[Rx] Glycerin 4 ounces Tincture of chloride of iron 1/2 ounce

Mix. Directions, half teaspoonful every half hour.

A mixture of hydrogen dioxide, equal parts, with water can also be used to advantage as a spray in an atomizer every two hours. The phenacetin and Dover's powder must be discontinued as soon as the pain and sleeplessness cease, but the iron preparation and spray should be continued until the throat regains its usual condition. A liquid diet is desirable during the first part of the attack, consisting of milk, cocoa, eggnog (made of the white of egg), soups, and gruels; orange juice may be allowed, also grapes. The bowels must be kept regular with mild remedies, as a Seidlitz powder in a glass of water in the morning, or one or two two-grain tablets of extract of cascara sagrada at night.

QUINSY.—Quinsy is a peritonsilitis; that is, it is an inflammatory disease of the tissues in which the tonsil is imbedded, an inflammation around the tonsil. The swelling of these tissues thrusts the tonsil out into the throat; but the tonsil is little affected. Quinsy involves the surrounding structures of the throat, and usually results in abscess. The disease is said to be frequently hereditary, and often occurs in those subject to rheumatism and gout. It is seen more often in spring and autumn and in those living an out-of-door existence, and having once had quinsy the victim is liable to frequent recurrences of the disease. Quinsy is characterized by much greater pain in the throat and in swallowing than is the case in tonsilitis, and the temperature is often higher—sometimes 104 deg. to 105 deg. F. When the throat is inspected, one or both tonsils are seen to be enlarged and crowded into its cavity from the swelling of the neighboring parts. The tonsils may almost block the entrance to the throat. The voice is thick and indistinct, the glands in the side of the neck become swollen, and the neck is sore and stiff in consequence, while the mouth can be only partially opened on account of pain. For the same reason the patient can swallow neither solid nor liquid food, and sits bent forward, with saliva running out of the mouth. The secretion of saliva is increased, but is not swallowed on account of the pain produced by the act. Sleep is also impossible, and altogether a more piteous spectacle of pain and distress is rarely seen. Having reached this stage the inflammation usually goes on to abscess (formation behind or above or below the tonsil), and, after five to ten days from the beginning of the attack, the pus finds its way to the surface of the tonsil, and breaks into the mouth to the inexpressible relief of the patient. This event is followed by quick subsidence of the symptoms. Quinsy is rarely a dangerous disease, yet, occasionally, it leads to so much obstruction in the throat that death from suffocation ensues unless a surgeon opens the throat and inserts a tube. Occasionally the pus from the ruptured abscess enters the larynx and causes suffocation.

Quinsy differs from tonsilitis in the following respects: the swelling affects the immediate surrounding area of the throat; there are no white spots to be seen on the tonsil unless the trouble begins as an ordinary tonsilitis; there is great pain on swallowing, and finally abscess near the tonsil in most cases.

Treatment.—A thorough painting of the tonsils at the onset of a threatened attack of quinsy with the silver-nitrate solution, as recommended under tonsilitis, may cut short the disorder. A single dose of calomel (three to five grains) is also useful for the same purpose. The tincture of aconite should be taken hourly in three-drop doses until five such have been swallowed, when the drug is to be no longer used. The constant use of a hot flaxseed poultice (as large as the whole hand and an inch thick, spread between thin layers of cotton and applied as hot as can be borne, and changed every half hour) gives more relief than anything else, and may possibly lead to disappearance of the trouble if employed early enough. The use of the poultices is to be kept up until recovery, although they need not be applied so frequently as at first. A surgeon's services are especially desirable in this disorder, as early puncture of the peritonsillar tissue may save days of suffering in affording exit for pus as soon as it forms.

DIPHTHERIA.—The consideration of diphtheria will be limited to emphasizing the importance of calling in expert medical advice at the earliest possible moment in suspicious cases of throat trouble. For, as we noted under tonsilitis, it is impossible in some cases to decide, from the appearance of the throat, whether the disease is diphtheria or tonsilitis. A specimen of secretion removed from the throat for microscopical examination by a bacteriologist as to the presence of diphtheria germs alone will determine the point. When such an examination is impossible, it is always best to isolate the patient, especially if a child, and treat the case as if it were diphtheria. Diphtheria may invade the nose and be discoverable in the nostrils. A chronic membranous rhinitis should be treated as a case of walking diphtheria.

Antitoxin is the treatment above all other remedies. It has so altered the outlook in diphtheria that, formerly regarded by physicians with alarm and dismay, it is now rendered comparatively harmless. The death rate has been reduced from an average of about forty per cent, before the introduction of antitoxin, to only ten per cent since its use, and, when it is used at the onset of the disease, the results are much more favorable still. This latter fact is the reason for obtaining medical advice at the earliest opportunity in all doubtful cases of throat ailments; and, we might add, that the diagnosis of any case of sore throat is doubtful, particularly in children, whenever there is seen a whitish, yellowish-white, or gray deposit on the throat. Antitoxin is an absolutely safe remedy, its ill effects being sometimes the production of a nettlerash or some mild form of joint pains. In small doses, it will prevent the occurrence of diphtheria in those exposed, or liable to exposure, to the disease. The proper dose and method of employing antitoxin it is impossible to impart in a book of this kind. Paralysis of throat, of vocal cords, or of arms or legs—partial or entire—is a frequent sequel of diphtheria. It is not caused by antitoxin.

The points which it is desirable for everyone to know are, that any sore throat—with only a single white spot on the tonsil—may be diphtheria, but that when the white spot or deposit not only covers the tonsil or tonsils (see Tonsilitis) but creeps up on to the surrounding parts, as the palate (the soft curtain which shuts off the back of the roof of mouth from the throat), the uvula (the little body hanging from the middle of the palate in the back of the mouth), and the bands on either side of the back of the mouth at its junction with the throat, then the case is probably one of diphtheria. But it is often a day or two before the white deposit forms, the throat at first being simply reddened. The fever in diphtheria is usually not high (often not over 100 deg. to 102 deg. F.), and the headache, backache, and pains in the limbs are not so marked as in tonsilitis.

MEMBRANOUS CROUP.—Membranous croup is diphtheria of the lower part of the throat (larynx), in the region of the Adam's apple. If in a case of what appears to be ordinary croup (p. 83) the symptoms are not soon relieved by treatment, or if any membrane is coughed up, or if, on inspection of the throat, it is possible to see any evidence of white spots or membrane, then a physician's services are imperative.

It is not very uncommon for patients with mild forms of diphtheria to walk about and attend to their usual duties and, if children, to go to school, and in that inviting field to spread the disease. These cases may present a white spot on one tonsil, or in other cases have what looks to be an ordinary sore throat with a simple redness of the mucous membrane. Sore throats in persons who have been in any way exposed to diphtheria, and especially sore throats in children under such circumstances, should always be subjected to microscopical examination in the way we have alluded to before, for the safety of both the patient and the public.

There is still another point perhaps not generally known and that is the fact that the germs of diphtheria may remain in the throat of a patient for weeks, and even months, after all signs in the throat have disappeared and the patient seems well. In such cases, however, the disease can still be communicated in its most severe form to others. Therefore, in all cases of diphtheria, examination of the secretion in the throat must show the absence of diphtheria germs before the patient can rightfully mix with other people.

Gargling and swabbing the throat with the (poisonous) solution of bichloride of mercury, 1 part to 10,000 parts of water (none of which must be swallowed), should be employed every three or four hours each day till the germs are no longer found in the mucus of the tonsils.

HOARSENESS (Acute Laryngitis).—This is an acute inflammation of the mucous membrane of the larynx. The larynx is that part of the throat, in the region of the Adam's apple, which incloses the vocal cords and other structures used in speaking. Hoarseness is commonly due to extension of catarrh from the nose in cold in the head and grippe. It also follows overuse of the voice in public speakers and singers, and is seen after exposure to dust, tobacco, or other smoke, and very commonly in those addicted to alcohol.

Symptoms.—Hoarseness is the first symptom noticed, and perhaps slight chilliness, together with a prickling or tickling sensation in the throat. There is a hacking cough and expectoration of a small amount of thick secretion. There may be slight difficulty in breathing and some pain in swallowing. The patient feels generally pretty well, and is troubled chiefly by impairment of the voice, which is either husky, reduced to a mere whisper, or entirely lost. This condition lasts for some days or, rarely, even weeks. There may be a mild degree of fever at the outset (100 deg. to 101 deg. F.). Very uncommonly the breathing becomes hurried and embarrassed, and swallowing painful, owing to excessive swelling and inflammation of the throat, so much so that a surgeon's services become imperative to intube the throat or to open the windpipe, in order to avoid suffocation. This serious form of laryngitis may follow colds, but more often is brought about by swallowing very hot or irritating liquids, or through exposure to fire or steam. In children, after slight hoarseness for a day or two, if the breathing becomes difficult and is accompanied by a crowing or whistling sound, with blueness of the lips and signs of impending suffocation, the condition is very suggestive of membranous croup (a form of diphtheria), which certainly is the case if any white, membranous deposit can be either seen in the throat or is coughed up. Whenever there is difficulty of breathing and continuous hoarseness, in children or adults, the services of a competent physician are urgently demanded.

Treatment.—The use of cold is of advantage. Cracked ice may be held in the mouth, ice cream can be employed as part of the diet, and an ice bag may be applied to the outside of the throat. The application of a linen or flannel cloth to the throat wrung out of cold water and covered with oil silk or waterproof material, is also beneficial, and often more convenient than an ice bag. The patient must absolutely stop talking and smoking. If the attack is at all severe, he should remain in bed. If not so, he must stay indoors. At the beginning of the disorder a teaspoonful of paregoric and twenty grains of sodium bromide are to be taken in water every three hours, by an adult, until three doses are swallowed.

