the " rest cure." The principle is the " conservation of energy " by keeping the patient in bed while feeding generously. A most important feature, however, is removal from the ordinary environment and the substitution of such quiet interests and companionship as may keep the patient's mind away from habitual worries. Those only who are confidants in the daily life of men and women know the harassing strain constantly put, more especially on the latter, in endeavouring to maintain uniformity of behaviour and demeanour under difficult circumstances — trying to keep one's temper and some one else's as well, suppressing natural inchnations out of consideration for others' interests, and pulhng generally against the stream. These things produce a civil war of emotions which leads to nervous exhaustion and can only be remedied by seclusion of the patient and exclusion of relatives and friends for a time, under judicious professional advice. A small proportion of cases only call for such a re- latively severe measure, and only a minority could afford the usual expense in a special establishment. Variation in the Tension and Distribution of Blood in the general circulation is liable to produce minor discomforts when the general tone of the system is relaxed. Such sensations as " pins and needles " in the ex- tremities, or numbness from relatively slight pressure, are prone to occur with very much greater frequency at such times than at others. This would appear to be due to loss of tone in the muscles associated with deficient arterial Syncope 155 tension. Under healthy conditions the general sustained muscular contraction tends to hold open not only the local vessels but to protect from pressure the main trunks lying between and beneath the muscles. When this is relaxed, these, hke pads of wet clay, offer no support, but tend rather, under the weight of the body, to oblite- rate the lumen of these trunks. This results in diminu- tion of the circulation not only in the distal part of the limb, but especially in the nerve trunks themselves. The aching tenderness which follows change of position is an indication of the restoration of circulation to the antemic parts. It may be noted that the effects of alcohol have a strong tendency in this same direction, and the worst cases of so-called " pressure paralysis " result from the deep sleep and relaxed arterial and mus- cular tension associated with excess of alcohol, and have been sometimes spoken of as " Saturday night paralysis." The recurrence of these minor discomforts in the general circulation indicates the desirability of taking such cardiac and general tonics as strychnine or quinine. Syneope. — Sudden loss of consciousness, associated with failure of the circulation, not involving serious organic disease, is frequently met with in young adults of both sexes. The most common exciting cause is emotional excitement, often associated with extremes of heat or cold, or impure atmosphere. It may also result from sudden attacks of acute pain, or from the lack of food. On this account it is particularly liable to occur in the early morning when any demand is made on the energies before breakfast, more particularly within doors. The preMminary sensations are usually tingling in the extremities, a feeling of giddiness and coldness, a slight clammy perspiration, and a gradual failing of the senses marked by apparent remoteness of sights and sounds, until consciousness is entirely lost. Complete relaxation of the muscles occurs, so that the patient subsides in a 156 Syncope heap, contrasting with epilepsy, in which the muscles are rigid and the patient falls more violently. The appear- ance of a person about to faint is characteristic. He becomes rapidly pale, has a vacant expression, the lids fall over the eyes, and the hands become flaccid and the grasp uncertain. In syncope of this description the attack is rarely so absolutely sudden but that the patient can lean on or seize some neighbouring object, and actual injury rarely occurs, unless there is proximity to some dangerous object, such as a fire, or declivity. In many cases, on feeling these indications, the patient attempts to reach the open air, and the effort of doing so, and assuming a vertical attitude, precipitates the attack. Actual fainting may often be averted by taking a con- trary course, sitting with the body forward and lowering the head as far as possible between the knees. This not only facilitates the circulation in the brain, but by com- pressing the abdomen expels a good deal of blood which is accumulating there. After a few minutes in this position the patient may be sufficiently recovered to attempt to get up and walk into the open air. When called upon to deal with a patient who has actually fainted, the first necessity is to get him into a horizontal position, to release any clothing which may be impeding free respiration and circulation, and to obtain as much air as is possible, at the same time applying any stimulant that may be at hand. The application of ammonia vapour to the nose is a common remedy, and even more effective is the application of cold water, especially to the face and behind the ears, and the administration of a strong stimulant by the mouth. As a fainting person is unable to swallow it is best to apply a crude spirit such as brandy or eau de Cologne to the inside of the lips and gums. By these means recovery may be so far advanced that the patient can be slightly raised while he sips some stimulating fluid. Palpitation 157 The mere act of sipping is in itself a stimulant even in the case of cold water, but a more rapid stimulating effect is derived from hot spirit and water in a very small quantity, — about a wineglassful. Syncope almost always occurs while the patient is inactive, and practically never during exertion. Even on recovery movement is sufficient to stimulate the circula- tion, so that there is little fear of recurrence if the patient is able to walk. This tendency to fainting is almost limited to adolescence, and is to be avoided by discouraging occupations of an inactive character before taking some nourishment. Palpitation. — Apart from any serious organic dis- order of the heart, occasional irregularity of the beat is met with at intervals in many healthy individuals. These disturbances are characterised by hurried and tumultuous action, sometimes by what appears to be an occasional tumble in the cardiac region, producing a sudden start either when waking or sleeping. This disturbance nearly always depends on some reflex impulse convej^'ed by the pneumogastric nerves. The most frequent instances occur in minor forms of indigestion, which have been already alluded to. It most often ensues in connection with gastric distension, usually by gas, and is occasional and of only temporary duration. The treatment of this necessarily involves the correction of the stomach dis- turbance, and is mostly met by antacids, such as the compound of equal parts of bicarbonate of soda, phosphate of soda, magnesia, and white sugar, of which a teaspoonful may be taken frequently. Another cause of common occurrence is the over-use of tobacco, especially in those not thoroughly accustomed to it. This induces increase of vascular tension, and may lead through this to insomnia and to tumultuous and forcible cardiac action, which is particularly distressing when lying down at night, and is more noticeable when the patient lies on the left side. 15^ Treatment Such an effect after the use of tobacco, whether in large or small quantity, is an important intimation that it should be discontinued for a time and certainly employed in reduced amounts, A persistence in tobacco smoking, in spite of this warning, leads to further disturbance and dilatation of the heart with very much more serious symptoms, which may even prove fatal. During the recent epidemic of influenza there have been very numer- ous cases in which a cardiac neurosis has taken the form of these attacks of palpitation, accompanied by either faintness, nausea, or giddiness. These do not commonly extend over longer periods than two or three weeks, but in some instances have settled down to persistent tachy- cardia of indefinite duration. Under the influence of emotional excitement palpitation of the heart is familiar to nearly every one, but when brought about by trifling psychical disturbance it should be regarded as an indica- tion for adopting a period of rest or a more even mode of existence. For various nervous disturbances of the heart cactein in the form of pillets, containing ^^ of a grain of cacteina, have been much used. They may be taken three or four times a day and increased from one to four at a time. The effect of overstrain of the heart not uncommonly results in turbulent action attended with dyspnoea, and is more liable to occur where any unwonted exertion is made without proper precaution, or by adults who are not accustomed to it. In connection with mountaineering it is a familiar experience with some to be arrested by lack of breath, on commencing to climb. For such the guide usually waits a few minutes, as it is only the result of some failure of the right heart which may presently recover, and the climber with care is able to continue walking for several hours. On the other hand, where a general tremulousness with weakness of the limbs shows itself, the guide refuses to proceed, these indications pointing to failure of the left heart, which is Epistaxis 159 more likely to be increased by further exertion, and later on lead to entire collapse of the climber. Many people may accomplish by slow degrees what cannot be effected in a hurry, and the expression, "It is the pace that kills," should be borne in mind where signs of cardiac over- strain show themselves. It would be wise if persons past middle age, at all events, could devote some time to training the heart by moderate and varying exercise before embarking on any violent or sustained exertion. Epistaxis. — Nose-bleeding is a very common occur- rence at all ages, but particularly in children. Apart from any injury it occurs as a result of excitement and often comes on quite spontaneously. The bleeding is usually restricted to one nostril and can be traced to a point about f of an inch within it, at the junction of the floor and septum. This corresponds to the position of the naso- palatine artery, an anastomotic vessel joining the internal maxillary and palatine arteries, and it is from this or one of its branches that the blood usually comes. The practice of advising a patient to lie on the back merely obscures the haemorrhage by permitting it to take place into the pharynx, though this position, by acting as a sedative to the heart, may have some influence in arresting it. Physiologically the means of stopping such haemorrhage is by raising the arms above the head. This causes con- traction of the vessels of the head and neck, and may even induce a feeling of faintness. Another method is the application of cold either behind the ears or to the nape of the neck. This is commonly effected by a piece of metal such as a door key, and is also effective in bringing about reflex contraction of the artery. Of local measures the most immediately effectual is undoubtedly the application of a solution of adrenalin, 1 in a 1000 or weaker, on a pellet of wool to the affected nostril. It must be inserted sufficiently far to reach the bleeding point, and for this purpose it is best i6o Varicose Veins and Phlebitis wrapped on a probe. Tincture of hamamelis, or Pond's extract, answers the same purpose, but these m(;asures failing the nostril must be stopped efficiently. The old practice of plugging the nostril back and front with rolls of lint should only be resorted to in the last instance. The cleanest and simplest apparatus is an indiarubber bladder shaped like an hour-glass, which can be inflated with air after insertion, but a very good plug may be rapidly made by shaping a piece of raw bacon fat to the size of the nostril. Either of these is easily adjusted, delays the flow of bloodsufficiently to permit of its clotting, and can then be easily removed. The danger of the more complete older methods w as the occurrence of sepsis which arises very early in connection with blood clot in a cavity abounding with micro-organisms. After removal of any of these plugs the nostril should be washed out with an antiseptic solution such as has been already mentioned in dealing with Catarrh. Where epistaxis occurs re- peatedly, constitutional remedies should be employed to deal with the cause of the complaint. In the simpler cases mild purgation may be sufficient, but in those where there is a general tendency to haemorrhage, as in some instances of chlorosis or anaemia allied to scurvy, it is better to administer lime salts, as chloride of calcium, in doses up to a drachm daily. Where there are no other indications of haemorrhagic tendency, and bleeding recurs from the nose, a careful examination should be made to ascertain if there is any local disease, such as ulcer or angeioma. Vapieose Veins and Phlebitis. — Varicose veins are immediately apparent, inasmuch as the vessels affected are superficial. They usually occur in the lower ex- tremities, more particularly on the left side, and are met with at almost any period of life, although most frequently appearing between the ages of twenty and thirty. Here- dity seems to play an important part in the occurrence Treatment 1 6 1 of the condition, though anything which interferes with the circulation, such as pregnancy, may also lead to their development. Occupations involving long-continued standing, habitual constipation, and the use of tight bands round the leg are very commonly accessory causes. The vessels become thickened, distended, and tortuous, the valves are rendered inoperative, and the weight of the entire column of blood is thrown on the lowermost veins. The circulation in the lower parts of the leg is often impaired, especially that in the skin. The Hmb feels heavy and painful, and after exertion or stand- ing there may be a little oedema of the ankle. The circulation in the skin being reduced, pigmentation and eczema may result, and any scratch or abrasion, instead of heaUng, tends to spread and form an ulcer — this ulcera- tion may extend through the vein wall, producing a most dangerous hsemorrhage. Injury to the vein may lead to thrombosis and spontaneous cure. Persons with varicose veins are especially liable to phlebitis ; if limited, this is not of serious moment, but sometimes the throm- bosis spreads into the larger veins while fragments of clot may be detached as emboli. On account of these dangers, as well as the discomfort attending varicosity in the veins, treatment should never hb neglected. The treatment of this troublesome complaint consists in removing all sources of obstruction in the form of tight bandages or garters, restricting the amount of standing and keeping the bowels well opened, together with the use of elastic bandages or stockings. Shght degrees of varicosity can in this way be dealt with, and only in the worst cases, in which hsemorrhage occurs and inflammation is frequent, need surgical methods be resorted to. Nothing is gained by resting too much^ movement rather helping the circulation than other- wise, especially when support is maintained. As a II 1 62 Varicocele primary affection, inflammation of the veins or phlebitis is usually rheumatic or gouty, but where coagulation of the blood has already taken place secondary in- flammation of a varicose vein frequently follows. In either case this is associated with pain and tenderness, with some local redness and swelUng, and is a sufficient indication that the patient should He up and rest the limb. The best local application in such a case is a mixture of equal parts of the ointments of belladonna and mercury. The limb should then be slightly raised and maintained absolutely quiet either on a pillow or in a sling. A period of six weeks is usually arbitrarily allotted to the cure of this affection, but half that time is often sufficient to allow the active changes to subside, and when there is no oedema, pain, or redness the patient may begin to get about provided sufficient pressure is main- tained on the damaged vessel to hinder the dislodgment of any loose clot. There is not sufficient evidence of iodide of potassium exercising any influence in causing disappearance of the coagulum for it to be systematically recommended, though in gouty cases in combination with salicylate of soda it may help to control the recurring phlebitis. In rheumatic cases salicylate of soda may be given internally, though it is better applied locally, as Gaultherium Oil 2 drachms to the ounce of Lanoline, to which 15 grains of Menthol may be added to relieve pain. Where signs of suppuration occur hot fomentations should be resorted to, and speedy evacuation of matter en- couraged. Varieoeele. — This, in some degree, is a very com- mon ailment though not always recognised by the patient and not always mentioned when discovered. Tho left side seems most often affected on account of the rect- angular junction of the spermatic with the renal vein not serving as a valve, as is the case with the more oblique opening into the cava on the right. Varicocele 163 Patients with varicocele chiefly complain of aching and dragging pain referred to the loin and abdomen, which may extend to the leg, causing a sense of weariness in standing and walking, attended sometimes by f aintness and nausea. An impulse may be appreciated on coughing owing to the continuity of the vessel within and outside the abdomen. The distension and tortuosity in the upper part of the scrotum can only be appreciated when t£e body is erect, and this sometimes leads to its being overlooked on examination when not directly mentioned. A man of thirty once consulted me on account of frequent " stomach ache," which occurred particularly when standing or sitting and not while lying down. Nothing amiss could be discovered in the abdomen while recumbent and no complaint was made of the scrotum. It was only by catching sight of the distending veins as he got up that double varicocele was recognised. IVIinor degrees of the condition may be temporary depending upon slight failure in the general health, cough, straining at stool, or a warm moist atmosphere, and may be remedied by cold bathing, tonics, and support ; but the severer and persistent degrees require careful surgical treatment — ligature of the distended vein, without injury to the cord, nerves, or artery. IJptieapia. — A capillary disturbance, chiefly notice- able in the skin as Urticaria, but liable to affect mucous membranes, especially those of the larjmx and bronchi, may follow copious draughts of cold fluid when the body is overheated, the ingestion of shellfish and other causes of gastric irritation, or the cutaneous phenomenon may result from sea-bathing in susceptible subjects. Immediate relief is usually obtained by taking ten or fifteen grains of aspirin, but it is useful to employ a brisk purgative as well, and in persistent cases ten-grain doses of calcium lactate. CHAPTER VI THE MUSCULAR SYSTEM The muscles themselves are for the most part free froix, morbid changes. The influence of their contraction on the vascular system is not always sufficiently appre- ciated, though this is considerably modified by physical activity. The blood may be considered to be divided principaUy between the skin, muscles, and viscera. Con- sequently a reduction of blood in the skin as a result of cold, and in the muscles as a result of cold or of inactivity, permits of an undue quantity of this fluid being distributed to the internal organs. Physiologically this may be of value in such circumstances as digestive or special brain activity in which there is a tendency to chilliness or actual coldness of the extremities while the main current of blood is so diverted. In the treatment of chronic valvular disease of the heart by the Nauheim system of baths and exercise, the distribution of blood in the skin and muscles by surface stimulation and rhythmical movements is taken advantage of to relieve the tension of the circulation and the work of the heart by widening the channels of peripheral distribution. On these lines the value of moderate exercise to the point of causing extra vascularity and functional activity of the skin and muscles may easily be appreciated in the reUef they afforc? to the heart and the extra freedom in the circulation oi x;he blood through the lungs and body generally. It is a peculiarity of the arrangement of the vessels 164 Muscular System 165 within and between the muscles that functional activity- tends to cause dilatation rather than compression of them, and as most of the cutaneous vessels are derived from muscular branches, the vascularity of the two systems is affected synchronously. A- very suggestive feature in connection with the muscles is the presence in them of haemoglobin, to which their colour is largely due, and which varies considerably in different states of the organism. For instance, in cases where death has been associated with cyanosis the muscles are very dark, while in those associated with deficiency of haemoglobin in the blood they are very pale ; indicating that the haemoglobin of muscle shares the changes of the blood. Individuals with large muscles are usually plethoric and those with small muscles commonly pale and exsanguine. That haemo- globin may possibly be stored in the muscles and trans- ferred to the blood is suggested by the case of a man recently under treatment by enemata of water only on account of gastric ulcer with haemorrhage, in whom distinct improvement in colour and the character of the blood occurred during a fortnight's entire abstinence from food. The function of haemoglobin, whether in the blood or muscles, is chiefly, if not entirely, as a holder of available oxygen, and the marked effect of muscular exertion in producing dyspnoea either in health or disease is striking evidence of the activity of oxidising processes in con- nection with muscle activity. It is also a well-known fact that in those who show a tendency to gout, acute attacks are specially liable to occur during periods of physical inaction — that is, while the metabolic changes in the muscles are suspended. The beneficial effect, therefore, of regular physical exercise must be attributed to the intrinsic influence of muscular metabolism on nutrient matters in the blood 1 66 Sprains leading to their complete oxidation as well as to the assistance their alternate contraction and relaxation afford to the circulation in the arteries, veins, and lym- phatics, and the stimulating effects on the functions of the heart, lungs, and, indirectly, the excretory organs. On account of the abundant demand for oxygen entailed, such exercise should be taken preferably in the open, and in the purest available air with careful avoidance of tight clothing or anything impeding respiration, and should be accompanied by a plentiful supply of fluid to encourage the solution and excretion of effete products — these requirements being in accord with the familiar indications of nature. Sprains. — Although the muscular tissue itself is but slightly prone to disease, the sheaths, the tendons, and the aponeuroses are very susceptible to slight injury, and the influence of such diathetic states as rheumatism and gout. In consequence of undue efforts, associated rather with mal-position and falls than with simple muscular contraction, the tendons are Kable to give way or to suffer partial disturbance of their attachments, giving rise to injuries known as " sprains." The term " sprain," commonly applied to local injury resulting from over-flexion or extension of a joint, necessarily involves stretching and injury to other tissues than the tendons, notably the ligaments and joints, as well as the parts covering them. Sudden and continued pain as well as swelling and tenderness are the usual accompaniments, and it is somewhat remarkable that though such fibrous structures as these are ordinarily insensitive, they develop acute sensitiveness with extra tension and inflammation. No small share in the sub- sequent effects of sprains is taken by the synovial mem- branes and tendon sheaths. Effusion occurs into both, so that some degree of synovitis and teno-synovitis is added. Sprains, then, are complex lesions, short ol Treatment of Sprains 167 actual fracture of the bones, or rupture of ligamentous structures, involving deep-seated haemorrhage from laceration of soft tissues and reactionary inflammation, though the actual limit of damage cannot always be estimated, and many severe sprains are found after some time to involve actual detachment of portions of bone, or rupture of tendinous structures. The uncertainty as to the extent of such a lesion suggests the inadvisa- bility of putting any strain on the affected part until recovery is secure. In those slight cases in which the immediate pain subsides in a few minutes, and is followed by no obvious sweUing, such precautions are uimecessary, but a few moments' rest will generally decide whether any serious damage has been done by the development or otherwise of swelling. Should this occur the joint must be fixed in a position of comfortable rest, and cold applied by means of wet cloths or an evaporating lotion. The old-fashioned remedy, tincture of