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HANDBOOK 
 
 FOK THE 
 
 HOSPITAL CORPS OF THE U. 8. ARMY 
 
 AND 
 
 STATE MILITARY FORCES 
 
 BY 
 
 CHARLES |MART 
 
 Assistant Surgeon General, U. S. A. 
 
 Approved by the Surgeon General of the Army 
 
 THIRD EDITION, REVISED AND ENLARGED 
 
 NEW YORK 
 WILLIAM WOOD AND COMPANY 
 
 1902 
 
 K 
 
|\.\SG1»"5»U 
 
 COPYRIGHT, 1903. 
 WILLIAM WOOD AND COMPANY 
 
Surgeon General George M. Sternberg, U. S. Army. 
 
 General : — WJien Congress authorized the organization 
 of a Hospital Corps for the Army, I wrote and published a 
 Handbook for the Corps with the view of assisting its mem- 
 bers in raising their qualifications to the higher standard 
 required of them than of the detailed men previously on 
 duty with the Medical Department. That the book 
 answered its purpose is shown by the Examination papers 
 filed by the candidates for the positions of Steward and 
 Acting Hospital Steward. 
 
 I have the honor to submit this revised edition in the 
 hope that it may prove of equal benefit to the men who 
 now enlist for service. 
 
 Eemaining with the highest respect, 
 
 Your obedient servant, 
 
 Charles Smart, 
 
 Assistant Surgeon General. 
 Washington, d. C, February, 1902. 
 
TABLE OF CONTENTS. 
 
 [T/ie paragraphic index at the end slumld be consulted wJien a special 
 milgeet is under consideration or inquiry.} 
 
 PAET I. 
 HOSPITALS AND HOSPITAL DUTIES. 
 
 PAGE 
 
 CHAPTER I.— The Post Hospital and the Hospital 
 CoBPS. Routine duties ; reports and papers ; etc., . . 1 
 
 CHAPTER II. — Active Service in the Field. Consolida- 
 tion for field service; division field hospitals; ambulance 
 companies and first aid stations. Service on the march and 
 on the battle-field ; during retreat ; reorganization after dis- 
 asters. Articles of the Geneva Convention. Reports and 
 papers, ... 16 
 
 CHAPTER III. — Sanitaky Care op Camps. Selection of 
 sites. Prevention of camp diseases; climatic exposures; 
 dietetic errors ; camp itch ; malarial fevers ; typhoid fever ; 
 dysentery; cholera; yellow fever, small-pox; scarlet fever ; 
 diphtheria; measles; typhus fever. Quarters; general po- 
 lice and sanitary government, . . 40 
 
 CHAPTER IV. — General Hospital Service. Base and 
 general hospitals ; their construction, water-supply, sewer- 
 age, personnel, administration, etc., . . .84 
 
 PAET II. 
 
 ANATOMY AND PHYSIOLOGY. 
 
 CHAPTER I.— The Locomotor System. The bones, joints, 
 and muscles, 103 
 
VI TABLE OP COKTBNTS. 
 
 PAGE 
 
 CHAPTER II.— Thb System op Organic Life. The blood 
 and its circulation ; digestion and absorption ; excretion by 
 the lungs, skin, and kidneys; animal heat, . . . 119 
 
 CHAPTER III. — The Administkative System. The brain, 
 spinal cord, nerves, ganglia, and organs of the senses, . 155 
 
 PAET III. 
 
 THE SPECIAL DUTIES OF THE HOSPITAL- CORPS. 
 
 CHAPTER I. — Genekal View of the Duties of a Nurse. 
 Qualifications. First aid; removal to hospital. Prepara- 
 tions for aseptic operations ; amputation ; antesthesia ; sur- 
 gical cleanliness. The record of a case; pulse; respiration; 
 temperature. Administration of medicines, etc., by the 
 mouth, the hypodermic syringe, the rectum. Care of bed- 
 ridden patients; bedsores; the urine, catheterization. Dis- 
 infectants.. Care of acute infectious diseases, . 165 
 
 CHAPTER II. — Shock, Reaction, and Inflammation. 
 Shock, reaction, inflammatory congestion, and symptomatic 
 fever; treatment by rest, position, cold, heat, warm- water 
 dressings, poultices, leeching, cupping, counter-irritation, 
 and general measures. Chronic inflammations and their 
 management. Hectic fever, . . 313 
 
 CHAPTER III.— Special Inflammations. Burns; scalds of 
 the throat ; frostbite ; chilblains ; contusions ; sprains ; ab- 
 scesses ; gumboils and minor surgery of the teeth ; boils ; 
 carbuncles ; whitlows ; corns ; bunions ; blisters on the feet, 
 and cliafings, . . . 226 
 
 CHAPTER IV. — Wounds. Incised ; lacerated ; contused ; 
 gunshot. First aid in shock and bleeding, and the field 
 dressing of gunshot injuries. Infected wounds; erysipelas 
 and gangrene; aiTow wounds; dissection wounds, etc. 
 Glanders, . 241 
 
 CHAPTER V. — Hemorrhage. Capillary, venous, and arte- 
 rial ; means of arresting, .... 258 
 
TABLE OF CONTENTS. Vll 
 
 PA(JK 
 
 CHAPTER VI.— Wounds of the Head, Neck, aud Trunk, 266 
 
 CHAPTER Vn. — CoKDiTioNs Causing Insensibility. Con- 
 cussion, compression, and congestion of the brain; apo- 
 plexy; sunstroke; epileptic stupor; convulsions; alcoholic 
 stupor; opium narcotism; insensibility from cold, from 
 asphyxia, and from heat exhaustion, . . 271 
 
 CHAPTER VIII. — Artificial Respiration, and the cases 
 in which it should be used, . . . 280 
 
 CHAPTER IX.— Foreign Bodies. In the eye, nose, ear, 
 trachea, pharynx, stomach, etc., . 287 
 
 CHAPTER X. — Fractures, their symptoms and treatment; 
 of the skull, lower jaw, spine, ribs, collar-bone, shoulder- 
 blade, arm, forearm, hand and lingers, pelvis, thigh, and 
 leg, .... 293 
 
 CHAPTER XI. — Dislocations, their symptoms and treat- 
 ment; of the lower jaw, collar-bone, shoulder- joint, elbow, 
 wrist, fingers, hip, knee-cap, knee-joint, ankle, and foot, 313 
 
 CHAPTER XII.— Management of Cases of Poisoning, 336 
 
 CHAPTER XIII.— Pharmacy. Outlines of course of instruc- 
 tion, . . . ... 339 
 
 CHAPTER XIV.— Elements of Cookery, 340 
 
 Analytical Index to Paragraph Numbers, . . 377 
 
PART I. 
 
 HOSPITALS AND HOSPITAL DUTIES. 
 
 1. A hospital is the shelter or quarters provided for the 
 sick and wounded of a command ; but in an enlarged sense 
 it includes the provision made for the cure of the disabled, 
 with no special reference to the shelter or building that 
 may be used. When a hospital is attached to a stationary 
 command it is a post hospital ; if it accompany the com- 
 mand on an expedition or campaign, it is a field hospital ; 
 if it be detached from the command, and particularly if it 
 receive the sick and wounded of any command, it is a gen- 
 eral hospital. 
 
 CHAPTER I. 
 
 THE POST HOSPITAL, AND THE HOSPITAL CORPS. 
 
 2. The regulation post hospital building at permanent 
 military posts is of brick, arranged for 12, 24, or 36 beds, 
 heated by hot water, and ventilated through brick flues 
 and galvanized iron ducts; but as a matter of fact the 
 building may be any kind of a shelter extemporized or 
 utilized for the care of the sick and wounded. 
 
 3. The service of the post hospital is performed by 
 members of the Hospital Corps enlisted for, and per- 
 manently attached to, the Medical Department, and by 
 such members of the Army Nurse Corps (female) as may 
 be considered necessary. Enlisted men may be transferred 
 from the line to the Hospital Corps as privates. Married 
 
 1 
 
2 THE HOSPITAL COKPS. 
 
 men are not accepted as recruits, nor transferred from the 
 line for service in the corps. Candidates for enlistment 
 should apply to a post medical officer or to a recruiting 
 officer. Applicants who have graduated in pharmacy, who 
 have been licensed by State boards of pharmacy, or who 
 have had training as nurses in civil hospitals should pre- 
 sent certificates of their special qualifications. Slight 
 physical defects which, under existing orders, would dis- 
 qualify for the line, do not disqualify for enlistment in 
 the corps, provided they are not of such a character as 
 would interfere with the full performance of the duties of 
 a sanitary soldier in garrison or in the field. 
 