Inhalation of steam from a pitcher containing boiling water is to be recommended. Fifteen drops of compound tincture of benzoin poured on the surface of a cup of boiling water increases the efficacy of the steam inhalation. The head is held above the pitcher, a towel covering both the head and pitcher to retain the vapor.

The employment, every two hours, of a spray containing menthol and camphor (of each, ten grains) dissolved in alboline (two ounces) should be continued throughout the disease. If the hoarseness persists and tends to become chronic, it is most advisable for the patient to consult a physician skilled in such diseases for local examination and special treatment.

CROUP.—Croup is an acute laryngitis of childhood, usually occurring between the ages of two and six years. The nervous element is more marked than in adults, so that the symptoms appear more alarming. The trouble frequently arises as part of a cold, or as a forerunner of a cold, and often is heralded by some hoarseness during the day, increasing toward night. The child may then be slightly feverish (temperature not over 102 deg. F., usually). The child goes to bed and to sleep, but awakens, generally between 9 and 12 P.M., with a hard, harsh, barking cough (croupy cough) and difficulty in breathing. The breathing is noisy, and when the air is drawn into the chest there is often a crowing or whistling sound produced from obstruction in the throat, due to spasm of the muscles and to dried mucus coating the lining membrane, or to swelling in the larynx. It is impossible to separate these causes. The child is frightened, as well as his parents, and cries and struggles, which only aggravates the trouble. The worst part of the attack is, commonly, soon over, so that as a rule the doctor arrives after it is past. While it does last, however, the household is more alarmed than, perhaps, by any other common ailment.

Death from an attack of croup, pure and simple, has probably never occurred. The condition described may continue in a less urgent form for two or three hours, and very rarely reappears on following nights or days. The child falls asleep and awakens next morning with evidences of a cold and cough, which may last several days or a week or two.

The only other disease with which croup is likely to be confused is membranous croup (diphtheria of the larynx), and in the latter disorder the trouble comes on slowly, with hoarseness for two or three days and gradually increasing fever (103 deg. to 105 deg. F.) and great restlessness and difficulty in breathing, not shortly relieved by treatment, as in simple croup. In fifty per cent of the cases of membranous croup it is possible to see a white, membranous deposit on the upper part of the throat by holding the tongue down with a spoon handle and inspecting the parts with a good light.

Croup is more likely to occur in children suffering from adenoids, enlarged tonsils, indigestion, and decayed teeth, and is favored by dry, furnace heat, by exposure to cold, and by screaming and shouting out of doors.

Treatment.—Place the child in a warm bath (101 deg. F.) and hold a sponge soaked in hot water over the Adam's apple of the throat, changing it as frequently as it cools. Hot camphorated oil rubbed over the neck and chest aids recovery. If the bowels are not loose, give a teaspoonful of castor oil or one or two grains of calomel. The most successful remedies are ipecac and paregoric. It is wise to keep both on hand with children in the house. A single dose of paregoric (fifteen drops for child of two years; one teaspoonful for child of seven years) and repeated doses of syrup of ipecac (one-quarter to one-half teaspoonful) should be given every hour till the child vomits and the cough loosens, and every two hours afterwards. The generation of steam near the child also is exceedingly helpful in relieving the symptoms. A kettle of water may be heated over a lamp. A rubber or tin tube may be attached to the spout of the kettle and carried under a sort of sheet tent, covering the child in bed. The tent must be arranged so as to allow the entrance of plenty of fresh air. Very rarely the character of the inflammation in croup changes, and the difficulty in breathing, caused by swelling within the throat, increases so that it is necessary to employ a surgeon to pass a tube down the throat into the larynx, or to open the child's windpipe and introduce a tube through the neck to prevent suffocation.

The patient recovering from croup should generally be kept in a warm, well-ventilated room for a number of days after the attack, and receive syrup of ipecac three or four times daily, until the cough is loosened. If ipecac causes nausea or vomiting, the dose must be reduced. The disease is prevented by a simple diet, especially at night; by the removal of enlarged tonsils and adenoids; by daily sponging, before breakfast, with water as cold as it comes from the faucet, while the child stands, ankle deep, in hot water; and by an out-of-door existence with moderate school hours; also by evaporating water in the room during the winter when furnace heat is used. When children show signs of an approaching attack of croup, give three doses of sodium bromide (five grains for child two years old; ten grains for one eight years old) during the day at two-hour intervals and give a warm bath before bedtime, and rub chest and neck with hot camphorated oil.



CHAPTER III

The Lungs and Bronchial Tubes

Meaning of Bronchitis—Symptoms and Treatment—Remedies for Infants—Pneumonia—Consumption the Great Destroyer—Asthma—La Grippe.

COUGH (occurring in Bronchitis, Pneumonia, Consumption or Tuberculosis, Asthma, and Influenza or Grippe).—Cough is a symptom of many disorders. It may be caused by irritation of any part of the breathing apparatus, as the nose, throat, windpipe, bronchial tubes, and (in pleurisy and pneumonia) covering membrane of the lung. The irritation which produces cough is commonly due either to congestion of the mucous membrane lining the air passages (in early stage of inflammation of these tissues), or to secretion of mucus or pus blocking them, which occurs in the later stages.

Cough is caused by a sudden, violent expulsion of air from the chest following the drawing in of a deep breath. A loose cough is to be encouraged, as by its means mucus and other discharge is expelled from the air passages.

A dry cough is seen in the early stages of various respiratory diseases, as bronchitis, pneumonia, pleurisy, consumption, whooping cough, and with irritation from enlarged tonsils and adenoids (see p. 61) occurring in children.

Irritation produced by inhaling dust, or any irritation existing in the nose, ear, or throat may lead to this variety of cough. The dry cough accomplishes no good, and if continuous and excessive may do harm, and demands medicinal relief.

Bronchitis.—Cough following or accompanying cold in the head and sore throat generally means bronchitis.

The larynx or lower part of the throat ends just below the "Adam's apple" in the windpipe. The windpipe is about four and a half inches long and three-quarters to an inch in diameter, and terminates by dividing into the two bronchial tubes in the upper part of the chest. Each bronchial tube divides and subdivides in turn like the branches of a tree, the branches growing more numerous and smaller and smaller until they finally end in the microscopic air sacs or air cells of the lungs. The bronchial tubes convey air to the air cells, and in the latter the oxygen is absorbed into the blood, and carbonic acid is given up. Bronchitis is an inflammation of the mucous membrane lining these tubes. In cough of an ordinary cold only the mucous membrane of the windpipe and, perhaps, of the larger tubes is inflamed. This is a very mild disorder compared to inflammation of the smaller and more numerous tubes.

In bronchitis, besides the ordinary symptoms of a severe cold in the head, as sneezing, running of mucus from the nose, sore throat and some hoarseness perhaps, and languor and soreness in the muscles, there is at first a feeling of tightness, pressure, and rawness in the region of the breastbone, with a harsh, dry cough. The coughing causes a strain of the diaphragm (the muscle which forms the floor of the chest), so that there are often pain and soreness along the lower borders of the chest where the diaphragm is attached to the inside of the ribs. After a few days the cough becomes looser, greatly to the patient's comfort, and a mixture of mucus and pus is expectorated. In a healthy adult such a cough is usually not in itself a serious affair, and apart from the discomfort of the first day or two, there is not sufficient disturbance of the general health to interfere with the ordinary pursuits. The temperature is the best guide in such cases; if it is above normal (98-3/5 deg. F.) the patient should stay indoors. In infants, young children, enfeebled or elderly people, bronchitis may be a serious matter, and may be followed by pneumonia by extension of the inflammation from the small bronchial tubes into the air sacs of the lungs, and infection with the pneumonia germ. The principal signs of severe attacks of bronchitis are rapid breathing, fever, and rapid pulse.

The normal rate of breathing in adults is seventeen a minute, that is, seventeen inbreaths and seventeen outbreaths. In children of one to five years the normal rate is about twenty-six breathing movements a minute. In serious cases of bronchitis the rate may be twenty-five to forty in adults, or forty to sixty in children, per minute.

Of course the only exact way of learning the nature of a chest trouble is thorough, careful examination by a physician, for cough, fever, rapid breathing and rapid pulse occur in many other diseases besides bronchitis, particularly pneumonia.

Pneumonia begins suddenly, often with a severe chill, headache, and general pains like grippe. In a few hours cough begins, short and dry, with violent, stabbing pain in one side of the chest, generally near the nipple. The breathing is rapid, with expanding nostrils, the face is anxious and often flushed. The matter coughed up at first is often streaked with blood, and is thick and like jelly. The temperature is often 104 deg.-105 deg. F.

If the disease proceeds favorably, at the end of five, seven, or ten days the temperature, breathing, and pulse become normal suddenly, and the patient rapidly emerges from a state of danger and distress to one of comfort and safety. The sudden onset of pneumonia with chill, agonizing pain in side, rapid breathing, and often delirium with later bloody or rusty-colored, gelatinous expectoration, will then usually serve to distinguish it from bronchitis, but not always.

Whenever, with cough, rapid and difficult breathing occur with rise of temperature (as shown by the thermometer) and rapid pulse, the case is serious, and medical advice is urgently demanded.

Treatment of Acute Cough and Bronchitis.—In the case of healthy adults with a cough accompanying an ordinary cold, the treatment is very simple, when there is little fever or disturbance of the general health. The remedies recommended for cold in the head (p. 55) should be taken at first. It is also particularly desirable for the patient to stay in the house, or better in bed, for the first day or two, or until the temperature is normal.