arnica, is still often used, and its effect in cooKng the part by evapora- tion of the alcohol may itself be useful. SHght sprains may be remedied by firmly embracing the joint in every part with strapping, preferably of thin leather or kid, which sets a limit to movements and affords support without entirely disabling the hmb. Of all the joints probably the ankle is the one most commonly the seat of this injury, owing to its receiving the entire weight of the body, and the involuntary attempt to rectify mal-position by sudden tension of the controlling muscles. A very common feature of these injuries is the rupture of the tendon of the peroneus tertius, which results from sudden forcible inversion of the foot. The occurrence of this lesion can generally be traced by a line of tenderness extending to the base of the fifth metatarsal bone, also by ecchymosis here, and the notice- able absence of the tendon when the foot is raised. In most instances the breakage is made good by organise- 1 68 Synovitis tion of efFusion in the sheath which occurs in a few weeks. Synovitis. — The effusion of an extraordinary amount of fluid in a joint, usually as a result of over-use or a blow, accompanied by some degree of pain, is a matter of com- mon occurrence and one which is too often neglected. When effusion occurs within an hour of such injury, it is most often due to blood, the increase of synovial fluid taking a longer time. As the degree of pain in either case may not be intense nor protracted, patients are very apt to neglect the mere stiffness and swelling pro- duced by the effusion, and by continued use to render such either chronic or recurrent. Simple synovitis is usually distinguished from that due to rheumatism or gout by the relative absence of pain, and by a single joint only being affected. The important element of treatment is rest, the limb being placed in the position of greatest comfort, usually half flexed, and well supported. In case of restlessness, it may be necessary to place it upon a splint, extending sufflciently far above and below to fix the articulation and muscles. Not only should move- ment be prevented, but the patient should be discouraged from exerting any pressure on the joint, as in walking with a stiff leg. Local applications, first cooling, such as an ice-bag or evaporating lotion, are best, and subsequently some form of counter-irritation, such as preparations of iodine or a dilute ointment of the red iodide of mercury, 5 or 10 grains to the ounce. In the case of smaller joints, especially of the hand, the application of counter- irritation alone may be sufficient. Teno-Synovitis. — Effusion into the sheath of a tendon most commonly results from over-use, particularly in the forcible or continued use of some particular move- ment. It is met with most frequently in the wrist and hand, more particularly the thumb, and it is characterised hj tenderness and swelling in the course of certain tendons, Teno^Synovitis 169 the movements of which become stiff and painful. The rest obtained by a bandage exerting moderate pressure is usually sufficient to allay this, provided the particular movement is desisted from. Obscure pains and areas of tenderness in connection with the muscular system are often traceable to bursitis. Many of the superficial bursse are sufficiently well known, and effusion into them produces such noticeable swelling that they are not easily overlooked, but the deeper ones are more difficult to define, and it is rather by the situation and occurrence of the pain, in association with particular muscular movements, that the complaint is apparent. Common situations for trouble in these spaces are the outer side of the hip, beneath the tensor vaginae femoris, over the ischial tuberosity, under the insertion of the glutei muscles both behind and outside the trochanter, above the insertion of the ilio-psoas muscle, about the knee, and, perhaps most obscure of all, the large bursal space lying between the gastrocnemius and soleus in the calf of the leg. These bursse are liable to inflammation and effusion, in consequence of over-use and fatigue, and are sometimes affected by local pressure, or by gouty or rheumatic inflammation. The inflammation of the sural bursa has indeed often been mistaken for phlebitis. Traumatic bursitis may be relieved by counter-irritants and rest, and that of over-use and fatigue usually subsides with prolonged inactivity of the muscles, but is one of the causes of pain and aching which follow protracted exertion. Bursitis arising in connection with gout or rheumatism must be treated as part of this complaint, and in the case of sural bursitis the most rapid cure is effected by the local application of salicylate of methyl in fomentations or ointment. Some of the commonest instances of bursitis, synovitis, ?ind teno-synovitis are afforded by such local lesions 1 70 Bruises resulting from special use of particular joints, as golfer's shoulder, tennis and fisherman's elbow. Bpuises. — The extravasation of blood beneath and into the skin as the result of contusion is usually regarded as irremediable, and for the most part having passed through successive colour transformations it disappears, and causes no inconvenience beyond transitory tenderness. In some situations, however, it may be of importance to avoid discoloration, which lasts for a week or more. This can only be done by preventing exudation of blood at the time of injury, by cold or pres- sure. The avoidance of a " black eye " after a contusion by the firm apphcation of a piece of raw beef-steak is time-honoured, and fairly effectual. A pad of cotton- wool, soaked in cold water, is cleaner and as efficient, but to be effective the application must be made immedi- ately, and continued for a couple of hours at least. There are no means of hastening the removal of bruises which are once established and are passing through their colour gradations. Myalgia. — Pain associated with movement in the region of the muscular attachments, and excited by contraction, does not necessarily involve actual change in the muscle-fibre itself, and forthemostpart such pain comes and goes without any recognisable change in the size of the muscle, and without leaving any sequel such as fixation or loss of bulk. Tenderness on pressure there may be at times, but even this is rare and but slightly developed, the main feature being pain more or less sharp attending movements in which the particular muscle or group of muscles is involved, persisting but a second or two after the contraction has ceased, the intervals being quite free of discomfort or attended with but subdued aching. It may fairly be assumed, then, that the change consists in an alteration of vascularity with some excess of exuda- tiion, interfering with the free movement of adjacent Myalgia 1 7 1 structures, but restricted almost entirely to the fibrous parts, such as the attachments, sheaths, aponeuroses, and septa. In a considerable number of cases, termed myalgia or muscular rheumatism, the onset of the attack can be traced to cold, or cold associated with wet, to which the particular part has been exposed. Such attacks are more often unilateral, affecting particularly the side of the neck, constituting what is known as a " sti£f neck," or the muscles about the shoulder or hip. These attacks may be protracted over three or four days, causing limi- tation of movement, and appearing worse after prolonged rest, as on first waking in the morning. Other attacks, similar in many respects, affect the muscles of the trunk, more particularly in the upper, middle, and lower parts of the back, and for the most part come on spontaneously and are commonly discovered on making some extra- ordinary movement. These spontaneous attacks, which are indeed constitutional in origin, occur both in hot and cold weather, often in the absence of exercise, and depend upon toxaemia, usually associated with defective func- tional activity in the digestive tract, consequently they should not be treated nor regarded merely as local affections. They are best remedied by mercury or calomel in 2 or 3-grain doses, followed by salines. The salicylates and especially aceto-salicylic acid may be subsequently administered internally, or the salicylate of methyl, 2 drachms to the ounce of wool fat, applied locally, as the pain does not always entirely subside, though the acuteness is remarkably reduced by the mer- curial treatment. Though these local pains are spoken of as muscular rheumatism, they are unattended by any rise in temperature as in the articular disorder, and are not at any time associated with other recognisable mani- festations of rheumatism. The fact that the salicylates are helpful in remedying the complaint is no evidence of its being rheumatic, since these drugs are known to act 172 Myalgia efficiently in promoting the flow of bile and so prolong tlie effect of the mercury. Of all local measures none are so efficient as the application of heat and massage. A turpentine stupe applied for twenty minutes is often both comforting and curative. More generally distributed pains, associated with slight rise of temperature, are liable to recur from time to time in both adolescents and people of middle age. This general fibrositis in the young, often referred to as " growing pains," is not infrequently a rheumatic manifestation and deserves more serious attention than it commonly receives on account of the possible involvement of the heart, a matter of special importance at this age. In older people recurrent attacks of general pain in the muscles are usually referred to in- fluenza, but the fever is slighter, general nervous pro- stration less, and the rapidity of recovery greater than in that complaint. Discrimination between the two is more important since influenza requires rest, and subse- quent supporting regimen, while this general form of fibrositis rather calls for exercise and reduced diet, with diminution of stimulants. The pains in influenza are distributed mainly in the back, less in the extremities, are particularly intense, and associated generally with a temperature above 103° . The pains in what is probably toxic fibrositis are more widely distributed, persist for two or three days, and are unassociated with fever beyond a degree or two. What has often been termed a " crick in the neck " is occasioned by some forcible and unguarded movement, or more often by sleeping in an attitude which allows of persistent over-extension of some of the articulations. It often follows the use of too high a piUow when lying on the side. The pain is due to over-extension of liga- ments and articular surfaces, and is initially traumatic, but diathetic states are prone to express themselves in such slightly damaged localities and to render the pain Cramp 173 more lasting than it would otherwise be. It is hardly necessary to refer to the treatment of so slight a trouble except to point out its causation so that it may be avoided, and recourse should be had to remedies already mentioned when constitutional disturbance is responsible for persistence of the pain. Cpamp. — This consists in painful sustained involun- tary contraction of muscles or groups of muscles, usually associated with fatigue or toxaemia. In the latter case it may be associated with convalescence from cholera, influenza, or other acute fevers, and may take the form of tetany of the upper limbs. Attacks of cramp for the most part affect muscles whose attachments are approximated either actively or passively, and pass off with extension of the affected muscles and massage. When recurrences are frequent, warm bathing, antacids, and free imbibition of water assist in banishing them. The extremities are most commonly affected, but portions of the rectus abdominis, the platysma, extrinsic muscles of the tongue, or other groups may be affected, producing peculiar discomfort. CHAPTER VII SPECIAL SUBJECTS THE EYE Foreign bodies in the conjunctival sac constitute a very common source of discomfort, and are more formidable when, as frequently happens, gritty par- ticles become embedded in the surface of the cornea. Their detection requires the use of a lens, a good light, and the employment of a local anaesthetic, of which the best for general use is a solution of 10 grains of cocaine in an ounce of castor oil. By these means a minute examination may be made, and the half-buried particle, when discovered, should be removed carefully with a small spud, the eye being subsequently closed and covered with a wet pad. Such injuries most often result from cinders in the course of a railway journey, which leave small ulcers, taking twenty-four to forty-eight hours to heal. Over this period the occasional use of cocaine in oil is of great service. A foreign body in the conjunctival sac is easily exposed when in the lower part by pulling down the lid while the eye is directed upwards. In the upper portion a thorough examination is not so easy, as even if the lid be completely everted the upper portion of the sac still remains un- exposed. By gently tilting the everted lid while the globe is rotated downwards a foreign body there situated is usually brought into view. A small wet pledget of wool or camel-hair brush offers the best means of sweeping the object off the conjunctiva. In many instances by merely pulling the upper lid downwards over the lower 174 Conjunctivitis 1 7 5 so that its inner surface may be swept by the lower lashes, a foreign body in this situation is at once removed, or at all events displaced. Unless embedded in the conjunctiva or cornea most particles if left to themselves are swept oy the natural stream of tears into the inner corner of the aye, where they cease to annoy. Rubbing the eye should especially be avoided. Dust or infective material may lead to certain forms of septic inflammation, which often convey to the patient the same impression as grit in the eye, with hyperasmia of the mucous membrane, increased flow of tears, and often some flakes of lymph, which may be sufficient to cause the Kds to adhere. The milder forms of eonjunetivitis, with muco- purulent or catarrhal exudation, being contagious, some- times occur in epidemics, especially in schools. They are best treated by mild astringent or antiseptic lotions, such as 1-5,000 solution of perchloride of mercury, a 10 per cent, solution of boric acid or borax in distilled water, hazeline tiX XX to 5 j, acetozone or zinc chloride | grain to the ounce, the acetozone solution being filtered after standing four hours. To prevent the edges of the lids from sticking together, a simple ointment such as that of boracic acid should be applied along the edges of the lids at night. Isolation is necessary to prevent extension of the disease to others. In the more severe attacks attended by purulent dis- charge, more drastic measures are necessary, such as the apphcation of a solution of nitrate of silver 10 grains to the ounce, or of protargol 15 grains to the ounce, applied once to the conjunctival sac, followed by a continuance of the treatment by boracic solution and ointment. A septic form of conjunctivitis, commencing in one eye, though commonly affecting both, is frequently met with in cities during the summer as a result of infection by foul dust from wood pavements. 176 Phlyctenular Conjunctivitis Another form, especially common in children, is phlyetenulap eonjunetivitis, characterised by the presence on the ocular conjunctiva at the edge of the cornea of small white tubercle-Uke collections of leucocytes sur- rounded by a hmited vascular zone, into which a leash of dilated vessels can be traced across the white part of the globe. It is usually accompanied by photophobia and lachrymation, and is best treated by the local application of yellow mercuric oxide ointment gr. iv-viij to the ounce in soft paraffin, or by calomel locally, and a general tonic regimen, with an open-air hfe. Small haBmopphag'es in the conjunctiva are very conspicuous on account of the bright colour developed by oxidation of the haemoglobin through the thin membrane. They often accompany attacks of conjunctivitis, and may result from the paroxysms of whooping-cough or some local injury. They usually disappear in the course of a few days without any treatment. Episelepitis, an inflammation of the fibrous tunic of the eye, producing a reddish purple patch, usually between the cornea and outer canthus, sometimes results from exposure to cold as in motoring ; it is apt to last for some months, and to relapse. Pain and tenderness are variable, but inflammation may extend to the interior of the eye. It is more often met with in women than in men, and is generally associated with a rheumatic or gouty diathesis. Locally warm fomentations, with opium, massage, and leeches to the temple, may be required, but the main treatment consists in the administration of sahcylate of soda, iodide of potassium, or other constitutional remedy appropriate to the systemic conditions. Ciliapy blephapitis or Tinea Tarsi, a common in- flammatory afiection of the lid margins, is usually chronic, and either follows some acute fever or is associated with refractive errors or some general constitutional disturb- ance. The ciliary border is red and eczematous, and Meibomian Cyst 177 more or less destruction of the eyelashes is produced by the inflammation extending to the hair follicles. The best treatment is afforded by an alkaline solution such as that of bicarbonate of soda 15 grains to the ounce, with a weak mercurial ointment such as Unguentum Hydrargyri Nitratis, 1 drachm, diluted with 7 drachms of white vaseline, applied along the edges of the lids night and morning. In severe cases benefit results from removal of the damaged lashes and painting the borders of the lids with a solution of silver nitrate 10 grains to the ounce. Meibomian eyst, resulting from chronic inflamma- tion of the deep part of a Meibomian gland, with retention of secretion, is the commonest form of tumour of the lid. It forms a small hard white and painless swelling beneath the skin, and on everting the tarsus a bluish spot is usually seen, marking its site. Treatment consists in incising this spot, and evacuating the fluid and solid contents by pressure or a small scoop on the conjunctival surface. Such a cyst may suppurate, and must then be evacuated. Others may appear, whether the first be removed or not. They may be left alone unless very conspicuous, and in time usually shrink to some extent. More common are the small hard sebaceous or epi- thelial collections at the orifices of the glands at the lid margins internal to the lashes, which appear as little yellowish white spots slightly raised above the edge of the Ud. They are either soft or gritty, and may some- times be gently picked or rubbed off. They only rarely give rise to slight irritation. Stye has been already mentioned in connection with furunculosis of the skin. Tophi sometimes develop in connection with the tarsal cartilages as in the auricle, and may be similarly dealt with, but they are best left alone. Al trifling ailment is a slight shimmering of the orbi- 12 1 78 Musc3e Volitantes cularis muscle occurring involuntarily at certain times. It has been spoken of as " live blood " and its occurrence is an indication for the use of mild mercurial purgatives and salines. The yellowish dry patches appearing at the inner corner of the upper lid, known as xanthelasma, are some- times regarded as an indication of chronic liver disturbance and are best left untreated locally. MuseSB Volitantes. — Black or grey spots floating in the field of vision are commonly discovered by ado- lescents at some time, and can be observed by many individuals throughout life when looking at a plain Hght surface such as a white wall or cloud, or when read- ing or working with the microscope. They represent small particles in the vitreous and follow to some extent the motions of the eye. Beyond being the cause of some concern when first discovered and becoming more ob- trusive with defects of health, they are of no importance, and attention should be diverted from them. Synchisis scintiUans is a somewhat similar condition due to minute flakes of cholesterine in a fluid vitreous, possibly derived from a small haemorrhage. The appearance is likened to a shower of ghttering particles with each movement of the eye, and has been compared with that of the hqueur known as Eau de Dantzig when viewed with the oph thalmoscope. It is not amenable to treatment. It is a common experience after receiving a blow on the head or a sudden jar of the body to " see stars," or floating scintillations for a few seconds. This is probably associated with concussion in the optic tracts, as it is equally apparent when the eyes are closed and subsides rapidly. Some interference with vision accompanied by a sense of irritation in the eyes not infrequently follows exposure to strong light, such as the glare reflected from snow or water, or from looking directly at electric lamps or the The Ear 179 sun, and some years ago was commonly known as " eclipse blindness " on account of the number of persons so affected by viewing an eclipse of the sun without adequate protection. It results from fatigue of the retina, and passes off with time and protection from bright light. THE EAR The diseases of the ear which will be considered are chiefly characterised by pain, discharge, and either partial loss of hearing or the development of subjective sensations. The auricle being composed almost entirely of skin or fibro-cartilage may be involved in the disorders peculiar to the dermal covering, such as eczema, herpes, etc. These do not call for any treatment other than that applied to the rest of the skin. Deposits which are peculiar to the pinna are small chalk stones composed of urate of soda, regarded as an indication of gout, and which sometimes itch slightly. They may either be picked out when superficial or ab- sorbed by compresses of carbonate of soda or lithium solution. Another is haematoma, resulting often from injury, and made up of blood effusion between the cartilage and skin. This usually subsides to a great extent spontaneously, though often leaving some thicken- ing which is rather conspicuous. It may therefore be considered worth while to aspirate such effusions, with aseptic precautions, but should suppuration occur, as occa- sionally happens, an incision must be made to free the pus. The meatus is hable to inflammation from direct injury, particularly in scratching or attempts to remove foreign bodies, and sometimes by extension of skin disease from the scalp. This is productive of pain and subse- quently discharge, and where the lumen is obstructed may involve some temporary loss of hearing. There are 1 80 Furuncles redness and swelling of the skin round the meatus, a sense of fulness, throbbing, and occasional tinnitus, followed by serous or sero-purulent discharge. The epithelium becomes white and swollen, occupying a considerable portion of the lumen, and separates in flakes. Pain is increased by movement of the jaw or pressure over the ear, and there may be a sense of itching and heat, some- times attended by shght fever. These developments may follow the penetration of flies and other insects into the meatus, or the introduction of water when bathing. In the initial stage a cold compress or astringent lotion will give some relief. When the secretion is established the meatus should be washed out with a warm solution of boracic acid 10 grains to the ounce, and later with equal parts of alcohol and water ; or powdered boracic acid may be blown in with the aid of a small screw of paper. Should the discharge continue, the surface may be painted with solution of nitrate of silver 30 grains to the ounce, Liquor Plumbi Subacetatis, or Ung. Hydrarg. Subchlor. 1 drachm to the ounce. A similar condition to this often results in children from infection by pustular eczema, conveyed by the fingers or extending from the head. This is best treated by dilute white precipitate ointment, after removing the crusts with warm sweet oil. Fupuneles. — The occurrence of small boils in the skin of the meatus, due to inflammation of sebaceous follicles, leads to the development of acute pain, while the sweUing may close the lumen. The usual site is just inside the meatus, on the anterior or posterior wall. The deeper it is situated the greater the amount of pain. As in other diseases of the meatus, the pain is increased by movements of the jaw or pressure on the ear. Not un- commonly one such boil succeeds another from auto- infection. With discharge of the contents, the pain and swelling subside. For immediate relief a hot fomentation Cerumen 1 8 1 should be appKed over the ear and the side of the head, while a hot concentrated solution of boracic acid in alcohol should be instilled in the ear, or a plug of cotton-wool may be used, soaked in glycerine and laudanum, or laudanum, tincture of belladonna, and saturated alcohoHc solution of cocaine, in equal parts. Pus should be released by pricking the boil as soon as it can be recognised, and subsequent formation of boils can be prevented by the application of dilute nitrate of mercury ointment. Opium may be required to procure sleep, and constitutional treatment is necessary to restore the health, or such drugs as arsenic or sulphide of calcium given internally may control the further development of boils. Perhaps the most effective remedy is the injection of an antidotal serum prepared from the organism present. Cepumen. — As a result of high temperature, and perhaps more often in elderly people, a collection of wax and epithehum may cause a hard plug in the meatus, which acts as a foreign body, producing deafness, pain, and tinnitus, occasionally associated with vertigo or dry cough. This may sometimes be removed by syringing with warm soap and water. If it is too hard, it should first be softened by dropping into the ear at night a warm solution of bicarbonate of soda 10 grains to the ounce, or bicarbonate of soda gr. xx, glycerine 5 j and rosewater ^], or a few drops of oUve oil poured in from a hot teaspoon. In India similar plugs in the meatus are made up of a vegetable fungus mixed with epithelium, the condition being known as Otomycosis. Similar symptoms result, often accompanied by shght serous discharge. The treat- ment consists in frequent syringing with warm solution of perchloride of mercury, 1 in 1000, chlorinated hme 2 grains to the ounce, or hyposulphite of soda 4 grains to the ounce, followed by alcohol as an astringent, and to dry the surface. 