CHAPTER I

The Eye and Ear

Injuries to the Eye—Inflammatory Conditions—"Pink Eye"—Nearsightedness and Farsightedness—Deafness—Remedies for Earache.

CINDERS AND OTHER FOREIGN BODIES IN THE EYE.—Foreign bodies are most frequently lodged on the under surface of the upper lid, although the surface of the eyeball and the inner aspect of the lower lid should also be carefully inspected. A drop of a two-per-cent solution of cocaine will render painless the manipulations. The patient should be directed to continue looking downward, and the lashes and edge of the lid are grasped by the forefinger and thumb of the right hand, while a very small pencil is gently pressed against the upper part of the lid, and the lower part is lifted outward and upward against the pencil so that it is turned inside out. The lid may be kept in this position by a little pressure on the lashes, while the cinder, or whatever foreign body it may be, is removed by gently sweeping it off the mucous membrane with a fold of a soft, clean handkerchief.

Hot cinders and pieces of metal may become so deeply lodged in the surface of the eye that it is necessary to dig them out with a needle (which has been passed through a flame to kill the germs on it) after cocaine solution has been dropped into the eye twice at a minute interval. Such a procedure is, of course, appropriate for an oculist, but when it is impossible to secure medical aid for days it can be attempted without much fear, if done carefully, as more harm will result if the offending body is left in place. It is surprising to see what a hole in the surface of the eye will fill up in a few days. If the foreign body has caused a good deal of irritation before its removal, it is best to drop into the eye a solution of boric acid (ten grains to the ounce of water) four times daily.

"BLACK EYE."—To relieve this condition it is first necessary to reduce the swelling. This can be done by applying to the closed lids, every three minutes, little squares of white cotton or linen, four fold and about as large as a silver dollar, which have laid on a cake of ice until thoroughly cold. This treatment is most effective when pursued almost continuously for twenty-four hours. The cold compresses should not be permitted to overlap the nose, or a violent cold in the head may ensue. The swelling having subsided, the discoloration next occupies our attention. This may be removed speedily by applying, more or less constantly below the lower lid, little pieces of flannel dipped in water as hot as can be borne. The cloths must be changed as often as they cool. Repeat this treatment for a half hour every two hours or so during the day.

STYE.—A stye is a boil on the eyelid; it begins at the root of a hair as a hard swelling which may extend to the whole lid. The tip of the swelling takes on a yellowish color, breaks down and discharges "matter" or pus. There are pain and a feeling of tension in the lid, and, very rarely, some fever. When one stye follows another it is well to have the eyes examined by an oculist, as eye-strain is often an inviting cause of the trouble, and this can be corrected by the use of glasses. Otherwise the patient is probably "run down" from chronic constipation and anÆmia (poverty of the blood) and other causes, and needs a change of air, tonics, and exercise out of doors. In a depreciated condition, rubbing the lids causes introduction of disease germs.

The immediate treatment, which may cut short the trouble, consists in bathing the eyelid for fifteen minutes at a time, every hour, with a hot solution of boric acid (half a teaspoonful to the cup of water). Then at night the swelling should be painted with collodion, several coats, being careful not to get it in the eye, as it would cause much smarting. If the stye persists in progressing, bathing it in hot water will cause it to discharge pus and terminate much sooner.

TWITCHING OF THE EYELIDS.—This condition may be due to eye-strain, and can be relieved if the eyes are fitted to glasses by an oculist (not an optician). It is frequently an accompaniment of inflammation of the eyes, and when this is cured the twitching of the lids disappears. When the eyes are otherwise normal the twitching is frequently one of the signs of nerve fag and overwork.

WOUNDS AND BURNS ABOUT THE EYES.—Slight wounds of the inner surface of the eyelids close readily without stitching if the boric-acid solution (ten grains to the ounce of water) is dropped into the eye four times daily. Burns of the inner surface of the lids follow the entrance of hot water, hot ashes, lime, acids, and molten metals. Burns produced by lime are treated by dropping a solution of vinegar (one part of vinegar to four of water) into the eye, while those caused by acids are relieved by similar treatment with limewater or solution of baking soda (half a teaspoonful to the glass of water). If these remedies are not at hand, the essential object is attained by washing the eye with a strong current of water, as from a hose or faucet. If there is much swelling of the lids, and inflammation after the accident, drop boric-acid solution into the eye four times daily. Treatment by cold compresses, as recommended for "black eye," will do much also to quiet the irritation, and the patient should wear dark glasses.

SORE EYES; CONJUNCTIVITIS.—The mucous membrane lining the inner surface of the eyelids also covers the front of the eyeball, although so transparent here that it is not apparent to the observer. Inflammation of this membrane is more commonly limited to that portion covering the inner surfaces of the lids, but may extend to the eyeball when the eye becomes "bloodshot" and the condition more serious. For the sake of convenience we may speak of a mild form of sore eye, as congestion of the eyelids, and the more severe type, as true conjunctivitis (see p. 18).

CONGESTION OF THE EYELIDS.—This may be caused by smoke or dust in the atmosphere, by other foreign bodies in the eye; frequently by eye-strain, due to far- or near-sightedness, astigmatism, or muscular weakness, which may be corrected by an oculist's (never an optician's) prescription for glasses. Exposure to an excessive glare of light, as in the case of firemen, or, on the other hand, reading constantly and often in a poor light, will induce irritation of the lids. The germs which cause "cold in the head" often find their way into the eyes through the tear ducts, which connect the inner corner of the eyes with the nose, and thus may set up similar trouble in the eyes.

Symptoms.—The eyes feel weary and "as if there were sand in them." There may be also smarting, burning, or itching of the lids, and there is disinclination for any prolonged use of the eyes. The lids, when examined, are found to be much deeper red than usual, and slightly swollen, but there is no discharge from the eye, and this fact serves to distinguish this mild type of inflammation from the more severe form.

Treatment.—The use of dark glasses and a few drops of zinc-sulphate solution (one grain to the ounce of water) in the eye, three times daily, will often cure the trouble. If this does not do so within a few days then an oculist should be consulted, and it will frequently be found that glasses are needed to secure freedom from irritation of the eyes. In using "eye-drops" the head should be held back, and several drops be squeezed from a medicine dropper into the inner corner of the eye.

CONJUNCTIVITIS; CATARRHAL INFLAMMATION OF THE EYES.—In this disorder there is discharge which sticks the lids together during the night. The inner surface of the lids is much reddened, the blood vessels in the lining membrane are much enlarged, and the lids are slightly swollen. The redness may extend to the eyeball and give it a bloodshot appearance. There is no interference with sight other than momentary blurring caused by the discharge, and occasionally there is very severe pain, as if a cinder had suddenly fallen in the eye. This symptom may occur at night and awaken the patient, and may be the reason for his first consulting a physician.

One eye is commonly attacked twenty-four to thirty-six hours before the other, and even if it is thought that the cause is a cinder, in case of one eye, it can hardly be possible to sustain this belief in the case of the involvement of both eyes. There is a feeling of discomfort about the eyes, and often a burning, and constant watering, the tears containing flakes of white discharge.

When the discharge is a copious, creamy pus or "matter," associated with great swelling of the lids and pain on exposure to light, the cause is usually a germ of a special disease, and the eyesight will very probably be lost unless a skillful physician be immediately secured. Early treatment is, however, of great service, and, until a physician can be obtained, the treatment recommended below should be followed conscientiously; by this means the sight may be saved. This dangerous variety of inflammation of the eyes is not rare in the newborn, and infants having red eyes within a few days of birth should immediately receive proper attention, or blindness for life will be the issue. This is the usual source of that form of blindness with which babies are commonly said to have been born.

All forms of severe inflammation of the lids are contagious, especially the variety last considered, and can be conveyed, by means of the discharge, through the agency of towels, handkerchiefs, soap, wash basins, etc., and produce the same or sometimes different types of inflammation in healthy eyes. Therefore, if the severe form of conjunctivitis breaks out among any large number of people, as in schools, prisons, asylums, and almshouses, isolation of the patients should be enforced.

"PINK EYE."—This is a severe epidemic form of catarrh of the eye, which is caused by a special germ known as the "Koch-Weeks bacillus." The treatment of this is the same as that outlined below. The germ of pneumonia and that of grippe also often cause conjunctivitis, and "catching cold," chronic nasal catarrh, exposure to foul vapors and gases, or tobacco smoke, and the other causes enumerated, as leading to congestion of the lids, are also responsible for catarrhal inflammation of the eye.