 4. If the candidate is accepted he is forwarded to a com- 
 pany or detachment of the corps for instruction in military 
 discipline, drill, first aid, nursing, cooking, pharmacy, 
 clerical work, field work, and the care and management of 
 animals. The order of exercises of a company of instruc- 
 tion requires the early hours of every morning except Sun- 
 day to be occupied with policing or cleaning up the hos- 
 pital and the surrounding grounds, after which on every 
 day except Saturday and Sunday half an hour is devoted 
 to calisthenics or setting up drill, and from three-quarters 
 of an hour to an hour each to study and litter drill; in 
 addition to this the junior section has an hour on pharmacy 
 on each of four days of the week, with elementary cooking 
 on the fifth day, while the senior section at the same hour 
 has anatomy on three days and first aid on two days. In 
 the afternoon an hour each is given to study and to reci- 
 tations on nursing and on four days to bandaging, with 
 disinfection and the care of instruments on the fifth 
 day. 
 
 5. When the education of the recruit is considered com- 
 plete he is assigned to duty at some post, where his services 
 
THE HOSPITAL CORPS. 3 
 
 are utilized as nurse, cook, or attendant, according to his 
 special qualifications. 
 
 6. Privates who have served three months in the Hos- 
 pital Corps, and have shown particular fitness, may be 
 recommended for promotion by the surgeon. From those 
 thus recommended acting stewards are detailed after pass- 
 ing examination as to physical condition, moral character, 
 and general aptitude, and in the principles of arithmetic, 
 in orthography and penmanship, the regulations affecting 
 enlisted men, care of the sick, ward management, minor 
 surgery, hospital corps drill and first aid, the ordinary 
 modes of cooking, and elementary hygiene. 
 
 7. No person is appointed a hospital steward until he 
 has served a year as an acting steward, nor until he has 
 shown by examination a more extensive and detailed 
 knowledge of the above subjects than is required of the 
 acting steward. A re-examination before his first re- 
 enlistment may not be required if the surgeon certifies that 
 the candidate has performed his duties efficiently ; but a 
 re -examination is called for before a second re-enlistment, 
 after which no further examination is ordinarily required. 
 
 8. Army Regulations provide for at least one noncom- 
 missioned officer and four privates at each permanent mili- 
 tary post, with an additional noncommissioned officer for 
 every additional four privates ; six privates when the gar- 
 rison is two hundred, and two privates additional for 
 every additional one hundred of strength. 
 
 9. The duties of stewards and acting stewards are, under 
 the direction of the surgeon, to look after and distribute 
 hospital stores and supplies ; to care for hospital property ; 
 to compound and administer medicines; to supervise the 
 preparation and serving of food ; to maintain discipline in 
 the hospital and watch over its general police; to pre- 
 
4 THE SEETICE OF THE POST HOSPITAL. 
 
 pare the hospital reports and returns ; to supervise the duties 
 of the hospital corps in hospital and in the field ; and to 
 perform such other duties connected with their positions as 
 may, by proper authority, be required of them. 
 
 10, The steward must be an efficient disciplinarian, ex- 
 pert clerk, accurate arithmetician, and a trustworthy phar- 
 macist, with as much knowledge of materia medica, thera- 
 peutics, and minor surgery as will enable him to give sound 
 advice and suitable treatment in the minor ailments and 
 accidents which in civil life rely on the resources of domestic 
 medicine or on the knowledge of the nearest pharmacist ; 
 in addition, he must have that higher knowledge, for use 
 in the wards, which enables the experienced nurse to ap- 
 preciate the condition of those who are seriously ill, that 
 their improvement may be fostered and all harmful influ- 
 ences excluded. At small posts, during the temporary 
 absence of the surgeon, the unforeseen casualties and even 
 many of the exigencies of military life impose duties upon 
 him. the satisfactory performance of which may be of the 
 first importance to the individuals concerned. 
 
 11. The daily routine of the service of a post hospital 
 begins at reveille, when, after roll call, the wards are 
 tidied up and breakfast is served and cleared away before 
 surgeon's call is sounded. Promptly on this call the First 
 Sergeant of each company brings his sick to hospital for 
 inspection. The surgeon examines each man, iiidicatuig 
 in the sergeant's book those who are to be treated in hos- 
 pital and those who are to be excused from duty or portions 
 thereof as sick in quarters, etc. Morning reports are then 
 sent to the Adjutant's office for the information of the 
 commanding officer. Prescriptions for those in quarters 
 are now filled; and the Begistei- of Sick and Wounded is 
 brought up to date by the careful entry of the morning's 
 
THE SERVICE OF THE POST HOSPITAL. 5 
 
 changes. The wards are then visited and the prescription 
 and diet orders recorded. After this the kitchen, dining- 
 room, and other parts of the hospital are inspected, and 
 the regulation visit is at end. Emergency calls bring the 
 medical officer to the hospital at any hour, and generally, 
 when serious cases are on hand, he may be expected before 
 retreat or tattoo. After the morning visit he attends to his 
 patients, in the families of officers, married soldiers, laun- 
 dresses, and otljer attaches of the garrison, and his pre- 
 scriptions reach the dispensary from time to time during 
 the forenoon. By the time these are filled the steward has 
 posted the records, supplied the wards with needful articles 
 of bedding, etc., given directions for the diet of the day, 
 and provided the required supplies from his subsistence and 
 hospital stores and hospital-fund purchases. The after- 
 noon may be devoted to drills, exercise, or amusement, in 
 the absence of special calls for its occupation otherwise, 
 and the evening to study, or, at certain periods, to the 
 preparation of official reports and papers. 
 
 12. The studies of the members of the corps are natu- 
 rally such as will fit them to act intelligently in all matters 
 relating to the management of the hospital and the sick 
 and wounded. Every surgeon supervises the instruction of 
 his men and the higher education of his stewards; the 
 latter guide and direct the acting stewards, and these per- 
 form similar offices to those who serve under them. The 
 medical officer is required by regulations to devote at least 
 eight hours in each month to instructing the men of the 
 corps in the duties of litter-bearers and the methods of 
 first aid. These studies will eventually lead every capable 
 member of the corps to a stewardship ; but besides this 
 personal influence they serve a higher end by preparing the 
 corps for a sudden expansion in time of war. "When every 
 
6 REPORTS AND PAPERS. 
 
 acting steward is qualified to undertake the duties of 
 steward, and every private ready to step into a higher 
 position, the expansion of the command can be effected by 
 merely recruiting for the lowest grade. 
 
 13. The surgeon is responsible for the timely and accu- 
 rate rendition of the reports and papers required in the ser- 
 vice of a post hospital ; but the work, except in the case of 
 special and professional reports, is usually performed by a 
 member of the corps, to whom the clerical work has been 
 assigned. For all routine reports blank forms are provided 
 by the War Department, and full instructions are printed 
 on each of these to insure accuracy, the said instructions 
 having the force of Army Regulations. The reports and 
 papers are as follows : 
 
 14. Reports and papers relating to members of the 
 Medical Department and Hospital Corps and detached men 
 in hospital : 
 
 A Morning 'Report of the Hospital Corps, for the in- 
 formation of the post commander. 
 
 A Monthly Return, m duplicate. Form 32, of the Per- 
 sonnel and Means of Transportation of the Hospital Corps, 
 giving a nominal list of the members and the matrons on 
 duty, with the changes that have taken place in their 
 status ; and a numerical list of ambulances, harness, litters, 
 etc. , one copy to the Chief Surgeon, the other to the Sur- 
 geon General direct. Changes in the status of any member 
 of the corps, or matron, as by death, discharge, re-enlist- 
 ment, or transfer to meet emergencies, are to be reported 
 immediately, by information slip, to the Chief Surgeon. 
 