1 82 Otorrhoea During tlie recent epidemic of influenza many instances have occurred of sudden intense pain in ttie ear, some- times followed by deafness, which appears to be due to small haemorrhages both in the internal ear and tympanic membrane. As in other kinds of earache, pain may be allayed by the instillation of a solution of morphia or laudanum, and a hot application to the side of the head. Other preparations that may be employed in the same way are simple hot water, almond oil, 10 or 20 per cent, solution of glycerine or carbolic acid in water, or a 20 per cent, solution of cocaine. Externally, poppyhead fomentations or a hot flannel bag of camomile flowers are popular remedies. OtOPPhcea, or chronic purulent catarrh, following middle-ear disease, is commonly associated with the exanthemata or naso-pharyngeal catarrh, especially in early life. In young children acute otitis may constitute a very obscure complaint, giving rise to high fever lasting several days without any lesion being apparent, until discharge occurs, unless the ears are specially examined. In all conditions in which the meatus is occluded by exfoliation or discharge, the instillation of a 3 per cent, solution of hydrogen peroxide or mopping out with ozonic ether affords a ready method of clearing the lumen. THE NOSE In connection with the skin of the nose and adjacent parts, dilatation of capillary veins sometimes produces spots or small nsevoid patches, which are mainly objection- able on account of being conspicuous. They are best obliterated by the galvanic current conveyed through a platinum needle, both poles being apphed to the dilated vessel. Acne posaeea consists of small patches of dilated capillaries about the nose, this being a terminal portion of the circulation, accompanied in later stages by hyper- Lipoma Nasi 183 trophy with increased secretion of the sebaceous follicles. Outbreaks of deep red spots occur at intervals, and are very disfiguring. The disturbance has been referred to indigestion, exposure to weather, and perhaps in many cases to the abuse of alcohol, though as previously men- tioned congestion of the nose may be associated with interference with the circulation, exerted by tight clothing, whether of the neck or waist. The treatment consists in removing any cause of indigestion or of embarrassment of the circulation, and attending to the general health. Locally some preparation of sulphur, either ointment or lotion, or lotion of perchloride of mercury, appears to exert some beneficial effect, probably by controlling decomposition in the contents of the follicles. In severe cases the dilated vessels may be scarified, haemorrhage being restrained by the use of perchloride of iron or liquefied carbolic acid ; or recourse may be had to the galvanic needle. Only small areas should be thus treated at one time. Lipoma nasi is characterised by the development of irregular patches at the tip and alae of the nose, often of a purple colour. It occurs in elderly men and is usually attributed to alcoholism. The protuberance is due to a general hypertrophy of the skin, subcutaneous tissue, and sebaceous follicles, and not to adipose tissue alone. Treatment consists in discontinuing the use of alcohol, and shaving off the thickened skin, leaving the deeper layers with portions of the glands, from which renewal of epithelium spreads over the raw surface. During this process protection should be afforded by a simple oint- ment, as in skin-grafting. The interior of the nostrils, except for superficial dis- turbance of the mucous membrane, is generally the province of the surgeon. In hot dry weather either irritation or soreness may result from desiccation and the inhalation of irritating 1 84 Ozaena or septic dust. This may be relieved by introducing into the nostril, with the little finger, glycerine and water, or hazeline ointment. Hyperaemia and swelling of the mucous membrane, with partial obstruction of nasal breathing, may be remedied by a spray of adrenalin solution 1 to 1000, directed into the nostril, or by sniffing the vapour of menthol and camphor, using the solution given on p. 98. This local ansesthetic is also of value in suppressing the continued and violent attacks of sneezing from which some individuals suffer, apart from catarrh. These vaso-motor disturbances are specially prominent in the condition known as hay-fever, associated with inhalation of grass pollen during the early weeks of summer, ac- companied by sneezing and lachrymation. If the patient is unable to avoid the surroundings in which the attacks are set up, relief may be obtained by spraying or paint- ing the interior of the nares with a solution containing 2 grains of cocaine to 2 drachms of 1-1000 adrenalin solution. This application needs repetition at intervals of three or four hours, and is a valuable local anaesthetic, OzSBna. — This term has been comprehensively ap- phed to foul-smelling discharge from the nose, usually not apparent to the patient. It covers a very large number of local conditions, such as atrophic nasal catarrh, caries, and necrosis of the bone, tuberculosis, and other affections of the mucous membrane, the presence of foreign bodies and rhinoliths, as well as purulent affections of the accessory sinuses, and some forms of new growth which require careful investigation and independent treatment. Chronic or hypeptpophie rhinitis most commonly occurs in children, associated with repeated attacks of ordinary catarrh, adenoid vegetations in the vault of the pharynx, enlarged tonsils or obstruction of the nares from any caus^. In the early stage the disease is char- Treatment 185 acterised by continuous thin mucous or muco-purulent discharge, with congestion of the mucous membrane. If untreated the mucous membrane becomes thickened by swelhng and congestion, especially over the turbinate bones, and finally by hypertrophy, infiltration with in- flammatory material, and increased size and activity of the glands. The symptoms which ensue are blocking of the nose with frequent need to clear it, a nasal tone of voice, a vacant expression due to mouth-breathing, and sometimes deafness from extension to the orifice of the Eustachian tube. Reflex disturbances may occur in the respiratory system. Posterior rhinoscopic examination discloses granular pharyngitis, with over-growth of gland tissue in the vault of the pharynx and bulging of the posterior extremities of the turbinate mass in the region of the posterior nares. In atpophie Phinitis, sometimes referred to as dry or foetid catarrh, or ozsena, the changes are rather in the opposite direction of shrinking and atrophy of the mucous membrane and glands. The nasal cavities appear unusually large, the membrane being paler than natural, and covered with yellowish green adherent crusts, decomposition in these supplying the foetor which is generally present. Treatment in both instances must be directed to the general health. A tonic regimen, with cod-liver oil and maltine, or the iodide or phosphate of iron in the form of syrup, should be prescribed. Provided the nostrils are not occluded a nasal douche should be used, one of the best solutions being that known as Dobefl's, mentioned on p. 100, or a saturated watery solu- tion of acetozone, or a 3 per cent, solution of peroxide of hydrogen. In some cases it may be necessary to dislodge some of the crusts with the aid of the speculum beforehand. Failing the use of the douche, a solution 1 86 Balanitis may be employed in spray, sucli as the mixture men- tioned on p. 98, diluted if necessary with liquid petroleum, or a solution of thymol gr. x to an ounce of the same medium. Tannic acid, sulphocarbolate, and iodide of zinc in solutions of the same strength in water are also used. The advanced stages, more particularly of the hyper- trophic form, demand the surgeon's interference in order to remove obstructing masses and clear the passage. In the atrophic form crusts should be removed by softening them with boric ointment overnight, and washing out the nares with bicarbonate of soda solution 5-20 grains to the ounce of water, or one of the collunaria described on p. 100. Small furuncles not infrequently occur in the ala nasi either just within or outside the nostril, and are very painful. They result from the irritation of dust, and no doubt also from scratching with the finger-nail. Their treatment is much the same as that recommended in connection with the external auditory meatus. Epistaxis is mentioned in the chapter on the Circulatory System. GENITO^URINARY SYSTEM Balanitis. — Accumulation and decomposition of secretion under the prepuce result, particularly in hot weather, from neglect in the matter of soap and water, and in cases of phimosis from inability to properly expose the fold behind the glans. This leads to irritation, and later to actual soreness from the development of fatty acids and bacteria — sometimes associated with inflam- matory oedema of the skin and pus-liktj discharge. It is easily remedied by cleanliness, and should not be allowed to occur. One point of interest Hes in the close resemblance of the Smegma bacillus to that of VuIvO'Vaginitis 187 tubercle in general appearance and staining properties, as well as, to some extent, in resistance to acids, which has led now and then to suspicion of tuberculosis in the genito-urinary tract when it has been discovered in the urine. Adequate decolorisation by acid in preparing slides should prevent this mistake, as the Smegma bacillus does not retain the fuchsin stain as completely as the tubercle bacillus when so treated. In the female similar conditions may prevail as regards the vulva under hke circumstances of neglect, and the baciUi are then to be met with in greater quantity in the urine. Owing to the admixture of other local discharges, the discovery of pus albumen, blood, or organised deposits in the urine of females may often be discounted unless the specimen has been obtained by the use of the catheter. Vulvo-vaginitis in little girls may in some measure be regarded as the counterpart of the preceding, being commonly the result of dirt and neglect, and associated septic infection, but owing to the wider scope for extension and greater inaccessibility of the passages, it is a very much more serious and protracted matter from the point of view of treatment. Added to this, the HabiHty of infection to be conveyed not only to the patient's eyes, but to others, renders the most stringent pre- cautions necessary in order to limit the disease as well as to cure it. One of the first things the practitioner has to do is to combat the idea of specific infection, which is often advanced and can be estabhshed only in very rare cases by other evidence than that of the presence of diplococci in the secretion, the gonococcus being by no means a distinctive organism. The important points in the case of this affection are isolation, absolute cleanliness, the removal of any ascertainable sources of irritation, and the free use of antiseptic or astringent lotions, such as perchloride of 1 8 8 Enuresis mercury (1-2000), boracic acid 4 per cent., sulphate of zinc or alum 5 grains to the ounce, or as the Lotio Sulphatum — ^. Zinci Sulphatis , . gr. XXX Aluminis . , , . gr. XXX Ferri Sulphatis gr. XX Cnpri Sulphatis gr. ij Aquam ad. . ad § vlij This may need some further diluting, as it contains about 10 grains of salts to the ounce. Discharge should be first washed away with warm water, and the superficial parts afterwards dusted with iodoform. The apphcations should be made at the body temperature by means of an irrigator, the labia being held well apart. Aphthous Vulvitis causing superficial ulceration with accumulation of fungus, epithelium and dried blood on the labia requires similar treatment. Both con- ditions call for tonics and a Hberal regimen. Enuresis. — Nocturnal incontinence of urine is not uncommon in both sexes, though more frequent in males, up to the age of puberty, and may be connected with defective nursery instruction, as it usually yields to disciplinary measures. Lack of control over the bladder is so general in infants that it sometimes continues unnoticed later into childhood than is reasonable, so that complaint is not usually made till some occasion arises for the child to leave home, either to go to school or perhaps to a con- valescent institution. The condition under consideration must be regarded as a habit and not the occasional effect of the irritation caused by threadworms, long prepuce or calculus or growth in the bladder, or even the loss of control which may accompany or follow an acute illness, though these causes should be borne in mind and carefully excluded. Dysuria 189 Habitual incontinence runs on from infancy and is scarcely ever interrupted by a definite interval. The most efficient remedy consists in waking the child at intervals to pass water — at first every three hours, then every four, gradually lengthening the interval till the whole night can be passed without disturbance. After six or seven years of age a week of such treatment is usually sufficient. Tonics, cold baths, and the administration of belladonna increased till its physiological effects appear may expedite matters. Tinctura Lycopodii Tr|_xv-lx and Antipyrin gr. v-x have been given with the same object. A practical expedient is to fasten an empty cotton reel by means of a tape over the lumbar spine, so as to prevent dorsal decubitus, as it is in this position that the accident usually occurs. The application of a faradic or galvanic current, the poles being placed over the upper lumbar region and the perineum, has been made with good effect. In obstinate cases. Sir Henry Thompson recommended the application of silver nitrate solution (gr, x ad 5J) to the neck of the bladder. Some benefit may be as- sociated with restraint in taking fluid for two or three hours before bedtime. Dysupia. — Undue frequency and urgency in the call for micturition are associated not only with con- ditions in which there is actual polyuria, but with states of the bladder and urine which are not necessarily patho- logical. At the end of the summer, or still more after residence in a hot climate, the bladder has become so unused to distension that discomfort occurs when the con- tents perhaps do not exceed six ounces, this intolerance passing off in a few weeks or days, especially if it is not too readily indulged. Marked acidity or alkalinity of the secretion likewise causes irritation, and may vary with the time of day and character of the food. In many instances of strongly acid urine a deposit of uric 1 9^ Haematuf ia acid or oxalate of lime takes place which may supply an additional indication to that afforded by the rapid and intense change produced on litmus paper. The exhibition of alkaHs and a preponderance of vegetable food will generally correct this abnormality. The opposite condition of over-alkahnity, excluding ammoniacal urine which is generally associated with chronic cystitis, usually accompanies acid dyspepsia, the urine being alkahne in proportion as the gastric contents are acid. This state is often associated with separation of phosphates, either as a white precipitate rendering the urine cloudy when passed, or appearing as an iridescent pellicle on the surface after standing. In either case tricalcic phosphate is the material separated. It may be owing to the absence of muscular exertion in the early hours of the day, or the preponderance of vegetable food in the first meal, that this alkaHnity of the urine and associated frequency of micturition are most marked before noon. Frequent micturition from this cause may be remedied by increased animal food, and the administration of benzoate of ammonia in 10-grain doses. Irritation due to over-concentration of the urine may be corrected by an increase of fluid. The presence of some unusual con- stituent in the urine derived from the food or faulty metabolism has a similar effect, depending perhaps on idiosyncrasy — such articles of diet as tea, champagne, and asparagus may be mentioned, and the effect of glycosuria apart from polyuria. In all cases of frequent micturition, tincture of hyos- cyamus, the bromides, dilute hydrocyanic acid, and infusion of buchu have a sedative effect. There is a nervous element in most, and some may be regarded as entirely neurotic. HaBmatupia. — The causes of this occurrence are manifold and usually serious, but there is one form Menstruation 191 occasionally met with in children which is of little account and may easily be avoided. This is hsematuria usually occurring in the spring, and associated with eating rhubarb. A sufficient number of cases have appeared annually in the early months of the year to render this matter quite certain. The attacks come on unexpectedly in otherwise healthy individuals, and naturally give rise to some alarm ; but quickly subside and are not accom- panied by any serious symptoms. The blood, which is generally abundant enough to render the urine quite red, is accompanied by crystals of oxalate of lime derived from the rhubarb, but there is no albumen beyond what may be attributed to the blood itself. Menstpuation is often attended both by pain and temporary change in disposition, which may be more marked in some individuals and on some occasions, and may even be attended by syncopal attacks. At these times it is very important to avoid chill and over-fatigue, and it need hardly be said that any device to arrest or postpone the natural process, sometimes attempted in view of particular engagements, is to be seriously deprecated. Relief from pain is generally obtained by lying down or raising the feet to a level with the body, and such drugs as ammonol or chloretone in 5-grain doses will relieve minor pain and discomfort, but the treatment of severe dysmenorrhoea is a more serious matter. The use of opiates is especially to be avoided. Towards the cessation of the menstrual periods at about fifty years of age, various peculiar symptoms — psychical changes and neuroses — are prone to develop, and may give rise to much speculation and perplexity in diagnosis unless this climacteric state is recognised. Syncopal attacks, vertigo, headache, mental depression or excitement, and variorus vaso-motor phenomena, such as flushing, tingling, pins and needles, or sensations of 192 Infants cold patches and nervous shivering occur. The psychical changes may be very marked so as to call for seclusion, constant companionship, or even removal to an asylum, but these more serious developments are, fortunately, comparatively rare, and the minor ones are intermittent. A socially quiet life for a time and the bromides, with valerian or asafetida, ichthyol 5 grains in pU. or other anti-spasmodics, may be of some use occasionally. INFANTS At the time of birth the anatomy of the child is not absolutely complete, and in many instances the estab- lishment of function is delayed for some weeks. The average height is just under twenty inches, the increase for the first year being eight, and for subsequent years about three inches, so that the height is about doubled in six years, and by fourteen growth has reached com- pletion to within one-twelfth of the full stature. The average weight of the infant at birth is 7 lb. There is commonly a slight loss of weight during the first week of Hfe, and then a steady increase amounting to about 6 ounces a week in the first three months, 5 ounces in the second three months, and 3 ounces a week for the remainder of the first year. Variations occur very readily in connection with slight disturbances, but the average is usually made up when one day is compared with another. Both temperature and pulse-rate are higher in infants than in adults, the normal temperature being 99° and the pulse-rate declining from 130 to 140 at birth to 100 at the end of the fifth year. At first the special senses are undeveloped, objects and sounds not being distinguished till the child is a week or two old. The lachrymal secretion does not appear till about the second month, and the secretion of the skin about the same time. Perhaps more important is the delay in Post«'NataI Development 193 functional activity of the salivary glands and pancreas. Saliva is only sufficient to moisten the mouth until about the fourth month, but it does not exert any amylolytic effects until towards the end of the sixth to the ninth month, and it may be assumed that the same is true of the pancreas, so that starchy materials cannot be digested before this. Deficiency of bile acids in the early months is sufficient to account for the incomplete assimilation of fats in excess. The stomach at birth has a capacity of 1 to 2 fluid ounces, doubled by the end of the first month and reaching 10 ounces at the end of the first year. The infant is usually able to hold up his head after two months, to sit up after seven months, and stand at twelve months. Attempts to hasten these muscular efforts may result in spinal curvature or flat foot, the muscular and ligamentous structures not being adapted to sustain the weight of the body at an earlier period. At the end of the sixth month the teeth begin to appear, and it is about this time that dribbling of saliva is most apt to occur. Their appearance may be attended with febrile attacks, irritability, disturbances of digestion, and sometimes skin eruptions, or even convulsions, but these must not be hastily attributed to teething. These symptoms are usually met by laxatives and small doses of bromide of potassium. Only very occasionally, where there are great vascularity and tension in the gums, should recourse be had to scarification. This may afford relief by diminishing hypersemia, but it is very questionable if it facilitates eruption of teeth. Perhaps the earliest abnormality noticed immediately after birth is the misshapen appearance of the head, called caput succedaneum. It is a form of local oedema, with congestion and some blood extravasation in the scalp, which disappears of itself within twenty-four hours. Distinct from this is the indented appearance due to 194 Icterus Neonatorum cephalhsematoma, the external form of which usually develops just after birth, and is distinguished by the presence of a raised ring at the circumference, though it may be elastic and fluctuating at first. The condition calls for no treatment, and subsides of itself in the course of a few weeks. Stomatitis, whether catarrhal or aphthous, is generally benefited by small doses of rhubarb and soda, and the local application of the glycerine of borax. Symmetrical superficial ulcers over the hard palate, described as Bednar's Aphthae, may be touched with a solution of permanganate of potash 5 grains to the ounce, or boric acid 15 grains to the ounce, or with lapis divinis composed of equal parts of sulphate of copper, alum, and saltpetre fused together. In the parasitic form of stomatitis known as thrush, occurring in weakly infants, the whitish patches should be painted with a solution of sulphate of copper or carbolic acid 2 grains to the ounce of water. Icterus Neonatopum. — This general yellow staining of the skin usually appears about the second day after birth, and lasts about a fortnight. The skin seems to be chiefly affected, and there are no evidences in the con- junctiva or secretions, nor are there any symptoms, but while it lasts there may be some check to nutrition and growth. It is stiU doubtful whether there is any local disturbance in the liver, or whether it may not be due entirely to blood changes in the skin. Beyond bathing no treatment is called for, and the practice of adminis- tering calomel is of very doubtful value. Epythema neonatOPum is characterised by deep redness of the skin soon after birth, which may be associ- ated later with some desquamation. The treatment consists in avoiding irritation by soap, employing oatmeal water instead, and the subsequent application of a dusting powder of zinc oxide 1 ounce, powdered starch 4 ounces. Diarrhoea 195 Vomiting" in infants is usually associated with over- feeding or the administration of unsuitable food. The best treatment consists in diminishing the amount or altering the constitution of the diet, usually in the direc- tion of making it more dilute and more alkaline, and in- creasing the intervals between meals. If diluted milk or