Treatment.—In the milder attacks of conjunctivitis the treatment should be that recommended above for congestion of the lids. The swelling and inflammation, in the severer types, are greatly relieved by the application of the cold-water compresses, advised under the section on "black eye," for an hour at a time, thrice daily. Confinement in a dark room, or the use of dark glasses, and drops of zinc sulphate (one grain in an ounce of water) three times a day, with hourly dropping of boric acid (ten grains to the ounce of water) constitute the ordinary treatment.

In inflammations with copious discharge of creamy pus, and great swelling of the lids, the eyes should be washed out with the boric-acid solution every half hour, and a solution of silver nitrate (two grains to the ounce of water) dropped into the eye, once daily, followed immediately by a weak solution of common salt in water to neutralize the nitrate of silver, after its action has been secured. The constant use of ice cloths, already mentioned, forms a necessary adjunct to treatment. The sound eye must be protected from the chance of contagion, arising from a possible infection from the pus discharging from its mate. This may be secured by bandaging the well eye, or, better, by covering it with a watch crystal kept in place by surgeon's plaster.

In treating sore eyes with discharge, in babies, the infant should be held in the lap with its head backward and inclined toward the side of the sore eye, so that in washing the eye no discharge will flow into the sound eye. The boric acid may then be dropped from a medicine dropper, or applied upon a little wad of absorbent cotton, to the inner corner of the eye, while the eyelids are held apart.

Hemorrhages occurring under the conjunctiva (or membrane lining the inner surface of the lids and covering the front surface of the eyeball) may be caused by blows or other injury to the eye, by violent coughing, by straining, etc. Dark-red spots may appear in the white of the eyeball, slightly raised above the surface, which are little blood clots under the conjunctival membrane. No special trouble results and there is nothing to be done except to wait till the blood is absorbed, which will happen in time. If the eyes water, solution of zinc sulphate (one grain to the ounce of water) may be dropped into the eye, twice daily. Hot applications are beneficial here to promote absorption of the clot.

EYE-STRAIN.—Eye-strain is commonly due to either astigmatism, nearsightedness, farsightedness, or weakness of the eye muscles. The farsighted eye is one in which parallel rays entering the eye, as from a distance, come to a focus behind the retina. The retina is the sensitive area for receiving light impressions in the back of the eyeball. Sight is really a brain function; one sees with the brain, since the optic nerve endings in the back of the eye merely carry light impressions to the brain where they are properly interpreted.

In order that vision be clear and perfect, it is essential that the rays of light entering the eye be bent so that they strike the retina as a single point. In the farsighted or hyperopic eye, the eyeball is usually too short for the rays to be properly focused on the sensitive nerve area in the back of the eye.

This defect in vision is, however, overcome by the act of "accommodation." There is a beautiful transparent, double-convex body, about one-third of an inch thick, which looks very much like an ordinary glass lens, and is situated in the eye just back of the pupil. This is what is known as the crystalline lens, and the rays of light are bent in passing through it so as to be properly focused on the retina.

The foregoing statements have been made as though objects were always at a distance from the eye, so that the rays of light coming from them were almost parallel. Yet when one is looking at an object within a few inches of the eye the rays diverge or spread out, and these the normal eye (if rigid) could not focus on the retina—much less the farsighted eye. But the eye is adaptable to change of focus through the action of a certain muscle, situated within the eyeball about the lens, which controls to a considerable extent the shape of the lens. When the muscle contracts it allows the lens to bulge forward by virtue of its elasticity, and, therefore, become more convex. This is what happens when one looks at near objects, the increased convexity of the lens bending the rays of light so that they will focus as a point on the retina. (See Plate I, p. 30.)

Now in the farsighted eye this muscular control or "accommodative action" must be continually exercised even in looking at distant objects, and it is this constant attempt of nature to cure an optical defect of the eye which frequently leads to nervous exhaustion or eye-strain. The nerve centers, which animate and control the nerves supplying the eye muscles to which we have just alluded, are in close proximity to other most important nerve centers in the brain, so irritation of the eye centers will produce sympathetic irritation of these other centers, leading to manifold and complex symptoms which we will describe under this head. But these symptoms do not necessarily develop in everyone having farsightedness or astigmatism, since both are often present at birth.

The power of accommodation is sufficient to overcome the optical defect of the eye, providing that the general health is good and the eye is not used much for near work. If, on the other hand, excessive use of the eyes in reading, writing, figuring, sewing, or other fine work is required, and especially if the health becomes impaired, it happens that the constant drain on the eye center in the brain will result in a group of symptoms which we will consider later. Failure of accommodation comes on at about forty, and gradually increases until all accommodation is lost at the age of seventy-five.

For this reason it is necessary for persons over forty-five years of age, having normal or farsighted eyes, to wear convex glasses in reading or doing near work, and these should be changed for stronger ones every year or two. These convex glasses save the eyes in their attempt to make the lens more convex when looking at near objects in farsightedness, and also prove serviceable in the same manner when accommodation begins to fail in the case of what is called "old sight." The neglect to provide proper glasses for reading any time after the age of forty-five, and the failure to replace them by stronger lenses when required, distinctly favor the occurrence of cataract in later life.

In the act of accommodation, in addition to the muscular action by which the lens is made more convex, there is the tendency for the action of another group of muscles outside the eyeball, which turn the eyes inward when they are directed toward a near object. Here then is another source of trouble resulting from farsightedness, i. e., the not infrequent occurrence of inward "squint" occasioned by the constant use of the muscles pulling the eyes inward during accommodation for near objects. Again, inflammation of the eyelids, and sometimes of deeper parts of the eyeball, follows untreated hyperopia. Early distaste for reading is often acquired by farsighted persons, owing to the strain on the accommodative apparatus. The convex lens is that used to correct farsightedness.

NEARSIGHTED EYE.—In the nearsighted eye the eyeball is too long for parallel rays entering the eye to be focused upon the retina; they are bent, instead, to a point in front of the retina, and then diverge making the vision blurred. (Plate I, p. 30.) The act of accommodation in making the lens more convex will not aid this condition, but only make it worse, so that it is not attempted.

Eye-strain in this optical defect is brought on by constant use of the eye muscles (attached to the outside of the eyeball) in directing both eyes inward so that they will both center on near objects; the only ones which can be seen. Outward squint frequently results, because the muscular efforts required to direct both eyes equally inward to see near objects are so great that the use of both eyes together is given up, and the poorer eye is not used and squints outward, while the better eye is turned inward in the endeavor to see. Nearsighted persons are apt to stoop, owing to the habitual necessity for coming close to the object looked at. Their facial expression is also likely to be rather vacant, since they do not distinctly see, and do not respond to the facial movements of others.

Nearsightedness, or myopia, is not a congenital defect, but is usually acquired owing to excessive near work which requires that the eye muscles constantly direct both eyes inward to see near objects. In so acting the muscles compress the sides of the eyeballs and tend to increase their length, interfere with their nutrition, and aggravate the condition when it is once begun. (See Diagram.) Concave lenses are used to correct myopia, and they must be worn all the time.

ASTIGMATISM.—This is a condition caused by inequality of the outer surface of the front of the eyeball, and rarely by a similar defect in the surfaces of the lens. The curvature of the eyeball in the astigmatic eye is greater in one meridian than in the opposite. In other words, the front of the eyeball is not regularly spherical, but bulges out along a certain line or meridian, while the curvature is flattened or normal in the other meridian. For instance, if two imaginary lines were drawn, one vertically, and the other horizontally across the front of the eyeball intersecting in the center of the pupil, they would represent the principal meridians, the vertical and the horizontal. As a rule the meridian of greatest curvature is approximately vertical, and that of least curvature is at right angles to it, or horizontal.

