CHAPTER I

Growths and Enlargements

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Causes.—Varicocele occurs usually in young, unmarried men and often disappears of itself in later life. Undue sexual excitement may produce the condition.Treatment.—When any treatment is necessary, the application of a snugly fitting suspensory bandage—which can be procured at any good drug shop—and bathing the testicles night and morning in cold water, with the avoidance of constipation and of the cause noted, will be generally sufficient to relieve any discomfort arising from varicocele. The enlargement of the veins will not, of course, be altered by this treatment, and absolute cure can only be effected by a surgical removal of the veins, which is not a serious undertaking, but is rarely necessary.

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

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

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

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

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

CHAPTER III

Rheumatism and Kindred Diseases

Causes of Rheumatic Fever—Relief of Pain in the Joints—Lumbago—Stiff Neck—Gout—Symptoms and Cure of Scurvy.

RHEUMATIC FEVER; INFLAMMATORY RHEUMATISM; ACUTE RHEUMATISM.—This variety of rheumatism is quite distinct from the other forms, being in all probability due to some special germ. It occurs in temperate climates during the fall, winter, and spring—less often in summer. Persons more frequently suffer between the ages of ten and forty years. It is rare in infants; their pain and swelling of the limbs can be attributed more often to scurvy (p. 180), or to surgical disease with abscess of joint or bone. Exposure to cold and damp, in persons insufficiently fed, fatigued, or overworked, is the most common exciting cause.

Symptoms.—Rheumatic fever may begin with tonsilitis, or other sore throat, with fever and pains in the joints. The joints rapidly become very painful, hot, red, swollen, and tender, the larger joints, as the knees, wrists, ankles, and elbows, being attacked in turn, the inflammation skipping from one joint to another. The muscles near the joints may be also somewhat swollen and tender. With the fever, which may be high (the temperature ranging from 102° to 104° F.), there are rapid pulse, copious sweating, and often the development of various rashes and minute blisters on the skin. There is also loss of appetite, and the bowels are constipated. The urine is usually very dark-colored. Altogether, victims of the disease are truly pitiable, for they suffer agony, and are unable to move without increasing it. The weakness and prostration are marked. Small, hard lumps, from the size of a shot to that of a pea, sometimes appear on the skin of the fingers, hands, wrists, knees, and elbows. These are not tender; they last for weeks and months. They are seen more often in children, and are most characteristic of rheumatic fever, but do not show themselves till late in the disease.

Complications of rheumatic fever are many. In about half the cases the heart becomes involved, and more or less permanent crippling of the heart persists in after life. Unconsciousness and convulsions may develop—more often when the fever runs high.

Lung trouble and pleurisy are not infrequent. Chorea or St. Vitus's dance follows inflammatory rheumatism, in children, in some instances. Repeated attacks at intervals, varying from one to four or five years, are rather the rule—more particularly in young persons. Acute rheumatism frequently takes a milder form, with slight fever (the temperature running not over 100° or 101° F.) and slight pain, and swelling of the joints. In children this is a common occurrence, but heart disease is just as apt to follow, and, therefore, such cases should receive a physician's attention at the earliest moment. Recovery from rheumatic fever is the usual result, but with an increased tendency to future attacks, and with the possibility of more or less permanent weakness of the heart, for acute rheumatism is the most common origin of chronic heart troubles. The milder form often follows the more severe, and may persist for a long time. The duration of rheumatic fever is variable; in severe cases the patient is bedridden for six weeks or so.

Rheumatism may be named through a mistake in diagnosis. There are numerous other febrile disorders in which inflammation of the joints may occur. Among these are gonorrhea, pneumonia, scarlet fever, blood poisoning, diphtheria, etc. The joint trouble in these cases is caused by the toxins accompanying the special germ which occasions the original disease, and the joint inflammation is not in any way connected with rheumatism. The constant attention of a physician is emphatically demanded in every case of rheumatic fever, since the complications are so numerous, and since permanent damage of the heart may be prevented by proper care. Only frequent examinations of the heart by the medical man will reveal the presence or absence of heart complications.

Treatment.—It appears extremely doubtful whether rheumatic fever can be cut short by any form of treatment. The disease is self-limited, that is, it will pass away of itself after a certain time. The pain, however, can be rapidly abated by treatment. Warmth is of great value. It is best for the patient to sleep between blankets instead of sheets, and to wear flannel nightgowns, changing them as often as they become damp with sweat. To facilitate the changing, it is well to have the nightgowns slit all down the front, and also on the outside of the sleeves. Wrapping the joints in cotton batting and applying splints to secure absolute rest are great aids to comfort. The diet should be fluid, consisting of gruels, milk, broths, and soups. To relieve pain in the joints, cloths, wrung out of a saturated solution of baking soda and very hot water, wrapped about the joint and covered with oil silk will be found extremely serviceable. Oil of wintergreen is another remedy which has proven of value when applied to the joints on cloths saturated in the oil and covered with cotton wool.