whey is rejected it may be necessary for a few days to substitute veal broth, or albumen water consisting of the white of four eggs to the pint of water sweetened with cane sugar or lactose. Diapphcea commonly occurs in children and infants from irritation or fermentation in connection with negli- gence in diet. Suckling infants may develop looseness of the bowels from the colostrum, or other features of the milk dependent on emotional disturbance, or from variation in health or in food on the part of the mother ; while those fed artificially are liable to suffer in conse- quence of lack of cleanliness in connection with feeding bottles or unsuitable food. The stools, besides being more liquid and numerous than normal, are usually green in colour, offensive, acid in reaction, frothy, and contain much undigested curd. There is excoriation of the nates, increased peristalsis with abdominal distension, attended by pain and restlessness. The tongue is furred, desire for food capricious, and wasting is obvious in a day or two. If the attack does not quickly subside there may ensue a chronic catarrh or dysenteric form of diarrhoea, with emaciation. The countenance becomes drawn, the eyes sunken, cyanosis or convulsions occur in bad cases, and in such death not infrequently ensues. Treatment. — Mild cases may be relieved by partial starvation and a laxative dose of carbonate of magnesia gr. V or ^ Pulv. Rhei , , , gr. iij Sodffi Bic. ... gr. jss P. Zingib. , , , gr. ss 196 Constipation Desiccated milk such as Horlick's, barley-water, arrow- root-water and whey (2 ounces of either with a small teaspoonful of white sugar), barley-water 10 ounces, white of egg 5 ss, white sugar 5 j or veal broth may be given in quantities suitable to age, instead of milk, when curds appear in the motions. For the first day castor oil emulsion or fractional doses of calomel should be given every two hours to clear away the irritating intestinal contents, and when the stools approach the normal in number and appearance, a sedative mixture such as ^ Sodii Bicarb. . gr. ij Bismuth. Garb. , , . gr. jss Pulv. Tragac. co. gr. j Sp. Chloroformi ttl S3 Aq. Cinnamomi . . ad3i may be given every four hours. Bismuth subgallate gr. ii-v may be substituted in this mixture if diarrhoea continues. Among domestic remedies a small quantity (5 j) of brandy, or a teaspoonful of raw arrowroot is often effective. Constipation is not uncommon in quite young infants and sometimes depends on absence of peristalsis in the colon. This may be excited by abdominal massage or by introducing the tip of the little finger, a glycerine suppository, or a small piece of white soap into the anus. More often a general laxative may be required, such as a teaspoonful of ohve oil or a small piece of mannite ; the latter may be given in the milk of artificially fed infants. In those who are being suckled it is often best to give some laxative to the mother, such as stewed fruit, confection of senna, or cascara, which affects the infant indirectly through the milk. In artificially fed infants it is most important to revise the diet, in the direction of diminishing the quantity of curd, increasing the fat and adding extract of malt, malted food, or even oatmeal water or finely ground oatmeal in small quantity to the Flatulence and Colic 197 contents of tlie bottle. Administration of drugs is to be avoided as far as possible, but if other means fail, small doses of magnesia such as 3 grains of the carbonate or 1 or 2 drachms of fluid magnesia given several times a day in the milk are usually sufficient. To stimulate the hver J-l grain doses of calomel, grey powder, or Purgen twice a day, 15-30 minims of the aromatic syrup of cascara or of the Liquor Euonymin and pepsin, or syrup of figs may be given. In the case of older children the general and dietetic rules given for adults on p. 28 should be followed, but in regard to drugs it is often difficult to continue the administration of such as are nauseous, and pills are usually out of the question, so recourse must be had to such expedients as laxol, fig syrup, confection of senna, cascara chocolate, or Tamar Indien. It may be recalled that castor oil is the most satisfactory purgative for continued use, and when well shaken in milk as small a dose as half a drachm is quite effective and almost tasteless. Flatulence and Colie in infants must be regarded as painful accompaniments of indigestion resulting from acid fermentation, and should be met by antacid and carminative remedies and correction in the mode of feeding. For the most part such fermentation results from excess or too hurried ingestion in the matter of food, which should be diminished in quantity or con- sistence, or be given at longer intervals. The nurse's remedy consists in laying the infant on his stomach across her knees and patting his back, which may result in either eructation or vomiting, with some relief to gastric distension. Hot flannels to the distended abdomen are also employed with some good effect, especially when the gas is in the intestines. The most urgent symptoms may be relieved by giving teaspoonful doses of lime water and cinnamon, dill or peppermint water in equal parts, or grain doses of carbonate of am- 198 Flatulence and Colic monia or soda in these waters, or soda-mint tabloids in syrup, or the following mixture may be administered ; ^. Magnesii Garb. . • 1 • gr. jss Pulv. Ehei • • • gr.i Syrup. Zingib. . . Ttl, V Aq. Menth. Pip. . ad3j Every two hours. The soothing of the child and reUef of distension must first be considered, but partial starvation is necessary for some hours, and the resumption of feeding should be gradual and modified in accord with the necessities of the case. During the protracted hot summer of 1911 many cases of multiple skia abscesses occurred as a result of gnat bites followed by auto-infection, disablement continuing in some for several weeks. A modification of the old-fashioned method of cupping proved remarkably effective in these and similar con- ditions. When the boil had matured, the contents were withdrawn by applying the mouth of a soda water bottle, which had been heated by means of hot water, the power- ful exhaust accompanying cooling withdrawing in many instances both the pus and central slough with a good deal of infected serum from contiguous regions, so that heahng proceeded rapidly, and the risk of further infection was reduced. The degree of suction can be regulated by the size and temperature of the bottle which can be subsequently detached by allowing air to enter under the hp, or en- veloping in a hot wet cloth. CHAPTER VIII MAINTENANCE OF INDIVIDUAL HEALTH Under this heading it is not intended to study valetudinarianism in its morbid aspect ; but merely to point out some common features in everyday Hfe which are either to be encouraged or avoided, so as to steer clear of some of the disorders which may develop from them, as weU as those which are imposed from without, so far as this can be done by what may be considered ordinary means. At the present time it is even considered necessary that children should be taught to breathe, to walk, and to vocalise, functions which it might be thought could be left to natural instincts. It is only in exceptional cases in which the developments of these instincts are deficient or are interfered with by some unusual circumstance that such instrucKon is reaUy required ; but it is none the less evident that the proper performance of these matters is essential to the well-being of the individual. Numbers of people scarcely exceed the ordinary requirements of breathing and physical exertion for days together, losing sight of the fact that the maintenance and development of a reserve power is a most important safeguard against ill- health. In regard to breathing, comparative stasis of the air in the lungs impairs the full oxidation of the blood, and encourages the local settlement and growth of micro- organisms, and the vigour of the lungs themselves. The J99 200 Respiratory Exercise quality of the air breathed has necessarily an important bearing on the general health, both in regard to its vitaUs- ing qualities and freedom from injurious matter. The ordinary conditions of indoor life and the limitations imposed by clothing tend to discourage free respiratory movement, and it is valuable once or twice a day to take several full inspirations as part of the general routine. This ensures every portion of the lungs being fully ex- panded, and by encouraging for a brief period extra func- tional activity, helps to develop the chest, maintain reserve power, and prevent the incidence of pulmonary disease. When opportunity serves, the reserve power of the heart and lungs should be exercised and tested by such physical exertion as is suitable to the individual. There is usually no need in adolescence to make special provision for this, but it is noticeable how very frequently pulmonary disease, and especially consumption, attacks young people at an age when the exercises and games of school life are put an end to by the exactions of more serious occupations. It should therefore be looked upon as one of the duties of life to devote some minutes in each day, and some hours in each week, to the full exercise of these important organs. As age advances, indulgence in the violent exercises of youth is unsuitable, though the capacity for them might well be prolonged, certainly till mid-life, and can then find a substitute in those of a quieter nature. " Discern of the coming on of years, and think not to do the same things still, for age will not be defied." It should, however, be regarded as an axiom that no exercise is worthy of the name which falls short of increasing the rate of the respiration and pulse, and pro- moting a definite action of the skin. The value of exercise is by no means limited to the development of heart and lung power, but has an important influence in maintaining a healthy skin, and in promoting the general metabohsm by the functional activity of the muscles, while exerting Physical Exercise 201 a similar influence on the lymphatics as is accomplished in a minor degree by massage. The enjoyment of fresh vitalising air is unfortunately not within the reach of every one under modern conditions of city life, but it is well to remember that it is at its freshest before eight in the morning, which is the most suitable time for constitu- tional exercise, and is much purer during the night than in the day — during the winter months at all events — owing to the relative absence of smoke. When it is recalled that the organism absorbs twice as much oxygen in a given time during sleep as when awake, the great import- ance to health of free circulation of air in the bedroom is evident. It is during the night that the haemoglobin of the blood is largely built up, and during the period of rest of the tissues oxygen is specially required to effect the complete oxidation and removal of the effete product of tissue waste. One of the principal features in the main- tenance of health is the daily provision for full expansion of the lungs, and a supply of the purest of available air. The question of the amount and distribution of sleep is one to which no uniform answer can be given as applied to all individuals. Some have worked hard and long with as small an allowance as three hours in the twenty-four, while others, particularly during growth and development, require twelve or more, and suffer when deprived of it. As a general average it may be said that the night should be half as long as the day, an ordinary sixteen-hour day being followed by an eight-hour night. When under stress of circumstances the period of activity is lengthened, say to twenty hours, it is more economical and refreshing to extend the rest to ten hours than to attempt to make up for deficient sleep by rest during the day or by working off the arrears by degrees on succeeding nights. It is as weU to be aware of the fact that too much sleep is almost as detrimental to health and vigour as too little. On the one hand, insufficiency leads to impaired 202 Sleep nutrition, with loss of weight, the development of nervous irritability, impaired vigour, and loss of reserve power, though it is consistent, temporarily at all events, with in- creased nervous activity, resembling in this respect partial starvation, or at least restriction of food below the usual limits. The effect of too much sleep is to encourage the development of fat, with increased general bulk, a decline in nervous activity, dulness of the faculties generally, with defective power of attention, impaired memory, and mental lethargy. It was an axiom of Celsus that too much should be varied with too little, with a special tendency towards too little, and this applies to sleep as much as Celsus intended towards food. The difficulty with most people in regard to sleep is to get sufficient on account of the distractions of business and social matters, or sometimes, the inability to sleep when occasion offers. It is well to remember that excitement of the brain towards the end of the day makes sleep difficult, and the natural tendency in most people to become drowsy at ten or eleven o'clock at night points to a natural cycle of the nervous mechanism, and when this time is passed the brain becomes active again and sleep is more difficult to obtain some hours later. The first hours of sleep are the most important and the most profound, disturbance after four or five hours being much less distressing and injurious than after one or two. Circumstances sometimes affect the distribution of sleep, and during very hot weather, as in the tropics, it is often a good plan to take two hours' rest and sleep in the middle of the day, and do with a shorter night, so as to take advantage of the cooler hours in the early morning ; but this is a habit which needs to be acquired, and should be so adapted to the hour of the mid-day meal as not to follow immediately upon it, but should succeed the first hour of digestion. The question of sleeping after nieals is perhaps not Sleeping after Meals 203 one that can be answered in the same sense for all. It is generally considered that to fall asleep, as most people are prone to do, when sitting quietly after lunch or dinner tends to arrest the early processes of digestion and permit of fermentation and dilatation of the stomach, with present discomfort and sacrifice of the nutrient value of the food. On the other hand, there is a natural disposition to h3rper8emiaof the digestive system after taking food, which involves relative anaemia of other parts of the body, so that a feeling of chilliness, especially in the extremities, and disinclination to mental exertion usually occur, and elderly people and invalids commonly sleep after easily digestible meals without hurt. The first thing that commonly occupies the attention in the morning is the question of bathing, and the tempera- ture of the bath. It may be considered highly salutary to expose the skin completely both to air and water at least once in the day, both as an exercise to the cutaneous vessels and for the purpose of removing the secretions from the surface and thus assisting to maintain not only the health of the skin but that of the body generally. After the relaxation of the cutaneous vessels in the night, the most appropriate application is that of cold water rather than hot. The actual temperature for most individuals should not be dependent on that of the atmo- sphere, but should be regulated according to the power of reaction of the circulation. The temperature of the cool bath is from 60° to 70° Fahrenheit ; below this it is too cold for many, and above it is so nearly tepid as to fail in promoting reaction. Greater cold can be tolerated in a sponge bath than in one in which the body is entirely immersed. The duration of the bath should be such that the first sharp sensation of cold has worn off. The skin is then contracted, and a satisfactory reaction ensues, which is assisted by the exercise and friction of drying. Orve of the principal benefits of the cold bath as regards 204 The Morning Bath the general health is the comparative immunity from the ill-effects of varying temperature in the course of the day and a general increase in the muscular tone. What may be considered indications for reducing the degree of cold are those instances in which blueness of the surface occurs and local anaemia, with numbness and coldness of the extremities. These features indicate that the degree of cold is beyond the reactionary power of the individual, and morning bathing should either be given up or pursued under milder conditions. The effect of some sudden application of cold to the surface in those who, from constitutional reasons, are pre-disposed is often apparently causative of sudden seizures of lumbago or muscular rheumatism. Though this may prohibit the use of the bath for a time on account of the difficulty of movement, it is no indication for giving it up, but rather for attending to the particular condition of the blood which is associated with the attack. The most important adjunct is abund- ance of fresh air by free ventilation in the bath-room, as the use of artificial heating, except for invalids, largely detracts from the invigorating effect of the bath. For those who are unable to tolerate cold or even tepid water, the hot bath, at a temperature of 90° to 100° Fahrenheit, may be substituted. The immersion should be brief, not more than five minutes, and under these circumstances it is better to maintain the bath-room at a mean temperature of 60° to 65^. The hot bath is rather cleansing than invigorating, and on account of the re- laxation of the surface vessels which ensues, it is really better taken at night just before going to bed than the first thing in the morning. On rising and retiring it is a wholesome custom to drink half a pint of water, either hot or cold. This does not impair the appetite for breakfast an hour later, as does the early cup of tea and bread and butter, and it helps to make up the quantity of fluid necessary during the day, Bathing for Pleasure 205 a matter in which very many people fall short, besides acting as a natural laxative. As regards swimming and bathing for pleasure, this is best indulged in before breakfast, though it is as well to take a biscuit or some fruit beforehand, and immersion should not be prolonged beyond five to ten minutes, or it will result rather in fatigue than refreshment. At other times, the precautions to be observed are the adjustment of the occasion so that it does not follow within two hours of an important meal, and the avoidance of suddenly checking natural perspiration by plunging into cold water while overheated, as many attacks of rheumatic fever have followed immediately on this erroneous practice. The degree of cold and duration of stay in the water are important matters, since extreme or prolonged abstraction of heat from the surface tends to contract the cutaneous vessels and presently those of the muscles also, thus concentrating the blood on the internal organs in what may be a dangerous degree of congestion ; while putting a severe strain on the heart, which is thus called upon to sustain the effort of muscular exertion and of great increase of peripheral resistance in the circulation. It is probably this which induces that dangerous con- dition which has been unsatisfactorily termed " cramp," and which consists in sudden loss of power and conscious- ness, from which the subjects most rarely recover, even when rescued from the immediate danger of drowning. The condition is really one of acute cardiac overstrain allied more nearly to angina pectoris than to anything else. Such attacks are fortunately rare, as they are almost invariably fatal, and it would be a pity if dread of such a calamity interfered unnecessarily with a healthy enjoyment. Provided bathers do not expose themselves to undue lowering of the surface temperature either by the intensity or prolongation of cold, or to exhaustion from attempting what is beyond their strength — for fatigue 2o6 Diet occurs rapidly from exertion in the water, owing to con- tinued abstraction of heat and contraction of the vessels in the muscles — bathing, at aU events in the summer, can be conducted with a minimum of risk. It might be added that it is imprudent to bathe alone or to attempt a long swim when already fatigued. Spare individuals are more quickly affected by immersion in cold water than those with large muscles or much fat. The subject of occupation before breakfast is one which has been much debated in recent years in regard to school life, and the consensus of opinion has been against any serious work before some food is taken. Objection cannot be made to being out of doors for a short time in the early morning, and this is never attended with the liability to syncope which in the young accom- panies indoor tasks, nor is there the same objection to physical work or exercise for those who retire early ; but, more particularly in town life, exertion of any kind on an empty stomach is apt to be followed by lassitude before the day is far advanced, and is quite incompatible with late hours and responsible work during the day. The subject of diet is too wide and complex to treat of in detail in a short space. The important feature, however, which is often lost sight of, is the proper interval between meals, which should be four or five hours, to enable digestion to be completed and to allow of a short period for physiological rest, before another is taken. In the course of the day it is better that the meals should be characterised by some prevailing class of food than that they should be aU alike. It is customary, for instance, to employ carbohydrates prin- cipally for breakfast with a small amount of animal food, and to make the chief meal in the middle or at the end of the day one of animal food, with only a small proportion of carbohydrates. Animal food generally is adapted to growth and muscular exertion, and to the resistance of Diet 207 cold. With the exception of milk it is unsuitable for infants and quite young children, but is particularly necessary after seven years until middle life. As people get old they do wisely to limit animal food and substitute fruit and vegetables, both for the sake of digestion and to accommodate their food to the less perfect metabohsm of advancing years. It is generally admitted that the majority of people take more food than is either necessary or really wholesome. This to some extent merely leads to waste, but it also results in passing through the organism more dissolved nutriment than the functions of the body call for or are perhaps able to deal with, so that much of the impaired health depending upon imperfect combustion of food-matters depends as much upon excess of food as deficiency of work and oxygen. Besides a proper quantity of food and proper intervals between meals, and the necessary physiological work and respiratory activity, a due amount of simple fluid is required to keep the products of tissue-change in proper solution. A minimum quantity is two pints in the twenty-four hours, and should be made up chiefly of plain water or weak infusions such as tea or coffee. It is, however, marred by the addition of sugar and other soluble substances. The character of the food and amount of fluid should naturally vary with the season of the year, the loss by the skin in summer calling for at least double the supply that is sufficient in winter. With regard to food, the demands of cold for heat- producing materials, such as fat and meat, are greater in the winter, but in the summer a more suitable meal can be made of carbohydrates, fruit and vegetables, approximating to the regime followed in the tropics. Variation in diet is not only an aid to appetite, but is beneficial for the system, and changes with the season afford the best opportunity of obtaining the most whole- some class of food at any time. 20 8 Selection of Food In connection with raw food, there are certain dangers which may be provided against when borne in mind. Salads, and especially watercress, are liable to convey parasites, unless protected during growth and carefully washed before being used. In the late summer and autumn, especially, there is a risk of introducing tjrphoid fever in such uncooked articles as water, milk, and oysters, and even in partially cooked whitebait. The risk of this largely disappears with the first frosts, but during the months from July to the end of November or December it is wise to avoid these things unless their source is unimpeachable or they have been submitted to a sufficient temperature in cooking. Water should be boiled for twenty minutes if required for drinking, and may be freshened by passing through a carbon filter ; but for the most part in London and most of the large towns the water supply is under such careful supervision that danger from this source is reduced to a minimum. This is not quite the same in the case of mUk, which often comes from great distances and is much mixed and subject to risks of indirect infection by the local washing of cans, sometimes with infected water. Milk can be sterilised by heating in boiling water for twenty minutes without being much altered in appear- ance or taste ; it is then more easily digested, keeps longer, and is freed from living germs of disease. This is specially important