Rays of light in passing through the different meridians of the astigmatic eye are differently bent, so that in one of the principal meridians rays may focus perfectly on the retina, while in the other the rays may focus on a point behind the retinal field. In this case the eye is made farsighted or hyperopic in one meridian, and is normal in the other. Or again, the rays may be focused in front of the retina in one meridian, and directly on the retina in the other; this would be an example of nearsighted or myopic astigmatism. Farsightedness and nearsightedness are then both caused by astigmatism, although in this case not by the length of the eyeball, but by inequality in the curvature of the front part (cornea) of the eyeball. For example, in simple astigmatism one of the principal meridians is hyperopic (turning the rays so that they focus behind the retina) or myopic (bending the rays so that they focus in front of the retina), while the other meridian is normal. In mixed astigmatism, one of the principal meridians is myopic, the other hyperopic; in compound astigmatism the principal meridians are both myopic, or both hyperopic, but differ in degree; while in irregular astigmatism, rays of light passing through different parts of the outer surface of the eyeball are turned in so many various directions that they can never be brought to a perfect focus by glasses.

It is not by any means possible for a layman to be able always to inform himself that he is astigmatic, unless the defect is considerable. If a card, on which are heavy black lines of equal size and radiating from a common center like the spokes of a wheel, be placed on a wall in good light, it will appear to the astigmatic eye as if certain lines (which are in the faulty meridian of the eyeball) are much blurred, while the lines at right angles to these are clear and distinct. Each eye should be tested separately, the other being closed. The chart should be viewed from a distance as great as any part of it can be seen distinctly. All the lines on the test card should look equally black and clear to the normal eye.

Astigmatism is corrected by a cylindrical lens, which is in fact a segment of a solid cylinder of glass. The axis of the cylindrical lens should be at right angles to the defective meridian of the eye, in order to correct the astigmatism. Eye-strain is caused by astigmatism in the same manner that it is brought about in the simple farsighted eye, i. e., by constant strain on the ciliary muscle, which regulates the convexity of the crystalline lens. For it is possible for the inequalities of the front surface of the eyeball or of the lens to be offset or counterbalanced by change in the convexity of the lens produced by the action of this muscle, and it is conceivable that the axis of the lens may be tilted one way or another by the same agency, and for the same purpose. But, as we have already pointed out, this continual muscular action entails great strain on the nerve centers which animate the muscle, and if constant near work is requisite, or the health is impaired, the nervous exhaustion becomes apparent. The lesser degrees of astigmatism often give more trouble than the greater.

WEAKNESS OF THE EYE MUSCLES.—There are six muscles attached to the outside of the eyeball which pull it in various directions, and so enable each eye to be directed upon a common point, otherwise objects will appear double. Weakness of these muscles or insufficiency, especially of those required to direct the eyes inward for near work, may lead to symptoms of eye-strain. When reading, for example, the muscles which pull the eye inward soon grow tired and relax, allowing the opposing muscles to pull the eye outward so that the eyes are no longer directed toward a common point, and two images may be perceived or, more frequently, they become fused together producing a general blurring on the page. Then by a new effort of will the internal muscles pull the eyes into line again, only to have the performance repeated, all of which entails a great strain upon the nervous system, and may lead to permanent squint, as has been pointed out. In addition to these symptoms caused by weakness of the eye muscles—seeing double, blurred vision, and want of endurance for close work—there are others which are common to eye-strain in general, as headache, nausea, etc., described in the following paragraph.

Symptoms of Eye-strain.—Headache is the most frequent symptom. It may be about the eyes, but there is no special characteristic which will positively enable one to know an eye headache from that arising from other sources, although eye-strain is probably the most common cause of headache. The headache resulting from eye-strain may then be in the forehead, temples,[Pg 30]
[Pg 31] top or the back of the head, or limited to one side. It frequently takes the form of "sick headache" (p. 113). It is perhaps more apt to appear after any unusual use of the eyes in reading, writing, sewing, riding, shopping, or sight-seeing, and going to theaters and picture galleries, but this is not by any means invariably the case, as eye headache may appear without apparent cause.

Nausea and vomiting, with or without headache, nervousness, sleeplessness, and dizziness often accompany eye-strain. Sometimes there is weakness of the eyes, i. e., lack of endurance for eye work, twitching of the eyelids, weeping, styes, and inflammation of the lids. In view of the extreme frequency of eye-disorders which lead to eye-strain, it behooves people, in the words of an eminent medical writer, to recognize that "the subtle influence of eye-strain upon character is of enormous importance" inasmuch as "the disposition may be warped, injured, and wrecked," especially in the young. Some of the more serious nervous diseases, as nervous exhaustion, convulsions, hysteria, and St. Vitus's dance may be caused by the reflex irritation of the central nervous system following eye-strain.

Treatment of Eye-strain.—The essential treatment of eye-strain consists in the wearing of proper glasses. It should be a rule, without any exception, to consult only a regular and competent oculist, and never an optician, for the selection of glasses. It is as egregious a piece of folly to employ an optician to choose the glasses as it would be to seek an apothecary's advice in a general illness. Considerably more damage would probably accrue from following the optician's prescription than that of the apothecary, because nature would soon offset the effects of an inappropriate drug; but the damage to the eyes from wearing improper glasses would be lasting.

Properly to determine the optical error in astigmatic and farsighted eyes it is essential to place drops in the eye, which dilate the pupil and paralyze the muscles that control the convexity of the crystalline lens, and to use instruments and methods of examination, which can only be properly undertaken and interpreted by one with the general and special medical training possessed by an oculist.

The statement has been emphasized that farsighted and astigmatic persons, up to the age of forty-five or fifty, can sometimes overcome the optical defects in their eyes by exercise of the ciliary muscle which alters the shape of the lens, and, therefore, it would be impossible for an examiner to discover the fault without putting drops in the eye, which temporarily paralyze the ciliary muscles for from thirty-six to forty-eight hours, but otherwise do no harm. After the age of fifty it may be unnecessary to use drops, as the muscular power to alter the convexity of the lens is greatly diminished. Opticians are incompetent to employ these drops, as they may do great damage in certain conditions of the eye which can only be detected by a medical man specially trained for such work. Opticians are thus sure to be caught on one of the horns of a dilemma; either they do not use drops to paralyze the ciliary muscle, or, if they do employ the drops, they may do irreparable damage to the eye. Any abnormality connected with the vision, especially in children, should be a warning to consult an oculist. Squint, "cross-eye" (Strabismus), as has been stated, may often result from near- or far-sightedness, and it may be possible in young children to cure the squint by the use of glasses or even drops in the eye, whereas in later life it may be necessary to cut some of the muscles of the eyeball to correct the condition. It is a wise rule to subject every child to an oculist's examination before entering upon school life.

DEAFNESS.—Sudden deafness without apparent reason is more apt to result from an accumulation of wax than from any other cause. It is a very common ear disorder. The opening into the ear is about an inch long, or a little more, and is separated from that part of the ear within, which is known as the middle ear, by the eardrum membrane. The drum membrane is a thin, skinlike membrane stretched tightly across the bottom of the external opening in the ear or auditory canal, and shuts it off completely from the middle ear within, and in this way protects the middle ear from the entrance of germs, dust, and water, but only secondarily aids hearing. The obstruction caused by wax usually exists in about the middle of the auditory canal or opening in the ear, and only causes deafness when it completely blocks this passage.

The deafness is sudden because, owing to the accidental entrance of water, the wax quickly swells and chokes the canal; or, in attempts to relieve irritation in the ear, the finger or some other object is thrust into the opening in the ear (auditory canal) and presses the wax down on the ear drum. The obstruction in the ear is usually a mixture of waxy secretion from the canal, and little scales of dead skin which become matted together in unwise efforts at cleansing the ear by introducing a twisted towel or some other object into the ear passage and there turning it about; or it may occur owing to disease of the ear altering the character of the natural secretion. In the normal state, the purpose of the wax is, apparently, to repel insects and to glue together the little flakes of cast-off skin in the auditory canal, and these, catching on the hairs lining the canal, are thrown out of the ears upon the shoulders by the motion of the jaws in eating.

Nothing should be introduced into the ear with the idea of cleansing it, as the skin growing more rapidly from within tends naturally to push the dead portions out as required, and so the canal is self-cleansing.