 A Monthly Personal Report from each medical officer to 
 the Surgeon General and Chief Surgeon on information 
 slips, and when at stations where no post return is made 
 to the Adjutant General by letter, giving post-office ad- 
 
REPORTS AND PAPERS. 7 
 
 dress, duty on which engaged, and the source, number, and 
 date of orders under which acting. Similar reports are 
 required when an officer arrives at or leaves a station. A 
 hospital steward on furlough reports to the Surgeon Gen- 
 eral and the surgeon of his station. 
 
 Ration Returns call for the articles of subsistence for 
 each person who has to be provided for by the medical de- 
 partment, except for those on special diet, for each of whom 
 there is a credit of forty cents a day in the hands of the 
 commissary of subsistence. Issues of rations are made by 
 the subsistence officer for a few days, generally ten, at a 
 time ; and at each issue settlements are effected between 
 the companies and the hospital to prevent injustice from 
 the sending of men to quarters after they have been dra^vn 
 for on hospital returns and vice versa. The money value 
 of articles on the return not drawn for use is added to the 
 hospital fund. Money thus accruing is expended exclu- 
 sively for the benefit of the sick and the members of the 
 corps in the purchase of such articles of diet, comfort, and 
 convenience as may be required. A Statement of the Hos- 
 fj'dal Fund, Form 35, is forwarded monthly to the Chief 
 Surgeon for transmission to the Surgeon General. Pro- 
 vision is made on this form for a Return of Durable Prop- 
 erty purchased with the fund. 
 
 Muster and Pay Rolls. ' On the last day of February, 
 April, June, August, October, and December muster rolls 
 are made out in duplicate, one copy for the Adjutant Gen- 
 eral, the other to be retained ; and on the last day of every 
 month three muster and pay rolls are prepared, two for 
 the paymaster and one to be retained. These rolls bear 
 the names of the members and attaches of the hospital 
 corps ; soldiers in hospital, detached from their companies, 
 ' Blanks from the Adjutant General's Office. 
 
8 REPORTS AND PAPERS. 
 
 are mustered on separate rolls, one set for the men of each 
 regiment. The accounts of each soldier are settled up 
 from time to time, and when required their status is entered 
 on his Descriptive List and Pay and Clothing Account.' 
 When a soldier is transferred from one command to another 
 his descriptive list must be transmitted to the officer with 
 whose command he is next to be mustered, and all the data 
 in the said list must be noted in the Descriptive and De- 
 posit Book.' Clothing is drawn on Special Requisitions 
 from the quartermaster and is issued by the surgeon on 
 duplicate Receipit Rolls, in which is entered the money- 
 value of the articles. The commutation value of the sol- 
 dier's clothing allowance constitutes a stated sum, against 
 which the value of the issued articles is entered in a Cloth- 
 ing Account Book, ' which is balanced June 30th and De- 
 cember 31st. Balances due the soldier are continued as . 
 a credit in the clothing account book, but any indebtedness 
 to the Government is charged on the muster rolls and de- 
 ducted from the pay. In the case of transfer, desertion, 
 discharge, or death the balance due the soldier or the Gov- 
 ernment is stated on the muster rolls, descriptive list, or 
 final statements, as may be required for the continuation 
 or closing up of the account. Clothing burned by order, 
 to prevent contagion, is replaced on approval of the Sur- 
 geon General. When a soldier detached from his command 
 is returned to duty, transferred, discharged, dies, or deserts, 
 a new descriptive list containing a complete statement of 
 his accounts is sent to his company or other commander 
 and the original descriptive list is retained by the surgeon 
 for his own protection. If the detached soldier is dis- 
 charged, the surgeon will furnish him with final statements ' 
 in duplicate and will notify the Adjutant General of the 
 ' Blanks from the Adjutant General's Office. 
 
REPORTS AND PAPERS. 9 
 
 Army and the company commander of the date, place, and 
 cause of the discharge. The final statements give an ex- 
 hibit of his accounts and are the vouchers on which the 
 paymaster settles them. When a member of the hospital 
 corps dies the surgeon is required to notify the nearest 
 relatives ; final statements are prepared as in the case of 
 discharge, with an Inventory of Effects,' in triplicate. 
 These, except one copy of the latter, which is retained, are 
 forwarded to the Adjutant General. When the effects are 
 claimed by relatives receipts are taken in triplicate to offset 
 the copies of the inventory; when sold by a Council of 
 Administration the money is deposited with a paymaster 
 who gives the necessary receipts. AVhen a detached man 
 dies his company commander and nearest relatives are 
 notified, and duplicates of the inventory with final state- 
 ments are sent to the Adjutant General. 
 
 15. Reports relating to sickness and other casualties or 
 changes in the garrison : 
 
 A Morning Rexjort of Side and Wounded for the informa- 
 tion of the commander. 
 
 A Monthit/ Report of Sick and, Wounded, Form 25, to 
 the Chief Surgeon and the Surgeon General, which is 
 practically a transcript from the Rfgister of Patients. In 
 time of war only one copy is required to be made out. It 
 is forwarded from general hospitals direct to the Surgeon 
 General and from organizations in the field to the Surgeon 
 General through the Chief Surgeon. This blank form has 
 spaces for Remarks on prevailing diseases, their causation, 
 and the measures adopted for their prevention; but his- 
 tories of cases possessing a professional interest should be 
 transmitted in the form of Special Reports to the Surgeon 
 General. When a sick or. wounded soldier is transferred 
 ' Blanks from the Adjutant General's Office. 
 
10 EEPOKTS AKD PAPERS. 
 
 to another hospital a Transfer Slij} giving full particulars 
 of the case is forwarded with the patient. The surgeon 
 of the receiving hospital enters the data into his register 
 and countersigning the slip forwards it to the Surgeon 
 General. On the occurrence of cholera, yellow fever, 
 smallpox, or other infection liable to become epidemic 
 a report is sent to the Chief Surgeon and Surgeon Gen- 
 eral; a Monthly List of Patients Suffering from Epidemic 
 Disease, Form 27, is furnished in duplicate during the 
 continuance of the epidemic and a detailed history of 
 the outbreak is called for at its close. Local boards of 
 health interested should be notified at the beginning of 
 the epidemic. 
 
 When a soldier completes his enlistment in the Regular 
 Army by taking the oath an Outline Figure Card ' showing 
 the situation and character of permanent marks and scars 
 on his person, is forwarded direct to the Surgeon General. 
 A card is forwarded also in the case of men received as re- 
 cruits from recruiting stations and rendezvous where there 
 is no Medical Examiner. A Monthly Report of the Physical 
 Examination of Recruits, Form 30, is required by the Sur- 
 geon General. 
 
 16. Reports relating to the post or post hospital : 
 A Monthly Satiitary Report, Form 41, giving expression 
 to the sanitary condition of the quarters, including all 
 buildings belonging to the post, their drainage and sewer- 
 age systems, the character and cooking of the rations, the 
 quantity and quality of the water supply, and the clothing 
 and habits of the men, with such recommendations as are 
 considered needful. This report is acted on by the post 
 commander, who returns it to the surgeon that the action 
 taken may be entered in the Medical History of the Post. 
 ' Blanks from the Adjutant General's Office. 
 
REPORTS AND PAPERS. 11 
 
 The report is then forwarded through military channels to 
 the Surgeon General. 
 
 Estimates for Repairs, Alterations, or Additions to the 
 Post Hospital, accompanied by such drawings as are need- 
 ful, are forwarded to the Surgeon General by March 1st 
 annually. They are required to show in detail the kind 
 and cost of the materials and labor to be procured and to 
 what extent the labor can be performed by the troops. If 
 no repairs are required a communication to that effect 
 should be forwarded at the proper tune. Estimates, dis- 
 tinct from those for the hospital, are made at the same 
 time for the Construction or Repair of Hospital Stcirurds' 
 Quarters. 
 
 A Meteorological Report, Form 29, is called for monthly 
 from certain posts to be transmitted to the Surgeon Gen- 
 eral through the State ofB.ce of the Weather Bureau. 
 