for children and invalids who subsist largely on a milk diet. In regard to supernumerary meals, which are taken rather as a matter of routine by invalids, especially those who are unable to digest a full meal, it may be considered that for those in average health these are unsatisfactory, and even unwholesome. Such are the early morning cup of tea and bread and butter, something at eleven o'clock in the morning, and more commonly afternoon tea. In many cases the taking of small quantities of food Supernumerary Meals 109 at these times provokes a freer secretion of the gastric juice than is requisite for their digestion, producing the condition known as heartburn or acidity, and in any case impairs the appetite for the ensuing ordinary meal. There is not so much objection to taking fluids in the intervals — indeed, the best time for this is about an hour in advance of the solid food ; and perhaps the same objection should not be raised to light supper in the case of those who defer retiring to rest till four or five hours after late dinner, but in this case the nutriment should be specially light and for the most part fluid, since the main functions of digestion are in abeyance during sleep and an undigested meal is one of the worst enemies to satisfactory repose. A brief remark may be here made as to the danger of drinking quantities of cold fluid, particularly when over-heated. This is generally accepted and impressed on the young, being associated popularly with the occur- rence of colic and various cutaneous eruptions, but greater danger lies in the spasmodic contractions set up, and I can recall at least one instance in which gangrene of the appendix was thus induced, involving a fatal termina- tion within three days. Deliberation in connection with meal-times is most important. In the words of Francis Bacon, " To be free-minded, and cheerfully disposed at hours of meat, and sleep, and of exercise, is one of the best precepts of long lasting." In regard to the matter of clothing, it is unnecessary and would be useless to oppose what is customary and generally found convenient, but it may be pointed out that a great number of people err in the direction of employing too heavy clothing both night and day, and pf submitting to unhealthy restriction of natural move- raent, not perhaps so much in the limbs as in the thorax and abdomen. Interference with the full and easy 14 2IO Clothing movements of respiration tends greatly to limit their natural range, and to impose on the individual habitually a restricted degree of breathing. This in adolescence actually impairs the proper development of the body, and in all interferes not only with the due aeration of the blood, but also with its easy circulation, for the respiratory movements have an important influence on the flow of blood through the main veins, and the movement of the diaphragm exerts a similar influence on them both in the abdomen and thorax. Persistent constriction of the waist favours downward displacement of the solid organs in the upper zone of the abdomen, and has an undoubted effect in encouraging prolapse and hernia in the lower. One important result of abdominal constriction is the development under violent effort of inguinal hernia, instances having frequently occurred in boys in climbing or jumping while wearing a leather belt. The effect of a tight collar inducing cerebral congestion and headache has already been referred to in dealing with that subject. Constriction of the waist and lower thorax in impeding the circulation is sometimes indicated by congestion of terminal vessels in the nose and ears, and in some instances has led to temporary failure of vision, all which symptoms have immediately subsided on releasing the constricted area. The amount of clothing which should be employed, whether by night or day, should be just sufficient to prevent a sensation of chilliness, and must be adapted to the particular circumstances of the individual. The chief protection is required when inactive in the open air, as when driving, and the least during active exertion, or when sitting in a warm room. The difficulty of adapting oneself to variations in these different states is better met by extra wraps than by constantly keeping the body over-thickly clad. It is generally considered that loose- textured fabrics, owning a certain porosity, are both healthier and more comfortable than others. Such an Clothing 2 1 1 impermeable substance as the ordinary waterproof is perhaps the worst of all. The material which should be worn next the skin is the one which ought to be most definitely porous, and it is for this reason, rather than on account of their fibre, that woollen materials are usually advocated. " Wool is more porous and more hygroscopic than vegetable fabrics, and is a slightly less perfect conductor of heat. While it absorbs moisture readily, it gives it o£E slowly, so that far less cold is produced by the evaporation from a woollen garment than from one made of vegetable fibre. It conserves the heat of the body, and protects it from the heat of the sun, the latter property being at its height if the garment be white." " For work in a climate like ours flannel is the safest material to wear ; if cotton or linen be worn, it must be loose-woven, so as to give some thickness and porosity to the fabric " (G. V. Poore). Any smooth close material communicates chill too readily, and does not as a rule absorb the moisture. On the other hand some people find flannel too irritating to the skin, and it is not by any means essential to employ it ; but whether silk, linen, or cotton be used, it should be so woven that the surface is not quite smooth and the general texture loose, allowing it to retain and transmit air readily. Perhaps the best alternative is the Chinese method of wearing a net next the skin which prevents complete contact. The main reason for advising such porous material is to provide against the alternation of heat and cold, wet and dry, which are inseparable from ordinary climatic conditions and changes of occupation, the principal danger arising from the rapid cold of evapora- tion while resting after exertion. It is customary to bring up the young to change into dry garments when moist from exertion or exposure to wet, and for the most part adults follow the same good rule. Many instances 212 Clothing of lumbago can be traced to remaining in damp clothes after being over-heated, the chill of continued evapora- tion being specially prolonged by the over-lapping of garments in the lumbar region. The ordinary foot covering is particularly adapted to retaining moisture ; and chilling of the feet in consequence, as well as exposure of the less protected ankles and shins to draughts, which are more common near the floor than is generally realised, are productive of the effects of a lowered blood temperature. Sufficient warmth round the middle of the body is the most important, and many instances of so-called indigestion are the result of insufficient clothing, and are at once remedied by a flannel belt. Even in the tropics, more particularly at night, as a protection against sudden lowering of tempera- ture, such a flannel binder is usually worn, the absence of it often leading to serious attacks of abdominal pains and various forms of inflammation. Any special pro- tection of this kind should be continuous, disorder arising from intermittence of covering, as is perhaps best seen in connection with the throat. There are thosewho advocate little, and others who advocate much, with equal success, the incidence of chill and catarrh being on those in the intermediate class, who vary one with the other. The natural effect of warmth is to dflate the vessels and an area so suffused is particularly liable to suffer by sub- sequent exposure to cold. Speaking generally, the degree of protection by clothing must be adapted to the power of resistance of the individual to cold and the degree of exposure to which he is liable. Variations in what is usually worn are more productive of ill-health than being habitually too thickly or too thinly clad. After food and clothing perhaps the next most im- portant influence on the health and comfort of the indi- vidual is exercised by the dwelling and its suiroundings. The Dwelling 213 One of the most important points is the character of the subsoil, preference being given to high ground and dry porous strata in which surface drainage is efficient. Gravel, sand, chalk, and rock form satisfactory founda- tions for houses. On the other hand, clay and marsh- land are unsuitable owing to the amount of water re- tained in them, and the cold damp atmosphere which usually overlies them. In towns where the surface is largely covered and drainage has been carried on for years there is less force in the objection, but in the country and in suburbs especially, the damp and cold atmosphere associated with this soil favours the occurrence of catarrh and rheumatism and is not conducive to permanent good health. The house itself may be unsuitable owing to incomplete ventilation and insufficient exposure to sunhght. One great objection to fiats as compared with the ordinary house is the absence of a through current of air, the main direction of which is from the bottom to the top of the house, such as is maintained by an open staircase. Though it is usual to shut up rooms which are not in actual use, it is always well to provide for a change of atmosphere before re-entering a room which has been recently occupied. The previous history of a dwelling also should be taken into account, in that either tuberculosis or cancer may be apparently endemic, especially in old houses. Instances are on record in which as many as four successive and unrelated tenants have died of cancer within a few years. Attention must also be paid to the question of water supply not only from the point of view of purity as regards organic matter, but as to the amount of calcareous salts in solution. The presence of an excess of Hme constituting a hard water is sometimes productive of dyspepsia, con- stipation, and even urinary calculus. The chief of the previous considerations have been in the direction of maintaining good physical health by 214 Water Supply attention to the physiology of the body, but in order to live happily and contentedly it is necessary to consider the occupations and amusements of the mind. A due proportion of mental effort and relaxation is necessary to most individuals for this purpose, the time being also divided between interests in and out of doors. It is generally recognised that continuous occupation of one kind is more fatiguing than where some variety is introduced, although the same number of hours are employed. " The morning for creation, the evening for reading, and the afternoon for the work of the file " was the distribution suggested by Francis Bacon. Varia- tion in occupation is not only less fatiguing and produc- tive of the best work, but favours health by encouraging a proper balance of wear and tear in the bodily functions. The muscles may be rested while performing mental work, and undoubtedly the best rest from mental work is found in physical exertion. CHAPTER IX DIET In the course of the preceding chapters references have occasionally been made to questions of diet, and it may be convenient to give a brief account of this subject. The regulation of food in accordance with the normal requirements of the body in different periods of life, conditions of climate, and degrees of activity, as well as the modifications demanded by a disturbed metabolism, or actual disease, is a matter both of theoretical interest and practical importance. In order to sustain life a due amount and proper proportion of nitrogenous, non- nitrogenous, and inorganic mineral matter are necessary, and with these may well be considered, in connection with ordinary civilised life, the effects of such local and general stimulants as condiments and alcohol — not that these are necessary, but they are usuaUy introduced into the customary dietary. Though the amount and proportion of these principles may be slightly varied, under the conditions already alluded to, none can be altogether dispensed with, and for the maintenance of good health the consumption of some part of the organic constituents in a fresh state is essential. The primitive food provided by nature for the development of the young, such as milk and eggs, may be taken as typically complete, containing all necessary con- stituents, their percentage constitution being estimated a,s follows ; »X5 2l6 Diet Gautier I luman MUk. Cow's Milk. Egga. Water . 86-08 . . 85-77 . . 73-67 Albumen 2-48 . . 3-04 . . 12-55 Fat . 4-28 . 4-04 . . 12-11 Carbohydrate . 5-69 . . 403 . . 0-55 Salts . 0-02 . . 0-54 . . 112 Compare with these the following Moleschott's diet for Average diet medium work. in Paris. Water . . 7300 . . 80-0 Albumen . 4-58 . . 4-1 Fat . 2-96 . • jl50 Carbohydrate . . 14-25 . Salts 1-05 . . 0-9 Sandow's training diet, consisting of about six pints of fluid, twenty ounces of meat, six ounces of fat, and twenty-eight ounces of carbohydrate food, represents potential energy of 4,462 calories, and is rather in excess of the average, being adapted to severe muscular exer- cise. The previous diets are calculated in the dry state, the water of the food and drink being tabulated together. In actual food material the daily diet calculated by Moleschott for a man performing medium physical work would be represented as follows : Meat 13|^ oz. Butter 2^ „ Bread 171,, Vegetables . 16 „ Sugar 2| „ The following is estimated as the efficient daily diet for a man of 150 lb. under different conditions of physical activity, reckoned in the dry state : Diet 217 Subsistence. Best. Medium Severe Very Labori- "Work. Work. ous Work. oz. oz. oz. oz. oz. Proteid . . 2-32 . 3-52 . 4-59 . 4-94 . 6-50 Fat . 0-84 . 1-76 . 2-96 . 3-17 . 2-85 Carbohydrate . . 11-5 . 14-08 . 14-26 . 15-31 . 20-10 Salts . . 6-5 . 0-64 . 1-06 . 1-13 1-40 15-16 2000 22-87 24-55 30-85 These quantities being calculated as dry food, must be doubled to give the actual amounts consumed in the moist state. It will be noted that the proteid con- stituents concerned in the building up of the tissues are capable of smaller variation in quantity than non- nitrogenous constituents, which are mainly concerned in the changes associated with muscle activity. It is estimated that an individual occupied in brain work requires the same food as one at rest. The proportion of proteid to carbohydrate is as 23 to 77 — that is, nitro- genous food should constitute about one-fourth of the non-nitrogenous food. The chief variations which occur in the alimentation of different classes of society concern mainly the consumption of proteid to a greater or less extent as animal food, and involve also difEerent amounts of animal food in the form of fat instead of carbohydrate of vegetable origin. It should be recalled that the proteid constituents of food may be entirely supplied either by meat or bread, the latter being cheaper but more bulky. In the same way non-nitrogenous con- stituents may be supplied either as fat or carbohydrate with the same distinction. " If the lean of meat only were consumed, rather over six pounds would be needed to furnish the requisite amount of carbon, and there would be a very large surplus of inutilisable nitrogen, whilst if bread only were taken the amount necessary to supply the necessary amount of nitrogen would be rather more than four 2i8 Variations in Diet pounds, and this contains nearly double the amount of carbon wanted " (Pavy). The preponderance of fat over carbohydrate is in accord with the requirements of a cold climate, as in the habitual diet of the Eskimo, while a preponderance of carbohydrates over fat is better suited to life in a hot climate, as is seen in the usual rice diet of Hindoos, a due proportion of proteid material being necessary in either case to maintain the structure of the body. The modification in amount of food is perhaps best illustrated by the starvation diet adopted in what is known as Tufnell's treatment for aneurism, which consists of eight ounces each of fluid and solid, of which half is ad- ministered as the mid-day meal, and a quarter morning and evening. The actual articles employed are 4 oz. Meat. 4 „ Bread. 4 „ Milk. 4 „ Claret. On the other hand, the treatment of chronic nervous diseases and pulmonary tuberculosis by over-feeding involves as much as four or five pounds of solid food daily, in addition to two pints of milk. The importance of permitting one or other of these classes of food to predominate is exemplified in the treatment of such diseases as diabetes, in which carbohydrates, on account of their easy conversion into sugar, must be entirely replaced by fat, while in defective conditions of the kidneys, in which the output of nitrogen is hindered, the nitrogenous substances of the diet must be cor- respondingly reduced. A very important feature, apart from the nutritive value of particular foods, is the question of digestibility — that is to say, the rapidity and completeness with which solution is effected in the digestive tract. Digestibility 219 From Penzoldt, Quoted by Gautier Average Time necessary for the Stomach to remove the different Alimentary Materials which it digests to the Intestine, Quantity in gnns. Time in liours. A. Waters and Alimentary Drinha : Pure or gaseous water Infusion of weak tea Coffee . Coffee with cream Pure cocoa Cocoa with milk Beer . . Light wine Ordinary wine Malaga wine . Gravy soup . B. Flesh of Mammals or Birds Cooked beefsteak, hot or cold Roast beef Roast fillet of beef Raw beef (lean) The same boiled Raw ham Cooked ham . Roast veal, hot or cold (lean) Smoked meat Smoked tongue Sausage of raw meat Roast hare Roast goose moderately fat Roast duck . Roast partridge . Boiled pigeon . Roast pigeon. Boiled or roast chicken C. Other dishes derived from Animals Sweetbread Boiled calf's foot Calf's brain . Boiled rmlk . id ri 00-200 . 1300-500 . . 200 . . 200 . . 200 . . 200 . . 200 . / . 200 . 1300 500 . . 200 cc, . 200 „ . 200 „ . 200 „ 100 250 100 250 250 160 160 100 100 250 100 250 250 250 230 230 195 250 . 250 . 250 . 250 (100-200 t 300-500 to 2 „ 3 3 „ 4 2 „ 3 1 „ 3 2 „ 3 220 Digestibility Quantity in grms. Time in hours. Soft-boUed eggs .... . 100 . . 1 to 2 Hard-boiled eggs or omelettes . 100 . . 2 „ 3 Gravy soup . 200 . . 1 „ 2 D. Fish and Analogous Dishes : Boiled carp ..... . 200 . . 2 „ 3 BoUed pike ..... . 200 . . 2 „ 3 Boiled haddock .... . 200 . . 2 „ 3 Fresh-boUed cod .... . 200 . . 2 „ 3 Lamprey with vinegar . . 200 . . 3 „ 4 Boiled Rhine salmon . 200 . . 3 „ 4 Salted or smoked herring . 200 . . 4 „ 5 Salted caviare .... . 72 . . 3 „ 4 Raw oysters ..... . 72 . . 2 „ 3 E. Cooked Vegetables : Steamed potatoes eaten with salt . . 150 . . 2 „ 3 Mashed potatoes .... . 150 . . 2 „ 3 Potatoes with vegetables . 150 . . 3 „ 4 Boiled cauliflower . . . . . . 150 . . 2 „ 3 Cauliflower cooked in salad . . 150 . . 2 „ 3 Cooked asparagus .... . 150 . . 2 „ 3 Rice cooked in water . . 150 . . 3 „ 4 Cooked turnips .... . 150 . . 3 „ 4 Boiled carrots .... . 150 . . 3 „ 4 Boiled spinach .... . 150 . . 3 „ 4 French beans .... . 150 . . 4 „ 5 Mashed peas . 200 . . 4 „ 5 Mashed lentils .... . 150 . . 4 „ 5 Green peas cooked in water . . 150 . . 4 „ 5 F. Raw Vegetables : Cucumber salad .... . 150 . . 3 „ 4 Raw radish . 150 . . 3 „ 4 G. Bread and Biscuit : White bread, fresh or stale, dry or with te f 70 . ^ {l50 . . 2 „ 2 . 3 „ 4 Rye bread 150 . . 3 „ 4 Albert biscuits .... f 50 . \150 . . 2 „ 3 . 3 „ 4 H. Fruits : Apples ...... . 150 . . 3 „ 4 Raw cherries .... . 150 . . 2 „ 3 Stewed cherries .... . 150 . . 2 „ 3 Diet in Childhood 221 Diet in Childhood. — It will have been noticed in connection with the analysis of milk and egg that these foods of the young contain a greater proportion of proteid than is recommended in the diet for adults. The child shows greater activity in metabolism than the adult, consuming and breaking up greater quantities, especially of proteid, in proportion to weight. There is indeed a gradual diminution in the output of nitro- genous waste from early infancy to old age, ranging from 1-35 grms. urea per kilogramme at eighteen months to "5 grm. at twenty-five years and onwards. Feeding in infancy and adolescence should be liberal. Un- questionably the best method of nourishing the newly born is by maternal suckling. This should be carried on systematically, at first every two hours, and then every three hours during the day, and twice during the night, the quantity of milk ingested increasing pro- gressively from 80 grms. (about 3 iij) at a time in the first month to 150 grms. (5 vj) in the fourth. The duration of nursing must depend on the development of the infant and its capacity in the later months for taking and digesting other foods, and the ability of the mother to continue the supply. It may be pointed out here that the enormous mortality of children from diarrhoea during hot weather is closely associated with artificial feeding, and there would be a great security for infant life if suckling were continued through these periods. Failing this method, mares' or asses' milk, collected with strict antiseptic precautions, offers the closest approximation. If cow's milk is employed, as is most general, it should be mixed with half its volume either of water, sweetened with 5 per cent, of sugar, preferably lactose, or with a similar quantity of decoction of oatmeal or flour. Of this mixture one pint should be given daily, gradually increased to two pints at the third month, which corresponds to 595 calories. With i22 Diet in Childhood the appearance of the teeth after the sixth month, additions to the milk diet should consist of bread, flour, yolk of egg, biscuit and the gravy of meat. To- wards the end of the first dentition, at about the second year, small quantities of finely minced meat or chicken, with various starchy materials as puddings and cooked fruit, should constitute the diet, avoiding condiments, seasonings, and smoked articles, thus gradually accustom- ing the child to ordinary adult food. From six to fifteen years the child should be supplied with nearly double the amount of proteid matter in proportion to his body weight as is required by the adult. Fats also ought to be pro- portionately abundant on account of the greater loss of heat which occurs. The young have a natural craving for sugar, which may be indulged in moderation, as this is a valuable nutrient. Sweets are best digested about an hour after meals ; when given before they disturb digestion by provoking secretion of mucus. Growth and development require also an ample supply of mineral elements, such as the salts of potash, lime, and phosphorus, these being contained in the cereals, fish, and milk. From fifteen years onwards, which is perhaps the most active period of muscular exertion, while the excretory organs are in full activity, full allowances of meat are required and are easily disposed of. From the time when growth is completed there should be a gradual diminution in the amount of food, particularly as regards the proteid constituents and in accordance with the mode of life of the individual, bearing in mind the statement already made, that the output of urea per day per kilogramme of body weight gradually descends from 1-35 grms. at eighteen months to -5 at twenty -five years. In old age, the lessened activity of chemical changes and of the digestive and excretory functions demands a lessened amount of food, especially in relation to proteid. Condiments 223 Tlie question of digestibility is of special importance, and one must also take into account defective powers of mastication. The most suitable foods are broths, grated meats, eggs, such vegetables as peas, beans, and lentils, besides an abundance of carbohydrates, and in most cases stimulants, but where there is evidence of high arterial tension stimulants and nitrogenous food should only be given in very small quantities. Condiments may be regarded comprehensively as local stimulants affecting appetite and digestion, arrest- ing fermentation and promoting secretion and peristalsis throughout the digestive tract, when taken in small quantities. Such are mustard, pepper, vinegar, sauces, pickles, the various spices, savouries and such easily absorbed articles as soup and oysters ; one or other of which condiments usually constitutes part of the food either separately or in the preparation of dishes. With these may be considered alcoholic beverages in small amounts, such as a glass or two of light wine and the smaller glass of brandy or liqueur with coffee at the termination of the meal, as digestive aids. The two features which are concerned in retardation of digestion are the bulk of fluid and the quantity of active principle, whether aromatic or alcoholic, when taken in excess. In the case of some wines, however, the retarding influence on digestion appears to be out of proportion to the amount of alcohol present, which is scarcely opera- tive till it amounts to 10 per cc-nt. of the gastric contents. Such are port, sherry, marsala, and madeira, usually regarded as heavy wines, more appropriate at dessert than to accompany the usual courses. On the other hand hock, moselle, claret, champagne, and perhaps burgundy with the white wines of cor- responding districts, when taken in moderate quantity, exert no deterring influen^,e