The feeling of tightness and distress in the chest may be relieved by applying a mild mustard paper over the breastbone, or a poultice containing mustard, one part, and flour, three parts, mixed with warm water into a paste and spread between two single thicknesses of cotton cloth about eight inches square. The tincture of iodine painted twice over a similar area forms another convenient application instead of the mustard. If the cough is excessive and troublesome at night the tablets of "ammonium chloride compound with codeine" are convenient. One may be taken every hour or two by an adult, till relieved.

Children suffering from a recent cough and fever should be kept in bed while the temperature is above normal. It is well to give infants at the start a grain of calomel or half a teaspoonful of castor oil, and to children of five to eight years double the dose.

The chest should be rubbed with a liniment composed of one part of turpentine and two parts of camphorated oil. It is well also to apply a jacket made of sheet cotton over the whole chest. It is essential to keep the room at a temperature of about 70 deg. F. and well ventilated, not permitting babies to crawl on the floor when able to be up, or to pass from a warm to a cold room. Sweet spirit of niter is a serviceable remedy to use at the beginning: five to fifteen drops every two hours in water for a child from one to ten years of age, for the first day or two.

If the cough is harsh, hard, or croupy (see p. 83), give syrup of ipecac every two hours: ten drops to an infant of one year or under, thirty drops to a child of ten years, unless it causes nausea or vomiting, when the dose may be reduced one-half. If children become "stuffed up" with secretion so that the breathing is difficult and noisy, give a teaspoonful of the syrup of ipecac to make them vomit, for until they are six or seven years old children cannot expectorate, and mucus which is coughed up into the mouth is swallowed by them. Vomiting not only gets rid of that secretion which has been swallowed, but expels it from the bronchial tubes. This treatment may be repeated if the condition recurs.

In infants under a year of age medicine is to be avoided as much as possible. A teaspoonful of sweet oil and molasses, equal parts, may be given occasionally to loosen the cough in mild cases. In other cases use the cough tablet for infants described on p. 91. A paste consisting of mustard, one part, and flour, twenty parts, is very useful when spread on a cloth and applied all about the chest, front and back. The diet should be only milk for young children during the first day or two, and older patients should not have much more than this, except toast and soups. In feeble babies with bronchitis it is wise to give five or ten drops of brandy or whisky in water every two hours, to relieve difficulty in breathing.

Children who are subject to frequent colds, or those in whom cough is persistent, should receive Peter Moeller's cod-liver oil, one-half to one teaspoonful, according to age, three times daily after eating. One of the emulsions may be used instead if the pure oil is unpalatable. Adenoids and enlarged tonsils are a fruitful source of constant colds and sore throat, and their removal is advisable (see p. 61). Hardening of the skin by daily sponge baths with cold salt water, while the child stands or sits in warm water, is effective as a preventive of colds, as is also an out-of-door life with proper attention to clothing and foot gear.

Treatment of Pneumonia.—Patients developing the symptoms described as suggestive of pneumonia need the immediate attention of a physician. If a person is unfortunate enough to have the care of such a case, when it is impossible to secure a physician, it may afford some comfort to know that good nursing is really the prime requisite in aiding recovery, while skillful treatment is of most value if complications arise.

One in every ten cases of pneumonia in ordinarily healthy people proves fatal. In specially selected young men, as soldiers, the death rate from pneumonia is only one in twenty-five cases. On the other hand, pneumonia is the common cause of death in old age; about seventy out of every hundred patients who die from pneumonia are between sixty and eighty years of age. Infants under a year old, and persons enfeebled with disease or suffering from excesses, particularly alcoholism, are also likely to die if stricken with the disease.

The patient should go to bed in a large, well-ventilated, and sunny room. The temperature of the room should be about 70 deg. F., and the patient must not be covered so warmly with clothing as to cause perspiration. A flannel jacket may be made to surround the chest, and should open down the whole front. The nightshirt is worn over this; nothing more. Daily sponging of the patient with tepid water (85 deg. to 90 deg. F.) should be practiced. The body is not to be all exposed at once, but each limb and the trunk are to be separately sponged and dried. If the fever is high (104 deg. F.) the water should be cold (77 deg. to 72 deg. F.), and the sponging done every three hours in the case of a strong patient. Visitors must be absolutely forbidden. No more than one or two persons are to be allowed in the sick room at once.

The diet should consist chiefly of milk, a glass every two hours, varied with milk mixed with thin cooked cereal or eggnog. It is wise to give at the beginning of the disease a cathartic, such as five grains of calomel followed in twelve hours by a Seidlitz powder, if the bowels do not act freely before that time. To relieve the pain in the side, if excruciating, give one-quarter grain morphine sulphate,[4] and repeat once, if necessary, in two hours. The application of an ice bag to the painful side frequently stops the pain, and, moreover, is excellent treatment throughout the course of the disease. The seat of pain usually indicates that the lung on that side is the inflamed one, so that the ice bag should be allowed to rest against that portion of the chest. Water should be freely supplied, and should be given as well as milk even if the patient is delirious.

The bowels are to be moved daily by glycerin suppositories or injection of warm water. Dover's powder in doses of five grains is useful to assuage cough. It may be repeated once, after two hours' interval if desirable, but must not be employed at the same time as morphine. After the first two or three days are passed, or sooner in weak subjects, give strychnine sulphate, one-thirtieth grain, every six hours in pill or tablet form. The strychnine is to be continued until the temperature becomes normal, and then reduced about one-half in amount for a week or ten days while the patient remains in bed, as he must for some time after the temperature, pulse, and breathing have become normal.

CONSUMPTION; TUBERCULOSIS OF THE LUNGS; PHTHISIS.—This disease demands especial attention, not only because it is above all others the great destroyer of human life, causing one-seventh of all deaths, but because, so far from being a surely fatal disease as popularly believed, it is an eminently curable disorder if recognized in its earliest stage. The most careful laboratory examinations of bodies dead from other causes, show that very many people have had tuberculosis at some time, and to some extent, during life. The reason why the disease fails to progress in most persons is that the system is strong enough to resist the inroads of the disease. The process becomes arrested by the germs being surrounded by a barrier of healthy tissue, and so perishing in their walled-in position. These facts prove that so far from being incurable, recovery from consumption frequently occurs without even our knowledge of the disease. It is only those cases which become so far advanced as to be easily recognized that are likely to result fatally. Many more cases of consumption are now cured than formerly, because exact methods have been discovered which enable us to determine the existence of the disease at an early stage of its development.

Consumption is due to the growth of a special germ in the lungs. The disease is contagious, that is, it is capable of being communicated from a consumptive to a healthy person by means of the germs present in the sputum (expectoration) of the patient. The danger of thus acquiring the disease directly from a consumptive is slight, if one take simple precautions which will be mentioned later, except in the case of a husband, wife, or child of the patient who come in close personal contact, as in kissing, etc. This is proved by the fact that attendants in hospitals for consumptives, who devote their lives to the care of these patients, are rarely affected with consumption. The chief source of danger to persons at large is dust containing the germs derived from the expectoration of human patients, and thus finding entrance into the lungs.

Consumption is said to be inherited. This is not the case, as only most rarely is an infant born actually bearing the living germs of the disease in its body. A tendency to the disease is seen in certain families, and this tendency may be inherited in the sense that the lung tissue of these persons possesses less resistance to the growth of the germ of consumption. It may well be, however, that the children of consumptive parents, as has been suggested, are more resistant to the disease through inherited immunity (as is seen in the offspring of parents who have had other contagious diseases), and that the reason that they more often acquire tuberculosis is because they are constantly exposed to contact with the germ of consumption in their everyday home life.

It is known that there are certain occupations and diseases which render the individual more susceptible to consumption. Thus, stone cutters, knife grinders and polishers, on account of inhaling the irritating dust, are more liable to the disease than any other class. Plasterers, cigar makers, and upholsterers are next in order of susceptibility for the same reason; while out-of-door workers, as farmers, are less likely to contract consumption than any other body of workers except bankers and brokers. Among diseases predisposing to consumption, ordinary colds and bronchitis, influenza, pneumonia, measles, nasal obstruction causing mouth-breathing, and scarlet fever are the most important.

No age is exempt, from the cradle to the grave, although the liability to the disease diminishes markedly after the age of forty.

About one-third more women than men recover from consumption, probably because it is more practicable for them to alter their mode of life to suit the requirements of treatment.

It is, then, the neglected cold and cough (bronchitis) which offers a field most commonly favorable for the growth of the germs in the lungs which cause consumption. And it is essential to discover the existence of the disease at its beginning, what is called the incipient stage, in order to have the best chance of recovery. It becomes important, therefore, that each individual know the signs and symptoms which suggest beginning consumption.

Cough is the most constant early symptom, dry and hacking at first, and most troublesome at night and in the early morning. Expectoration comes later. Loss of weight, of strength, and of appetite are also important early symptoms. Dyspepsia with cough and loss of weight and strength form a common group of symptoms. The patient is pale, has nausea, vomiting, or heartburn, and there is rise of temperature in the afternoon, together with general weakness; and, in women, absence of monthly periods. Slight daily rise of temperature, usually as much as a half to one degree, is a very suspicious feature in connection with chronic cough and loss of weight. To test the condition, the temperature should be taken once in two hours, and will commonly be found at its highest about 4 P.M., daily. The pulse is also increased in frequency. Night sweats are common in consumption, but not as a rule in the first stage; they occur more often in the early morning hours.

Chills, fever, and sweating are sometimes the first symptoms of consumption, and in a malarial region would very probably lead to error, since these symptoms may appear at about the same intervals as in ague. But the chills and fever are not arrested by quinine, as in malaria, and there are also present cough and loss of weight, not commonly prominent in malaria. Persistently enlarged glands, which may be felt as lumps beneath the skin along the sides of the neck, or in the armpits, should be looked upon with suspicion as generally tuberculous, containing the germ of consumption. They certainly demand the attention of early removal by a surgeon.