The bed must be smooth and soft, with good springs. High fever is reduced by the employment of cold to the head and by sponging the body with cool water at intervals of two hours or so.

The two drugs of most value are some form of salicylic acid and an alkali. Sodium salicylate in solution in water should be given to the adult in doses of ten to fifteen grains every two hours till the pain is relieved, and then once in four hours as long as the fever lasts. At the same time baking soda should be administered every three hours, one-half a level teaspoonful dissolved in water, and this may be continued as long as the fever persists. The patient must use a bedpan in relieving the bladder and bowels, and should remain in bed for a great while if the heart is damaged. It is a disease which no layman should think of treating if it is possible to obtain the services of a medical man.

MUSCULAR RHEUMATISM (Myalgia).—In this disease there is pain in the muscles, which may be constant, but is more pronounced on movement. Exposure to cold and wet, combined with muscular strain, frequently excite an attack. On the other hand, it often occurs during hot, dry, fine weather. Attacks last usually but a few days, but may be prolonged for weeks. The pain may be dull, as if the muscle had been bruised, but is often very sharp and cramplike. There is, commonly, slight, if any, fever, and no general disturbance of the health. The following are the most common varieties:

LUMBAGO.—This attacks the muscles in the small part of the back. It comes on often with great suddenness, as on stooping or lifting. It may be so severe that the body cannot be moved, and the patient may fall in the street or be unable to rise or turn in bed. In less severe cases the pain "catches" the patient when attempting to straighten up after stooping. Pain in the back is often attributed by the laity to Bright's disease, but is rarely seen in the latter disorder, and is much more often due to rheumatism.

STIFF NECK.—This is a very common variety of muscular rheumatism, and is seen more especially in young persons. It may appear very suddenly, as on awakening. It attacks the muscles of one side and back of the neck. The head is held stiffly to one side, and to turn the head the body must be turned also, as moving the neck causes severe pain. Sometimes the pain on moving the neck suddenly, or getting it into certain positions, is agonizing, but when it is held in other positions a fair amount of comfort may be secured.

RHEUMATISM OF THE CHEST.—In this form there is more or less constant pain, much increased by coughing, sneezing, taking long breaths, or by movements. It attacks usually one side, more often the left. It may resemble neuralgia or pleurisy. In neuralgia the pain is more limited and comes in sharper attacks, and there are painful spots. The absence of fever in rheumatism of the chest will tend to separate it from pleurisy, in which there is, moreover, often cough. Examination of the chest by a physician, to determine the breath sounds, is the only method to secure certainty in this matter.

Muscular rheumatism also affects the muscles about the shoulder and shoulder blade and upper part of the back; sometimes also the muscles of the belly and limbs.

Treatment.—Rest, heat, and rubbing are the most satisfactory remedies. In stiff neck, rub well with some liniment, as chloroform liniment, and lie in bed on a hot-water bag. Phenacetin or salophen in doses of ten grains, not repeated more frequently than once in four hours for an adult, may afford relief; only two or three doses should be taken in all. In lumbago the patient should remain in bed and have the back ironed with a hot flatiron, the skin being protected by a piece of flannel. This should be repeated several times a day. Or a large, hot, flaxseed poultice may be applied to the back, and repeated as often as it becomes cool. At other times the patient may lie on a hot-water bag. Plasters will give comfort in milder cases, or when the patient is able to leave the bed. A good cathartic, as two compound cathartic pills, sometimes acts very favorably at the beginning of the attack. Salicylate of sodium is a useful remedy in many cases, the patient taking ten grains three times daily, in tablets after eating, for a number of days. In rheumatism of the chest, securing immobility by strapping the chest, as recommended for broken rib (Vol. I, p. 84), gives more comfort than any other form of treatment. Many other measures may be employed by the physician, and are applicable in persistent cases, as electricity and tonics. The hot bath, or Turkish bath, will sometimes cut short an attack of muscular rheumatism if employed at the onset of the trouble.