 17. Papers relating to medical and other supplies : 
 
 Requisitions for Medical and Hospital Sii2)plips, Form 
 15, for the year beginning January 1st, are forwarded in 
 triplicate to the Chief Surgeon, who transmits one copy to 
 the Surgeon General and another to the Supply Depot. 
 They are made for articles of the regular supply that are 
 or probably will be deficient, and they must show the 
 quantity of every article on hand, whether more is wanted 
 or not. Unexpected deficiencies are provided for on 
 Special Requisitions, Form 16, in triplicate, giving a list 
 of the articles and the quantity on hand. These are for- 
 warded to the Chief Surgeon, who retains one copy and 
 sends the others to the Surgeon General. In emergencies 
 Chief Surgeons are empowered to act on special requisitions, 
 sending one copy with their action to the Supply Depot, 
 one to the Surgeon General with an explanation of the cir- 
 cumstances, and retaining one; hnt Requisitions for Articles 
 
12 REPORTS AND PAPERS. 
 
 not in the Sitpply Table must in all cases be forwarded to 
 the Surgeon General. When the supplies are received the 
 Invoice, Form 18, and the Packer's List, Form 17, are 
 verified, and Receipts, Form 19, are prepared in duplicate, 
 one copy for the issuing officer and one for the Surgeon 
 General. 
 
 Requisitions, on the Surgeon General's Office, /or Blank 
 Forms for the reports and returns, etc., mentioned in this 
 list of official papers, with the exception of those noted as 
 furnished by other bureaus of the War Department, are 
 forwarded when necessary and always for a year's supply. 
 
 Returns of Medical Property, Form 20, are made out in 
 duplicate on December 31st, annually, after an account of 
 stock has been taken for the preparation of the regular 
 requisitions, or when an officer is relieved from the duty to 
 which the returns relate. The original is sent to the Sur- 
 geon General ; the duplicate with its vouchers is retained. 
 They show everything received, expended, etc, and re- 
 maining on hand. Names of articles that may be expended 
 are printed on the blank form in Roman type, of non- 
 expendable articles in italic. Articles of the latter class, 
 worn out or unfit for use, are condemned on Inventory and 
 Inspection Reports of Unserviceable Property,^ and these 
 constitute the vouchers relieving from responsibility. 
 Articles destroyed to prevent contagion are covered by the 
 certificate of the officer responsible; articles lost or de- 
 stroyed by certificate in like manner or by the certificate 
 of an officer or the affidavit of an enlisted man or citizen 
 personally cognizant of the circumstances. 
 
 Quarterly Returns of Quartermaster' s Supplies j' embody- 
 ing the responsibility of the surgeon for clothing drawn for 
 
 ' Blanks.from the Inspector General's Office. 
 
 * Blanks from the Quartermaster General's Office. 
 
REPORTS AND PAPERS. 13 
 
 issue to the men of the Hospital Corps and soldiers de- 
 tached from their commands, and for ambulances, litters, 
 tents, lamps, etc. , obtained by requisition on the Quarter- 
 master's department. They are made out in duplicate, one 
 copy for the Quartermaster General, the other to be re- 
 tained, £(iid are accompanied with invoices for articles re- 
 ceived, receipts for those transferred or issued, and other 
 vouchers specially called for in cases of loss, damage, or 
 unserviceability. 
 
 18. The Books of Record required to be kept are a 
 Medical History of the Post ; a Morning Report of Sick 
 and Wounded ; a Register of Patients ; a Register of the 
 Hospital Fund ; a Register of the Physical Examination of 
 Recruits; a Record of Deaths and Interments; an Order 
 and Letter Book; a Meteorological Register at certain 
 posts, and a Book of Information Slips for use when formal 
 letters are unnecessary. In addition to these are the fol- 
 lowing from the Adjutant General's oflB.ce: A Descriptive 
 and Deposit Book ; a Morning Report Book of the Hospital 
 Corps, and a Clothing Account Book. 
 
 19. Drills by word of command are needful to perfect 
 men in movements that require concerted or co-operative 
 action. It is a mistaken notion to suppose that because a 
 drill is authorized and provided for, the various details of 
 that drill must be rigidly observed on every occasion. The 
 drill is merely a means to an end. A well-manned battery 
 keeps up a rapid fire on the enemy because every man at 
 every gun knows the duty devolving upon him, and does it 
 without command at the precise moment when it should be 
 done ; but this perfection of co-operative work can be at- 
 tained only by repeated and careful drills in the consecu- 
 tive movements, each executed at the word of command. 
 An analogous drill with the litter, ambulance, and a repre- 
 
14 THE HOSPITAL CORPS. 
 
 sentative of the disabled human body familiarizes men with 
 the management of these objects, and prepares them to act 
 intelligently one with the other and irrespective of com- 
 mands when the necessities of the occasion require such 
 action. 
 
 20. The Drill Regulations for the Hospital Corps ' pre- 
 scribes the method of formation and alignment of the de- 
 tachment, its marchings, turnings, rests, and dismissal. It 
 then describes the litter and the methods of handling it, 
 closed, open, and loaded. After these instructions come 
 paragraphs on improvisation of litters; the removal of 
 wounded without litters ; the use of the travois, the horse, 
 the two-horse litter, and the ambulance; inspection and 
 muster, and the pitching and packing of hospital tents. 
 The book closes with Outlines of First Aid, which are used 
 as a text for the instruction of the enlisted men of the line, 
 who are required to be drilled by their company officers 
 for at least four hours in each month in the duties of litter- 
 bearers and the methods of rendering first aid. 
 
 21, The uniform of the corps for ordinary wear consists 
 of a dark blue flannel blouse and trousers of light blue kersey 
 with stripes of emerald green, one-half inch, one inch, and 
 one and a half inches wide respectively for privates, acting 
 stewards and stewards. The chevrons of the steward 
 consist of three bars and an arc of one bar of' emerald green 
 cloth, enclosing a modified maltese cross of the same cloth, 
 worn above the elbow, points down; the bars and cross 
 have a narrow white border. The chevrons of the acting 
 steward are the same as those of the steward, omitting the 
 arc. The private of the hospital corps wears a modified 
 maltese cross of emerald green cloth with a white border 
 on both sleeves of the blouse, midway between the elbow 
 
 1 "Washington, D. Q., Government Printing-OflBce, 1900. 
 
THE HOSPITAL COKPS. 15 
 
 and shoulder, and on the overcoat, below the elbow, one- 
 half inch above the cuff. In time of war with a signatory 
 to the Geneva Convention the Red Cross brassard of the 
 Convention [54] is worn on the left arm above the elbow 
 by all members of the corps on duty m the field of opera- 
 tions. The waist belt is of leather, black, with plate. 
 The cap is of dark blue cloth, with a rounded and sloping 
 visor of black patent leather, the private and acting steward 
 having a modified maltese cross of German silver in front, 
 and the steward a similar cross in a wreath of dead or 
 unburnished gilt metal. The equipment consists of the 
 litter-sling and the hospital corps or orderly pouch. 
 
 The uniform for ward service is of cotton duck. 
 
 For feld service the cap of the barrack suit is replaced 
 by a campaign hat of drab-colored felt, and the legs are 
 protected by leggings of strong cotton duck The equip- 
 ment for field service consists of the litter-sling, hospital 
 corps or orderly pouch, canteen j haversack, waist belt and 
 plate, and shelter tent piece. 
 
CHAPTER II. 
 
 ACTIVE SERVICE IN THE FIELD. 
 
 22. The size of a hospital establishment is proportioned 
 to that of the command to which it is attached ; for, when 
 troops are eoneentratiiig, every detachment or subordinate 
 command brings with it its quota of hospital corps men. 
 At first, in the progress of concentration, every material 
 addition to the strength of the command necessitates a 
 corresponding change in the organization of its hospital, to 
 provide a share of the work to the newcomers. For organi- 
 zation consists essentially in so apportioning the work to 
 be done by a number of individuals as to produce satisfac- 
 tory co-operative results. But in the progressive concen- 
 tration of troops there comes a stage or period of the 
 aggregation when the hospital corps is able to provide one 
 man or set of men for every part of the work ; and when 
 every part of the work thus assigned draws out the full 
 energies of the man or men charged with it, the organiza- 
 tion is perfect. Further additions do not strengthen it, 
 because there is no room for them. They can be used to 
 advantage only in building up another such organization. 
 This perfected hospital is the unit of organization for field 
 service in time of war ; and the field hospital system of a 
 large army consists of a series of such units, just as the 
 army itself consists of a series of regiments which are the 
 units of its organization for purposes of drill, discipline, 
 and administration. 
 