The spitting of bright-red blood is one of the most certain signs of consumption, and occurs in about eighty per cent of all cases, but rarely appears as an early warning. The pupils of the eyes may be constantly large at the onset of the disease, but this is a sign of general weakness. Pain is also a frequent but not constant early symptom in the form of "stitch in the side," or pain between or beneath the shoulder blades, or in the region of the breastbone. This pain is due to pleurisy accompanying the tuberculosis. Shortness of breath on exertion is present when consumption is well established, but is not so common as an early symptom. The voice is often somewhat hoarse or husky at the onset of consumption, owing to tuberculous laryngitis.

To sum up then, one should always suspect tuberculosis in a person afflicted with chronic cough who is losing weight and strength, especially if there is fever at some time during the day and any additional symptoms, such as those described. Such a one should immediately apply to a physician for examination of the chest, lungs, and sputum (expectoration). If the germs of tuberculosis are found on microscopical inspection of the sputum, the existence of consumption is absolutely established. Failure to find the germs in this way does not on the other hand prove that the patient is free from the disease, except after repeated examinations at different times, together with the inability to discover any signs by examination of the chest. This examination in some instances produces no positive results, and it may be impossible for the physician to discover anything wrong in the lungs at the commencement of consumption. But, generally, examination either of the lungs or of the sputum will decide the matter, one or both giving positive information.

The use of the X-rays in the hands of some experts sometimes reveals the presence of consumption before it is possible to detect it by any other method. There is also a substance called tuberculin, which, when injected under the skin in suspected cases of consumption causes a rise of temperature in persons suffering from the disease, but has no effect on the healthy. This method is that commonly applied in testing cattle for tuberculosis. As the results of tuberculin injection in the consumptive are something like an attack of grippe, and as tuberculin is not wholly devoid of danger to these patients, this test should be reserved to the last, and is only to be used by a physician.

Treatment.—There is no special remedy at our disposal which will destroy or even hinder the growth of the germs of tuberculosis in the lungs. Our endeavors must consist in improving the patient's strength, weight, and vital resistance to the germs by proper feeding, and by means of a constant out-of-door life. The ideal conditions for out-of-door existence are pure air and the largest number of sunshiny days in the year. Dryness and an even temperature, and an elevation of from 2,000 to 3,000 feet, are often serviceable, but not necessarily successful.

When it is impossible for the patient to leave his home he should remain out of doors all hours of bright days, ten to twelve hours daily in summer, six to eight hours in winter without regard to temperature, and should sleep on a porch or on the roof, if possible. In the Adirondacks, patients sit on verandas with perfect comfort while the thermometer is at ten degrees below zero. A patient (a physician) in a Massachusetts sanitarium has arranged a shelf, protected at the sides, along the outside of a window, on which his pillow rests at night, while he sleeps with his head out of doors and his body in bed in a room inside. If it becomes stormy he retires within and closes the window. If the temperature ranges above 100 deg. F. patients should rest in bed or on a couch in the open air, but, if below this, patients may exercise. A steamer chair set inside of a padded, wicker bath chair, from which the seat has been removed, makes a convenient protected arrangement in which a consumptive can pass his time out of doors. If the patient is quite weak and feverish he may remain in bed, or on a couch, placed on a veranda or balcony during the day, and in a room in which all the windows are open at night. Screens may be used to protect from direct draughts.

No degree of cold, nor any of the common symptoms, as night sweats, fever, cough, or spitting of blood, should be allowed to interfere with this fresh-air treatment. The treatment may seem heroic, but is most successful. The patient must be warmly clothed or covered with blankets, and protected from strong winds, rain, and snow. During clear weather patients may sleep out of doors on piazzas, balconies, or in tents.

Nutritious food is of equal value with the open-air life. A liberal diet of milk and cream, eggs, meat and vegetables is indicated. Raw eggs swallowed whole with a little sherry, or pepper and salt on them, may be taken between meals, beginning with one and increasing the number till three are taken at a time, or nine daily. If the appetite is very poor it is best that a glass of milk be taken every two hours, varied by white of egg and water and meat juice. Drug treatment depends on individual symptoms, and can, therefore, only be given under a physician's care. Sanitarium treatment is the most successful, because patients are under the absolute control of experts and usually in an ideal climate. Change of climate is often useful, but patients should not leave their homes without the advice of a competent physician, as there are many questions to consider in taking such a step.[5] There is a growing tendency among physicians to give consumptives out-of-door treatment at their homes, if living out of cities, as careful personal supervision gives much better results than a random life in a popular climatic resort.

Prevention.—Weakly children and those born of consumptives must receive a generous diet of milk, eggs, meat, and vegetables, and spend most of their time in the open air. Their milk should be heated for fifteen minutes to a temperature of 160 deg. F., in order to kill any germs of tuberculosis, unless the cows have been tested for this disease. The patient must have a separate sleeping room, and refrain from kissing or caressing other members of the family.

The care of the sputum (expectoration) is, however, the essential means of preventing contagion. Out of doors, it should be deposited in a bottle which is cleaned by rinsing in boiling water. Indoors, paper bags or paper boxes made for the purpose are used to receive the sputum, and burned before they become dry. The use of rags, handkerchiefs, and paper napkins is dirty, and apt to cause soiling of the hands and clothes and lead to contagion. Plenty of sunlight in the sick room will cause destruction of the germs of consumption, besides proving beneficial to the patient. No dusting is to be done in the invalid's room; only moist cleansing. All dishes used by a consumptive must be boiled before they are again employed.

ASTHMA.—This is a disorder caused by sudden narrowing of the smaller air tubes in the lungs. This narrowing is produced by swelling of the mucous membrane lining them, or is due to contraction of the tubes through reflex nervous influences. It may accompany bronchitis, or may be uncomplicated. It may be a manifestation of gout.

The sufferers from asthma are usually apparently well in the period between the attacks. The attack often comes on suddenly in the night; the patient wakening with a feeling of suffocation. The difficulty in breathing soon becomes so great that he has to sit up, and often goes to a window and throws it open in the attempt to get his breath. The breathing is very labored and panting. There is little difficulty in drawing the breath, but expiration is very difficult, and usually accompanied by wheezing or whistling sounds. The patient appears to be on the brink of suffocation; the eyeballs protrude; the face is anxious and pale; the muscles of the neck stand out; the lips may be blue; a cold sweat covers the body; the hands and feet are cold, and talking becomes impossible. Altogether, a case of asthma presents a most alarming appearance to the bystander, and the patient seems to be on the verge of dying, yet death has probably never occurred during an attack of this disease. The attacks last from one-half to one or several hours, if not stopped by treatment, and they often return on several successive nights, and then disappear, not to recur for months or years.

Attacks are brought on by the most curious and diverse means. Atmospheric conditions are most important. Emanations from plants, or animals, are common exciting agencies. Fright or emotion of any kind; certain articles of diet; dust and nasal obstruction are also frequent causes. Patients may be free from the disease in cities and attacked on going into the country. Men are subject to asthma more than women, and the victims belong to families subject to nervous troubles of various kinds. The attack frequently subsides suddenly, just when the patient seems to be on the point of suffocation. There is often coughing and spitting of little yellowish, semitransparent balls of mucus floating in a thinner secretion.

Asthma is not likely to be mistaken for other diseases. The temperature is normal during an attack, and this will enable us to exclude other chest disorders, as bronchitis and pneumonia. Occasionally asthma is a symptom of heart and kidney disease. In the former it occurs after exercise; in the latter the attack continues for a considerable time without relief. But, as in all other serious diseases, a physician's services are essential, and it is our object to supply only such information as would be desirable in emergencies when it is impossible to obtain one.

Treatment.—An attack of asthma is most successfully cut short by means of one-quarter of a grain of morphine sulphate[6] with 1/20 of a grain of atropine sulphate, taken in a glass of hot water containing a tablespoonful of whisky or brandy. Ten drops of laudanum,[7] or a tablespoonful of paregoric, may be used instead of the morphine if the latter is not at hand. Sometimes the inhalation of tobacco smoke from a cigar or pipe will stop an attack in those unaccustomed to its use. In the absence of morphine, or opium in the form of laudanum or paregoric, fifteen drops of chloroform or half a teaspoonful of ether may be swallowed on sugar.

A useful application for use on the outside of the chest consists of mustard, one part, and flour, three parts, mixed into a paste with warm water and placed between single thicknesses of cotton cloth. Various cigarettes and pastilles, usually containing stramonium and saltpeter, are sold by druggists for the use of asthmatic patients. They are often efficient in arresting an attack of asthma, but it is impossible to recommend any one kind, as one brand may agree with one patient better than another. Amyl nitrite is sold in "pearls" or small, glass bulbs, each containing three or four drops, one of which is to be broken in and inhaled from a handkerchief during an attack of asthma. This often affords temporary relief.

To avoid the continuance of the disease it is emphatically advisable to consult a physician who may be able to discover and remove the cause. The diet should consist chiefly of eggs, fish, milk, and vegetables (with the exception of beans, large quantities of potatoes, and roots, as parsnips, beets, turnips, etc.). Meat should be eaten but sparingly, and also pastries, sugar, and starches (as cereals, potato, and bread). The evening meal ought to be light, dinner being served at midday. Any change of climate may stop asthmatic seizures for a time, but the relief is apt to be temporary. Climatic conditions affect different patients differently. Warm, moist air in places destitute of much vegetation (as Florida, Southern California, and the shore of Cape Cod and the Island of Nantucket, in summer) enjoy popularity with many asthmatics, while a dry, high altitude influences others much more favorably.