CHRONIC RHEUMATISM.—Chronic rheumatism is a disease attacking persons of middle age, or after, and is seen more commonly in poor, hard-working individuals who have been exposed to cold and damp, as laborers and washerwomen. Several of the larger joints, as the knees, shoulders, and hips, are usually affected, but occasionally only one joint is attacked. There is little swelling and no redness about the joint; the chief symptoms are pain on motion, stiffness, and tenderness on pressure. The pain is increased by cold, damp weather, and improved by warm, dry weather. There is no fever. The general health suffers if the pain is severe and persistent, and patients become pale, dyspeptic, and weak. The disease tends rather to grow worse than recover, and the joints, after a long time, to become immovable and misshapen. Life is not, however, shortened to any considerable degree by chronic rheumatism. Heart disease is not caused by this form of rheumatism, although it may arise from somewhat similar tendencies existing in the same patient. It may be distinguished from other varieties of rheumatism by the fact that the larger joints are those attacked, and also by the age of the patients and general progress of the disease. It very rarely follows acute rheumatism.

Treatment.—The treatment of chronic rheumatism is generally not very successful unless the patient can live in a warm, dry climate the year round. Painting the joint with tincture of iodine and keeping it bandaged in flannel affords some relief. The application of a cold, wet cloth covered with oil silk and bandage, by night, also proves useful. Hot baths at night, Turkish baths, or special treatment conducted under the supervision of a competent medical man at one of the hot, natural, mineral springs, as those in Virginia, often prove of great value. Rubbing and movement of the joints is of much service in all cases; any liniment may be used. Drugs are of minor importance, but cod-liver oil and tonics may be required. These should be prescribed by a physician.

RHEUMATIC GOUT (Arthritis).—Notwithstanding the name, this disease has no connection with either gout or the other forms of rheumatism described. It occurs much more frequently in women, with the exception of that form in which a single joint is attacked. The disease may appear at any age, but more often it begins between the years of thirty and fifty-five. The cause is still a matter of doubt, although it often follows, or is associated with, nervous diseases, and in other cases the onset seems to be connected with the existence of influenza or gonorrhea, so that it may be of germ origin. Constant exposure to cold and dampness, excessive care and anxiety, and injury are thought to favor the disease. The disease is sometimes limited to the smaller joints of the fingers and toes, little, hard knobs appearing on them. At times the joints may be swollen, tender, and red, and are usually so at the beginning of the disease, as well as at irregular intervals, owing to indigestion, or following injury. At first only one joint, as of the middle finger, may be attacked, and often the corresponding finger on the other hand is next affected. The joints of the fingers become enlarged, deformed, and stiffened. The results of the disease are permanent so far as the deformity is concerned and the stiffness which causes interference with the movement of the finger joints, but the disease may stop during any period of its development, leaving a serviceable, though somewhat crippled, hand. In these cases the larger joints are not generally involved. There is some evidence to indicate that this form of the disease is more commonly seen in the long-lived.

General Form.—In this type the disease tends to attack all the joints, and, in many cases, to go from bad to worse. The hands are usually first attacked, then the knees, feet, and other joints. In the worst cases every joint in the body becomes diseased, so that even movements of the jaw may become difficult. There are at first slight swelling, pain and redness about the joints, with tenderness on pressure. Creaking and grating are often heard during motion of the affected joints. This condition may improve or subside for intervals, but gradually the joints become misshapen and deformed. The joints are enlarged, and irregular and stiff; the fingers become drawn over toward the little finger, or bent toward the palm, and are wasted and clawlike. The larger limbs are often bent and cannot be straightened, and the muscles waste away, making the joints look larger. In the worst cases the patient becomes absolutely crippled, helpless, and bedridden, and the joints become immovable. The pain may be great and persistent, or slight. Usually the pain grows less as the disease advances. Numbness and tingling of the skin often trouble the patient, and the skin is sometimes smooth and glossy or freckled.

The general health suffers, and weakness, anÆmia, and dyspepsia are common. Even though most of the joints become useless, there is often sufficient suppleness in the fingers to allow of their use, as in writing or knitting. In old men the disease is seen attacking one joint alone, as the hip, shoulder, knee, and spine. Children are occasionally sufferers, and in young women it may follow frequent confinements or nursing, and often begins in them like a mild attack of rheumatic fever. The heart is not damaged by rheumatic gout.

It is frequently impossible to distinguish rheumatic gout from chronic rheumatism in the beginning. In the latter, creaking and grating sounds on movement of the joints are less marked, the small joints, as of the hand, are not so generally attacked, nor are there as great deformity and loss of motion as is seen in late cases of rheumatic gout.

Outlook.—It often happens that after attacking several joints, the disease is completely arrested and the patient becomes free from pain, and only a certain amount of interference with the use of the joint and stiffness remain. Life is not necessarily shortened by the disease. The deformity and crippling are permanent.