Symptoms.—Sudden deafness in one ear usually calls the attention of the patient to an accumulation of wax. There is apt to be more or less wax in the other ear as well. Noises in the deaf ear and a feeling of pressure are also common. Among rarer symptoms are nausea and dizziness. But the only way to be sure that deafness is due to choking of the ear passage with wax is to see it. This is usually accomplished by a physician in the following way: he throws a good light from a mirror into a small tube introduced into the ear passage. This is, of course, impossible for laymen to do, but if the ear is drawn upward, backward, and outward, so as to straighten the canal, it may be possible for anyone to see a mass of yellowish-brown or blackish material filling the passage. And in any event, if the wax cannot be seen, one is justified in treating the case as if it were present, if sudden deafness has occurred and competent medical aid is unobtainable, since no harm will be done if wax is absent, and, if it is present, the escape of wax will usually give immediate relief from the deafness and other symptoms.

Treatment.—The wax is to be removed with a syringe and water as hot as can be comfortably borne. A hard-rubber syringe having a piston, and holding from two teaspoonfuls to two tablespoonfuls, is to be employed—the larger ones are better. The clothing should be protected from water by towels placed over the shoulder, and a basin is held under the ear to catch the water flowing out of the canal. The tip of the syringe is introduced just within the entrance of the ear, which is to be pulled backward and upward, and the stream of water directed with some force against the upper and back wall of the passage rather than directly down upon the wax. The water which is first returned is discolored, and then, on repeated syringing, little flakes of dry skin, with perhaps some wax adhering, may be seen floating on the top of the water which flows from the ear, and finally, after a longer or shorter period, a plug of wax becomes dislodged, and the whole trouble is over.

This is the rule, but sometimes the process is very long and tedious, only a little coming away at a time, and, rarely, dizziness and faintness will require the patient to lie down for a while. The water should always be removed from the ear after syringing by twisting a small wisp of absorbent cotton about the end of a small stick, as a toothpick, which has been dipped into water to make the cotton adhere. The tip of the toothpick, thus being thoroughly protected by dry cotton applied so tightly that there is no danger of it slipping off, while the ear is pulled backward and upward to straighten the canal, is gently pushed into the bottom of the canal and removed, and the process repeated with fresh cotton until it no longer returns moist. Finally a pledget of dry cotton should be loosely packed into the ear passage, and worn by the patient for twelve or twenty-four hours.

PERSISTENT AND CHRONIC DEAFNESS.—A consideration of deafness requires some understanding of the structure and relations of the ear with other parts of the body, notably the throat. It has been pointed out that the external ear—comprising the fleshy portion of the ear, or auricle, and the opening, or canal, about an inch long—is separated from that portion of the ear within (or middle ear) by the drum membrane. The middle ear, while protected from the outer air by the drum, is really a part of the upper air passages, and participates in disorders affecting them. It is the important part of the ear as it is the seat of most ear troubles, and disease of the middle ear not only endangers the hearing, but threatens life through proximity to the brain.

In the middle ear we have an air space connected with the throat by the Eustachian tube, a tube about an inch long running downward and forward to join the upper air passage at the junction of the back of the nose and upper part of the throat. If one should run the finger along the roof of the mouth and then hook it up behind and above the soft palate one could feel the openings of these tubes (one for each ear) on either side of the top of the throat or back of the nose, according to the view we take of it.

Then the middle ear is also connected with a cavity in the bone back of the ear (mastoid cavity or cells), and the outer and lower wall is formed by the drum membrane. Vibrations started by sound waves which strike the ear are connected by means of a chain of three little bones from the drum through the middle ear to the nervous apparatus in the internal ear. The head of one of these little bones may be seen by an expert, looking into the ear, pressing against the inside of the drum membrane. Stiffening or immovability of the joints between these little bones, from catarrh of the middle ear, is most important in producing permanent deafness. The middle ear space is lined with mucous membrane continuous with that of the throat through the Eustachian tube. This serves to drain mucus from the middle ear, and also to equalize the air pressure on the eardrum so that the pressure within the middle ear shall be the same as that without.

When there is catarrh or inflammation of the throat or nose it is apt to extend up the Eustachian tubes and involve the middle ear. In this way the tubes become choked and obstructed with the oversecretion or by swelling. The air in the middle ear then becomes absorbed in part, and a species of vacuum is produced with increased pressure from without on the eardrum. The drum membrane will be pressed in, and through the little bones pressure will be made against the sensitive nervous apparatus, irritating it and giving rise to deafness, dizziness, and the sensation of noises in the ear. Noises from without will also be intensified in passing through the middle ear when it is converted into a closed cavity through the blocking of the Eustachian tube.

A very important feature following obstruction of the Eustachian tubes, and rarefaction of the air in the middle ear, is that congestion of the blood vessels ensues and increased secretion, because the usual pressure of the air on the blood vessels within the middle ear is taken away.

This then is the cause of most permanent deafness, to which is given the name catarrhal deafness, because every fresh cold in the head, or sore throat, tends to start up trouble in the ear such as we have just described. Repeated attacks leave vestiges behind until permanent deafness remains. In normal conditions every act of swallowing opens the apertures of the Eustachian tubes in the throat, and allows of equalization of the air pressure within and without the eardrum, but if the nose is stopped up by a cold in the head, or enlargement of the tonsil at the back of the nose (as from adenoids, see p. 61), the process is reversed and air is exhausted from the Eustachian tubes with each swallowing motion.

The moral to be drawn from all the foregoing is to treat colds properly when they are present, keeping the nose and throat clean and clear of mucus, and to have any abnormal obstruction in the nose or throat and source of chronic catarrh removed, as enlarged tonsils, adenoids, and nasal outgrowths.

FOREIGN BODIES IN THE EAR.—Foreign bodies, as buttons, pebbles, beans, cherry stones, coffee, etc., are frequently placed in the ear by children, and insects sometimes find their way into the ear passage and create tremendous distress by their struggles. Smooth, nonirritating bodies, as buttons, pebbles, etc., do no particular harm for a long time, and may remain unnoticed for years. But the most serious damage not infrequently results from unskillful attempts at their removal by persons (even physicians unused to instrumental work on the ear) who are driven to immediate and violent action on the false supposition that instant interference is called for. Insects, it is true, should be killed without delay by dropping into the ear sweet oil, castor, linseed, or machine oil or glycerin, or even water, if the others are not at hand, and then the insect should be removed in half an hour by syringing as recommended for wax (p. 35).

To remove solid bodies, turn the ear containing the body, downward, pull it outward and backward, and rub the skin just in front of the opening into the ear with the other hand, and the object may fall out.

Failing in this, syringing with warm water, as for removal of wax, while the patient is sitting, may prove successful. The essentials of treatment then consist, first, in keeping cool; then in killing insects by dropping oil or water into the ear, and, if syringing proves ineffective, in using no instrumental methods in an attempt to remove the foreign body, but in awaiting such time as skilled medical services can be obtained. If beans or seeds are not washed out by syringing, the water may cause them to swell and produce pain. To obviate this, drop glycerin in the ear which absorbs water, and will thus shrivel the seed.

EARACHE.—Earache is due usually not to neuralgia of the ear, but to a true inflammation of the middle ear, which either subsides or results in the accumulation of inflammatory products until the drum is ruptured and discharge occurs from the external canal. The trouble commonly originates from an extension of catarrhal disease of the nose or throat; the germs which are responsible for these disorders finding their way into the Eustachian tubes, and thus into the middle ear. Any source of chronic catarrh of the nose or throat, as enlarged and diseased tonsils, adenoids in children, or nasal obstruction, favor the growth of germs and the occurrence of frequent attacks of acute catarrh or "colds." The grippe has been the most fruitful cause of middle-ear inflammation and earache in recent years. Any act which forces up fluid or secretions from the back of the nose into the Eustachian tubes (see section on Deafness) and thus into the middle ear, is apt to set up inflammation there, either through the introduction of germs, or owing to the mechanical injury sustained. Thus the use of the nasal douche, the act of sniffing water into the nose, or blowing the nose violently when there is secretion or fluid in the back of the nose, or the employment of the post-nasal syringe are one and all attended with this danger. Swimming on the back, diving, or surf bathing also endangers the ear, as cold water is forcibly driven not only into the external auditory canal, but, what is more frequently a source of damage, into the Eustachian tubes through the medium of the nose or throat. In this case the plugging of the nose with cotton would be of more value than the external canal, as is commonly practiced. If water has entered the Eustachian tube, blowing the nose and choking merely aggravate the trouble. The wiser plan is to do nothing but trust that the water will drain out, and if pain ensues treat it as recommended below for earache.