INFLUENZA; LA GRIPPE.—Influenza is an acute, highly contagious disease due to a special germ, and tending to spread with amazing rapidity over vast areas. It has occurred as a world-wide epidemic at various times in history, and during four periods in the last century. A pandemic of influenza began in the winter of 1889-90, and continued in the form of local epidemics till 1904, the disease suddenly appearing in a community and, after a prevalence of about six weeks, disappearing again. One attack, it is, perhaps, unnecessary to state, does not protect against another. The mortality is about 1 death to 400 cases. The feeble and aged are those who are apt to succumb. Fatalities usually result from complications or sequels, such as pneumonia or tuberculosis; neurasthenia or insanity may follow.

Symptoms.—There are commonly four important symptoms characteristic of grippe: fever; pain, catarrh; and depression, mental and physical. Grippe attacks the patient with great suddenness. While in perfect health and engaged in ordinary work, one is often seized with a severe chill followed by general depression, pain in the head, back, and limbs, soreness of the muscles, and fever. The temperature varies from 100 deg. to 104 deg. F. The catarrh attacks the eyes, nose, throat, and larger tubes in the lungs. The eyes become reddened and sensitive to light, and movements of the eyeballs cause pain. Sneezing comes on early, and, after a day or two, is followed by discharge from the nose. The throat is often sore and reddened. There may be a feeling of weight and tightness in the chest accompanied by a harsh, dry cough, which, after a few days, becomes looser and expectoration occurs. Bodily weakness and depression of spirits are usually prominent and form often the most persistent and distressing symptoms.

After three or four days the pains decrease, the temperature falls, and the cough and oppression in the chest lessen, and recovery usually takes place within a week, or ten days, in serious cases. The patient should go to bed at once, and should not leave it until the temperature is normal (98-3/5 deg. F.). For some time afterwards general weakness, associated with heart weakness, causes the patient to sweat easily, and to get out of breath and have a rapid pulse on slight exertion.

Such is the picture of a typical case, but it often happens that some of the symptoms are absent, while others are exaggerated so that different types of grippe are often described. Thus the pain in the back and head may be so intense as to resemble that of meningitis. Occasionally the stomach and bowels are attacked so that violent vomiting and diarrhea occur, while other members of the same family present the ordinary form of influenza. There is a form that attacks principally the nervous system, the nasal and bronchial tracts escaping altogether. Continual fever is the only symptom in some cases. Grippe may last for weeks. Whenever doubt exists as to the nature of the disorder, a microscopic examination of the expectoration or of the mucus from the throat by a competent physician will definitely determine the existence of influenza, if the special germs of that disease are found. It is the prevailing and erroneous fashion for a person to call any cold in the head the grippe; and there are, indeed, many cases in which it becomes difficult for a physician to distinguish between grippe and a severe cold with muscular soreness and fever, except by the microscopic test. Influenza becomes dangerous chiefly through its complications, as pneumonia, inflammation of the middle ear, of the eyes, or of the kidneys, and through its depressing effect upon the heart.

These complications can often be prevented by avoiding the slightest imprudence or exposure during convalescence. Elderly and feeble persons should be protected from contact with the disease in every way. Whole prisons have been exempt from grippe during epidemics, owing to the enforced seclusion of the inmates. The one absolutely essential feature in treatment is that the patient stay in bed while the fever lasts and in the house afterwards, except as his strength will permit him to go out of doors for a time each sunny day until recovery is fully established.

Treatment.—The medicinal treatment consists at first in combating the toxin of the disease and assuaging pain, and later in promoting strength. Hot lemonade and whisky may be given during the chilly period and a single six- to ten-grain dose of quinine. Pain is combated by phenacetin,[8] three grains repeated every three hours till relieved. At night a most useful medicine to afford comfort when pain and sleeplessness are troublesome, is Dover's powder, ten grains (or codeine, one grain), with thirty grains of sodium bromide dissolved in water. After the first day it is usually advisable to give a two-grain quinine pill together with a tablet containing one-thirtieth of a grain of strychnine three times a day after meals for a week or two as a tonic (adult). Only mild cathartics are suitable to keep the bowels regular as a Seidlitz powder in the morning before breakfast. The diet should be liquid while the fever lasts—as milk, cocoa, soups, eggnog, one of these each two hours. A tablespoonful of whisky, rum, or brandy may be added to the milk three times daily if there is much weakness.

The germ causing grippe lives only two days, but successive crops of spores are raised in a proper medium. Neglected mucus in nose or throat affords an inviting field for the germ. Therefore it is essential to keep the nostrils free and open by means of spraying with the Seiler's tablet solution (p. 49), and then always breathing through the nostrils.

FOOTNOTES:

[4] Caution. Dangerous. Use only on physician's order.

[5] Arizona, New Mexico, Colorado, and the Adirondacks contain the most favorable climatic resorts in this country.

[6] Caution. Dangerous. Use only on physician's order.

[7] This dose is only suitable for strong, healthy adults of average weight and those who are not affected peculiarly by opium. Delicate women and others not coming under the above head should take but half the dose and repeat in an hour if necessary.

[8] Caution. A powerful medicine.



CHAPTER IV

Headaches

Treatment of Sick Headache—Effects of Indigestion—Neuralgia—Headaches Occasioned by Disease—Other Causes—Poisoning—Heat Stroke.

Headache varies according to its nature and causes. The first variety to be considered is "sick headache" or migraine.

SICK HEADACHE.—This is a peculiar, one-sided headache which takes the form of severe, periodic attacks or paroxysms, and is often inherited. It recurs at more or less regular intervals, as on a certain day of each week, fortnight or month, and the attacks appear and disappear at regular hours. The disorder generally persists for years and then goes away. If it begins in childhood, as it frequently does between the years of five and ten, it may stop with the coming of adult life, but if not outgrown at this time it commonly vanishes during late middle life, about the age of fifty-one in a man, or with the "change of life" in a woman. While in many instances arising without apparent cause, yet in others sick headache may be precipitated by indigestion, by eye-strain, by enlarged tonsils and adenoids in children, or by fatigue.

There may be some warning of the approach of a sick headache, as mental depression, weariness, disturbances of sight, buzzing in the ears, or dizziness. The pain begins at one spot on one side of the head (more commonly the left), as in the eye, temple, or forehead, and later spreads over the whole side of the head and, in some cases, the neck and arm. The face may be pale, or pale on one side and red on the other. The headache is of a violent, boring nature, aggravated by light and noise, so that the patient is incapacitated for any exertion and is most comfortable when lying down in a quiet, dark room. Vomiting usually comes on after a while, and often gives relief. The headache lasts several hours or all day, rarely longer. The duration is usually about the same in the case of any particular individual who is suddenly relieved at a certain hour generally after vomiting, a feeling of well-being and an enormous appetite following often. Patients may feel perfectly well between the attacks, but if they occur frequently the general health suffers.

In the majority of cases there is no apparent cause discoverable save heredity, and for these the following treatment is applicable. Each case should, however, be carefully studied by a physician, if possible, as only in this way can any existing cause be found and removed.

Treatment.—Any article of diet which experience has shown to provoke an attack should naturally be avoided. A Seidlitz powder, or tablespoonful of Epsom salts in a glassful of water, is advisable at the onset of an attack. Rubbing the forehead with a menthol pencil will afford some relief. Hot strong tea with lemon juice is sometimes of service. To actually lessen the pain one of the following may be tried: phenacetin (eight grains) and repeat once in an hour if necessary until three doses are taken by an adult; or, migraine tablets, two in number, and do not repeat; or fluid extract of cannabis indica, two drops every half hour until relieved, or until six doses are taken.

HEADACHE FROM VARIOUS CAUSES.—It is impossible to decide from the location or nature of the pain alone to what variety of headache it belongs, that is, as to its cause. It is only by considering the general condition of the body that such a decision can be attained.

Headache from Indigestion.—The pain is more often in the forehead, but may be in the top or back of the head. The headache may last for hours, or "off and on" for days. Dull headache is seen in "biliousness" when the whites of the eyes are slightly tinged with yellow and the tongue coated and yellowish, and perhaps dizziness, disturbances of sight and a feeling of depression are present. Among other signs of headache due to indigestion are: discomfort in the stomach and bowels, constipation, nausea and vomiting, belching of wind, hiccough, and tender or painful eyeballs.

In a general way, treatment for this sort of headache consists in the use of a cathartic, such as calomel (three-fifths of a grain) at night, followed by a Seidlitz powder or a tablespoonful of Epsom salts in a glass of cold water in the morning. A simple diet, as very small meals of milk, bread, toast, crackers with cereals, soups, and perhaps a little steak, chop, or fresh fish for a few days, may be sufficient to complete the cure.

Sympathetic Headaches.—These are caused by irritation in various parts of the body, which is conveyed through the nervous system to the brain producing headache. Headache from eye-strain is one of this class, and probably the most common, and, therefore, most important of all headaches. There is unfortunately no sure sign by which we can tell eye-headaches from others, except examination of the eyes (see p. 29). Redness, twitching, and soreness of the eyelids, and watering of the eyes, together with headache, after their excessive use may suggest the cause in some cases. The pain may be occasioned or almost constant, and either about the eyes, forehead, top or back of the head, and often takes the form of "sick headache." The headache may at times appear to have no connection with use of the eyes. When headache is frequent the eyes should always be examined by a competent oculist (a physician) not by any sort of an optician.

Decayed Teeth.—These not uncommonly give rise to headache.

Disorders of the Nose and Throat.—Such troubles, especially adenoids and enlarged tonsils in children, enlarged turbinates, and polypi (see Nose Disorders, p. 60) are fruitful sources of headache. In nose-headaches there is often tenderness on pressing on the inner wall of the bony socket inclosing the eyeball.