Treatment.—Rheumatic gout is a chronic disease in most instances, and requires the careful study and continuous care of the medical man. He may frequently be able to arrest it in the earlier stages, and prevent a life of pain and helplessness. In a general way nourishing food, as milk, eggs, cream, and butter, with abundance of fresh vegetables, should be taken to the extent of the digestive powers. Everything that tends to reduce the patient's strength must be avoided. Cod-liver oil and tonics should be used over long periods. Various forms of baths are valuable, as the hot-air bath, and hot natural or artificial baths. A dry, warm climate is most appropriate, and flannel clothing should be worn the year round. Moderate exercise and outdoor life, in warm weather, are advisable, and massage, except during the acute attacks of pain and inflammation, is beneficial. Surgical measures will sometimes aid patients in regaining the usefulness of crippled limbs.

SCURVY.—Scurvy used to be much more common than it is now. In the Civil War there were nearly 50,000 cases in the Union Army. Sailors and soldiers have been the common victims, but now the disease occurs most often among the poorly fed, on shore. It is caused by a diet containing neither fresh vegetables, preserved vegetables, nor vegetable juices. In the absence of vegetables, limes, lemons, oranges, or vinegar will prevent the disease. It is also thought that poisonous substances in the food may occasion scurvy, as tainted meat has experimentally produced in monkeys a disease resembling it. Certain conditions, as fatigue, cold, damp quarters, mental depression and homesickness, favor the development of the disease. It attacks all ages, but is most severe in the old.

Symptoms.—Scurvy begins with general weakness and paleness. The skin is dry, and has a dirty hue. The gums become swollen, tender, spongy, and bleed easily, and later they may ulcerate and the teeth loosen and drop out. The tongue is swollen, and saliva flows freely. The appetite is poor and chewing painful, and the breath has a bad odor. The ankles swell, and bluish spots appear on the legs which may be raised in lumps above the surface. The patient suffers from pain in the legs, which sometimes become swollen and hard. The blue spots are also seen on the arms and body, and are due to bleeding under the skin, and come on the slightest bruising. Occasionally there is bleeding from the nose and bowels. The joints are often swollen, tender, and painful. Constipation is rather the rule, but in bad cases there may be diarrhea, nausea, and vomiting, and the victim becomes a walking skeleton. Mental depression or delirium may be present.

Treatment.—Recovery is usually rapid and complete, unless the disease is far advanced. Soups, fresh milk, beef juice, and lemon or orange juice may be given at first, when the digestion is weak, and then green vegetables, as spinach (with vinegar), lettuce, cabbage, and potatoes. The soreness of the mouth is relieved by a wash containing one teaspoonful of carbolic acid to the quart of hot water. This should be used to rinse the mouth several times daily, but must not be swallowed. Painting the gums with a two per cent solution of silver nitrate in water, by means of a camel's-hair brush, twice daily, will also prove serviceable. To act as a tonic, a two-grain quinine pill and two Blaud's pills of iron may be given three times daily.

INFANTILE SCURVY.—Scurvy occasionally occurs in infants between twelve and eighteen months of age, and is due to feeding on patent foods, condensed milk, malted milk, and sterilized milk. In case it is essential to use sterilized or pasteurized milk, if the baby receives orange juice, as advised under the care of infants, scurvy will not develop.

Scurvy is frequently mistaken for either rheumatism or paralysis in babies.

Symptoms.—The lower limbs become painful, and the baby cries out when it is moved. The legs are at first drawn up and become swollen all around just above the knees, but not the knee joints themselves. Later the whole thigh swells, and the baby lies without moving the legs, with the feet rolled outward and appears to be paralyzed, although it is only pain which prevents movement of the legs. Sometimes there is swelling about the wrist and forearm, and the breastbone may appear sunken in. Purplish spots occur on the legs and other parts of the body. The gums, if there are teeth present, become soft, tender, spongy, and bleed easily. There may be slight fever, the temperature ranging from 101° to 102° F. The babies are exceedingly pale, and lose all strength.

Treatment.—The treatment is very simple, and recovery rapidly takes place as soon as it is carried out. The feeding of all patent baby foods—condensed or sterilized milk—must be instantly stopped. A diet of fresh milk, beef juice, and orange juice, as directed under the care of infants, will bring about a speedy cure.