ACTIVE SERVICE IN THE FIELD. 17 
 
 23. The occurrence of the Civil War first aroused the 
 medical profession of this country to the necessity for a 
 satisfactory field hospital organization, but the succession 
 of important events in this war was so rapid that practice 
 had to meet emergencies without premeditation. In the 
 end, success was achieved; but every step taken toward a 
 better organization showed distinctly how much suffering 
 would have been prevented or alleviated by an earlier 
 recognition of its q,jivantages. 
 
 24. The unit. of organization was at first the regimental 
 hospital, but the inefficiency of this was speedily recognized. 
 Its incompetency was strikingly conspicuous during the 
 emergencies of the battlefield. The medical strength of 
 the army was scattered along the rear of the line of battle. 
 Some regiments suffered more than others, and their am- 
 bulances and stretcher-carriers were unable to remove the 
 wounded promptly from the field; their medical officers 
 were overworked, yet could not accomplish all that they 
 desired; their shelters were insufficient and their supplies 
 inadequate. Nor in this system could there be any efficient 
 co-operation, for other medical officers, whose regiments 
 perhaps had not become engaged, had to hold themselves 
 in readmess for the developments of the battle ; and al- 
 though they might be ready and willing to assist their 
 overworked comrades by their personal labors, they were 
 warranted in showing some hesitancy in sharing with others 
 the stores and dressings provided for their own men, if 
 there was a probability of their own command becoming 
 engaged before an opportunity would be afforded of replen- 
 ishing supplies. So the better to provide for the emergen- 
 cies of battle, a temporary consolidation was directed when- 
 ever an engagement was imminent; and as the medical staff 
 of a brigade was able to furnish an officer for every special 
 
 2 
 
18 ACTIVE SERVICE IIT THE FIELD. 
 
 duty connected with the hospital, and yet leave enough to 
 give first aid on the battlefield, the organization was usu- 
 ally effected by brigades. In this way, when one regiment 
 suffered more than another, the medical officers of several 
 regiments participated in the care of its wounded, and in- 
 dividual cases requirmg operative proceedings came under 
 the hands of those surgeons in the brigade best qualified to 
 undertake them. At this time, as soon as the surgical 
 work of the engagement was completed the hospitals re- 
 verted to their regimental status. An active campaign, 
 however, or a quick succession of battles, speedily demon- 
 strated the advisability of retaining the brigade organiza- 
 tion as long as the troops were within striking distance of 
 the enemy ; and while preserved in this way for a probable 
 emergency, the consolidated field hospital for the brigade 
 had an opportunity of showing its superiority to the regi- 
 mental hospitals, as well during the marches and strategic 
 manoeuvres of active service as during its battles. Fewer 
 wagons were required for the transportation of its property 
 and supplies than for those of the four or five small hos- 
 pitals which it replaced, because there was no unnecessary 
 duplication of material; and the sick and wounded were 
 held better in hand for sudden movements. Under the 
 regimental system the sick of all the regiments were carried 
 in ambulances, which generally followed in rear of the 
 division on the march, and, at its close, were distributed 
 among the several regimental camps. Here the sick had 
 to await the arrival of the heavy trains before shelter or 
 food could be provided for them ; and it was precisely when 
 both were most required, that is, during rainy and inclem- 
 ent weather, that the delay in their arrival was greatest. 
 They were cared for in the ambulances during the day; but 
 at night were transferred to their regimental camp, where 
 
ACTIVE SERVICE IN THE FIELD. 19 
 
 their regimental hospital had merely an official, not an 
 actual, existence. Under the brigade system the hospital 
 camp was formed where the ambulances halted, and food 
 and shelter were immediately provided, irrespective of the 
 arrival of the main supply train. Regimental hospitals 
 ultimately disappeared from the camps of veteran troops 
 even during seasons of inactivity and recuperation, their 
 official existence being represented merely by the regimental 
 surgeons, who gave first aid in emergencies, and examined 
 the command daily to find out who, if any, should be sent 
 to the consolidated hospitals. A regimental hospital or- 
 ganization exists in most of the state military forces, as 
 this system appears to answer the purposes of the Guard 
 in their home service. Volunteer troops, tendered by the 
 State for Federal service, would likely have a similar 
 medical organization; but when brigaded for actual war 
 service the field hospital system of the Civil War should be 
 substituted. Eegimental hospitals were used during the 
 Spanish-American war and for a time in the Philippine 
 Islands, but only as emergency or detention hospitals. 
 They were not intended for the treatment of the very ill 
 who, in the event of a move, would prove to be an incum- 
 brance to the regiment. Serious cases were promptly re- 
 moved to brigade or other larger hospitals. These regi- 
 mental hospitals were provided, each, with four hospital 
 tents [98], two of which were used as wards, one as dis- 
 pensary and for storage, and one for the mess, with six 
 common tents [96], two for non-commissioned officers, three 
 for privates, and one as a hospital kitchen. 
 
30 THE BKIGADE AND DIVISION FIELD HOSPITALS. 
 
 THE BRIGADE AND DIVISION FIELD HOSPITALS. 
 
 25. The brigade hospital, although a great advance on 
 the regimental system, was found defective on many oc- 
 casions during the Civil War -when the brunt of the battle 
 fell on a particular part of the line. A higher organiza- 
 tion was found to be necessary; and this was effected by 
 consolidating the brigade hospitals of the same division 
 into a division field hospital. One medical officer exercised 
 supervision over its various parts, the brigade hospitals be- 
 coming merely wards or sections of this larger organization. 
 This consolidation, effected, it might be said, under fire on 
 the field of battle, continued to the end of the war to give 
 thorough satisfaction to those who had most experience of 
 the difficulties to be overcome. 
 
 26. At the post hospital the ambulance wagon is one of 
 the belongings of tlie hospital, and when there is need for 
 its use the driver and attendant litter-bearers are temporary 
 assignments from the hospital force; and with small de- 
 tachments in tlie field, it similarly forms part of the field 
 hospital. But when the field hospital has reached that 
 stage of its growth which requires the presence of a sur- 
 geon in charge for its proper management, the ambulance 
 service must be placed under a special officer, for on im- 
 portant occasions the duties of the ambulance service lead 
 it where the surgeon in charge cannot be present to super- 
 intend, 
 
 27. The members of the hospital corps on duty with the 
 ambulances of the division are organized under the com- 
 mand of an officer, with brigade sections under junior offi- 
 cers especially assigned, and with stewards and acting 
 
THE BRIGADE AND DIVISION FIELD HOSPITALS. 21 
 
 stewards as noncommissioned officers. The strength of 
 the command is proportioned to that of the division, and 
 is prescribed in orders. The maximum percentage of loss 
 which may befall a command depends upon the size of the 
 command. Some company always suffers more than the 
 average loss of the regiment, some regiment more than the 
 average of the brigade, and so on. The larger the com- 
 mand, the less the percentage of loss. Suppose that 1,500 
 men were struck down in the division of 10,000 men. 
 The records of the civil war show 4.665 men wounded for 
 every man killed; in the years 1898 and 1899 7.4 men 
 were wounded for each man killed, and in 1900 3.1 men 
 were wounded for each killed outright. Of the 1,500 
 struck, about 270 would remain for burial, while 1,2;!0 
 would be entered on the list of wounded. The number of 
 those who reach the hospital without assistance is always 
 large, but it is relatively larger after severe engagements, 
 for when the dressing and ambulance stations are crowded 
 many will undertake the journey on foot rather than wait 
 for the return of the wagons. Of 245,790 gunshot injuries 
 recorded in the Surgical History of the War of the Re- 
 bellion, 56 per cent, were wounds of the upper part of the 
 body and upper extremities, including fractures of the 
 bones of the hand, which did not prevent their recipiei;ts 
 from finding their way to the rear without the assistance of 
 the ambulance service. This disposes of 689 of the 1,230 
 cases. Twenty-four per cent, were fractures of the upper 
 extremities, flesh wou.nds of the lower extremities, and 
 fractures of the bones of the foot which did not require 
 operative procedure at the hospital. These cases, number- 
 ing 296 of the 1,230, may be regarded as having been able 
 to bear transportation in the sitting posture. The remain- 
 ing 20 per cent., or 246 of the 1,230 cases, were of such a 
 
22 THE BRIGADE AND DIVISION FIELD HOSPITALS. 
 
 nature as to require carriage by ambulance or litter in the 
 recumbent position. Viewing the capacity of an ambulance 
 at seven, six inside and one with the driver, and allowing 
 one recumbent passenger to be equivalent to three seated, 
 the number of seats required for the transportation of the 
 wounded in the division which lost 1,500 men in killed and 
 wounded would be 1,033, or about three trips for each of 
 the 50 ambulances. Of course, an ambulance may make 
 its trip without being fully loaded, but as a rule, when the 
 wounded are as plentiful as in the case supposed, there is 
 seldom any spare space in a wagon which is starting from 
 a dressing-station. 
 