Diseases of the Maternal Organs.—These in women produce headache, particularly pain in the back of the head. If local symptoms are also present, as backache (low down), leucorrhea, painful monthly periods, and irregular or excessive flowing, or trouble in urinating, then the cause of the headache is probably some disorder which can be cured at the hands of a skillful specialist in women's diseases.

Nervous Headaches.—These occur in brain exhaustion and anaemia, and in nervous exhaustion. There is a feeling of pressure or weight at the back of the head or neck, rather than real pain. This is often relieved by lying down. Headache from anaemia is often associated with pallor of the face and lips, shortness of the breath, weakness, and palpitation of the heart. Rest, abundance of sleep, change of scene, out-of-door life, nourishing food, milk, cream, butter, eggs, meat, and iron are useful in aiding a return to health (see Nervous Exhaustion, Vol. III, p. 17).

Neuralgic Headaches.—The pain is usually of a shooting character, and the scalp is often exceedingly tender to pressure. They may be caused by exposure to cold, or by decayed teeth, or sometimes by inflammation of the middle ear (see Earache, p. 40).

Headache from Poisoning.—Persons addicted to the excessive use of tea, coffee, alcohol, and tobacco are often subject to headache from poisoning of the system by these substances. In tea, coffee, and tobacco poisoning there is also palpitation of the heart in many cases; that is, the patient is conscious of his heart beating, irregularly and violently (see Palpitation, Vol. III, p. 171), which causes alarm and distress. Cessation of the habit and sodium bromide, twenty grains three times daily, dissolved in water, administered for not more than three days, may relieve the headache and other trouble.

Many drugs occasion headache, as quinine, salicylates, nitroglycerin, and some forms of iron.

The poisons formed in the blood by germs in acute diseases are among the most common sources of headache. In these disorders there is always fever and often backache, and general soreness in the muscles. One of the most prominent symptoms in typhoid fever is constant headache with fever increasing toward night, and also higher each night than it was the night before. The headache and fever, together often with occasional nosebleed and general feeling of weariness, may continue for a week or two before the patient feels sick enough to go to bed. The existence of headache with fever (as shown by the thermometer) should always warn one of the necessity of consulting a physician. Headache owing to germ poisons is also one of the most distressing accompaniments of grippe, measles, and smallpox, and sometimes of pneumonia.

The headache caused by the poison of the malarial parasite in the blood is very violent, and the pain is situated usually just over the eye, and occurring often in the place of the paroxysm of the chill and fever at a regular hour daily, every other day, or every fourth day. If the headache is due to malaria, quinine will cure it (Malaria, Vol. I, p. 258). The headache of rheumatism is owing also to a special poison in the blood, and is often associated with soreness of the scalp. If there are symptoms of rheumatism elsewhere in the body, existing headache may be logically attributed to the same disease (see Rheumatism, p. 169).

The poison of gout circulating in the blood is sometimes a source of intense headache.

The headache of Bright's disease of the kidneys and of diabetes is dull and commonly associated with nausea or vomiting, swelling of the feet or ankles, pallor and shortness of breath in the former; with thirst and the passage of a large amount of urine (normal quantity is three pints in twenty-four hours) in the case of diabetes.

The headaches of indigestion are also of poisonous origin, the products of imperfectly digested food being absorbed into the blood and acting as poisons.

Another variety of headache due to poisoning is seen in children crowded together in ill-ventilated schoolrooms and overworked. Still another kind is due to inhalation of illuminating gas escaping from leaky fixtures.

Headache from Heat Stroke.—Persons who have been exposed to excessive heat or have actually had a heat stroke (Vol. I, p. 40) are very prone to headache, which is made worse by movements of the head. Sodium bromide, twenty grains dissolved in water, may be given to advantage three times daily between meals in these cases for not more than two days. Phenacetin in eight-grain doses may also afford relief, but should not be used more often than once or twice a day.

Constant Headache.—This, afflicting the patient all day and every day, and increasing in severity at night, is suggestive of some disease of the brain, as congestion, brain tumor, or meningitis, and urgently demands skillful medical attention.



Part II

TUMORS SKIN DISEASES RHEUMATISM

BY

KENELM WINSLOW

AND

ALBERT WARREN FERRIS



CHAPTER I

Growths and Enlargements

Benign and Malignant Tumors—Treatment of Rupture—Hernia in Children—Varicocele—Causes of Varicose Veins—External and Internal Piles.

TUMORS.—A tumor—in its original meaning—signifies a swelling. As commonly used it means a new growth or enlargement of a part, which is not due to injury or inflammation. Tumors occur at all ages, in both sexes, and may attack any part of the body. Tumors are usually divided into benign and malignant growths. In a general way the malignant tumors are painful; they do not move about freely but become fixed to the adjacent parts; their growth is more rapid; they often have no well-defined borders; frequently they return after removal; the skin covering them is often attached and cannot be moved readily without also moving the tumor. Malignant tumors are divided into cancers (carcinomata) and sarcomas (sarcomata). Cancer is much more frequent than sarcoma. Cancer occurs more often in persons over thirty; there appears to be a hereditary tendency to it in some families, and a number of individuals in the same house or locality sometimes develop cancer as if it were in some way communicated from one to another. The common situations of cancer are the breast and womb in women, and the lip and stomach of men. The neighboring glands become enlarged, as are shown by the lumps which form under the jaw in cancer of the lip, and which may be felt sometimes in the armpit in cancer of the breast; these are, however, late signs, and the growth should never be permitted to remain long enough for them to develop. Paleness, weakness, and loss of strength often attend the development of cancer, but many do not exhibit these symptoms.

Sarcoma is often seen in the young and well nourished; it grows very rapidly; the skin is usually not adherent to the tumor; there is generally no pain; heredity has no relation to its development; paleness is absent in many cases; the favorite seats are the muscle, bone, glands of neck, brain, and many other localities; it is not nearly so common as cancer.

Cancer of the breast begins as a lump, occurring more often to the outside of the nipple, but may develop in any part. It may or may not be painful at first, but the skin becomes attached to it; and sooner or later the nipple is drawn in. It is seen in women over forty, as a rule. Lumps in the breast, occurring during the nursing period, are often due to inflammation, but these generally have no relation to cancer unless they persist for a long time. Any lump which appears in the breast without apparent cause, or which persists for a considerable time after inflammation ceases, should be promptly removed by the surgeon, as without microscopic examination the most skilled practitioners will be unable absolutely to distinguish between a harmless and malignant tumor. As even so-called benign tumors often become cancerous (e. g., inflammatory lumps in the breast, warts, and moles), an eminent surgeon (Dr. Maurice Richardson) has recently formulated the rule that all tumors, wherever situated, should if possible be removed, whatever their apparent nature. Cancer of the womb may be suspected in middle-aged women if flowing is more profuse than is usual, or occurs at irregular times; if there is a discharge (often of offensive odor) from the front passage; and sometimes pain, as backache, and perhaps paleness. Early examination should be sought at the hands of a physician; it is suicidal to delay.

Cancer of the stomach is observed more often in men over forty, and begins with loss of appetite; nausea or vomiting; vomiting of blood; pain in the stomach; loss of weight, and paleness. Some of these symptoms may be absent. Improved methods of surgery have rendered early operation for cancer of the stomach a hopeful measure, and if cure does not result, the life will be prolonged and much suffering saved.

Cancer of the lip arises as a small lump, like a wart generally, on the lower lip in men from forty to seventy. Sometimes it appears at first simply as a slight sore or crack which repeatedly scabs over but does not heal. Its growth is very slow and it may seem like a trivial matter, but any sore on the lower lip in a man of middle age or over, which persists, should demand the immediate attention of a surgeon, because early removal is more successful in cancer of the lip than in any other form.

There are, of course, many comparatively harmless or benign forms of tumors which will not return if removed and do not endanger life unless they grow to a large size. Among these are the soft, flattened, fatty tumors of the shoulders, back, buttocks, and other parts, and the wen. This is often seen on the head and occurs frequently on the scalp, from the size of a pea to an egg, in groups. Wens are elastic lumps, painless and of slow growth, and most readily removed. Space does not permit us to recount the other forms of benign tumors and it would be impossible to describe how they could be distinguished from malignant growths.

Causes.—The causes of tumors are almost wholly unknown. There is no other branch of medicine which is receiving more scientific study the world over than cancer, and some definite and helpful knowledge may soon be expected. A cancer can be communicated by introduction of cancerous material into healthy tissues. This and other reasons have led many to believe that the disease was caused by a special germ; a chemical cause is thought to be the origin of cancer by other authorities. Neither of these theories has been substantiated and we are still completely at sea in the matter. Cancer appears to be excited sometimes by local irritation, as in the lip by the constant irritation of the hard, hot stem of a clay pipe; cancer of the tongue by the irritation of a rough, sharp tooth. Blows and injuries are also occasional agencies in the development of cancer. Malignant growths not rarely arise from moles and warts.

Treatment.—Early removal by the knife is the only form of treatment which is to be considered in most cases. Delay and neglect are suicidal in malignant disease. Cure is successful in just so far as the operation is done early. If dread of surgical operation were not so prevalent, the results of removal of cancer would be immeasurably better. The common, bad results of operation—that is, return of the disease—are chiefly due to the late stage in which surgeons are compelled to operate through the reluctance of the patient and, strangely enough, often of his family medical man. Cancer should be removed in so early a stage that its true nature can often not be recognized, except by microscopical examination after its removal. If Maurice Richardson's rule were followed, many cancers would never occur, or would be removed before they had developed sufficiently to show their nature.