Water in the ears is sometimes removed by jumping about on one foot with the troublesome ear held downward, and if it is in the external canal it may be wiped out gently with cotton on the end of a match, as recommended in the article on treating wax in the ear (see p. 35). In the treatment of catarrh in the nose or throat only a spray from an atomizer should be used, as Dobell's or Seiler's solutions followed by menthol and camphor, twenty grains of each to the ounce of alboline or liquid vaseline.[1]

Exposure to cold and the common eruptive diseases of children, as scarlet fever, measles, and also diphtheria, are common causes of middle-ear inflammation. In the latter disorders the protection afforded by a nightcap which comes down over the ears, and worn constantly during the illness, is frequently sufficient to ward off ear complications.

Although earache or middle-ear inflammation is common, its dangers are not fully appreciated, since the various complications are likely to arise, and the result is not rarely serious. Extension of the inflammation to the bone behind the ear may necessitate chiseling away a part of the skull to liberate pus or dead bone in this locality, and the occurrence of abscess of the brain will necessitate operation.

The use of leeches in the beginning of the attack is of great value, and though unpleasant are not difficult or painful in their application. One should be applied just in front of the opening into the ear (which should be previously closed with cotton to prevent the entrance of the leech), and the other behind the ear in the crease where it joins the side of the head and at a point a little below the level of the external opening into the ear. A drop of milk on these spots will often start the leeches immediately at work, or a drop of blood obtained with a pin prick. When the leeches are gorged with blood and cease to suck, they should be removed and bleeding encouraged for half an hour with applications of absorbent cotton dipped in hot water. Then clean, dry absorbent cotton is applied, and pressure made on the wounds if bleeding does not soon stop or is excessive.

The after treatment of the bites consists in cleanliness and the use of vaseline. The patient must stay in bed, and the hot-water bag be constantly kept on the ear till all pain ceases. If the drum perforates, a discharge will usually appear from the external ear. Then the canal must be cleansed, once or more daily, by injecting very gently into the ear a solution of boric acid (as much of boric acid as the water will dissolve), following this by wiping the water out of the canal with sterilized cotton, as directed for the treatment of wax in the ear (p. 35).

The syringing is permissible only once daily, unless the discharge is copious, but the canal may be wiped out in this manner several times a day with dry cotton. It is well to keep the opening into the ear greased with vaseline, and a plug of clean absorbent cotton loosely packed into the canal to keep out the cold. Excessive or too forcible syringing may bring about that complication most to be feared, although it may appear through no fault in care, i. e., an implication of the cavity in the bone back of the ear (mastoid disease). Germs find their way through the connecting passage by which this cavity is in touch with the middle ear, or may be forced in by violent syringing. When this happens, earache, or pain just back of the ear, commonly returns during the first or second week after the first attack, and tenderness may be observed on pressing on the bone just back of the ear close to the canal. Fever, and local redness and swelling of the parts over the bone in this region may also occur. Confinement to bed, and constant application of a rubber bag containing cracked ice, to the painful parts must be enforced. If the tenderness on pressure over the bone and pain do not subside within twenty-four to forty-eight hours, surgical assistance must be obtained at any cost, or a fatal result may ensue. The opening in the drum membrane, caused by escape of discharge in the course of middle-ear inflammation, usually closes, but even if it does not deafness is not a necessary sequence.

The eardrum is not absolutely essential to hearing, but it is of great importance to exclude sources of irritation, dust, water, and germs which are likely to set up middle-ear trouble. More ordinary after-effects are chronic discharge from the ear following acute inflammation and perforation of the eardrum, which may mean at any time a sudden return of pain with the occurrence of the more dangerous conditions just recited, together with deafness. Bearing all this in mind it is advisable never to neglect a severe or persistent earache, but to call in expert attention. When this is not obtainable the treatment outlined below should be carefully followed.

Symptoms.—Pain is severe and often excruciating in adults. It may be felt over the temple, side and back of the head and neck, and even in the lower teeth, as well as in the ear itself. The pain is increased by blowing the nose, sneezing, coughing, and stooping. There is considerable tenderness usually on pressing on the skin in front of the ear passage. In infants there may be little evidence of pain in the ear. They are apt to be very fretful, refuse food, cry out in sleep, often lie with the affected ear resting on the hand, and show tenderness on pressure immediately in front or behind the ear passage.

[Pg 46]
[Pg 47]Dullness, fever, chills, and convulsions are not uncommon in children, but, on the other hand, after some slight illness it is not infrequent for discharge from the ear to be the first sign which calls the attention of parent or medical attendant to the source of the trouble. For this reason the careful physician always examines the ear in doubtful cases of children's diseases. Unless the inflammation subsides with treatment, either a thin, watery fluid (serum) is formed in the middle ear, or pus, when we have an "abscess of the ear." The drum if left to itself breaks down in three to five days, or much sooner in children who possess a thinner membrane. A discharge then appears in the canal of the external ear, and the pain is relieved. It may occasionally happen that the Eustachian tube drains away the discharge, or that the discharge from the drum is so slight that it is not perceived, and recovery ensues. Discharge from the ear continues for a few weeks, and then the hole in the drum closes and the trouble ceases. This is the history in favorable cases, but unfortunately, as we have indicated, the opposite state of affairs results not infrequently, especially in neglected patients.

Treatment.—The patient with severe earache should go to bed and take a cathartic to move the bowels. He should lie all the time with the painful ear on a rubber bag containing water as hot as can be comfortably borne. Every two hours a jet of hot water, which has been boiled and cooled just sufficiently to permit of its use, is allowed to flow gently from a fountain syringe into the ear for ten minutes, and then the ear is dried with cotton, as described under the treatment of wax in the ear (p. 35). No other "drops" of any kind are admissible for use in the ear, and even this treatment is of less importance than the dry heat from the hot-water bag, and may be omitted altogether if the appliances and skill to dry the ear are lacking. Ten drops of laudanum[2] for an adult, or a teaspoonful of paregoric for a child six years old, may be given by the mouth to relieve the pain. The temperature of the room should be even and the food soft.

If the pain continues it is wiser to have an aurist lance the drum, to avoid complications, than to wait for the drum membrane to break open spontaneously in his absence. Loss or damage of the eardrums may call for "artificial eardrums." They do not act at all like the drumhead of the musical instrument by their vibrations, but only are of service in putting on the stretch the little bones in the middle ear which convey sound. Some of those advertised do harm by setting up a mechanical irritation in the ear after a time, and a better result is often obtained with a ball of cotton or a paper disc introduced into the ear by an aurist.

ANATOMY OF THE EAR

The illustration on the opposite page shows the interior structure of the ear. The concha and Meatus, or canal, comprise the external ear, which is separated from the middle ear by the Drum Membrane. Wax is secreted by glands located in the lining of the meatus, and should be detached by the motion of the jaws during talking and eating. If it adheres to the drum membrane it causes partial deafness.

The internal ear, or labyrinth, a cavity in the bone, back of the middle ear, consists of three parts: the Cochlea, the Semicircular Canals, and a middle portion, the Vestibule. The middle ear is connected with the throat by the Eustachian Tube.

Sound vibrations, which strike the drum membrane, are conveyed by means of a chain of three small bones through the middle ear to the nervous apparatus of the internal ear. The Eustachian tube and middle ear are lined throughout with mucous membrane, and any severe inflammation of the throat may extend to and involve the tube and the middle ear, causing deafness.

CHAPTER II

The Nose and Throat

Cold in the Head—Mouth-Breathing—Toothache—Sore Mouth—Treatment of Tonsilitis—Quinsy—Diphtheria.

NOSEBLEED.—Nosebleed is caused by blows or falls, or more frequently by picking and violently blowing the nose. The cartilage of the nasal septum, or partition which divides the two nostrils, very often becomes sore in spots, owing to irritation of dust-laden air, and these crust over and lead to itching. Then "picking the nose" removes the crusts, and frequent nosebleed results. Nosebleed also is common in both full-blooded and anÆmic persons; in the former because of the high pressure within the blood vessels, in the latter owing to the thin walls of the arteries and capillaries which readily rupture.