on the process of digestion 224 Alcohol and by slightly stimulating the circulation counteract the sedative effect of that process on the brain. The case of malt liquors is somewhat different, since both by the bulk usually consumed and the presence of saccharine, with other constituents besides alcohol, digestion is appreciably delayed and fermentation rather encouraged. Soup, as a preliminary to a meal, should be taken in very small quantity : " three spoonfuls " was the amount permitted by the late Sir Andrew Clark to an individual in difficulties with his digestion. Aerated fluids whether as sparkling wine or as mineral waters either alone or with small quantities of spirit, tend to assist digestion by slightly stimulating the mucous membrane of the stomach and aiding in the admixture of its contents. Error in these matters lies rather in the habit of satisfying thirst at the commencement of a meal by prematurely diluting the stomach contents with half a pint or more of fluid, or by over-stimulating and thus inhibiting the function of the mucous membrane by such articles as cayenne pepper, curry, or mulligatawny soup in quantity, or by drinking strongly alcoholic fluids. The practice, for instance, of drinking several glasses of the various forms of " cocktail " or gin and bitters before a meal is particularly pernicious in this respect. At the end of a meal the drinking of moderate quan- tities of fluid is not objectionable, since the food is already saturated with the digestive juices and partially dissolved. While taking food the object aimed at is to supply all necessary moisture through the medium of the saliva and gastric juice and not by drinking fluid, which should be taken an hour or more beforehand or he reserved for the end of the repast. Alcohol as a beverage must be regarded rather as making life temporarily agreeable than as being Alcohol 225 actually beneficial to the organism. In the average state of health it cannot be regarded as necessary. There are conditions, however, somewhat short of perfect health, such as old age, periods of over -work, and the state of fatigue, in which its beneficial effects are very definite, perhaps to a great extent through its influence on digestion. Locally alcohol is an irritant when evapora- tion is prevented, producing in the mouth or stomach a sensation of burning when introduced as neat spirit, more particularly in the case of an empty stomach. This may account for the chronic pharyngitis and gastric catarrh prevalent in spirit-drinkers, and will account also, through stimulation of the salivary glands, for the increased salivation which they experience. In small quantities, however, properly diluted, alcohol is an ad- junct to digestion. Up to a proportion of 2 per cent, of the stomach contents it increases peristalsis and secretion of gastric juice, improves the appetite, and aids absorption of some ingredients of the food. In increased quantity, up to 5 or 10 per cent, of the stomach contents, the digestion appears to be somewhat retarded, and 20 per cent, admixture arrests it. The greater part of the alcohol taken within moderate limits is directly and rapidly absorbed into the circula- tion. This rapidity of absorption is sometimes taken advantage of in accelerating the action of certain narcotic drugs, such as paraldehyde, chloral, and sulphonal with its congeners, when employed as soporifics, and is often administered with them for this purpose. The rapid absorption of alcohol by the stomach prevents any considerable quantity passing on with the chyme into the duodenum, but it is estimated that a 2 to 3 per cent, admixture is sufiicient to interfere with pancreatic digestion. One other effect of local irritant action of alcohol, when taken in excess, appears to be reflex inhibition of 15 ^26 Alcohol the heart's action through the medium of the vagus nerves, which may account for sudden death after SAYallowing a large quantity of neat spirit, as much as a pint having been taken at a time, generally for a wager. The principal effect of alcohol is that of a stimulant to the circulation, its first effect being to accelerate and increase the force of the heart's beat, somewhat raising the tension of the circulation with subsequent dilatation of peripheral vessels, especially in the skin, associated with perspiration. This stimulating effect cannot be indefinitely maintained, as reaction necessarily occurs, consequently the beneficial effects of such stimulation can hardly be looked for in habitual drunkards. It is on this account that the continued exhibition of alcohol is to be discouraged in cases of chronic disease of the heart, and for the most part in acute forms of illness the administration of alcohol should not be commenced before the real necessity for its use arises. In febrile diseases and others in which the frequency of the heart beat is increased, the beneficial effect of alcohol is seen in the reduction in the number of beats, while in cases of heart failure, with feebleness and infrequency, the effect of alcohol, when satisfactory, tends to increase the rapidity and force of the heart's action. Acting in these contrary directions it may be said that alcohol proves beneficial when its effect is to bring the heart's action towards the normal. In the case of fever, besides such an effect on the cardiac beat, sustaining and steadying it alcohol tends to reduce the temperature by dilating the superficial vessels, moistening the skin, and so encouraging loss by radiation and evaporation. While it reduces ceU activity and with it heat production, intervening between the ordinary food supply and the demands of the tissues, alcohol appears, in being itself oxidised, to spare both ordinary nutriment and the Malt Liquors 227 tissues themselves, diminishing the waste which is a constant accompaniment of continued fever. Thus, in sparing fat and carbohydrates and lessening cell metabohsm it acts practically as a food. Malt LiquoPS. — Malt liquors are obtained by the fermentation of carbohydrates, the standard source being malted grain, and contain, as also do wines, besides alcohol, a considerable quantity of saccharine, organic and mineral matter. The amount of alcohol is low, usually not more than 4 per cent., so that they are almost as much a food as a stimulant. Of the various forms, lager beer is the weakest in alcohol, is most aerated, and contains a considerable proportion of unchanged carbohydrate material, India pale ale, which, though hght, is fully fermented, contains more alcohol, and very little carbohydrate matter. These are considered the lighter forms of ale. Ordinary draught or bottled ale is usually richer both in alcohol and solid matter than the preceding ; stout and porter, much heavier beverages, contain half as much again both of alcohol and extracts. They are also more acid and more difficult of digestion, but are excellent soporifics. It is chiefly owing to the saccharine and other organic matters in the different forms of malt liquors that these are unsuitable to those predisposed to gout, arthritis, and arterio-sclerosis, and indeed to all those of sedentary habits who are liable to what are regarded as disturbances of the liver. Malt liquors are nourishing, and form excellent tonics in convalescence, and are well suited in health to those living a physically active life. As has been already suggested, they are the best form of alcoholic drink during the early years of adult life. Later on, when dissociated from physical activity, they tend to produce obesity or gout, and are unsuitable in diabetes. The bulk of fluid consumed in large potations may lead to distension of the stomach, and from over-fulness of the 22 8 Wines circulation to dilatation and hypertrophy, followed by failure of the heart. Cider and PePPy hold an intermediate position between malt liquors and light wines. They contain usually less than 4 per cent, of alcohol, bottled cider being rather weaker in this respect than draught, and re- taining more sugar. There is usually moderate acidity due to malic and citric acids. These have apparently rather a beneficial influence in rheumatism and gout, being solvents of uric acid ; and a fairly dry sample of this beverage may be drunk by patients prone to these diseases, much in the same way as hock, but the sweet aerated bottled ciders are not so suitable. Wines. — Wines are obtained by fermenting the juice of the grape, resembling malt liquors in that they contain a considerable amount of dissolved organic matter, in addition to a percentage of alcohol, with the addition of particular ethers. Natural wines, in which the grape juice is fully fer- mented, contain a relatively small amount of alcohol, less than 12 per cent, by weight, and practically no sugar. They are light in character, whether red or white, mature early, are not sweet, and supply the best beverage with meals. Such are hock and moselle, and the red and white wines of Burgundy and Bordeaux. With these may be included the wines of Hungary, Italy, Australia, and California, The different qualities of wine depend both on the yeast and the grape employed in their manufacture. Fortified wines contain alcohol to nearly double the amount present in the natural, this being provided by added spirit, which limits the extent of fermentation, 80 that these wines contain in addition a high proportion of sugar. Such are port, sherry, marsala, madeira, and the Greek wines, which on account of the alcohol and sugar they contain, as in the case of malt liquors, are unsuitable for gouty and arthritic subjects. spirits 229 The proportion of alcohol and ethers increases while the wine is in the vats and the ethers still further after the wine is bottled, with slight sacrifice of alcohol. These changes cause the wines to mellow with time. They do not, however, continue indefinitely, but the greater their strength in alcohol the longer wines take to mature and the longer they may be kept to advantage. It will be inferred from the foregoing observations that the natural wines, including with them champagne, are best fitted to accompany a meal, fortified wines being suited for occasional use and dessert, in much smaller quantities. Spirits as usually sold contain about 43 per cent, of alcohol, rum rather more, and gin a little less. Patent spirit, which forms a large proportion of that usually obtainable, is freer from by-products than pot-still spirit, and does not therefore improve to any per- ceptible degree by keeping. Rum, which is fermented molasses, or the juice of the sugar-cane, owes its flavour chiefly to ethyl butyrate and its colour to burnt sugar. It contains a larger amount of solid matter than any of the other spirits, besides being as a rule stronger in alcohol. It is seldom used medicinally, except as a mixture of rum and milk as a morning draught, par- ticularly in cases of consumption. Whisky, which may be regarded as distilled beer apart from the hops, is about half and half alcohol and water, its colour being obtained from being kept in sherry casks. It is slightly laxative, contains rather more alcohol than brandy, and is considerably cheaper and easier to procure than that spirit, and is perhaps, therefore, preferable for general use. Brandy, which is distilled wine, derives its colour, and perhaps some degree of astringency, from the wood of the oak casks in which it is kept. Both brandy and whisky, other than patent spirits, are mellowed by time through development of ethers and aldehydes with a 230 Spirits slight reduction in the percentage of alcohol. The best brandies are derived from Cognac and Spain. For cases with severe nervous and circulatory depres- sion old liqueur brandy is the very best stimulant, and it should be reserved for such infrequent cases, being expensive and difficult to procure. Owing to the smaU amount of tannin present, brandy is regarded as some- what constipating, and is occasionally employed as a household remedy in diarrhoea. Gin is distilled from fermented rye and malt liquor, flavoured with juniper. Being kept in cisterns lined with white tiles it remains colourless. The best is made in Schiedam, Holland. Gin is a somewhat weaker spirit than the others, containing 35 per cent, of alcohol, and very little else than this. It may therefore be looked upon as perhaps the purest spirit, quite free from sugar, and on this account and the presence of oil of juniper it is often selected as a stimulant in cases where the kidneys are defective and a diuretic action is required. Another advantage of gin is that it is relatively inexpensive. There being little in it to undergo secondary changes, it is practically as good when first made as when kept, and this materially diminishes its cost in comparison with other spirits. Where there is great nervous depression associated with delirium, dry tongue, and tremors, alcohol is of striking oenefit. Its physiological effects on the circulation are ex- perienced in the sense of warmth due to flushing of the skin, and in mental activity, associated with dilatation of the cerebral vessels ; but the fallaciousness of these im- pressions is shown in the one case by the increased loss or diminished production of heat, often illustrated in deaths from cold and exposure after excess of alcohol, and in the other by the reactionary depression and really defec- tive ideas due to cell paralysis. It may be inferred from this that alcohol is not a true brain stimalant, and that Spirits 231 while it increases vulnerability to cold when taken during or before exposure, it may be of service after chill by assisting the activity of the circulation and the more general distribution of the blood which has been retained internally by congestion. Long-continued use of alcohol produces vascular paralysis, and accounts for the bloated look and purple complexion of the chronic drunkard. The injury to the organism wrought by excess of alcohol, besides the local catarrh already mentioned, apparently depends on the passage of a proportion of the unchanged drug through the system, some 10 per cent, escaping oxida- tion. This free alcohol acts as an irritant in the circula- tion, causing fibrosis in the liver, blood vessels, brain, and kidneys. Such effects are most marked when a large quantity is taken at once, especially when undiluted. The limit of absolute alcohol that can be disposed of in the system at one time is from 1 to 1|- fluid ounces (which would be represented by some 2 ounces of spirit, 5 ounces of strong wine, such as port or sherry, ^ pint of light wine or champagne, and about 1 pint of beer). The danger to be avoided therefore is flooding the circulation with an amount of alcohol which it is beyond the power of the tissue cells to oxidise. Other effects of excess of alcohol, short of actual inebriety, are fatty degeneration of tissues and obesity. Idiosyn- crasy has much influence, and an open air life with constant activity does much to neutralise the effects of alcohol, and an amount which would exceed the capacity of the organism to deal with in one dose may be tolerated, if sufficiently diluted, or taken in subdividei' quantities in the course of the day. As a beverage alcohol is less noxious when, taken with meals, provided the quantity is below that \Fhich would unfavourably dilute the gastric contents. For the most part, beer is best suited to youth, wine to middle a^e, and spirits to the ol4. 232 Spirits In connection with disease, spirits are usually employed in acute phases, whether as a " sparing " aliment in fevers or as a direct stimulant to the circulation in cases of heart failure. The combination of tincture of digitahs or strophanthus in the proportion of a drachm to three or six ounces of spirits in the course of twenty- four hours supplies an efficient heart tonic. Stimulants should of course be given with the same strict dosage and regularity as medicine, and it should not be forgotten that when really required they are most necessary during the night. It is sometimes advisable rather to prescribe alcohol in such a form as the following : Tinct. Aurantii . . . oij Sp. ^theris . 3 S3 Sp. Am. Aromat. 3ss T. Nucis Vomicse . . mx Aq. Chloroformi . adgj This is a powerful diffusible stimulant which would not be recognised in a prescription as alcohol. Malt liquors and the fortified wines are chiefly used in convalescence from acute disease, sherry being revived at the present time, though port has long held first place. Champagne is of special service in rousing patients who are particularly exhausted or when there is frequent vomiting and nausea, and has been much used in influenza. It is speedy though transient in its effects, and when taken with meals is of great value in assisting appetite. Port has for a long time been regarded as of particular value in septic states both general andlocal,beingemployed in septic infection and intoxication and especially in cases of septic sore throat. The natural wines with cider and perry are wholesome general beverages in health, as are also malt liquors for those leading an active life, but in arthritis and those suffering with arterial and renal degeneration the lightest white wines are alone admissible. Coffee 233 The immediate effect of nerve stimulants, without actually supplying nutriment, is to excite the individual to exert his powers of resistance and activity, apparently by enabling certain reserves of energy and energy-supplying material to be drawn upon through the agency of the nervous system. Such stimulants are excitants which do not take the place of food nor diminish the expenditure of nutritive material in the body, consequently they exert their influence in bringing about activity at the expense of the materials already existing in the body. Ex- cluding alcohol, the nerve stimulants contain alkaloids of the puric family allied to xanthin and uric acid. These are coffee, tea, mat6, cocoa, kola, and guarana, though there are other substances which have a share in the stimulating effect besides the recognised alkaloid in each individual case. It has been stated by Le Blond that caffeine increases the central and diminishes the peripheral temperature of animals. It stimulates the action of the heart when given in moderate doses, causing arterial pressure to rise both by this and by contraction of the peripheral vessels. It increases the activity of the nervous centres and the excitability of the muscles, causing the sensation of fatigue to disappear ; but its chief effect is in inducing a greater amount of brain or mechanical work to be done upon the same amount of food. Coffee helps the digestion of milk and is less liable to interfere with that of proteid matters such as meat than is tea. Its effects on the nerve centres are valuable in taking the place of alcohol, and even in curing chronic alcoholism. When taken in excess or by individuals unaccustomed to its effects, coffee is liable to produce nervous excitement and especially insomnia ; and in great excess the condition produced is comparable with advanced alcoholism. It should be forbidden in the arthritic and uratic diatheses, to those suffering from 234 Tea gastrodynia and dyspepsia, or Bright's disease. As an antidote it is commonly used in opium and belladonna poisoning, as well as in that by alcohol. Tea is no more of a food than coffee, but it has a similar power of exciting functional activity of the nervous and muscular systems so that a greater amount of work can be done under its influence with the same amount of food, and without the usual sense of effort. It also excites the circulation, the digestive functions and the kidneys, by its alkaloids. The use of tea should be restricted in nervous subjects, and in those suffering from gastric disturbances. Owing to its exciting the activity of the skin, it is also unsuitable for those suffering from diseases such as eczema. Both tea and coffee, on account of their being allied to uric acid, are considered inadmis- sible in the subjects of chronic gout. An important point to remember in the preparation of tea is that the amount of tannin dissolved increases with the time occupied in infusing. Five minutes or less should dis- solve the thein and about one-third of the tannin ; pro- longed infusion serves only to extract further quantities of tannin, colouring matters and a bitter principle. For the most part it is the tannin which disturbs the stomach and interferes with the digestion of proteids. To make good tea cold water should be freshly boiled, and the teapot completely filled. The presence of lime salts interferes to some extent with the extraction of its constituents, and hard water should be softened with a little bicarbonate of soda. On the other hand too soft a water extracts the bitter principle from the leaf. The use of water which has been previously boiled or long heated, owing to the absence of dissolved air, gives a flat taste to the beverage. The importance of heating the teapot and employing actually boiling water depends on the fact that some of the volatile constituents of the lesbi which supply the aroma can only be properly ex- Chocolate 235 tracted at the boiling point. The water should not remain in contact with the leaves for more than five minutes, or the infusion will become bitter and astringent. The addition of milk, by forming an insoluble com- pound with the tannin, appears to obviate some of the ill- effects of tea on the digestive processes, but even then tea is an unsuitable beverage in association with meat meals. Irritating effects on the stomach are more likely to occur when this is otherwise empty, and is an objection to the early morning cup taken alone. As an habitual beverage coffee appears to exert a relaxing effect on the bowels and tea the opposite. The ill-effects of both tea and coffee show themselves in a disturbance of digestion and over-excitability of the nervous system. Coffee is often considered " bilious " and tea as productive of dyspepsia. These effects usually result from excess, or depend on personal idiosyncrasy. Choeolate. — The third substance used as a beverage differs from the other two in that it contains more nutriment and less constituents of a stimulating character. Theobromine, its peculiar alkaloid, is homonj'- mous with caffeine, and has very similar effects. Its richness in albuminoids and fatty matters, with the large amount of sugar which is added in manufacture, make up a food of great nutritive value. Owing to the presence of oxalates in considerable quantity, and also the large proportion of sugar, chocolate is unsuited for those suffering from uric acid or arthritic diatheses, rheumatic or gouty subjects, and those tending to obesity. Chocolate, being both a stimulant and a food, produces a more lasting effect than tea or coffee, with less excite- ment, and consequently forms a satisfactory drink before going to bed and in insomnia from hunger in the course of the night. Of the other stimulants mentioned, Kola contains a sustaining substance allied to thein, and is used as ai? 236 Vegetarian Diet actual nerve stimulant, forming a factor in Vi-cocoa. The kola -bean is largely employed by negroes in Central and Western Africa as a sustaining food, enabling them to resist the fatigue of long journeys for days together with no other substance than water. Mate, an infusion of which is extensively employed in South America, has very much the qualities of tea, the stimulating properties being due to nearly 2 per cent, of thein and 20 per cent, of metatannic acid. The infusion is slightly bitter, aromatic, and astringent, and is a neuro- muscular excitant. Guapana, which has been mentioned as a remedy in headache, is used in Brazil infused with boiling water much in the same way as tea, to aid in resisting hunger and fatigue during journeys. Tannate of caffeine amount- ing to 4 per cent, is the chief active principle. SPECIAL DIETS. Vegetarian Diet. — It may be inferred from what has been already written that the nitrogenous as well as the carbohydrate principles of food may be entirely supplied by the vegetable kingdom. This appears to be particularly suitable in hot climates, and prevails largely in India and Egypt as well as in many parts of Russia and Norway, without any sacrifice of energy, though, as in the case of herbivorous animals, such a diet appears more suited to steady continuous strain than to concentrated effort. Its advantages are largely those of temperance, tendency to arthritic or gouty diatheses being diminished, and the general tenor of life being rendered more equable, without loss of intel- lectual acuteness. It also has the advantage of being inexpensive. On the other hand, the bulk of food required, and its constitution, puts a greater strain on digestion, and Milk Diet 237 is ill suited to meet the lowered vitality incident to faulty heredity, illness, or advanced age. The amount of vegetable, as compared with animal food, in regard to proteid, averages in different substances from two to ten times the bulk, so that in order to obtain sufficient alimentation from vegetable sources alone the vegetarian necessarily encumbers his system as well as his stomach and alimentary canal with an excessive volume of material containing much superabundant and useless matter. As compared with herbivorous animals the human organism is neither suited to deal with such bulk, nor is it able to digest cellulose, which forms a considerable propor- tion of vegetable matter. Such a form of diet, however, is rendered possible by the addition of such animal foods as butter, milk, and eggs, and perhaps fish. The adoption of vegetarian diet results in an increase in faecal residues which stimulate the activity of the colon and so diminishes constipation, tends to render the urine more alkaline than would be the case with animal food, and further, by diminishing the supply of nitrogen, relieves the liver and kidneys from the elaboration and removal of nitrogenous products. A largely vegetable diet, on the other hand, tends to the production of flatulence. It increases the alkalinity of the blood, accelerates oxidation, and diminishes nitrogenous losses and the development of toxins. It is therefore specially suited for cases of renal disease, and it exerts a favourable influence on many diseases of the skin, tendency to arterio-sclerosis, arthritis and congestion of internal organs particularly when associated with a gouty diathesis. Milk Diet. — From the analysis of milk previously cited, it will be seen that under no circumstances can this offer a permanently complete form of nourishment to an adult, the quantity of albuminoids being too great in proportion to carbohydrates. The addition of bread, however, produces a complete diet on which an individual 238 Meat Diet might live indefinitely. An adequate milk diet for an invalid may be considered to include 3 pints of milk, with 10 ounces of bread, and about IJ ounces of rice or tapioca as pudding. Such a diet is suitable to con- ditions of fever in which a relatively large proportion of liquid is required, and where the digestive capacity is reduced in a serious degree. From the point of view of elimination of nitrogenous products, such a diet is commonly prescribed in renal diseases, though it may be necessary to reduce the amount of fluid while there is increasing oedema. An important point also to be attended to is the reduction of mineral matters, particularly common salt, which tends to increase the transudation of albumen. Owing to the constipating effeots of a milk diet, the addition of barley water or a decoction of oatmeal is usually necessary. It is important with a diet of milk that this should only be taken in very small draughts at a time, and rather slowly, while the admixture of lime-water in the proportion of an ounce to a pint diminishes the tendency to form hard curd. It may be mentioned that many persons with whom milk disagrees in health are able to take it in illness owing to lessened acid secretion in the stomach. Meat Diet. — This supplies the greatest amount of energy at short notice and in the smallest bulk, and is suited to healthy individuals leading an active life in which great and sudden demands may be made on the energy and courage. In the absence of fat and carbo- hydrates in the diet these matters are removed from the body, such diet being therefore suitable for the reduction of obesity. An animal diet, with due proportion of fat, is of necessity employed in cases of diabetes to avoid the development of sugar. The chief disadvantage of a meat diet is in the pro- duction of superabundant nitrogenous waste, especially Obesity 239 uric acid ; and the amount of work thrown on the liver results in dyspepsia, skin eruptions, and constipation, from the relatively small bulk and tenacity of the faeces. It is one of the most active predisposing causes of arterio- sclerosis. In Obesity it is necessary to reduce as far as possible fats, saccharine, and starchy matters, replacing them by some increase of meat and salads, also raw fruits, the omission of condiments and spices tending to diminish appetite. Such a diet would consist of : Gautier rl egg. 8 o'clock . . . ■] ^ oz. bread. If oz. meat. /-2 eggs. 10 o'clock . , J J oz. bread. 