All treatment by chemical pastes and special remedies is simply courting fatal results. Most special cures advertised to be performed in sanitoriums are money-getting humbugs. Even the X-ray has proved useless except in the case of most superficial growths limited to the skin or when directed against the scar left by removal of a cancer; and while the growth may disappear during treatment, in a large proportion of cases there is a recurrence. But when tumors are so far advanced that removal by the knife is inoperable, then other means will often secure great relief from suffering and will prolong life for a very considerable period in many cases.

RUPTURE.—Hernia or rupture consists in a protrusion of a portion of the contents of the abdomen (a part of the bowel or its covering, or both) through the belly wall. The common seats of rupture are at the navel and in the groin. Rupture at the navel is called umbilical hernia; that in the groin either inguinal or femoral, according to slight differences in site. Umbilical hernia is common in babies and occurs as a whole in only five per cent of all ruptures, whereas rupture in the groin is seen to the extent of ninety-four per cent of all ruptures. There is still another variety of hernia happening in the scars of wounds of the belly after injuries or surgical operations, and this may arise at almost any point.

Causes.—Rupture is sometimes present at birth. In other cases it is acquired as a result of various causes, of which natural weakness of the part is the chief. Twenty-five per cent of persons with rupture give a history of the same trouble in their parents. Rupture is three times more frequent in men than in women, and is favored by severe muscular work, fatness, chronic coughing, constipation, diarrhea, sudden strain, or blows on the abdomen.

Symptoms.—Rupture first appears as a fullness or swelling, more noticeable on standing, lifting, coughing, or straining. It may disappear entirely on lying down or on pressure with the fingers. In the beginning there may be discomfort after standing or walking for any length of time, and later there is often a dragging pain or uneasiness complained of, or a sensation of weakness or griping at the seat of the rupture. In case the rupture cannot be returned, it is called irreducible and is a more serious form. The great danger of hernias is the likelihood of their being strangulated, as the term is; that is, so nipped in the divided abdominal wall that the blood current is shut off and often the bowels are completely obstructed. If this condition is not speedily relieved death will ensue in from two to eight days. Such a result is occasioned, in persons having rupture, by heavy lifting, severe coughing or straining, or by a blow or fall. The symptoms of strangulated hernia are sudden and complete constipation, persistent vomiting, and severe pain at the seat of the rupture or often about the navel. The vomiting consists first of the contents of the stomach, then of yellowish-stained fluid, and finally of dark material having the odor of excrement. Great weakness, distention of the belly, retching, hiccough, thirst, profound exhaustion, and death follow if the condition is not remedied. In some cases, where the obstruction is not complete, the symptoms are comparatively milder, as occasional vomiting and slight pain and partial constipation.

If the patient cannot return the protrusion speedily, a surgeon should be secured at all costs—the patient meanwhile lying in bed with an ice bag or cold cloths over the rupture. The surgeon will reduce the protrusion under ether, or operate. Strangulation of any rupture may occur, but of course it is less likely to happen in those who wear a well-fitting truss; still it is always a dangerous possibility, and this fact and the liability of the rupture's increasing in size make a surgical operation for complete cure advisable in proper subjects.

Treatment.—Two means of treatment are open to the ruptured: the use of the truss and surgical operation. By the wearing of a truss, fifty-eight per cent of ruptures recover completely in children under one year. In children from one to five years, with rupture, ten per cent get well with the truss. Statistics show that in rupture which has been acquired after birth but five per cent recover with a truss after the age of fifteen, and but one per cent after thirty. The truss must be worn two years after cure of the rupture in children, and in adults practically during the rest of their lives. A truss consists of a steel spring which encircles the body, holding in place a pad which fits over the seat of hernia. The Knight truss is one of the best. The truss is most satisfactory in ruptures which can be readily returned. In very small or large hernias, and in those which are not reducible, the action of the truss is not so effective. In irreducible ruptures there is likely to be constipation and colic produced, and strangulation is more liable to occur. A truss having a hollow pad may prove of service in small irreducible ruptures, but no truss is of much value in large hernias of this kind. Every person with a reducible rupture should wear a proper truss until the rupture is cured by some means. Such a truss should keep in the hernia without causing pain or discomfort. It should be taken off at night, and replaced in the morning while the patient is lying down. In cases where the protrusion appears during the night a truss must be worn day and night, but often a lighter form will serve for use in bed. To test the efficiency of a truss let the patient stoop forward with his knees apart, and hands on the knees, and cough. If the truss keeps the hernia in, it is suitable; if not, it is probably unsuitable. Operation for complete cure of the hernia is successful in 95 cases out of 100, in suitable subjects, in the ruptures in the groin. The death rate is but about 1 in 500 to 1,000 operations when done by surgeons skilled in this special work. Patients with very large and irreducible hernias, and those who are very fat and in advanced life, are unfavorable subjects for operation. In young men operation—if it can be done by a skillful surgeon and in a hospital with all facilities—is usually to be recommended in every case of rupture. Umbilical hernias and ventral hernias, following surgical operations, may be held in place by a wide, strong belt about the body, which holds a circular flat or hollow plate over the rupture. These have been the most difficult of cure by operation; but recent improvements have yielded very good results—thirty-five cures out of thirty-six operations for umbilical rupture, and one death, by Mayo, of Rochester, Minn.—and they are usually the very worst patients, of middle age, or older, and very stout.

Umbilical rupture in babies is very common after the cord has dropped off. There is a protrusion at the navel which increases in size on coughing, straining, or crying. If the rupture is pushed in and the flesh is brought together from either side in two folds over the navel, so as to bury the navel out of sight, and held in this position by a strip of surgeon's plaster, reaching across the front of the belly and about two and one-half inches wide, complete recovery will usually take place within a few months. It is well to cover the plaster with a snug flannel band about the body. The plaster should be replaced as need be, and should be applied in all cases by a physician if one can be secured.

VARICOSE VEINS.—Varicose veins are enlarged veins which are more commonly present on the legs, but are also seen in other parts of the body. They stand out from the skin as bluish, knotty, and winding cords which flatten out when pressure is made upon them, and shrink in size in most cases upon lying down. Sometimes bluish, small, soft, rounded lumps, or a fine, branching network of veins may be seen. Oftentimes varicose veins may exist for years—if not extensive—without either increasing in size or causing any trouble whatsoever. At other times they occasion a feeling of weight and dull pain in the legs, especially on long standing. When they are of long duration the legs may become swollen and hard, and eczema, with itching, is then not uncommon. This leads to scratching and sores, and these may enlarge and become what are called varicose ulcers, which are slow and difficult of healing. Occasionally an old varicose vein may break open and give rise to profuse bleeding.

Causes.—Varicose veins are more frequent in women, especially in those who stand much, as do cooks. Any obstruction to the return flow of the blood from the veins toward the heart will produce them, as a tight garter about the leg; or the pressure of the large womb in pregnancy upon the veins, or of tumors in the same region. Heart and lung diseases also predispose to the formation of varicose veins.

Treatment.—Varicose veins are exceedingly common, and if they are not extensive and produce no discomfort they may be ignored. Otherwise, it is well to have an elastic stocking made to come to, or above, the knee. The stocking should be put on and removed while lying down. Cold bathing, outdoor exercise, and everything which will improve the general health and tone are desirable, also the avoidance of constipation. In the most aggravated cases surgical operation will cure varicose veins. Bleeding from a broken vein is stopped by pressure of a bandage and lying on the back with the foot raised on a pillow.

VARICOCELE.—This consists of an enlargement of the veins in the scrotum above the testicle of the male, on the left side in most cases. The large veins feel more like a bunch of earthworms than anything else. If they cause no discomfort they may be entirely neglected and are not of the slightest consequence. Even when they produce trouble it is chiefly imaginary, in most instances, since they are a common source of worry in young men in case of any irregularities in the sexual functions. Advantage is taken of this fact by quacks, who find it for their profit to advertise all sorts of horrible and impossible results of the condition. The testicle on the diseased side may become smaller than its fellow, but in few cases does any serious consequence result from varicocele. Pain in the hollow of the back may be the only symptom of varicocele in cases where there are any symptoms. A dragging pain in the groin, a pain in the testicles and about the rectum and in the bladder may cause complaint.

Causes.—Varicocele occurs usually in young, unmarried men and often disappears of itself in later life. Undue sexual excitement may produce the condition.

Treatment.—When any treatment is necessary, the application of a snugly fitting suspensory bandage—which can be procured at any good drug shop—and bathing the testicles night and morning in cold water, with the avoidance of constipation and of the cause noted, will be generally sufficient to relieve any discomfort arising from varicocele. The enlargement of the veins will not, of course, be altered by this treatment, and absolute cure can only be effected by a surgical removal of the veins, which is not a serious undertaking, but is rarely necessary.

PILES—HEMORRHOIDS.—Piles consist of enlarged, and often inflamed, veins in the rectum, or lower part of the bowel.

External Piles.—These are bluish swellings or little lumps which project from the bowel, interfering with walking or the toilet of the parts, and are sometimes exquisitely tender and painful when inflamed. In the course of time these become mere projections or fringes of flesh and cause no trouble unless through uncleanliness or other reasons they are irritated. The treatment of external piles may be summed up in great cleanliness—washing the parts after each movement of the bowels; rest in bed, if the soreness is great; the application of cold water or powdered ice in a rubber bag, or of hot poultices, and of various drugs. Among these are hamamelis extract, or witch-hazel, with which the parts may be frequently bathed; an ointment of nut-gall and opium; or extract of belladonna and glycerin, equal parts. Sitting in cold water, night and morning, in a tub also will prove serviceable. The more rapid and effectual method of cure consists in opening of the recent pile by the surgeon, or clipping off the fleshy projections. The bowels should always be kept regular in any form of piles by small doses of Glauber's or Epsom salts taken in a glass of hot water on rising, or some mineral water. In case these do not agree, extract of cascara or compound licorice powder may be taken at night. Equal parts of sulphur and cream of tartar is an old-fashioned domestic cathartic of which a teaspoonful may be taken each morning to advantage in piles.