Nosebleed is again an accompaniment of certain general disorders, as heart disease and typhoid fever. The bleeding comes usually from one nostril only, and is a general oozing from the mucous membrane, or more commonly flows from one spot on the septum near the nostril, the cause of which we have just noted. The blood may spout forth in a stream, as after a blow, or trickle away drop by drop, but is rarely dangerous except in infants and aged persons with weak blood vessels. In the case of the latter the occurrence of bleeding from the nose is thought to indicate brittle vessels and a tendency to apoplexy, which may be averted by the nosebleed. This is uncertain. If nosebleed comes on at night during sleep, the blood may flow into the stomach without the patient's knowledge, and on being vomited may suggest bleeding from the stomach.

Treatment.—The avoidance of excitement and of blowing the nose, hawking, and coughing will assist recovery. The patient should sit quietly with head erect, unless there is pallor and faintness, when he may lie down on the side with the head held forward so that the blood will flow out of the nose. There is no cause for alarm in most cases, because the more blood lost the more readily does the remainder clot and stop bleeding. As the blood generally comes from the lower part of the partition separating the nostrils, the finger should be introduced into the bleeding nostril and pressure made against this point, or the whole lower part of the nose may be simply compressed between the thumb and forefinger. If this does not suffice a lump of ice may be held against the side of the bleeding nostril, and another placed in the mouth. The injection into the nostril of ice water containing a little salt is sometimes very serviceable in stopping nosebleed. Blowing the nose must be avoided for some time after the bleeding ceases.If none of these methods arrest the bleeding the nostril must be plugged. A piece of clean cotton cloth, about five inches square, should be pushed gently but firmly into the nostril with a slender cylinder of wood about as large as a slate pencil and blunt on the end. This substitute for a probe is pressed against the center of the cloth, which folds about the stick like a closed umbrella, and the cotton is pressed into the nostril in a backward and slightly downward direction, for two or three inches, while the head is held erect. Then pledgets of cotton wool are packed into the bag formed by the cotton cloth after the stick is withdrawn. The mouth of the bag is left projecting slightly from the nostril, so that the whole can be withdrawn in twenty-four hours.

The bleeding nostril may be more readily plugged by simply pressing into it little pledgets of cotton with a slender stick, but it would be impossible for an unskilled person to get them out again, and a physician should withdraw them inside of forty-eight hours.

FOREIGN BODIES IN THE NOSE.—Children often put foreign bodies in their nose, as shoe buttons, beans, and pebbles. They may not tell of it, and the most conspicuous symptoms are the appearance of a thick discharge from one nostril, having a bad odor, and some obstruction to breathing on the same side. If the foreign body can be seen, the nostril on the unobstructed side should be closed and the child made to blow out of the other one. If blowing does not remove[Pg 54]
[Pg 55] the body it is best to secure medical aid very speedily.

COLD IN THE HEAD FROM OVERHEATING.—Chilling of the surface of the body favors the occurrence of colds, in which lowered bodily vitality allows the growth of certain germs always present upon the mucous membrane lining the cavities of the nose. Dust and irritating vapors also predispose to colds. Overwarm clothing makes a person susceptible to colds, while the daily use of cold baths is an effective preventive. There is no sufficient reason for dressing more warmly in a heated house in winter than one would dress in summer. It is, moreover, unwise to cover the chest more heavily than the rest of the body. Some one has wisely said: "The best place for a chest protector is on the soles of the feet." The rule should always be to keep the feet dry and warm, and adapt the clothing to the surrounding temperature. Among the germs which cause colds in the head, that of pneumonia is the one commonly found in the discharge from the nose. When pneumonia is epidemic it is therefore wise to take extra precautions to avoid colds, and care for them when they occur.

The presence of chronic trouble in the throat and nose, such as described under Mouth-Breathing, Adenoids, etc. (p. 60), is perhaps the most frequent cause of colds, because the natural resistance of the healthy mucous membrane to the attack of germs is diminished thereby, and the catarrhal secretions form a source of food for the germs to grow upon. It should also be kept in mind that cold in the head is the first sign of measles and of grippe. Colds are more common in the spring and fall.

Symptoms.—Colds begin with chilliness and sneezing, and, if severe, there may be also headache, fever, and pain in the back and limbs, as in grippe. The nose at first feels dry, but soon becomes more or less stopped with secretion. The catarrh may extend from the back of the nose through the Eustachian tube to the ear, causing earache, noises in the ear, and deafness (see p. 41). This unfortunate result may be averted by proper spraying of the nose, and avoidance of blowing the nose violently.

Treatment.—Treatment must be begun at the first suspicion of an attack to be of much service. The bowels should be opened with calomel or other cathartic; two-fifths of a grain for an adult, half a grain for a child. Rest in bed for a day or two, after taking a hot bath and a glass of hot lemonade containing a tablespoonful or two of whisky, is the most valuable treatment. The Turkish bath is also very efficacious in cutting short colds, but involves great risk of increasing the trouble unless the patient can return home in a closed carriage directly from the bath. Of the numerous remedies which are commonly used to arrest colds in the first stages are two which possess special virtue; namely, quinine and Dover's powder, given in single dose of ten grains of each for an adult. Both of these remedies may be taken, but while the Dover's powder is most effective it is often necessary for the patient to remain in bed twelve to eighteen hours after taking it on account of nausea and faintness which would be produced if the patient were up and moving about. Rhinitis tablets should never be used. They are generally abused, and, indeed, some fatal cases are on record in which they caused death. Drugs are of little value except in the beginning of a cold, when they are given with the hope of cutting short an attack.

The local applications of remedies to the inflamed region is of service. At the onset of the cold, Seiler's solution (conveniently made from tablets which are sold in the shops) or Dobell's solution should be sprayed from an atomizer, into the nostrils, every half hour, and, when the discharge becomes thick and copious, this is to be discarded for a spray consisting of alboline (four ounces) and camphor and menthol (each thirty grains), used in the same manner as long as the cold lasts. Containing bottles should be stood in hot water, in order that all sprays for the nostrils may be used warm.

It is well to give babies a teaspoonful of castor oil and a warm bath, and keep them in bed. If there is fever with the cold, five drops of sweet spirit of niter may be given in a teaspoonful of sweetened water every two hours. Liquid vaseline, or the alboline mixture advised for adults, may be dropped into the nostrils with a medicine dropper more conveniently than applied by spray.

TOOTHACHE.—When there is a cavity in an aching tooth it should be cleaned of food, and a little pledget of cotton wool wrapped on a toothpick may be used to wipe the cavity dry. Then the cavity should be loosely packed, by means of a toothpick or one prong of a hairpin, with a small piece of absorbent cotton rolled between the fingers and saturated with one of the following substances, preferably the first: oil of cloves, wood creosote or chloroform.

If wood creosote is used the cotton must be well squeezed to get rid of the excess of fluid, as it is poisonous if swallowed, and will burn the gum and mouth if allowed to overflow from the tooth.

ALVEOLAR ABSCESS (improperly called "Ulcerated Tooth").—An "ulcerated tooth" begins as an inflammation in the socket of a tooth, and, if near its deepest part, causes great pain, owing to the fact that the pus formed can neither escape nor expand the unyielding bony wall of the socket.

This explains why an abscess near the tooth is so much more painful than a similar one of soft parts. There may be no cavity in the tooth, but the tooth is commonly dead, or its nerve is dying, and the tooth is frequently darker in color. It often happens that threatened abscess at the root of a tooth, which has been filled, can be averted by a dentist's boring down into the root of the tooth, or removing the filling. It is not always possible to locate the troublesome tooth, from the pain, but by tapping on the various teeth in turn with a knife, or other metal instrument, special soreness will be discovered in the "ulcerated" tooth. The ulcerated tooth frequently projects beyond its fellows, and so gives pain when the jaws are brought together in biting.

Treatment.—The treatment for threatened abscess near a tooth consists in painting tincture of iodine, with a camel's hair brush, upon the gum at the root of the painful tooth, and applying, every hour or so, over the same spot a toothache plaster (sold by all druggists). The gum must be wiped dry before applying the moistened toothache plaster. Water, as hot as can be borne, should be held in the mouth, and the process repeated for as long a time as possible. Then the patient should lie with the painful side of the face upon a hot-water bag or bottle. The trouble may subside under this treatment, owing to disappearance of the inflammation, or to the unnoticed escape of a small amount of pus through a minute opening in the gum. If the inflammation continues the pain becomes intense and throbbing; there is often entire loss of sleep and rest, fever, and even chills, owing to a certain degree of blood poisoning. The gum and face swell on the painful side, and the patient often suffers more than with many more serious diseases.