1,6 oz. wine and water. '\ lb. lean meat. 1 oz. bread. 12 o'clock . • 1 5 oz. green vegetables with a simi- ^ lar quantity of wine and water. 4 o'clock . , . Tea without sugar. 7 o'clock . . A similar meal to that at 12. This diet supplies 1,290 calories per day, rather more than half that actually expended in a state of relative repose, the remaining 800 or 900 calories being compul- sorily borrowed from the combustion of stored-up fats, loss of weight being at the rate of nearly 1 lb. a day. Alcoholic beverages in any quantity must be excluded, but there is no need greatly to reduce the amount of fluid. Indeed, hot water appears to have a special influence in reducing fat. Skimmed milk may be allowed, as the fatty matters have been largely removed. The cure of obesity may be assisted by moderate exercise, warm drinks, and light purgatives, as in the regime adopted at Marienbad. Although the use of 240 Obesity thyroglandin reduces the weight of the body, by pro- ducing cardiac disturbance, and increasing nitrogenous waste, it is a less safe and satisfactory method than that by diet alone. Here may be appended an account of the purely nitrogenous diet described by Dr. Salisbury. In the first stage the diet is restricted practically to meat and hot water. The muscle pulp of beef is most recommended, and this made into cakes is broiled and then seasoned with butter, pepper, and salt. The use of certain sauces, of mustard, horse-radish, or lemon juice is permitted. A little celery as a rehsh is allowed. This constitutes the meal — there may be an occasional change to broiled mutton — and it is repeated three times daily. Nothing is drunk at the meal, but at about one and a half or sometimes two hours before the next meal half a pint to a pint of hot water at a temperature of from 110° to 150° Fahr. {i.e. at about the temperature of one's hot tea or coffee) is sipped — fifteen to thirty minutes being taken over the drinking of the water. Should the water nauseate, Dr. Salisbury recommends that a little salt should be sprinkled in, or a small quantity of clear tea or coffee, or half a teaspoonful of aromatic spirits of ammonia. He gives as the best times for the hot water 6 a.m., 11 a.m., 4 p.m., and 9 p.m. before retiring. The duration of the treatment will depend very much upon the nature of the trouble, and upon the mode of reaction to the diet. The hot-water part is recommended to be continued for months or even for years. The exclusive meat diet — half a pound to a pound or even more is taken at each meal — may be continued for some two to six weeks, and then gradually the choice of vegetables may be increased and some thoroughly cooked bread foods, such as baked chip bread, thin dry toast, rice, etc., introduced. Before this, or along with it, it will have Obesity 241 been allowable to extend the scale of meats as follows : broiled mutton and lamb, broiled game, broiled chicken, broiled codfish, broiled and baked fish free from fat, a soft-boiled egg, etc. Subsequently, health being re- stored, it is recommended to keep the starchy foods well in the background, the albuminate being the most pro- minent. Resting before and after the meal is advocated. Directions for cooking the beef cakes (according to Dr. Salisbury's plan) : " Take four ounces of the beef pulp, which has been nicely minced, as before directed, and freed from all connective tissue and fat, etc. ; season with black pepper and salt, but add no liquid. With two forks form it nicely and quickly into round flat cakes from a half to one inch thick, and broil them slowly and moderately well, over a clear but not a fierce fire, turning the griller every minute. They will take from six to eight minutes. If pressed hard and tight in the making, they are livery, not nice, and very indigestible. A small piece of fresh butter may be put on each cake when done ; serve on a flying hot plate." We may remember that Dr. Salisbury allows certain sauces : Worcester or Halford's, also mustard, horse-radish, lemon juice — a selection from these. Mince. — A thick steak from the top of the round, or prepared ox heart quite fresh, with all skin and fat removed, is finely minced. The pulp should be put in the saucepan with salt and black pepper, and cold water or well skimmed gravy in the proportion of a full dessert- spoonful to each ounce of the pulp. (If the meat is specially dry, add a little more liquid.) Beat it all well together to a thick cream. The saucepan must now be put on a cool part of the stove or range, and the pulp warmed through very gradually, and very slowly cooked, being briskly stirred and beaten up with a wooden spoon the whole time. 16 242 Arthritist Gout, Uric and Oxalic Gravel It should never get too hot to the touch while cooking (temperature about 115° Fahr.). If gradually and gently cooked thus, it takes from twenty to thirty minutes according to quantity, and should be turned out at once, when done, into a hot bowl and covered. If properly cooked, it is delicious, like a thick smooth cream. Apthpitis, Gout, Upie and Oxalie Gravel. — Though the subject of these maladies does not always eat in excess of others, it is certain that many exceed the limit of strict necessity, and the power which they have of consuming completely the food they take. Organic hyperacidity is the rule in arthritics, necessitating alkalinity of the diet. This requires restriction in all acid dishes except such organic acids as vinegar, lemon juice, and fruits. A meat diet, since it tends to the development of organic acids of nitrogenous constitution, must be suppressed or reduced in amount. Neither fortified wines, liqueurs, malt liquors, coffee, nor chocolate are admissible in such cases. The diet must be scanty, including a little bread and carbohydrates (although potatoes may be taken), still less meat, and few fatty bodies which impede nitrogenous metabolism, but in place of them a great deal of green vegetables and ripe fruits. An indoor life is as far as possible to be discouraged. As regards meat, the flesh of young animals and the gelatinous parts are particularly to be avoided, as well as smoked meats, and such as are rich in nuclein, as sweetbreads, brains, and eggs. Such vegetables as spinach, sorrel, and rhubarb, w^hich contain much oxalio acid, should be eschewed. Milk is the best nutrient, supplying the place of meat on the nitrogenous side, and a relative excess of fluid, which is favourable. With regard to beverages, pure water in abundance excites oxidation, and holds in solution uric acid, but most mineral waters answer the purpose, especially the Diabetes ^43 alkaline and laxative varieties. Light, non-acid wines, fruit juices, draught cider, lager beer, and weak tea are admissible. At Carlsbad the diet prescribed for gouty patients is as follows : Breakfast /'Weak tea with cream. J Biscuits, 2 to 4 oz. j Butter, J oz. \^2 soft-boiled eggs. Midday Dinner Supper Soup, either clear or with pearl barley or rice, 1 oz. Fish, 3^ oz., with melted butter and lemon juice. Potatoes, 2 oz. Roast meat, 3| oz. Cheese, 1 oz. Stewed fruit, 3^ oz. .Bread, 5 oz. (Soup, milk or weak tea. Biscuits. Lean bacon or 1 or 2 egga. With dinner and supper pure or mineral water, with half a pint of light claret or two tablespoonfuls of whisky, is allowed. Diabetes. — In this disease there is excessive loss of water, sugar, and nitrogenous bodies, which have to be limited and made good as far as possible by modifica- tions in the food taken. These consist in (1) eliminating as far as possible every article of diet which may furnish glucose, and (2) meeting the nitrogenous losses by an increased amount of animal food. Plenty of fluid must be given, a considerable amount of meat, while the carbohydrates are replaced by green vegetables and fats in various forms. Fruits, containing as they do starch and sugar, though in small proportion, may only be tolerated in small quantities. Objection does not extend to such as are not sweet, as tomatoes, olives, and hard nuts 244 Nephritis such as almonds, walnuts, filberts, etc. Such starchy fruits as bananas and chestnuts, and very sweet ones such as grapes and cherries, should be forbidden. The general rule is to avoid the roots and fruits and only to eat the intermediate stalks and leaves, remembering that white stalks contain some starch, as does also the head of cauliflower. Celery, seakale, and asparagus are permissible except in a very severe dietary — as are also mushrooms. French beans freed from seeds may also be eaten without inducing glycosuria. Green goose- berries and rhubarb stewed and sweetened with saccharin may be taken, and also tomatoes, cucumbers, and olives. The greatest difficulty is in finding a substitute for bread. Perhaps the best is protein or casoid made from milk, though many others are offered, such as soya, almond meal, and gluten. As it is not always absolutely necessary, or indeed possible, to entirely exclude carbohydrates, Jerusalem artichokes may be permitted and potatoes may some- times be employed in place of bread, containing as they do about half as much starch. Alcohol, particularly in the form of spirits and unsweetened wines, may be recommended. An illustrative diet is the following : Beef or mutton, about 2 lb. Diabetic bread, 3 oz. Green vegetables, 9 oz. Potatoes, 2 oz. Fish, 5 oz. Cream, 3 oz. Butter (fats), 3 oz. Cheese, 2 oz. Wine, J pint, such a diet representing about 3,000 calories. Nephritis and insufficiency of the kidneys, wldch interfere with the removal of nitrogenous waste, while permitting the transudation of albumen, require Nephritis 245 special consideration in regard to food. A milk diet is the most suitable, skimmed being better supported than pure milk in the worst cases, to which may be added carbohydrates, vegetables and fruits, with the exception of asparagus and cabbage. In less severe cases, eggs and even meat in small quantities may be employed, pork being perhaps best. Elimination of salt from the diet appears to lessen the transudation of albumen, and to reduce the oedema. All spices, smoked meats, and alcoholic liquors should be forbidden. A strict diet would include 5 pints of milk, 6 oz. of bread, 3 oz. biscuit, IJ oz. cheese, corresponding with about 2,500 calories per day. Perhaps the most frequently occurring cases in which diet has to be carefully arranged are those in which ordinary food gives rise to irritation with pain, vomiting, and diarrhoea owing to a disordered state of the mucous membrane in the stomach or intestines, possibly attended by actual ulceration. The object to be kept in view under such circumstances ia maintenance of nutrition, perhaps only approximate, for a time by the administration of bland, easily digestible, and highly nutritious food in small bulk, while carefully excluding aU irritants such as condiments, alcohol, and insoluble matters. The general principle being the same, details in mode of administration necessarily vary according to the site of disease. When it is necessary to avoid acid secretion or peri- stalsis in the stomach, or when for other reasons food cannot be introduced into the digestive tract, nutrition may, for a time, be maintained and thirst allfiviated by trans- or hypodermic alimentation. 246 Artificial Feeding Cod-liver oil is pretty freely absorbed by the skin when smeared and gently rubbed over the abdomen, the part being subsequently covered with a flannel binder, which must not be renewed too often, as it is an advantage for it to become saturated with the nutrient. This method is usually adopted in infants suffering from malnutrition especially in association with tuberculous disease of the peritoneum or intestines. In a more definite way and in larger quantity solution of glucose 5 ij to the pint or normal saline solution con- sisting of water with -6 per cent, of salt or bicarbonate of soda may be injected under the skin in volumes of a pint at a time, and sterilised serum of the sheep, ox, or horse, or olive oil may be administered in the same way in about one-fourth the amount. In a case of oesophageal cancer which was unsuitable for gastrostomy and where rectal alimentation had led to irritation and diarrhoea, the patient actually gained weight under treatment by hypodermic injection of broth. Such cases are fortunately rare, but it is useful to possess some means of sustaining life when the ordinary channels of nutrition are not available. When it is undesirable or impossible to give food by the stomach, recourse may generally be had to enemata, which may consist either of plain water, normal saline solution, or one of sanatogen (a teaspoonful to the pint), or of pre- digested foods. In any case enemata should be administered slowly, as high up in the bowel as possible, and at the body tem- perature ; the volume too should not exceed ten ounces or at first even five ounces, and the composition should be such as will cause no irritation. A cleansing enema once a day is necessary in addition. Continued experience in cases of gastric ulcer with simple water injections, commencing with five ounces, raised in twenty -four hours or less to ten ounces, and given Enemata 247 every four hours, has sufficiently proved their efficacy. The advantages are simplicity in administration, complete absence of irritation, of decomposition, and of the foul condition and ill-taste in the mouth which are commonly associated with the use of nutrient enemata ; while the patient approximately maintains weight and in gastric ulcer remains free from hunger and thirst till the time arrives for resumption of feeding by the mouth, even for as long a period as three weeks — which is as much as can be claimed for nutrient enemata. The following are some accepted formulae for the latter : Peptone Milk . 3 Eggs. Common Salt Milk . Grape Sugar . Milk . Starch (raw) Milk . Bij 3ix gr. 1 Six 5ij §ix Bij (^Leube) Wheat Flour, 2 table-spoonfuls. Lukewarm Water or Milk . g v Common Salt . , . gr. xv 1 or 2 Eggs. 15 per cent. Solution of Glucose .... §ij-iv 1 Glass of Claret. (Ewald) Milk . Yolks of 2 Eggs. Common Salt . Eed Wine . . Starch or Arrowroot (Boas) Milk . 2 or 3 Eggs. Common Salt Eed Wine (^Riegel) Beef Tea or Meat Juice Yolks of 6 Eggs. Common Salt Red Wine . (^Tournier) 3 IX gr. XV Sss Bss gr. XX Bj . Bv gr. XXX 3j Owing to the coagulating effect of the Bacillus Coli on casein, efficient cleansing of the bowel, and even the introduction of 2 grains of benzo-naphthol or chloretone as a disinfectant, is very necessary. Alcohol in small quantity and salt assist absorption. When the digestive capacity of the stomach com- 248 Graduated Feeding mences to be restored as shown by the subsidence of local symptoms and reawakening of appetite, feeding by the mouth may be resumed by slow degrees, fluid enemata being continued at first, the following being a suitable sequence of foods : Milk and Water or Soda Water, equal parts (peptonised if necessary). Albumen Water with Salt. Whey or Buttermilk. An ounce every hour, increased gradually in quantity with extension of interval. Benger's Food. Blancmange. Junket. Custard. Rusk in addition to milk, which may be fortified with one of the milk or meat dry extracts. Sheep's or Calf's Brains. Oysters. Eggs, in addition to milk, with Beef Tea or Soup. Tripe. Sweetbread. Boiled flat fish. Calf's Head. Stewed Sheep's Tongue. Tea made with boiling Milk. Bread-and-butter, or dry Toast. Milk Gruel or Arrowroot. Chocolate. Milk Puddings, especially Rice. Light Wine or Champagne. The more easily digestible forms of ordinary food carefully cooked may follow, if there has been no set- back in the matter of pain, vomiting, nausea, or diarrhoea. It may be useful here to suggest that the juice of pine- apple taken in small quantity at the end of a meal is an agreeable and powerful digestive agent. This gradation in diet may be usefully followed in convalescence from fevers and other severe illness, but is specially appropriate to gastric diseases and to cases after operations on the stomach, being adapted to en- feebled digestive power. As, however, such diet is .selected with a view to avoiding bulky and indigestible Limitations of Milk Diet 249 residues, it is also suited to disease of the small and large intestine in which mechanical or chemical irritation has to be avoided. In this respect the adoption of a purely mUk diet, especially when quantities are given exceeding three pints in the twenty-four hours, is open to criticism, as it may often be found that such a regime tends to the escape of considerable amounts of undigested casein. This, apart from waste, may cause unnecessary irritation throughout the digestive tract. The white curd is easUy detected in the fseces, and is commonly seen in infants and in cases of typhoid fever, sometimes associated with constipation, but more often with diarrhoea. The idea that milk feeding involves a fluid diet is a superficial error, since the proteid constituents which form the curd of milk, when this is taken in the crude state, are apt to traverse the digestive tract in a solid and by no means easily absorbed form. Even in the treatment of typhoid fever in which an exclusive mUk diet has had so long a sway, the practice is being departed from, though this objection may be met by dilution, reducing the quantity given or by predigestion. As has been mentione-d elsewhere, the addition of lime-water lessens the density of the curd, and may be obtained in an aerated form in syphons. FORMULiE FUNCTIONAL DISTURBANCE OF LIVER (pp. i-io) Pil. Hydrarg. . gr. iij Ext. Hyoscyam gr.j Ext. Aloes gr. j M. ft. pil The Quarter-grain Pill Enonymin 1 Podophyllin - ^a gr- J Iridin J Extract! Taraxaci q.s. Calomel gr. \ may be added M. ft. pil. Black Draught Magnesii Snlphatis 5]'ss Ext. Glycyrrhiz. Liq rn. xxiv Tincturse Sennce 3 J Tinct. Cardam. co 11 xxxvj Inf usum Sennae ad 5 j To be taken in the morning. For Bilious Indige Sodse Salicylatis Succi Taraxaci Sodse Sulphatis Sp. Am. Aromat. Sp. Chloroformi Infusum Gentianse Three times a day before meals. 250 tion gr. X 5ss 3ss Xtl XX Til X adgj Formulae Stimulant Draught 9. Ammonii Carbonatis ... , Lactis , gr. x-xxx Oss 251 Bile Stimulant ^. Podophyllin. ResinaB ... , Glycerini 3 j at intervals of 2-4 hours. FLATULENCE (pp. ^. Sp. Am. Arom. Sp. Chloroformi Tinct. Carminative Aquam . 9. Sp. Am. Arom. . Sp, Chloroformi Sodae Bicarbon. Infusum Caryophylli 9. Menthol. Calomel . Pulv. Zingiberis Maltine . 10-15) 3ss Til XX ITl X adSJ HI XX Til X • gr. X . ad5j • gr. I . gr. ij q.s M. ft. pil. One to be taken every quarter of an hour till relief is obtained. Emergency Prescription for Flatulence Pour a wine-glassful of boiling water on 5 crushed cloves and add 20 grains of Bicarbonate of Soda. Enema Terebinthinae T)i. Olei Terebinthinse . Mucilaginis Amyli . 53 Bxv '^. Olei Terebinthinse gss Bnema Saponis . ..... ss Enema Asafetidae ^. Asaf etidae . gr. xxx Aq. destillat. . , . .... § i^ 252 Formulae Enema Rutae 5;. Olei Eutse ni :!fxx Mucilag. Acacias .... • • • 3ij Enema Simplex . . . . . . . . ad 5 vj ACIDITY AND HEARTBURN (pp. 15^17) ]^. Magnesii Oxidi Sodii Bicarbonatis Sodii Phosphatis ^aaBss Sacchari Albi 5 j at intervals of half an hour or of tenet. For Hiccough Chloretono . gr. v In Gelatine capsule. FOR REMOVING SCYBALA (p. 31) ^i. 01. Crotonis . . . gr. -I Pulv. Zingiberis gJ". ij Maltlne q.s. M. ft. pil. 1 or 2 three times a day. FOR CRACKS ON THE LIP, FINGER, OR NIPPLE (p. 32) Hebra's Lotion ]^. Ac. Carbolici 3 iJ Glycerin! gj Etheris gj Sp. Vin. Rect. . . gvj Ft. lotio. ^. Plumbi Acetatis , . gr. xv Adipis prseparatEe . ...■.,. gj M. ft. ung. CATARRHAL HERPES (p. 33) 9i. Zinci Oxidi g j Acidi Borici g ij Amyli giij Formulae 253 PEPTIC ULCER (p. 36) Acid Nitro-Hydroch. dil "l x Liq. Strychninse '"l iv Sodii Sulphatis 5 ss Aq. Chlorof ormi . . ad 5 j Tliree times a day after food. MOUTH WASH (p. 36) Resembling Odol 9. Salol Saccharin . . . . • 01. Menth. Pip. . . ... Alcohol (80%) Add oils of Clove and Caraway. 2-5 parts •004 „ 97 Resembling Glycothymoline 9- Thymol Acid Benzoici Olei Gaultherii Eucalyptol Olei Menth. Pip. Spir. Vin. Pvcct. Acidi Borici . Glycerini Tincture Cocci Aq. destill. gr.j gr-j mss gr. ss 3J gr. XXV 3J TH, XX adOj REMEDY FOR TOOTHACHE (p. 4O Tincturae Aconiti .39 Linimenti lodi 3ij Chlorof ormi 5ij To be rubbed on the gum after drying. Odontodol for Toothache (p. 42) ^. Cocain. Eydrochloratis gr- xvj Acid. Hydrocyan. dil "1 xvj Tincturae Amicse 3 ij Liq. Am. Acetat ad5j To be applied to the tooth cavity or rubbed on the gum. 154 Formulae KEMEDffiS FOR LOSS OF HAIR (pp. 54 5) LOTIONS Erasmus Wilson ^. 01. Amygdalss • 5 j Liq. AmmoniEe oj Eau de Cologne § j 01. Eosmarini 3 iij 01. MyristicaB 3 i^ Tinct. Jaborandi 3j Aq. Eosse adgviij Hebra Tinct. Canthar. (or Ac. Tannici Sp. Vin. Eectif. Sp. Lavandula Ether. Sulphurat. Glycerini 01. Bergamot . Tanno-Quinine Quin. HydrochL Acidi. Tannici Alcohol. (60 %) Tinct. Cantharid. Glycerini Eau de Cologne Vanilin . Ligni Santali . Pilocarpin. Nitrat Mix, macerate i d 5 S3 gr. xij) 5v 5j 5ij 3iv Til X gr. XXIV 3J gxss 3J 5vj 3iv gr. ss gr. iij gr. iv ays and filter — (osij). POMADES Tanno-Quinine Olei Theobromi 5Js8 Ung. Emollient 5ss 01. Amygdala § jss Quin. Sulph. dissolved -with acid gr. x Aq. Eosae . . . gss 01. Citri 5 S3 01. Bergamot lU xx 01. Lavandulas "l xx Ac. Tannici gr. xl Tinct. Cantharid 3J Eau de Cologne 5 iiJ Formulae ^SS Duputrcn l^i. Medullas Ossium , . • 5ij Extracti Cinchons3 51] Tinct. Cantharid 3j Succi Citri 3 J Olei Limonis in, xx " Olei Bergamot iri x Gcmmarum Populi I^. Eesin. Gem. Populi . . ..... gj Adip. praeparatse gvj Aq. Eosae tti clx Heat together and add Olei Citri -v Olei Bergamot [- aa tri x Olei Eosmarini J FRECKLES (p. 69) Unna's Formula 9- Bismtithi Oxychloridi gj Calomelanos gr. J Hydrogen, Peroxid. (10 vol.) §j Adipis Lans et Vaselini aa 3 iv Ft. ung. 5;. Bismuthi Trinitratis 39 Hydrarg. Ammoniati 3 ij Adip. prseparatae §j To be spread on lint and laid on the patches at night Aqua Cosmetica Orientalis ]^. Hydrargyri Perchloridi , gj Aquas destillatEe . . . . . . . . giv Ovorum xxiv Albumen Succi Citri (i.e. Mal» Med.) . , . . . . 