Internal Piles.—In the beginning patients with internal piles feel as if the bowels were not wholly emptied after a passage, and sometimes there is difficulty in urinating and also pains in the hollow of the back and in the thighs. There is often pain on movement of the bowels, and blood follows the passage. Later, blood may be lost at other times, and the loss may be so great as to cause pronounced paleness and weakness. Itching is a frequent occurrence. Mucus and pus (matter such as comes from an abscess) may also be discharged. Loss of sexual desire and power is not uncommonly present. There may be no external protrusions; but bleeding, itching, and pain during movement of the bowels are the chief symptoms. If the pain is very severe during and also after a passage, it is probable that there is also present a fissure or crack in the flesh, or ulcer at the exit of the bowel which needs surgical attention. It not infrequently happens that the piles come out during the bowel movement, when they should be thoroughly washed, greased, and pushed back. Sometimes this is impossible, although after lying down for a while and applying ice or cold water the mass may shrink so as to admit of its return. When a large mass is thus protruded and cannot be returned, and becomes nipped by the anus muscles, it undergoes inflammation and is very painful, but a cure often results from its destruction. Such a mode of cure is not a safe or desirable one, however.

Treatment.—The cold sitz baths in the morning or injections of a half pint of ice water after a passage are useful. Ointments may be introduced into the bowel upon the finger, or, better, with hard rubber plugs sold for the purpose; or suppositories may be employed. An ointment, containing sixty grains of iron subsulphate to the ounce of lard (or, if there is much itching, an ointment consisting of orthoform, thirty grains, with one-half ounce of lard), will prove of value. Also the injection of one-half pint cold water, containing a teaspoonful of extract of hamamelis, after a passage, affords relief. Two or three grains of the subsulphate of iron may be employed in suppositories, and one of these may be introduced three times daily. The compound gall ointment or the glycerite of tannin will be found to act successfully in some cases. When one remedy does not serve, try another. The only positive cure for piles consists in surgical operation for their removal. Self-treatment is not recommended, as the physician can do better, and an examination is always advisable to rule out other conditions which may be mistaken by the layman for piles.

Causes.—Piles are seen chiefly in adults, in those in advanced life, and in those who exercise little but eat much. Constipation favors their occurrence, and the condition is commonly present in pregnant women. Fatigue, exposure, horseback exercise, or an alcoholic debauch will cause their appearance. Certain diseases also occasion the formation of piles.



CHAPTER II

Skin Diseases and Related Disorders

Household Remedies for Itching—Chafing and Chapping—Hives, Cold Sores and Pimples—Ringworms, Warts and Corns—Eczema and other Inflammatory Disorders.

No attempt will be made to give an extended account of skin diseases, but a few of the commoner disorders which can be readily recognized by the layman will be noticed. Although these cutaneous troubles are often of so trivial a nature that a physician's assistance is unsought, yet the annoyance is often sufficient to make it worth while for the patient to inform himself about the ailment. Then the affections are so frequent that they may occur where it is impossible to procure medical aid. Whenever an eruption of the skin is accompanied by fever, sore throat, headache, pains in back and limbs, vomiting, or general illness, one of the serious, contagious, eruptive diseases should be suspected, particularly in children, and the patient must be removed from contact with others, kept in isolation, and a physician immediately summoned.

ITCHING (Pruritus).—Itching is not a distinct disease by itself, but a symptom or sign of other skin or general disorders. Occasionally it must be treated as if it were a separate disease, as when it occurs about the entrance to the bowel (anus), or to the external female sexual parts (vulva), or attacks the skin generally, and is not accompanied by any skin eruption except that caused by scratching, and the cause be unascertainable. Itching, without apparent cause, may be due to parasites, as lice and fleas, and this must always be kept in mind; although debilitated states of the body and certain diseases, as gout and diabetes, are sometimes the source. Commonly, itching is caused by one of the many recognized skin diseases, and is accompanied by an eruption characteristic of the particular disorder existing, and special treatment by an expert, directed to remedy this condition, is the only reasonable way to relieve the itching and cure the trouble.

It may not, however, be improper to suggest means to relieve such a source of suffering as is itching, although unscientific, with the clear understanding that a cure cannot always be expected, but relief may be obtained until proper medical advice can be secured. The treatment to be given will be appropriate for itching due to any cause, with or without existing eruption on the skin, unless otherwise specified. If one remedy is unsuccessful, try others.

For itching afflicting a considerable portion of the skin, baths are peculiarly effective. Cold shower baths twice daily, or swimming in cold water at the proper time of year, may be tried, but tepid or lukewarm baths are generally more useful. The addition of saleratus or baking soda, one to two pounds to the bath, is valuable, or bran water obtained by boiling bran tied in a bag in water, and adding the resulting solution to the bath. Even more efficient is a bath made by dissolving half a cupful of boiled starch and one tablespoonful of washing or baking soda in four gallons of warm water. The tepid baths should be as prolonged as possible, without chilling the patient. The bran water, or starch water, may be put in a basin and sopped on the patient with a soft linen or cotton cloth and allowed to evaporate from the skin, without rubbing, but while the skin is still moist a powder composed of boric acid, one part, and pulverized starch, four parts, should be dusted on the itching area.

Household remedies of value include saleratus or baking soda (one teaspoonful to the pint of cold water), or equal parts of alcohol, or vinegar and water, which are used to bathe the itching parts and then permitted to dry on them. Cold solution of carbolic acid (one teaspoonful to the pint of hot water) is, perhaps, the most efficacious single remedy. But if it causes burning it must be washed off at once. Dressings wet with it must never be allowed to become dry, as then the acid becomes concentrated and gangrene may result. Calamine lotion (p. 145) is also a serviceable preparation when there is redness and swelling of the skin. When the itching is confined to small areas, or due to a pimply or scaly eruption on the skin, the following ointments may be tried: a mixture of tar ointment and zinc ointment (two drams each) with four drams of cold cream, or flowers of sulphur, one part, and lard, twelve parts.

CHAFING AND CHAPPING.—Chafing occurs when two opposing skin surfaces rub together and are irritated by sweat, as in the armpits, under the breasts and beneath overlapping parts of the belly of fat people, and between the thighs and buttocks. The same result is caused by the irritation induced by discharges constantly running over the skin, as that seen in infants, due to the presence of urine and bowel discharges, and that irritation which arises from saliva when the lips are frequently licked. The latter condition of the lips is commonly called chapping, but it is proper to consider chafing and chapping together as the morbid state of the skin, and the treatment is the same for both.

Chafing occurs more often in hot weather and after violent exercise, as rowing, riding, or running, and is aggravated by the friction of clothing or of tight boots. It may, on the other hand, appear in persons who sit a great deal, owing to constant pressure and friction in one place. The parts are hot, red, and tender, and emit a disagreeable odor when secretions are retained. The skin becomes sodden by retained sweat, and may crack and bleed. The same redness and tenderness are seen in chapping of the face and lips, and cracking of the lips is frequent.

In chafing the first requisite is to remove the cause, and then thoroughly wash the part with soap and water. Then a saturated solution of boric acid in water should be applied with a soft cloth, and the parts dusted with a mixture of boric acid and powdered starch, equal parts, three times daily. If the lips are badly cracked, touching them, once daily, with a stick of silver nitrate (dipped in water) is of service.

HIVES; NETTLERASH (Urticaria).—Hives is characterized by the sudden appearance of hard round or oval lumps in the skin, from the size of a pea to that of a silver dollar, of a pinkish-white color, or white in the center and often surrounded by a red blush. The rash is accompanied by much itching, burning, or tingling, especially at night when the clothes are removed. The peculiarity of this eruption is the suddenness with which the rash appears and disappears; the itching, the whitish or red lumps, the fact that the eruption affects any part of the body and does not run together, are also characteristic. Scratching of the skin often brings out the lumps in a few minutes. The swellings may last a few minutes or hours, and suddenly disappear to reappear in some other place. The whole trouble usually continues only a few days, although at times it becomes a chronic affection.

Scratching alters the character of the eruption, and causes red, raw marks and crusts, but the ordinary swellings can be seen usually in some part of the body. Rarely, the eruption comes in the throat and leads to sudden and sometimes dangerous swelling, so that suffocation has ensued. With hives there are no fever, sore throat, backache, headache, which are common to the contagious eruptive disorders, as measles, scarlet fever, etc.

Indigestion is the most frequent cause. Certain articles of diet are almost sure to bring on an attack of hives in susceptible persons; these include shellfish, clams, lobsters, crabs, rarely oysters; also oatmeal, buckwheat cakes, acid fruits, particularly strawberries, but sometimes raspberries and peaches. Nettlerash is common in children, and may follow any local irritation of the skin caused by rough clothes, bites of mosquitoes and fleas, and the stings of jellyfish, Portuguese man-of-war, and nettles.

Treatment.—Remove any source of irritation in the digestive canal, or externally, and employ a simple diet for a few days, as bread and milk.

A dose of castor oil, one teaspoonful for children; one tablespoonful for adults, or some other cathartic is advisable. Locally we use, as domestic remedies, a saturated solution of baking soda (or saleratus) in water, or equal parts of alcohol or vinegar and water to relieve the itching. The bath containing soda and starch (p. 141) is the most useful treatment when the nettlerash is general. Calamine lotion is one of the best applications which can be employed for this disorder. It should be sopped on frequently with a soft cloth and allowed to dry on the skin.