GOUT.—Notwithstanding the frequency with which one encounters allusions to gout in English literature, it is unquestionably a rare disease in the United States. In the Massachusetts General Hospital there were, among 28,000 patients admitted in the last ten years, but four cases of gout. This is not an altogether fair criterion, as patients with gout are not generally of the class who seek hospitals, nor is the disease one of those which would be most likely to lead one into a hospital. Still, the experience of physicians in private practice substantiates the view of the rarity of gout in this country.

We are still ignorant of the exact changes in the bodily condition which lead to gout, but may say in a general way that in this disease certain products, derived from our food and from the wear and tear of tissues, are not properly used up or eliminated, and are retained in the body. One of these products is known as sodium biurate, and is deposited in the joints, giving rise to the inflammation and changes to be described. Gout occurs chiefly in men past forty. The tendency to the disease is usually inherited. Overeating, together with insufficient exercise and indulgence in alcohol, are conducive to its development in susceptible persons. Injuries, violent emotion, and exposure to cold are also thought to favor attacks.

The heavier beers and ales of England, together with their stronger wines, as port, Madeira, sherries, and champagne, are more prone to induce gout than the lighter beers drunk in the United States and Germany. Distilled liquors, as brandy and whisky, are not so likely to occasion gout. "Poor man's gout" may arise in individuals who lead the most temperate lives, if they have a strong inherited tendency to the disease, or when digestion and assimilative disorders are present, as well as in the case of the poor who drink much beer and live in bad surroundings, and have improper and insufficient food. Workers in lead, as typesetters and house painters, are more liable to gout than others.

Symptoms.—There is often a set of preliminary symptoms varying in different persons, and giving warning of an approaching attack of gout, such as neuralgic pains, dyspepsia, irritability, and mental depression, with restless nights. An acute attack generally begins in the early morning with sudden, sharp, excruciating pain in the larger joint of one of the big toes, more often the right, which becomes rapidly dark red, mottled, swollen, hot, tense, shiny, and exceedingly sensitive to touch. There is commonly some fever; a temperature of 102° to 103° F. may exist. The pain subsides in most cases to a considerable degree during the day, only to return for several nights, the whole period of suffering lasting from four to eight days. Occasionally the pain may be present without the redness, swelling, etc., or vice versa.

Other joints may be involved, particularly the joint of the big toe of the other foot. Complete recovery ensues, as a rule, after the first attack, and the patient may thereafter feel exceptionally well. A return of the disease is rather to be expected. Several attacks within the year are not uncommon, or they may appear at much longer intervals.

Occasionally the gout seems to "strike in." In this case it suddenly leaves the foot and attacks the heart, causing the patient severe pain in that region and great distress in breathing; or the abdomen becomes the seat of violent pain, and vomiting, diarrhea, collapse and death rarely result. In the later history of such patients, the acute attacks may cease and various joints become chronically diseased, so that the case assumes the appearance of a chronic form of rheumatism. The early history of attacks of sharp pain in the great toe and the appearance of hard deposits (chalk stones) in the knuckles and the ears are characteristic of gout.

The greatest variety of other disorders are common in those who have suffered from gout, or in those who have inherited the tendency. "Goutiness" is sometimes used to describe such a condition. In this there may never be any attacks of pain or inflammation affecting the joints, but eczema and other skin diseases; tonsilitis, neuralgia, indigestion and biliousness, lumbago and other muscular pains, sick headache, bronchitis, disease of heart and kidneys, with a tendency to apoplexy, dark-colored urine, stone in the bladder, and a hot, itching sensation in the palms of the hands and soles of the feet, all give evidence of the gouty constitution.

Treatment.—One of the most popular remedies is colchicum—a powerful drug and one which should only be taken under the direction of a physician. A cathartic at the beginning is useful; for instance, two compound cathartic pills or five grains of calomel. It is well to give five grains of lithium citrate dissolved in a glass of hot water every three hours.

Laville's antigout liquid, imported by Fougera of New York, taken according to directions, may suffice during the absence of a physician. The inflamed toe should be raised on a chair or pillow, and hot cloths may be applied to it. The general treatment, between the attacks, consists in the avoidance of all forms of alcohol, the use of a diet rich in vegetables, except peas, beans, and oatmeal, with meats sparingly and but once daily. Sweets must be reduced to the minimum, but cereals and breadstuffs are generally allowable, except hot bread. All fried articles of food, all smoked or salted meats, smoked or salted fish, pastry, griddle cakes, gravies, spices and seasoning, except red pepper and salt, and all indigestibles are strictly forbidden, including Welsh rarebit, etc. Fruit may be generally eaten, but not strawberries nor bananas. Large quantities of pure water should be taken between meals—at least three pints daily. Mineral waters offer no particular advantage.