5 iij Sacchari Albi § viij REMEDIES FOR CHILBLAINS (pp. 75-76) Dusting Powders 5i. Acidi Borici 50 parts Taici Purificati . . 25 „ Amyli ... 25 „ Camphor vel Menthol j:!:r. xv in g j 2^6 Formulae 5;. Calamine 7 parts Menthol .1 part Unguentum 5.. Olei Gaultherii 5 ij Menthol gr. xv Adip. Lanse 5j Lotio ^. Plumbi Acetatis . gr. xvj Alcohol (90 %) (or Eau de Cologne) . . . . §j (Saturated Solution) Lotio Plumbi Spirituosus ^. Liq. Plumbi Subacet. fort 1 part Glycerin! 2 parts Alcohol. (90 %) . . 4 „ Aq. Eosse 25 „ Bath ^. Aluminis 5ij Aq, Calid Cj Steep Chilblains for 5 minutes. ty. Liq. Plumbi .... • . ■ • S j Tinct. Opii 5 J Glycerin! §j Aquam adgviij To be applied on lint, covered with protective. FOR BSOKEN CHILBLAINS Unna 5i. Eesorcin. vel Ichthyol 5 parts Acid. Salicj'lici 3 „ Paraffin! Mollis ....... 100 „ Ft. ung. Carbolic Acid in Vaseline ...... 5% REMEDIES FOR WARTS (p. 78) ^. Magnesii Sulphatis .... . , 5 ss Aq. Menth. Piperitas §j Three times a day for adults, 5 j for children. ^1. Acid. Nitro-Hydrochlor. dil. . . til xy Aq. Chloroform! .... ^1 After meals three times a day. 9. Formulae Tinct. Thuyse Occidentalis "l xxx-lx Ext. Glycyrrhiz. Liq 3 ^^ Aquam ^^SJ Three times a day. LOCAL KEMEDIES (p. 79) Nitric Acid Caustic Soda Acid Nitrate of Mercury Chromic Acid Liquefied Carbolic Acid Glacial Acetic Acid Sodium Ethylate Liquor Ferri Perchloridi fort. Caustic Potash Liq. Plumbi Subacetatis fort. Saturated Solution of Salicylic Acid in Alcohol. 257 Sulphuris Glycerini Acidi Acetici Kaposi's Solution To be applied daily. 5v 3is8 3ijs3 9- CORN CURE (p Acidi Salicylici Ext. Cannab. Ind. Alcohol. . Etheris . CoUodium Flexile 80 gr.xv gr. viij in, XV mxj adSij Inflamed Corn Apply a wet compress or pad steeped in Lotio Plumbi c Opio. ^■ RHEUMATIC SORE THROAT (p. 92) Sodii Salicylatis .. gr.xv Potassii Citratis gr.xv Olei Limonis ^ ^ Sp. Chloroformi '^ ^ Aquam ^"^^^ Every four hours for an adult. GARGLES FOR SEPTIC SORE THROAT (pp. 93-96) '^i. Hydrarg. Perchlor. Acid. Hydrochlor. dil. Glycerini Aquam destillat. 3ij 5j adgx 17 258 9. 9. Formulae Potass. CUoratis . . Acid. Hydrochlor. . • Aquam . . • « Potass. Permang. , • Aqnam . . t Formalin Solution (40 %) Aquam Acetozone. Saturated Solution in Water MIXTURES Potass. Chloratis Acid. Hydrochlor. Quin. Sulphatis Syrupi Aurant. Aquam . . 5j every three hours. 5i itixij adgx gr. iv Oj iti X adgx gr. s to j 5SS 5J gr. xxxvj §j . ad 3 xij Liq. Ferri Perchlor. Sp. Chloroformi Glycerin! Aquam destillat. . Three times a day. Liq. Hydrarg. Perchlor. Potassii lodidi ..... Sp. Am. Arom Decoct, Cinchona . ... Three times a day. Itl XV HI X ni XX adgj 33 gr. V ttl XX Bi 9. Liq. Ferri Perchlor , , itl xv Liq. Hydrarg. Perchlor. . . . . . tn, xv Liq. Strychninse ... .... in. v Tinct. Aconiti in, iij Potassii Chloratis gr. v Glycerin! . 3j Aquam destillat . . ad § j Three times a day. Tinct. Nucis Vom it v Tinct. Cinchonae co 5 ss Sp. Am. Arom tn, xx Aquam Chloroformi . . . . ad § j Three times a day. Formulae 259 9. 9. REMEDIES IN CA .TARR H (pp. 97-ioj i) Terebene 1 01. Bucalypti ■55 3ii Camphor. . , Menthol . 3-6 m for inhalation. COLLUNARTA Basis With either Sodii Bicarbon. vel Hazeline . m XX Sodii Biboratis ■ gr- iv Alum gr. V Aquam , . . ad5j Liq. Pot. Perm. m vj Quin. Sulph. . gr.| Zinc Sulph. . . gr.l Menthol . . . gr-i Dobell's Solution Gljcerini Acid. Carbol tnx Sodii Biboratis gr.vj Sodii Bicarbonatis gr.vj Aquam . Linctus ad§j Tinct. Camph. co. ^ Oxymel. Scilte aagss Succi Limonis J 3 j to be taken frequently. Vin. Antimon. , in X Vin. Ipecac. . ■ . . itix Sp. ^th. Nitros. • • • . 5ss Liq. Am. Acet. , , , . • 3ij Syrup. Limon. . . . 3j Mist. Amygdal. Every four hours • ad5i Ammon. Carb. • • • < . • gr.v Tinct. Camph. co. . . . III XX Syrup. Scillge . . . . • . 3ss Syrup. Tolu. . • • • • • • • 3J Infus. Senega Every four hours • ad§j Vin. Ipecac. . • • • • • • • 3ss Tinct. Scill^ . . • . 3ss Sp. Am. Arom. > • • • • • • 3ss Glycerini • • • • . 3j Aq. destillat. . . . adgjss 3j-ij every four hours for children. 26o Formulae PLEURODYNIA (pp. 107-110) Tinct. Ferri Perchloridi iti x Liq. Arsenic. Hydrochlor. tti v Glycerini 5ss Aq. Chlorof ormi ad 5 j Three times a day. aa gr. x Sodii Salicylatis Sodii Bromidi , , Phenazoni Aq. CamphorBe acl5j Three times a day. HYPNOTICS (pp. 113, 114) Morphini gr. i Atropini gr. ^^^ Strychnini gr. -^ Aquam .......... ni_ yj tn, iij-vj for hypodermic injection, particularly in cardiac cases. Potassii Bromidi . Sodii Bromidi Ammon. Bromidi . Acid. Hydrocyan. dil. Sp. Am. Arom. Sp. Chloroformi Aq. Menth. Pip. The draught to be taken at night. aa gr. x miij tri XX in, XX adSj Potass. Bromidi gr. xx Chloral. Hydratis gr. xv Tinct. Cannabis Indie nx x Mucil. AcaciEe gj Aq. Chloroformi ad g j The draught to be taken at night. HEADACHE (pp. 126-143) ^. Liq. Trinitrini ni^ ij Acid. Hydrobrom. dil iri xx Aquam § ss Twice with half an hour interval at the onset of migraine. Phenacetin. . Caffein. Citrat. gr. X gr. V Formulae 261 ^. Phenacetin gr.x Butyl Chloral gr. s '^. Antipyrin. . gr.x Caffein. Citrat. . . . . . . . . gr. v In cachet or powder. ^. Phenazoni "j Sod. Salicylat 1- aa gr. x Am. Bromidi J Aq. Camph ad § j Every two hours till four doses have been taken. 5. Quin. Muriat gr. ij Tincturse Guaranse . 5 ss Acid. Hydrobrom. dil m xx Aqaam Chloroformi ad § j Threa times a day before meals. 9. Butyl Chloral gr, ii] Gelseminini Hydroch gr. -^ Glycerini Tragacanth q.s. M. ft. pil. Pot. Bromidi . Tinct. Valerian. Am. Aq. Camphoras gr.xx 3J adBj Headache in Anaemia Sodii Salicylatis gr. xx Ferri et Am, Cit, . . gr. v Sp, Am. Aromat gr. xxx Aq, Chloroformi ad § j Three times a day. Tinct. Ferri Perchlor Liq. Arsenici Hydrochl. ..... Glycerini Aquam destill Three times a day after food. Headache with Digestive Disturbance Succi Taraxaci Sod. Sulphatis Tinct. Nucis Vom. Sp. Am. Aromat, Aq, Chloroformi Three times a day before food. vi X m V 5 S3 adSJ 3ss 3ss in, V in, XX ad §3 262 Formulae Headache with High Arterial Tension Potassii Citratis . Liq. Ammonii Acet. Sp. Ether. Nitros. . Aq. Laurocerasi Aquam Camphorse . Three times a day. Pot. lodidi . , Pot. Bromidi . Acidi Hydrobrom. dil. Aq. Camphorse Three times a day. Headache with Low Arterial Tension Tinct. Nuc. Vom Tinct. Quin. Ammon. . .... Tinct. Aurantii Aq. Chloroformi Three times a day before meals. gr. XV 3ij 3S3 3i ad§j gr. 11] gr. XV ITl XX adSj ni V 3J •3J adiSj REMEDIES IN SEA-SICKNESS (pp. 145-146) 1^. Pot. Bromidi ^ Am. Bromidi . . . . . . . . |- aa gr. xx Sod. Bromidi ........ J To be taken in J pint of Soda Water. Chloretone gr. v in gelatine cachet. ^. Morphini Tartarati . . , . , , gr. J Atropinas Sulphatis . . . . , • gr. ^j TONIC (pp. 151-154) ^. Tinct. Nucis Vomicas , iri v Tint. Cinchonse co 5 ss Sp. Am. Aromat , . fii xx Tinct. Aurantii 5 3s Aq, Chloroformi ad 5 j Three times a day before meals. EPISTAXIS AND OTHER H/EMORRHAGE (p. 160) 1^. Calcii Chloridi ... . . . gr. xx Syrupi Aurantii 3 ]' Aquam ... . . • • • ad5j Three times a day. Formulae 263 9 Magnesii Carbonat. levifl Magnesii Sulphatis . Aq. Menth. Piperit. 5] 3j FIBROSITIS AND MYALGIA (p. 172) ^. Sodii Sulphatis 5 ss Pot. lodidi gr. V Sodii Salicylatis . . . , , . . . gr. x Extract. Glycyrrhiz. liq 5 ss Aquam ... .... ad 3 j 9- REMEDIES FOR THE EYE (pp. 174-176) LOTION FOE STYES (p. 56) Sodii Bicarb. . Boracis . Acid Hydrocyan. dil. Aq, Sambuci . Aq. destillat . . 3J 3J 3 S3 . 3ij ad 5 -yiij Cocain. . Olei Eicini LOCAL ANESTHETIC gr. X 5j 9- OINTMENTS (p. 177) Ung. Hydrarg, Nit. Vaselin. Alb. . Acidi Borici Vaselin Alb. 3i adgj 3j adgj Hydrarg. Oxidi Flav. Paraffin! Mollis gr. iv-vu] 3j COLLYEIA (p 175) Acid. Borici. Aq. destillat. Sodii Bicarb. Aq. destillat. Boracis . Aquam dest. Hazeline Aquam dest. ■ • • ft • • . gr.x adSj . gr. XV . adSJ . gr.x . 5j . m XX . adgj 264 Formulae ^i. Zinci Chloridi * • . . gr. ss Aquam dest. . . . adgj 5i. Acetozone , , .gr. J Aquam dest ad § j Saturated watery solution filtered after standing 4 houra. SOLUTIONS FOR SINGLE APPLICATION Arg. Nitratis . Aq. destillat. . adgj Protargol gr. xv Aq. destillat adgj THE EAR (pp. 180-181) ^■ Acidi Borici Aq. destillat. ... ... . gr. X ^■ Argent. Nitratis . , . . Aq. destillat. . . .... gr. XXX ^• Hydrarg. Subchlor Adipis pr^parat. .,,... . 3j 9. Hydrarg. Ammon Paraffin. Moll. . gr. XX . . 5j ^. TJng. Hydrarg. Nit. . • « . Vaselini Alb . . 3J ^. Tinct. Opii Tinct. BelladonnEe Sol. Cocainse Alcoholic I p. seq. ^■ Sodii Bicarb Glycerini Aq. Posse Liq. Hydrarg. Perchlor. 1-1000 . gr. XX • 5j . adgj ^- Calcii Hypochloritis Aquam destill. ,*,»>> . gr.ij . adgj w Formulae 265 ;^. Sodii Hypochloritis gr. iv Aquam destillat adgj REMEDIES FOR NOSE (p. 183) Lotio Sulphufis c, Sapone 9. Saponis Mollis gr. ^ Sulphur, prsecipitat gr. xxx Eau de Cologne 3 J Glycerin! m v Aq. Eos» 5j Ung, Sulphuris ^. Sulphuris Sublimati 5 j Adip. Benzoat 3i^ FOE HAY FEVER (p. 184) ^. Cocaine gr. j Sol. Adrenalin. 1-1000 3 J COLLUNAEIA (pp. 184-185) Dobell's Solution, etc. (see p. 260). 3 per cent. Solution Peroxide of Hydrogen. Acetozone, Saturated Watery Solution. NEBULA (p. 186) 9. Thymol gr. x Petrol. Liq 5j ]^. Camphor , 'I Menthol . I iz-- Terebene ^ aa3i] Eucalyptol J GENITO'URINARY SYSTEM (p. 188) FOR VDLVO-VAGINITIS ^. Zinci Sulphatis gr. v Aq. destillat. . , , , ad § j "^ Aluminis . •..,.. ..gr. v Aq. destillat. , , , , , , , adgj 2^6 Formulae Lot. Sulphatura 9. Zinci Sulphatis .... . , gr. xxx Aluminis gr. xxx Ferri Sulphatis gr. xx Cupri Sulphatis , , . . . , , . gr. ij Aquam adgviij ENURESIS (p. 188) 9. Tinct. Lycopodii 5ss Syrupi Aurantii ... . . . . ni xx Phenazoni . , gr. v Aquam . , .adgss Before bedtime. DYSURIA (p. 190) ]^. Tinct. Hyoscyami . , 3 ss Sodii Bromidi . gr. x Acid. Hydrocyan. dil ni iv Infusum Buchu adgj Three times a day. ]^ Ammon. Benzoatis gr. x Tinct. Hyoscyami . 5ss Pot. Bromidi . . . . . . ; gr. x Infusum Buchu . ad § j Three times a day. MENSTRUATION (p. 191) AmmoDol, • : gr. v In Tabloid. Chloretone gr. v In Gelatine Cachet. CLIMACTERIC NEUROSES (p. 192) 9. Tinct. Valer. Am. ....... . 3 j Pot. Bromidi . . . gr. xv Aq. Camphorae . . adgj Three times a day. Ichthyol . gr. V In pil. three times a day. STIMULANT MIXTURE (p. 232) ^. Tinct. Aurantii 3 iJ Sp. .Etheris 5 ss Sp. Am. Aromat. . , ,5ss Tinct. Nucis Vomicae "l x Aq. Chloroformi adgj Formulae 267 INFANTS (pp. 194-198) STOMATITIS Glycerin! Boracis. ^. Potass, permanganatis . , , . . , ,gr. v Aq. destillat 5j ^. Acid. Borici , . . gr. xv Aq. destillat • • Sj Lapis Divinis 9. Cupri Sulphatis ....... ^ Aluminis j- p, seq. Potass. Nitratis J Fused together. DIAllRHCEA IN INFANTS (pp. 195-196) ^. Sodii Bic gr. iij Pulv. Ehei gr. vj Pulv. Zingib gr. j For a child up to two j-ears. '^. Sod. Bicarb gr. ij Bismuth. Carbon gr. jss Pulv. Tragac. co gr. j Sp. Chloroformi . til jss Aq. Cinnamomi ad 3 j Every 2-4 hours. Bism. Subgallatis gr, ij-v In place of Bism. Carbon., if Diarrhoea continues, ]^, Ext, Hsematoxyli . , gr, ijss Tinct. Catechu itl v Syrupi Tolu irv x Aq. Cinnam. . « ad5j Every 4 hours. CONSTIPATION (p. 197) ]^. Tinct. Belladon tti v Tinct. Nucis Vom . ri ss Syrupi Sennae ni x Inf. Gentian co ad 3 j Three times a day for a child of three or four, COLIC AND FLATULENCE (p. 198) 9. Mag. Carb. . . , gr. jss Pulv. Ehei. gr. J Syrup. Zingib. tn, v Aq. Menth, Pip ad3j Every 2 hours. INDEX Abdominal Massage, 47 Acanthosis Nigricans, 78 Acetanilid, 118, 131 Aceto-Pyrine, 133 Acetozone, 185 Acne Rosacea, 182 Actinic Melanoses, 69 Adenoid Growths, 184 Adrenalin in Epistaxis, 159 Alcohol as a beverage, 224 in Delirium, 230 and Digestion, 223 with Digitalis, 232 efiects of, 225 as a food, 226 complete Oxidation, 231 as a stimulant, 226, 231 and Soporifics, 225 Ale as a beverage, 227 Alimentation by Skin, 245 Alkaline Waters in Bilious Attack, 7 Alopecia Furfuracea, 53, 55 Alveolar Abscess, 42 Ammonol, 191 Anal Veins, dilatation of, 9 Anaemia, 136 and Debility, 150 and Headache, 120 and treatment of, 137 Anasarca, 5 Ant, wound made by, 58 Anti-Neuralgics, 133 Antipyrin in Neuralgia, 133 as a Hypnotic, 114 Caffeine Citricum, 127, 133 Antipyrin Salicylate, 135 Anus, fissure of, 43 Aphthous Stomatitis, 37 Vulvitis, 188 Appetite, loss of, 3 Arbor Vitae, for Warts, 79 Arterial Tension and Sleeplessness, 114 Arum Lily Bulbs, rash from handling, 65 Ascites, 5 Aspirin, 135 Asthma, 27 Atrophic Rhinitis, 184 Bacillus of Smegma, 186 Balanitis, 186 Baldness, 49 Ballooning of Rectum, 25 Bathing, 203 Baths, Hot, in Liver Chill, 10 Bednar's Aphthae, 193 Beef Cakes in Obesity, 241 Bees, stings of, 59 Bile Circulation, 4 Resorption, 4 Biliary Fistula, 4 Bilious Attack, 2 treatment of, 6 Bites of Insects, 58 Black Bean, poison from, 66 " Eye," 170 Blepharitis, 176 Blisters, 84 Blood Coagulability, 71 Pressure, variation in, 154 Index 269 Blue-stainlng of Feet, 86 " Blues, The," 8 Boils in Ear, 180 Borborygmi, 13 Bottled Ale as a beverage, 227 Brandy as a beverage, 229 Broken Chilblains, 76 Bromides, 113 in Sea-sicliness, 145 Brow Ague, 121, 129 Bruises, 170 Bulbs, rash from handling, 65 Bunion, 82 Bursitis, 169 Buttercups, rash from handling, 66 Buttocks, pimples on, 57 Butyl Chloral as a hypnotic, 114 in Neuralgia, 133 Cactein Fillets, 158 Caffeln, 133, 134 Callosities, 80 Cannabis Indica, 133, 134 Caput Succedaneum, 194 Carbonate of Ammonia in Bilious Attack, 7, 10 in Headache, 142 Cardiac Overstrain, 159 Caries of Teeth, 41 Carlsbad Salt, 140 Casinea Aculeata, see Dogwood Castanospermum Australe, see Black Bean Catarrh, 97 Duodenal, 8 of Stomach, 1, 106 Catarrhal Herpes, 32 ■ Sore Throat, 97 Caterpillar Rashes, 64 Cephalalgia, 115 Cephalhsematoma in Infants, 194 Cerumen, 181 Cheese and Folliculitis, 37 Chilblains, 70 Broken, 76 Childhood, diet in, 221 " Chill on the Liver," 9 Chloral in Insomnia, 113 Chloretone, 114, 121, 127, 131, 191 in Sea-sickness, 146 Chloride of Calcium, 160 Chocolate as a beverage, 235 Chromic Acid for Ulcer of Mouth, 35 Cider as a beverage, 228 Ciliary Blephlritis, 176 Circulatory System, 148 et seq. Clavus, 121 Hystericus, 129 Climacteric Neuroses, 191 Climatic Headache, 142 Clothing, 209 Cocoa as a beverage, 235 Cod Liver Oil, inunction of, 246 Codeine, 114 Coffee as a beverage, 233 Cognac as a beverage, 229 Cold Application in Headache, 120, 141 Cold in the Chest, 102 in the Head, 97 Colic in Infants, 197 Collunaria, 99 Colon, distension of, 14 Condiments, use of, 223 Congestion, 1 Congestive Headache, 119 Conjunctival Haemorrhage, 176 Conjunctivitis, 175 Phlyctenular, 176 Constipation, 1, 24 in Infants, 196 insufficient fluid in, 25, 28 Convulsions, 25 Coprsemia, 25 Corns, 80 and weather, 81 Soft, 82 Cough, Dry, 107 Habitual, 105 Hysterical, 106 loud barking, 106 Reflex, 181 Cracked Fingers, 84 1']Q Index Cracked Lips, 31 Cramp, 173, 205 "Crick in the Neck," 172 Croton Oil Pill, 31 Deafness, temporary, 179, 181, 182 Debility, 150 Defeecation, habit in, 27 Defluvium Capillitii, 49 Delirium, 113 Depression, 1 Diarrhoea, 3 Infantile, 195, 221 Diet, 215 et seq. in Arthritis, 242 - - at Carlsbad, 243 — in Childhood, 221 in Diabetes, 243 General, in health, 200 in Gout, 242 Graduated, 248 in Gravel, 242 Meat, 238 Milk, 237, 249 in Nephritis, 244 in Obesity, 239 in Old Age, 222 Salisbury, in Obesity, 240 Special, 236 et seq. Vegetarian, 236 Diet-Scales, 216 et seq. Digestibility Table, 219 Digestive System, 1 et seq. Diphtheria, 89 Diuretin, 135 Dobell's Solution, 100 Dogwood, rash from handling, 66 Dormiol as a hypnotic, 114 Drains, 93 Drinking Water, 213 Drowsiness, 9, 115 Dry Mouth, 33 Duodenal Catarrh, 8 Dwelling, the, 212 Dyes, irritant, 87 Dysoxylon Muelleri, see Red Bean Richii, irritation from hand Hng, 66 Dyspepsia, 1, 17 Atonic, 35 Dyspeptic Ulcer, 35 Dysuria, 189 Ear, the, 179 et aeq. Eating too Fast, 19 "Eclipse Blindness," 179 Eczema of Lips, 32 Sun, 67 Elder Leaves, rash from handling. 66 Emotional Palpitation, 158 Enemata Formulas, 247 of Hot Water, 21 Nutrient, 246 Enteroptosis, 45 Enterospasm, 13, 14 Enuresis, 188 Ephelides, 69 Episcleritis, 176 Epistaxis, 26, 159 Eructation, 12 Erythema Neonatorum, 194 Pernio, 70 Solare, 67 Eucalyptus Maculata, rash from handling, 66 Exalgin, 118, 131, 133, 134 Exercise, 30, 200 Eye, the, 174 et seq. foreign bodies in, 174 strain, 132 Fainting, 155 Falling Asleep after Eating, 2 Falling Hair, 49 Faradic Current lor Chilblains, 7G Fatigue Headache, 141 Fauchard's Disease, 37 Feather-Few, rash from, 66 Fibrositis, 172 Fig Poultice in Toothache, 42 Finger Cracks, 84 [nd ex l^i " Fisherman's Elbow," 170 Fissure of Anus, 42 Flatulence, 1, 10, 13 in Infants, 197 Flipping First Sound, 149 Fluid, daily amount necessary, 28 habitual quantity, 209 insufficient, 25, 28 Flushing of Face, 12 Follicular Pharyngitis, 96 Folliculitis, 57 of Palate, 37 Foreign Bodies in Eye, 174 Formic Acid, 69 Formolyptol, 37 Formulae, 250 Fortified Wines, varieties of, 228 Freckles, 69 Furuncles of Ear, 180 of Nose, 186 Gastric Dilatation, 11, 12 • Distension, 157, 227 Function, 16 Reflex, 47 Gaultherium Oil, 93, 102 Gelsemium, Gelseminine, 133, 134 Genito-Urinary System, 186 et seq. Giddiness, 1 Gin as a beverage, 230 Gingivitis, 37 Glenard's Disease, 46 Glycothymoline, 36 " Golfer's Shoulder," 170 Gouty Headache, 142 Greek Wines, 228 " Growing Pains," 172 Guarana, 128, 236 Guaranine, 134 Gumboils, 39 Gut, twisting of, 10 Habit in Defsecation, 27 Haematoma Auris, 179 Hsematuria, 190 Haemorrhoids, 44 Hair, Falling, 49 Hair Lotions, 54 Hamamelis in Epistaxis, 160 Hard Hats and Baldness, 49 Harvest Bug, irritation from, 58, 61 Headache, Climatic, 142 from Fatigue, 141 in Fever, 141 Gouty, 142 Leeches in, 120 in " Liver," 1 Malarial, 129 Occasional, 139 Periodic, 121 Persistent, 115 and Plethora, 118 in Renal Disease, 115 Toxic, 140 Heartburn, 12, 15, 209 Hebra's Lotion, for Cracked Lips, 32 Hedonal, 114 Hemicrania, 121 in Sea-sickness, 143 Heroine, 114 Herpes, Catarrhal, 32 Preputialis, 33 Herpetic Fever, 33 Hiccough, 16, 17 Hock as a beverage, 228 Hop Pillow, 114 Hops in Insom.nia, 114 Hordeolum, 56 Hornet, sting of, 59 Hot Baths in Liver Chill, 10 Hot Water Drinking, 9 in Bilious Attack, 9, 14 in Obesity, 239 Hyacinth Bulbs, rash from hand- ling, 65 Hydrogen Peroxide for Hornet sting, 60 Hypertrophic Rhinitis, 184 Hypnotics, 114 Ichthyol, 192 Pills, 57 Icterus Neonatorum, 194 272 Index India Pale Ale as a beverage, 227 Indigestion, 17 Infantile Diarrhcea, 195 Stomatitis, 194 Infants, 192 et seq. Influenza and Palpitation, 158 Ingrowing Toenail, 83 Insects, injuries inflicted by, 58 Insomnia, 111 Fanciful, 114 Intercostal Neuralgia, 107 Intestinal Croakings, 13 Invalids and Sea-sickness, 147 Itch Insect, irritation from, 58 Jigger, irritation from, 58 Kasemol for Chilblains, 76 Kola as a beverage, 235 Krameria Lozenge, 92 Kutnow's Powder, 140 Lager Beer as a beverage, 227 Languor, 148, 150 Lapis DIvinis, 194 Laxatives, 30 Lead Plates for Enteroptosis, 46 Lentigines of Crocker, 69 Lettuce, preparation of, in In- somnia, 114 Light Wines, varieties of, 228 Lipoma Nasi, 183 "Live Blood," 178 " Live-Long Tablets " in Heart- burn, 15 " Liver," 1 ChiU on the, 9 Lotio Sulphuratum, 188 Low Arterial Tension, 148 Leeches in Headache, 120 Lumbago, 171 Madeira as a beverage, 228 Maintenance of Individual Health, 199 et seq. Malarial Headache, 129 Malt Liquors, varieties of, 227 Marsala as a beverage, 228 Mastenea, see Dysoxylon Richil Mate as a beverage, 236 Maturation of Wine, 229 Meals, insufficient intervals be- tween, 18 Supernumerary, 208 Meatus of Ear, inflammation of, 179 Meibomian Cyst, 177 Menstruation, 191 Menthol PiU, 14 Mercury in Bilious Attack, 6 ia Headache, 118 Mesotan for Chilblains, 76 Meteorism, 10 Migraine, 121 " Reflex," 126 Migranin, 127, 133 Milk Diet, 237 Skimmed, in Obesity, 239 sterilising of, 208 Mlstura Blsmuthl Co., 23 Morphine as a hypnotic, 113 in Sea-sickness, 146 Moselle as a beverage, 228 Mosquitoes, bite of, 61 Mountaineering, Cardiac failure in, 158 Mouth, Ulcer of, 34 Mower's Mite, see Harvest Bug Muscae Volitantes, 3, 178 Muscle and Metabolism, 165 Muscular Debility, 3 System, 164 et seq. Myalgia, 108, 170 Myocardial Degeneration, 143 Narcolepsy, 115 Nares, congestion of, 184, 185 irritation of, 183 Nasal Douche, 99 Nauheim System, 164 Neck, pimples on, 57 Nerve Stimulants, 233 Nervous Dyspepsia, 22 System, 111 et seq. Nettles, rash from handling, 68 Index 273 Neuralgia, 41, 117, 121, 132 Neuralgics, Antl-, 133 Neurasthenia, 144 Neuroses, Climacteric, 191 Neurosis, 151 Nose, the, 182 et acq. Nose-Bleeding, 26, 159 Numbness, 154, 155 Nutrient Enemata, 246 Obesity, 239 Occasional Headaches, 139 Odol, 36 Odontalgia, 41 Odontodol, 42 CEsophageal tube in tympanites, 11 Ophiasis, 52 Oral Sepsis, 37 Otomycosis, 181 Otorrhoea, 182 Ozsena, 184 Palpitation, 157 Papules, 55, 57, 59 Paraldehyde, 114 Paronychia, 77 Patent Spirit as a beverage, 229 Periodic Headache, 121 Perry as a beverage. 228 Pharyngitis, Follicular, 96 Phebalium Argentum, 66 Phenacetin, 127 Phenazone, 114, 127, 133, 134 Phlebitis, 160 Phlyctenular Conjunctivitis, 176 Piles, 2, 44, 45 Pimples, on Buttocks, 57 on Neck and Face, 55 Pinna, deposits peculiar to, 179 " Pins and Needles," 154 Plant Rashes, 64 Plethora and Headache, 118 Pleurisy, 107, 108 Pleurodynia, 107 Poison ivy, rash from handling, 67 Poison Oak, rash from handling, 67 Sumach, rash from handling, 67 Pomades, 55 Port as a beverage, 128 Portal Circulation, 5 Reservoir, 6 Vein, dilatation of, 5, 9 Porter as a beverage, 227 Potassium Iodide, 142 in Headache, 119 Pot Still Whiskey as a beverage, 229 Pressure Palsy, 155 Primula Obconica, 65 Sinensis, 65 Proponal, 114 Protective Action of Liver, 4 Psychoses at Climacteric, 191 Purin Bodies, 134 Pustular Eczema, 78 Pyorrhoea Alveolaris, 37 Pyramidon, 133, 134 Quinine, 133 Rashes, from plants, etc., 64 et aeq. Raw Food, 208 Red Aniline Irritation, 87 Bean, poison from, 66 Reflex Migraine, 126 Refractive Errors, 126, 128, 132 Relaxed Throat, 90 Renaglandine, 45 Respiration, 200 Respiratory System, 88 et aeq. " Rest Cure," 154 Restlessness, 113 Rheumatic Sore Throat, 92 Rhinitis, Atrophic, 184, 185 Chronic, 184 Hypertrophic, 184 Rhubarb and Hsematuria, 190 Rhus Diversiioba, see Poison Oak Radicans, see Poison Ivy Vernix, see Poison Sumach Rigg's Disease, 37 *' Run Down," 151 18 274 Index Salicyl Acetic Acid, 135 Salipyrin, 135 Salisbury Treatment, 22 Salt and Albuminuria, 238 Sandow's Training Diet, 216 Saturday Night Paralysis, 155 Scabies, 58 Schiedam as a stimulant, 230 Scurf, 50, 51 Sea-siclsness, 143 Sebaceous Glands, inflammation of, 55 Seborrhaea, 51 treatment of, 53 ♦* Seeing Stars," 178 Sentinel Pile, 44 Septic Throat, 93 Serum Nutrition, 246 Therapy, 90 Sherry as a beverage, 228 Shoulder Pain, 2 Skimmed Milk in Obesity, 239 Skin, diseases of, 48 et aeq. Abscess, 198 Sleep, 201 after meals, 203 Sleeplessness, 134 Smegma Bacillus, 186 Snake Venom (ingested), 5 Soda Lozenge in Heartburn, 15 Soporifics, 114 Sore Throat, 88 Catarrhal, 97 Rheumatic, 92 Spanish Brandy, 229 Special Subjects, 174 Spiders, wound made by, 58 Spirits, 229, 232 Patent, 229 . Pot Still, 229 Spiritus Saponatus Ealiaus in Seborrhea, 53, 55 Spotted Gum Rash, 66 Sprains, 166 Still Neck, 171 Stimulants in Bilious Attack, 7 Stimulation. 226 Stinging Nettle, irritation from touching, 69 Stings, 58 Stitch in the Side, 109 Stomatitis, Aphthous, 37 in Infants, 193 Ulcerative, 37 Stout as a beverage, 227 Stye, 56, 177 Sulphonal as a hsrpnotic, 114 Sun Eczema, 67 Sunburn, 67 Synehisis SeintlUans, 178 Syncope, 155 Synovitis, 168 Tachycardia, 158 Taraxacum, 140 Tartar on Teeth, 36, 40 Tea as a beverage, 234 Teak, inflammation from sawdust of, 67 Teeth, Caries of, 41 Tartar on, 36 Teleangectasis, 182 "Tennis Elbow," 170 Teno-Synovitls, 168 Tetronal as a hypnotic, 114 Theobromine, 133, 134 Salicylate, 135 Throat, Catarrhal Sore, 97 Examination of, 88 Relaxed, 90 Rheimaatic Sore, 93 Septic, 93 Sore, 88 Ulcerated, 93 Thrombosed Pile, 45 Thrush, 194 Thuya Occidentalis, 79 Thyroglandin in Obesity, 240 Tic Douloureux, 121, 130 Tinea Tarsi, 176 Tobacco, eSect on heart, 157 and Insomnia, 157 Tongue, Dyspeptic Ulcer of, 35 Ulcer of, 34 Index 275 Toothache, 41 ■ Tophi in Lid, 177 Toxic Headache, 140 Tracheitis, 102 Trional as a hypnotic, 114 Trophoneurosis, 53 Tufnell's Diet, 218 Turkish Baths in Liver Chill, 10 Tympanites, 10 Ulcer, Dyspeptic, 35 of Mouth, 34 of Tongue, 34 Ulcerated Throat, 93 Ulcerative Stomatitis, 37 Uncoolied Food, dangers of, 208 Urea, output of, 222 Urethane as a hypnotic, 114 Urticaria, 163 Uvula, Elongated, 91 Variations in Blood Pressure, 154 Varicocele, 162 Varicose Veins, 160 Variety of Occupation, 214 Vegetarian Diet, 236 Veronal as a hypnotic^ 114 Verruca, 78 Vertigo, 3, 60, 115, 191 Volvulus in Flatulence, 10 Vomiting in Infanta, 195 Vulvo-Vaginitis, 187 Warts, 78 Wasps, stings of, 59 Water Enemata, 246 Water, Hot, in Bilious Attack, 9, 14 in Obesity, 239 Weakness due to Obscure Diseases, 148 and low Blood Pressure, 150 Weather and Bilious Attacl^s, 9, 14 and Corns, 81 Weir-Mitchell System, 154 in Enteroptosis, 46 West Australian Blister Plant, rash from handling, 66 Whiskey as a beverage, 229 Whitlow, 77 Wine as a stimulemt, 232 Wines, maturation of, 229 varieties of, 228 Xanthelasma, 178 Xerodermia Pigmentosa, 69 Printed by Haselt, Vyai^on