After several days of distress, the bony socket of the tooth gives way, and the pus makes its exit, and, bulging out the gum, finally escapes through this also, to the immediate relief of the patient. But serious results sometimes follow letting nature alone in such a case, as the pus from an eyetooth may burrow its way into the internal parts of the upper jaw, or into the chambers of the nose, while that from a back tooth often breaks through the skin on the face, leaving an ugly scar, or, if in the lower jaw, the pus may find its way between the muscles of the neck, and not come to the surface till it escapes through the skin above the collar bone. Pulling the tooth is the most effective way of relieving the condition, the only objection being the loss of the tooth, which is to be avoided if possible.

If the pain is bearable and there are no chills and fever, the patient may save the tooth by remaining in bed with a hot-water bottle continually on the face, and taking ten drops of laudanum to relieve the pain at intervals of several hours. Then many hours of suffering may be prevented if the gum is lanced with a sharp knife (previously boiled for five minutes) as soon as the gum becomes swollen, to allow of the escape of pus. The dentist is, of course, the proper person to consult in all cases of toothache, and the means herein suggested are to be followed only when it is impossible to obtain his services.

MOUTH-BREATHING (including Adenoids, Chronic Tonsilitis, Deviation of the Nasal Septum, Enlarged Turbinates, and Polypi).—Any obstruction in the nose causes mouth-breathing and gives rise to one or more of a long train of unfortunate results. Among the disorders producing mouth-breathing, enlargement of the glandular tissue in the back of the nose and in the throat of children is most important. Glandular growths in the upper part of the throat opposite the back of the nasal cavities are known as "adenoids"; they often completely block the air passage at this point, so that breathing through the nose becomes difficult. Associated with this condition we usually see enlargement of the tonsils, two projecting bodies, one on either side of the entrance to the throat at the back of the mouth. In healthy adult throats the tonsils should be hardly visible; in children they are active glands and easily visible.

We are unable to see adenoids because of their position, but can be reasonably sure of their presence in children where we find symptoms resulting from mouth-breathing as described below. The surgeon assures himself positively of the existence of adenoids by inserting a finger into the mouth of the patient and hooking it up back of the roof of the mouth, when they may be felt as a soft mass filling the back of the nose passages.

Other less common causes of mouth-breathing, seen in adults as well as children, are deviation of the nasal septum, swelling of the mucous membrane covering certain bones in the nose (turbinates), and polypi.

Deviation of the nasal septum means displacement of the partition dividing the two nostrils, so that more or less obstruction exists. This condition may be occasioned by blows on the nose received in the accidents common to childhood. The deformity which results leads in time to further obstruction in the nose, because when air is drawn in through the narrowed passages a certain degree of vacuum is produced and suction on the walls of the nose, as would occur if we drew in air from a large pair of bellows through a small thin rubber tube. This induces an overfilling of the blood vessels in the walls of the passages of the nose, and the continued congestion is followed by increased thickness of the lining mucous membrane, thus still further obstructing the entrance of air. A one-sided nasal obstruction in a child with discharge from that side leads one to suspect that a foreign body, as a shoe button, has been put in by the child.

Polypi are small pear-shaped growths which form on the membrane lining the nasal passages and sometimes completely block them. They resemble small grapes without skins.

These, then, are the usual causes of mouth-breathing, but of most importance, on account of their frequency and bearing on the health and development, are adenoids and enlarged throat tonsils in children. Adenoids and enlarged tonsils are often due to inflammation of these glands during the course of the contagious eruptive disorders, as scarlet fever, measles, or diphtheria; probably, also, to constant exposure to a germ-laden atmosphere, as in the case of children herded together in tenements.

Symptoms.—The mouth-breathing is more noticeable during sleep; snoring is common, and the breathing is of a snorting character with prolonged pauses. Children suffering from enlarged tonsils and adenoids are often backward in their studies, look dull, stupid, and even idiotic, and are often cross and sullen; the mouth remains open, and the lower lip is rolled down and prominent; the nose has a pinched aspect, and the roof of the mouth is high. Air drawn into the lungs should be first warmed and moistened by passing through the nose, but when inspired through the mouth, produces so much irritation of the throat and air passages that constant "colds," chronic catarrh of the throat, laryngitis, and bronchitis ensue.

The constant irritation of the throat occurring in mouth-breathers weakens the natural resistance against such diseases as acute tonsilitis, scarlet fever, and diphtheria, so that they are especially subject to these diseases. But these are not the only ailments to which the mouth-breather is liable, for earache and deafness naturally follow the catarrh, owing to obstruction of the Eustachian tubes (see Earache, p. 40, and Deafness, p. 38). Deformity of the chest is another result of obstruction to nose-breathing, the common form being the "pigeon breast," where the breastbone is unduly prominent. The voice is altered so that the patient, as the saying goes, "talks through the nose," although, in reality, nasal resonance is reduced and difficulty is experienced in pronouncing N and M correctly, while stuttering is not uncommon. Nasal obstruction leads to poor nutrition, and hence children with adenoids and enlarged tonsils are apt to be puny and weakly specimens.

Treatment.—The treatment is purely surgical in all cases of nasal obstruction: removal of the adenoid growths, enlarged tonsils, and polypi, straightening the displaced nasal septum, and burning the thickened mucous lining obstructing the air passages in the nose. None of the operations are dangerous if skillfully performed, and should be generally done, even in the case of delicate children, as the very means of overcoming this delicacy. The after treatment is not unimportant, consisting in the use of simple generous diet, as plenty of milk, bread and butter, green vegetables and fresh meat, and the avoidance of pastries, sweets, fried food, pork, salt fish and salt meats, also the roots, as parsnips, turnips, carrots and beets, and tea and coffee. Life in the open air, emulsion of cod-liver oil, daily sponging with cold water while the patient stands in warm water, followed by vigorous rubbing, will all assist the return to health.

SORE MOUTH; INFLAMMATION OF THE MOUTH.—There are various forms of inflammation of the mouth, generally dependent upon the entrance of germs, associated with indigestion or general weakness following some fever or other disease. Unclean nipples of the mother or of the bottle, or unclean bottles, allow entrance of germs, and are frequent causes. Irritation of a sharp tooth, or from rubbing the gum, or from too vigorous cleansing of the mouth, may start the disease. Some chemicals, especially mercury improperly prescribed, produce the disease. The germs may gain admission in impure milk in some cases. Inflammation of the mouth is essentially a children's disease, only the ulcerated form being common in adults.

Symptoms.—In general, the mouth is hot, very red, dry, and tender; the child is fretful and has difficulty in nursing, often dropping the nipple and crying; the tongue is coated, and there may be fever and symptoms of indigestion, as vomiting; sometimes the disease occurs during the course of fevers; later in the course of the disorder the saliva often runs freely from the mouth.

Simple Form.—In this there are only redness, swelling, and tenderness of the inside of the mouth. The tongue is at first dry and white, but the white coating comes off, leaving it red in patches. After a while the saliva becomes profuse. The treatment consists in washing the mouth often in ice water containing about one-half drachm of boric acid to four ounces of water by means of cotton tied on a stick, and holding lumps of ice in the mouth wrapped in the corner of a handkerchief. It is well also to give a teaspoonful of castor oil.Aphthous Form.—In this there are yellow-white spots, resulting in little shallow depressions or ulcers, on the inside of the cheeks and lips, and on the tongue and roof of the mouth. These occur in crops and last from ten to fourteen days. The disease is often preceded by vomiting, constipation, and fever, with pain in the mouth and throat, and is accompanied by lumps or swelling of the glands under the jaw and in the neck. The treatment consists in the use of castor oil, and swabbing the mouth, several times a day, after each feeding, with boric-acid solution, as advised before, or better with permanganate of potash solution, using ten grains to the cup of water.

Thrush (Sprue).—This form is due to the growth of a special fungus in the mouth, causing the appearance of white spots on the inside of the cheeks, lips, tongue, and roof of the mouth, looking like flakes of curdled milk, but not easily removed. There are also symptoms of indigestion, as vomiting, diarrhea, and colic. The disease is contagious, and is due to some uncleanliness, often of the bottles, nipples, or milk. Sometimes ulcers or sore depressions are left in the mouth, and in weak children, in which the disease is apt to occur, the result may be serious, and a physician's services are demanded. The treatment consists in applying saleratus and water (one teaspoonful in a cup of water) to the whole inside of the mouth, between feedings, with a camel's-hair brush or with a soft cloth. A dose of castor oil is also desirable, and great care as regards cleanliness of the bottles and nipples should be exercised.