 The tabulations of gunshot injuries in the Reports of 
 the Surgeon General show that during the calendar years 
 1898 and 1899, 3,872 men were shot in action, of whom 
 431 were killed, or 1 killed to 8 wounded. Of the 3,441 
 whose cases were entered on the hospital registers, 40.4 
 per cent were presumably able to reach the hospital on 
 foot and 35. 6 per cent, by carriage in the sitting posture, 
 while 24 per cent, required transportation in the recumbent 
 position. From these data may be calculated the number 
 of ambulances required, or the number of trips to be made 
 by a given number of ambulances to cap ry off the wounded, 
 corresponding to a loss of 1,500 men in the division. 
 
 28. Existing orders do not provide specifically for the 
 personnel of the Division Hospital. Its organization is 
 left to the discretion of the chief surgeon. Under the 
 pressure of war conditions the medical staff may be 
 strengthened by the assignment of contract surgeons. A 
 steward, an acting steward, and ten or more capable hos- 
 pital corps privates for each brigade, in addition to the 
 teamsters of the supply wagons, are required for efficient 
 service. When the hospital is crowded with wounded after 
 
THE BRIGADE AND DIVISION FIELD HOSPITALS. 23 
 
 a battle, details may be made from the raaks of the litter- 
 bearers whose special duties for the time being have ceased. 
 
 29. The surgeon in charge is responsible for the care of 
 the sick and wounded on the march and in camp, and for 
 the comfort and general welfare of the wounded when 
 brought to his establishment by the ambulance service. 
 He makes requisition for medicines, medical and hospital 
 stores, supplies, and property, and is responsible for their 
 proper expenditure or use: An executire officer aids him 
 in his work of supervision, and has special charge of the 
 records. A subsistence officer superintends the cooking and 
 diet of the' hospital, drawing rations from the Subsistence 
 Department, issuing to the brigade sections, and keeping 
 the accounts of the hospital fund; he has also special 
 charge of the hospital stores and of such articles of hospital 
 property as are connected with the cooking and serving of 
 
 ' food. A division steward looks after all articles of prop- 
 erty borne on the returns of the surgeon in charge, taking 
 care that by timely requisitions all deficiencies are made 
 good and the hospital is always j^repared for the possible 
 emergency. 
 
 30. The attending surgeon cares for the sick of his brigade 
 on the march and in camp, and during an engagement looks 
 after the management of his wards, making notes of oper- 
 ative procedures, deaths, and of the progress of cases for 
 subsequent report to the surgeon in charge and entry on 
 the records of the hospital. Each brigade section requires 
 for its complement a steward and one or more acting stew- 
 ards, the former to exercise general supervision and to have 
 charge of the medical supplies and instruments, the latter 
 to act as wardmasters. In the wagon train should be car- 
 ried from thirty to forty hospital tents, with picks, spades, 
 and other implements for use in pitching the tents, trench- 
 
34 THE BBIGADE AND DIVISION FIELD HOSPITALS. 
 
 ing the ground, digging sinks, burying the dead, etc. ; bed- 
 sacks and blankets, and cots, mattresses, and pillows for 
 special cases. The svirgeon in charge 'should endeavor to 
 have cots or spare litters for all the cases that his canvas will 
 cover, but restricted means of transportation usually pre- 
 vent this. Woollen and light rubber blankets are brought 
 from the field with the wounded, go that the hospital stock 
 is made? use of only in cold or wet weather, or to supply 
 occasional necessities. Sheets, drawers, and socks should 
 be provided to replace those that have become unfit for use. 
 Eations of bread and beef stock, tea, coffee, sugar, and salt 
 are carried for use during an engagement to insure food to 
 the wounded until communication is opened with the main 
 supply trains after the battle ; and when this communica- 
 tion has been effected these stores should be immediately 
 replaced to provide for the next emergency of the kind. 
 The ambulances may also be utilized for the transportation 
 of such supplies. Each should be fitted up with a water- 
 keg and a locked box, the latter containing beef stock, tea, 
 sugar, and hard bread, except in one instance in each 
 brigade, in which the contents should consist of aiises- 
 thetics, morphine, antiseptics, and dressings. Each should 
 also be provided with an axe, lantern, candles, and an iron 
 pail which can be used in case of need as a camp-kettle. 
 By this arrangement field supplies and stores are found by 
 the side of the wounded as soon as they are brought from 
 the field, and the work of the hospital can progress on this 
 preliminary supply until the arrival of the main train. 
 The heavy wagons of the hospital carry also the ordinary 
 army ration for its employees and sick for the number of 
 days that will elapse before new issues are made from the 
 base or general supply train ; the kitchen outfits ; the tents 
 and personal baggage of the officers ; the blanket-rolls of 
 
ON THE MARCH. 25 
 
 the men, and forage for the horses and mules. The weight 
 and bulk of this material are such that ten six-mule army- 
 wagons will suffice for its transportation. The capacity of 
 an army wagon, on good roads and with full forage for the 
 animals, is about 3,000 pounds. A blacksmith's forge 
 accompanies the train. 
 
 ON THE MARCH. 
 
 31. Camp is usually broken up soon after reveille. Am- 
 bulance-drivers and teamsters groom, feed, and water their 
 animals ; litter-carriers pack up their shelters and blankets, 
 and fill the ambulance kegs with fresh water, while nurses 
 and cooks attend to their respective duties. After break- 
 fast, the sick are examined and medicines prescribed and 
 provided for their use during the day. They are then trans- 
 ferred to the ambulances, while the hospital tents and bed- 
 ding, kitchen utensils, and other property are packed up 
 and stowed away in the heavy wagons, which by this time 
 have reported for their loads. The ambulances, medical 
 wagons, and those carrying the subsistence of the hospital 
 usually take position in the column of march immediately 
 in rear of the division ; but the transport wagons remain in 
 camp until the troops of the army corps or of the army 
 have passed, when they join the column of the regimental 
 baggage, ordnance, subsistence, and forage wagons, under 
 the protection of the rear guard of the army corps or army. 
 Generally, these wagons come into camp at the close of the 
 day's march shortly after the troops and their ambulances 
 have reached it ; but occasionally the conditions are such 
 that the separation is for a longer period. 
 
 32. The ambulance train on the march receives those 
 who have fallen out of the column from accident or disease. 
 
26 ON THE MARCH. 
 
 Usually each of these new cases has been examined by the 
 regimental medical officer and furnished with a permit to 
 await the passage of the train. The march has its sufferers 
 as well as the battlefield. With raw troops, the sick and 
 exhausted accumulate from day to day, untij. it becomes 
 necessary to relieve the ambulances by sending the serious 
 cases to the base of supplies. In -the absence of trans- 
 portation, this excess of sick may have to be left in extem- 
 porized quarters, or, if need be, in a section of the field 
 hospital establishment. 
 
 33. At the conclusion of the day's march, when not im- 
 mediately in front of the enemy, the ambulances are halted 
 in rear of the division. AVhile waiting the arrival of the 
 baggage wagons, the sick are examined and treated. Such 
 as are considered fit for duty are sent under charge of a 
 steward to their regiments; and a notification is sent to 
 regimental surgeons in the case of men admitted without 
 permits and retained as unfit for duty, that these men may 
 be properly accounted for on the regimental reports. 
 Meanwhile wood and water are procured, and the fires are 
 lighted. 
 
 34. As soon as the baggage train arrives, as many hos- 
 pital tents as will accommodate the sick are unloaded, 
 pitched, and provided with such bedding and other articles 
 as may be needful, after which the litter-bearers transfer 
 the sick from the ambulance wagons. The tents of the 
 officers are then pitched. Meanwhile, the cooks provide a 
 refreshment of tea, coffee, or consomme. Later in the 
 evening dinner* is served. Pending its preparation, the 
 ambulances and baggage wagons are parked in rear of the 
 tents, and the horses and mules fed, watered, and groomed, 
 while the litter-bearers pitch their shelters between the 
 wagon park and hospital tents, and trench around the 
 
ON THE BATTLEFIELD. 27 
 
 wards to keep their floors dry in case of rain. With dinner 
 the labors of the day are at an end, save for the wagon 
 guard, the hospital guard, if the season requires one to 
 attend to the fires, and the special work of medical officers 
 and nurses in particular cases. In the establishment of 
 this camp each man, by drill and experience, knows his 
 particular duty, and by doing it well enables the whole to 
 be accomplished with ease and rapidity. Less than an 
 hour will suffice to transform a deserted field into a hospital 
 settlement as orderly and perfect in its field appointments 
 as if it had been in existence there for many days. 
 
 ON THE BATTLEFIELD. 
 
 35. To meet the emergencies of battle, a standing order 
 is issued the requirements of which take effect as soon as it 
 is evident that a struggle is imminent. This order pre- 
 scribes the duties of each medical officer during the antici- 
 pated engagement. An operator and assistants report to 
 the surgeon in charge of the hospital for duty in each 
 brigade section. The other medical officers are assigned to 
 duties on the field or at the hospital, as may be determined 
 by the chief surgeon. A severe engagement seldom takes 
 place without premonitory signs. The chief surgeon is 
 aware of what is impending, and satisfies himself that his 
 command is well in hand As soon as he learns the posi- 
 tion of the line of battle, he indicates to the surgeon in 
 charge, personally or by messenger, his views as to the 
 location of the hospital The ambulance officer, on his re- 
 turn from a survey of the roads leading to the front, may 
 be the bearer of this information. The particular locality 
 in this neighborhood is selected by the surgeon in charge, 
 with due consideration to questions of water and fuel, dry- 
 
28 ON THE BATTLEFIELD. 
 
 ness of site, facility of communication with main roads, 
 and availability of neighboring buildings as hospital acces- 
 sories. 
 
 36. The hospital should not be too near the front. 
 Nothing is so depressing to the wounded, already more or 
 less prostrated by their injuries, than exposure to fire while 
 under the hospital flag, as it is suggestive of a disaster to 
 the line of battle Even in the best-disciplined establish- 
 ments the effect is sometimes demoralizing. The hospital 
 cannot be moved farther to the rear under these circum- 
 stances without detriment to the wounded already brought 
 in, while those on the field would have to be left for so 
 much longer before obtaining shelter and care. Nor, for 
 manifest reasons, should the hospital camp be too far from 
 the front. A distance of from one and a half to two miles 
 will give f^iir security; while, if the roads are good, there 
 will be little delay in the transport of the wounded. The 
 immediate vicinity of a farmhouse, country seat, or other 
 dwelling affords many advantages. Water, fuel, and direct 
 communication with the main roads are usually associated 
 with it ; it offers a point of prominence for the display of 
 the hospital flag, should it become exposed to the fire of 
 the enemy; and its rooms may be made use of as adjuncts 
 to the hospital should the number of wounded exceed the 
 capacity of the tents to accommodate them. 
 
 37. If the hospital train is not on the ground, special 
 messengers are despatched to hasten and guide it, and on 
 its arrival the men of the hospital corps proceed with the 
 routine work of unloading, pitching, trenching, and furnish- 
 ing the tents, building fires, and preparing for the issue of 
 beef soup, tea, and coffee, every section or part of the work 
 under the personal supervision of an officer, every squad 
 controlled by a noncommissioned officer, and every man 
 
ON THE BATTLEFI,ELD. 29 
 
 familiarized by practice with the duties required of him. 
 At the same time, on the ground allotted by the surgeon in 
 charge, each brigade steward has the operating fly of his 
 command pitched and furnished with its table, instruments, 
 antiseptic solutions, dressings, and supplies pending the 
 arrival of the operating staff from the front 
 
 38. On orders issued by the Adjutant General of the 
 Division the services of musicians and members of the 
 dmm-corps may be utilized in pitching tents and preparing 
 the hospital camp for the reception of the wounded. 
 Thereafter they may be employed according to their indi- 
 vidual capacities, the main body, however, being assigned 
 to duty as the police party of the camp. Some medical 
 officers have reported against the use of drum-corps details 
 for such duties on the ground that they are troublesome 
 and unmanageable; others, however, have credited them 
 with valuable services. 
 
 39. Meanwhile, at the front, the chief surgeon supervises 
 the arrangements for first aid to the wounded Existing 
 orders require that the wounded shall receive attention at 
 three points on their way to the division hospital : 1st, on 
 the line of battle ; 2d, at the first dressing-stations, and 3d, 
 at the ambulance stations. 
 
 40. The attention they receive on the line is that afforded 
 by the litter-bearers of the ambulance company, who have 
 reached the front, under command of their company officers 
 and stewards. First aid here is limited to giving water or 
 some restorative, relieving the wounded man from harmful 
 pressure of equipments, and getting him by the shortest 
 and safest route to the dressing-station. Dangerous bleed- 
 ing is controlled by pressure, and fractured limbs are ad- 
 justed for transportation on the litter. 
 
 41. The dressing-stations are situated at the nearest point 
 
30 OK THE BATTLEFIELD. 
 
 where protection may be obtaiaed from musketry fire. If 
 the men are fighting behind breastworks, the best protec- 
 tion may be on the line itself ; otherwise, advantage is taken 
 of some superficial depression, gully, ravine, fence, wall, 
 or building, two or three hundred yards in rear. Under 
 such cover as he can find, each medical officer who has been 
 assigned to this duty takes position with a steward and 
 orderly. The amount of surgical work performed here is 
 greatly affected by circumstances. If the cases are numer- 
 ous or the station exposed, many may be permitted to pass 
 to the ambulances after a glance at their condition and a 
 caution to permit no unauthorized handling of the wound, 
 while the attention is mainly devoted to arresting bleeding, 
 removing shock, and supporting fractures in slings or light 
 splints for ease in transportation. But if casualties are 
 infrequent and the station well protected, flesh wounds may 
 be thoroughly cleaned with boiled water, the first aid dress- 
 ing applied, and the patient tagged to intimate that further 
 interference is unnecessary. Dressing-stations are dis- 
 tinguished during the day by Eed Cross flags and at night 
 by red lanterns. 
 
 42. The ambulance stations are situated as close to the 
 rear of each brigade as the nature of the ground will per- 
 mit. Here the medical officers clean and place protective 
 dressings on wounds that escaped attention at the first 
 dressing-stations, marking such as require no further in- 
 vestigation, and also such as seem to call for immediate 
 operative procedure. They superintend the loading of the 
 ambulances, and see that every case is in the best possible 
 condition to undertake the journey to the hospital. The 
 topographical features of the battlefield are often such that 
 the first dressing-stations and ambulance stations may be 
 consolidated. When the ambulances can get close up, there 
 
ON THE BATTLEFIELD. 31 
 
 is 110 need for an intermediate halt in the removal of the 
 wbunded ; and when the roads and the ground permit of it, 
 ambulance stations should be established at more than one 
 point in rear of a brigade, in order to shorten the distance 
 over which the wounded have to be assisted or carried. In 
 the event of an advance or a yielding of the line of battle, 
 a corresponding change of position of the dressing and 
 ambulance stations must be effected. In the former case, 
 a few of the ambulances follow up the advancing line, leav- 
 ing the greater part to clear the field before participating 
 in the forward movement. In the latter case, positions 
 are assumed in rear of the re-formed line, except when the 
 hospital becomes exposed, in which case special orders 
 from the chief surgeon determine the further movements. 
 