Ulcerous Form.—This does not occur in children under five, but may attack persons of all greater ages. It is often seen following measles and scarlet fever, and in the poor and ill nourished, and after the unwise use of calomel. There are redness and swelling of the gum about the base of the lower front teeth, and the gums bleed easily. Matter, or pus, forms between the teeth and the gum, and the mouth has a foul odor. The gum on the whole lower jaw may become inflamed, and a yellow band of ulceration may appear along the gums. The glands under the jaw and in the neck are enlarged, feeling like tender lumps, and saliva flows freely. In severe cases the gums may become destroyed and eaten away by the ulceration, and the bone of the jaw be diseased and exposed. As in the graver cases it may become necessary to remove dead bone and teeth, and the very dangerous form next described may sometimes follow it, it will be seen that it is a disease requiring skilled medical attention. The treatment consists in using, as a mouth wash and gargle, a solution of chlorate of potash (fifteen grains to the ounce) every two hours. Cases usually last at least a week.

Gangrenous Form.—This is a rare and fatal form of inflammation of the mouth and occurs in children weak and debilitated from other diseases, as from the contagious eruptive fevers, chronic diarrhea, and scurvy. It is seen more often in hospitals and is contagious. A foul odor is noticed about the mouth, in which will be seen an ulcer on the gum or inside of the cheek. The cheek swells tremendously, with or without pain, and becomes variously discolored—red, purple, black. The larger proportion of patients die of exhaustion and blood poisoning within one to three weeks, and the only hope is through surgical interference at the earliest possible moment.

CANKER.—A small, shallow, yellow ulcer, appearing on the inside of the lips or beneath the tongue during some disorder of the digestion. It is very tender when touched and renders chewing or talking somewhat painful. Treatment consists of touching the ulcer carefully with the point of a wooden toothpick which has been dipped in pure carbolic acid (a poison) and then rinsing the resulting white spot and the whole mouth very carefully, so as not to swallow any of the acid.

Inflammation of the mouth occurs in two other general diseases, in syphilis and rarely in diphtheria. In children born of syphilitic parents, deep cracks often appear at either side of the mouth and do not heal as readily as ordinary sores, but continue a long time, and eventually leave deep scars. In diphtheria the membrane which covers the tonsils sometimes spreads to the cheeks, tongue, and lips, but in either case the general symptoms will serve to distinguish the diseases, and neither can be treated by the layman.

MILD SORE THROAT (Acute Pharyngitis).—The milder sore throat is commonly the beginning of an ordinary cold, although sometimes it is caused by digestive disorders. Exposure to cold and wet is, however, the most frequent source of this form of sore throat. Soreness, dryness, and tickling first call attention to the trouble, together with a feeling of chilliness and, perhaps, slight fever. There may be some stiffness and soreness about the neck, owing to swelling of the glands. If the back of the tongue is held down by a spoon handle, the throat will be seen to be generally reddened, including the back, the bands at the side forming the entrance to the throat at the back of the mouth, and the uvula or small, soft body hanging down from the middle of the soft palate at the very back of the roof of the mouth. The tonsils are not large and red nor covered with white dots, as in tonsilitis. Neither is there much pain in swallowing. The surface of the throat is first dry, glistening, and streaked with stringy, sticky mucus.

Treatment.—The disorder rarely lasts more than a few days. The bowels should be moved in the beginning of the attack by some purge, as two compound cathartic pills or three grains of calomel, and the throat gargled, six times daily, with potassium chlorate solution (one-quarter teaspoonful to the cup of water), or with Dobell's solution. In gargling,[Pg 70]
[Pg 71] simply throw back the head and allow the fluid to flow back as far as possible into the throat without swallowing it. The frequent use of one of these fluids in an atomizer is even preferable to gargling. As an additional treatment, the employment of a soothing and pleasant substance, as peppermints, hoarhound or lemon drops, or marshmallows or gelatin lozenges, is efficacious, and will prove an agreeable remedy to the patient in sad contrast with many of our prescriptions. The use of tobacco must be stopped while the throat is sore.

TONSILITIS (Follicular Tonsilitis).—Tonsilitis is a germ disease and is contagious. Exposure to cold and wet and to germ-laden air renders persons more liable to attacks. It is more likely to occur in young people, especially those who have already suffered from the disease and whose tonsils are chronically enlarged, and is most prevalent in this country in spring. The disease appears to be often associated with rheumatism. Tonsilitis begins much like grippe, with fever, headache, backache and pain in the limbs, sore throat, and pain in swallowing. On inspecting the throat (with the tongue held down firmly by a spoon handle and the mouth widely open in a good light, preferably sunlight) the tonsils will be seen to be swollen, much reddened, and dotted over with pearl-white spots.

Sometimes only one tonsil is so affected, but the other is likely to become inflamed also. Occasionally there may be only one spot of white on the tonsil. The swelling differs in degree; in some cases the tonsils may be so swollen as almost to meet together, but there is no danger of suffocation from obstruction of the throat, as occurs in diphtheria and very rarely in quinsy. The characteristic appearance then consists in large, red tonsils covered with white spots. The spots represent discharge which fills in the depressions in the tonsil. The fever lasts three days to a week, generally, and then subsides together with the other symptoms.

With apparent tonsilitis there must always be kept in mind the possibility of diphtheria, and, unfortunately, it is at times impossible for the most acute physician to distinguish between these two diseases by the appearances of the throat alone. In order to do so it is necessary to rub off some of the discharge from the tonsils, and examine, microscopically, the kind of germs contained therein. The general points of difference are: in diphtheria the tonsils are usually completely covered with a gray membrane. In the early stage, or in mild cases of diphtheria, there may be only a spot on one tonsil, but it is apt to be yellow in color, and is thicker than the white spots in tonsilitis. These are the difficult cases. Ordinarily, in diphtheria, not only are the tonsils covered with a grayish membrane, but this soon extends to the surrounding parts of the throat, whereas in tonsilitis the spots are always found on the tonsil alone. The white spot can be readily wiped off with a little absorbent cotton wound on a stick, in the case of tonsilitis, but in diphtheria the membrane can be removed in this way only with difficulty, and leaves underneath a rough, bleeding surface. The breath is apt to have a bad odor in diphtheria, and the temperature is lower (not much over 100° F.) than in tonsilitis, when it is frequently 101° to 103° F. Notwithstanding these points, it is never safe for a layman to undertake the diagnosis when a physician's services are obtainable. On the other hand, when this is not possible and the patient's tonsils present the white, dotted appearance described, especially if subject to similar attacks, one may be reasonably sure that the case is tonsilitis.

Treatment.—The patient should be put to bed and kept apart from children and young persons, and, if living among large numbers of people, should be strictly quarantined. For, although the disease is not dangerous, it quickly spreads in institutions, boarding schools, etc. If the tonsils are painted with a solution of silver nitrate (one drachm to the ounce of water), applied carefully with a camel's-hair brush, at the beginning of the attack, and making two applications twelve hours apart, the disease may sometimes be arrested. It is well also at the start to open the bowels with calomel, giving three grains in a single dose, or divided doses of one-half grain each until three grains have been taken. Pain is relieved by phenacetin in three- to five-grain doses as required, but not taken oftener than once in three hours, while at night five to ten grains of Dover's powder (for an adult) will secure sleep. For children one-half drop doses of the (poisonous) tincture of aconite is preferable to phenacetin. The outside of the throat should be kept covered with wet flannel wrung out in cold water and covered with oil silk, or an ice bag may be conveniently used in its place. A half teaspoonful of the following prescription is beneficial unless it disagrees with the stomach. It must not be taken within half an hour of a meal, and is not to be diluted with water, as it acts, partly through its local effect, on the tonsils when allowed to flow from a spoon on the back of the tongue.

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° to 105° 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° to 102° 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° to 101° 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° 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° to 105° 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° 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 (983/5° 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°–105° 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° 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 MÖller'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° 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° to 90° 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° F.) the water should be cold (77° to 72° 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° 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° 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° to 104° 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 (983/5° 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.