 43. Generally, some time before the first ambulance load 
 of wounded arrives from the front, the surgeons on duty at 
 the hospital are engaged in receiving, dressing, or operating 
 on, injuries of the hand and flesh wounds attended with 
 little hemorrhage or shock. These cases probably left the 
 field stations without waiting for attention and made the 
 journey unaided and on foot. Each is assigned to a specified 
 ward, the acting steward or wardmaster of which is there- 
 after responsible for his comfort. Shelter-tents are pitched 
 at regular intervals near the hospital tents to form the 
 ward for these lighter cases. Hospital-corps or drum-corps 
 men attend to this work, trenching the ground, weather- 
 guarding the open ends of the shelters, and providing some 
 material, as hay, straw, freshly cut grass, leafy twigs, 
 wood-shavings, etc., for bedding. If no suitable material 
 can be found in the immediate vicinity, one of the now- 
 empty transport wagons may be despatched to some point 
 where a supply may be obtained ; and if no such point is 
 known, a detachment of the drum-corps^ under responsible 
 
32 ON THE BATTLEFIELD. 
 
 leadership, may be sent out as foragers. During inclement 
 weather these slighter cases may be housed in the as yet 
 unoccupied hospital tents until their special camp is pre- 
 pared. When thus systematically camped, their wants are 
 not overlooked, as each wardmaster has his duties aggre- 
 gated and defined. 
 
 44. When ambulances arrive from the field, the whole 
 staff of the hospital becomes at once engaged. Should the 
 reports from the front indicate that ,the tents will be in- 
 sufficient for the accommodation of the wounded, the flies 
 are moved forward to extend the wards, and extra bedsacks 
 are filled with such material as may have been collected. 
 If this extension is insufficient for the shelter of the in- 
 coming wounded, the neighboriag dwelling or its outhouses 
 may be utilized. 
 
 45. The end and aim of the work of the hospital is to 
 have all operations that are imperatively called for com- 
 pleted and the wounded ready for transportation to the base 
 of supplies at the earliest possible moment, because an ad- 
 vance or retreat is sure to follow the battle unless it has 
 left both sides unfit for immediate aggression. The im- 
 portant part of this work falls upon the operating staff. 
 The surgeon in charge should therefore see that these offi- 
 cers are provided with a steady succession of cases until 
 the work is finished. Time lost in field surgery is lost be- 
 tween cases for want of that systematic direction which 
 enables all to be constantly employed. 
 
 46. The chief surgeon provides the transportation for the 
 removal of the wounded from the hospital. If railroad or 
 steamboat communications are available, the ambulances of 
 the division may be used to convey the sick and wounded 
 to the station or wharf; but if the journey is one of con- 
 siderable length, these wagons should not be employed uu- 
 
ON THE BATTLEFIELD. 33 
 
 less they can return to the hospital in time to secure need- 
 ful rest before the march is renewed. Ambulances from 
 the base may sometimes be sent forward to relieve the 
 hospital. Usually, however, the empty wagons of the 
 subsistence and ordnance trains are employed. The sur- 
 geon in charge superintends the loading of these wagons, 
 and provides the medical officers to accompany them, with 
 such articles of food and medicine as are needful for the 
 journey. He may have to part with many of his mattresses, 
 bedsack.s, and blankets in outfitting the train, but requisi- 
 tions to replace them, and to replenish supplies generally, 
 may at the same time be transmitted to the purveyor at 
 the base. 
 
 47. The medical officer in charge of the wagon train, 
 railroad train, or steamboat, should be provided with a 
 nominal list of the sick and wounded intrusted to his care. 
 Frequently, however, the military conditions are such that 
 no list of names can be made out. At starting he may be 
 able to learn of his train merely that it consists of so may 
 medical of&cers, or, if small, of so many stewards and act- 
 ing stewards, each of whom reports himself responsible for 
 so many men and their supplies. On delivering up his 
 charges to the authorities at the base hospitals, he should 
 report back to the surgeon in charge of the division hos- 
 pital all the deaths or other losses that have occurred dur- 
 ing the journey, that they may be entered on the register 
 and communicated through regimental surgeons to the com- 
 pany officers on whose muster-rolls the names of the men 
 in question are carried. 
 
 48. If, as an immediate result of the battle, the enemy 
 withdraws to another position, it is not necessary for the 
 hospital to follow up the advance of the troops unless the 
 distance is considerable. Should this be so, the hospital 
 
 3 
 
34 ON THE BATTLEFIELD. 
 
 moves forward, carrying the wounded, if few in number, 
 with it, or leaving them in a detached section of the estab- 
 lishment until they have been put in condition to undertake 
 a rearward journey in the supply wagons. 
 
 49. Should the battle be indecisive, the losses will prob- 
 ably be great, but time will usually be afforded for the 
 completion of the surgical work, because neither party is 
 in a condition to renew the contest. The hospital, there- 
 fore, remains undisturbed probably for several days; but 
 so great is the uncertainty of battlefield conditions that 
 every effort should be made to complete the surgical work. 
 Promptly on the cessation of the battle, medical officers 
 who have been on duty at the stations report to the surgeon 
 in charge for assignment to temporary duty at the hospital. 
 Extra surgical help may also be drawn from the base or 
 general hospitals, if telegraphic and railroad connections 
 have been kept up. 
 
 50. Should the troops in the line of battle be driven 
 back, the exposure of the hospital is unavoidable, unless 
 anticipated by prompt action on the part of those in charge. 
 The hospital and its accumulated wounded should be moved 
 to a suitable site in rear of the new position . The wounded 
 left upon the field must be cared for by the medical depart- 
 ment of the opposing force ; but such as have reached the 
 shelters prepared by friends should not be given up without 
 the strongest efforts to save them. Medical officers and 
 members of the hospital corps should be officially detached 
 to remain with any left behind; and shelter, bedding, 
 medical and hospital supplies, and food should be amply 
 provided for them. Tents and supplies thus lost should 
 be replaced by immediate requisitions on the supply 
 depots. 
 
 51. If the disaster is so serious that none of the wounded 
 
ON THE BATTLEFIELD. 35 
 
 can be removed, the surgeon in charge and ambulance offi- 
 cer should endeavor to preserve the organization by with- 
 drawing the ambulances, wagons, supplies, stores, and per- 
 sonnel not specially assigned to remain with the wounded. 
 When the hospital is thus disabled, an immediate renewal 
 of hostilities necessitates the occupation of the available 
 buildings in the vicinity of the new site ; but this utilization 
 of pre-existing shelter would have been necessary if, with- 
 out the repulse, the wounded had been equally numerous. 
 
 52. If the disaster involves the capture of the transporta- 
 tion and supplies, while certain of the officers and men 
 have escaped, these must be organized by the senior medical 
 officer for the duty of caring for the wounded who may 
 fall in the skirmishes of a subsequent retreat. Notwith- 
 standing breaks in the ranks, their training holds them to- 
 gether for this special service until the command is re- 
 enforced and refitted. 
 
 53. When a regiment or brigade is detached for perma- 
 nent assignment to some other command, it carries with it, 
 when needful, its section of the ambulance company, hos- 
 pital property, and transportation ; but when this detached 
 command is en route to a rendezvous where it can be re- 
 fitted, its section of the hospital is left behind and applied 
 by the chief surgeon in repairing deficiencies in other 
 brigades, or is held subject to disposal by higher authority. 
 
 54. The Treaty of Geneva has of late years done much 
 to mitigate the sufferings of the wounded of a defeated army. 
 The Articles of the Convention, which were adopted by 
 every European power and the majority of the South 
 American States, at different times since 1864, provide :— 
 1st. For the neutrality of ambulances on the battlefield, 
 and military hospitals as long as they contain any sick ; 
 2d. For *lie neutrality of the staff, medical, and administra- 
 
36 ON THE BATTLEFIELD. 
 
 tive officers, attendants and litter-bearers; 3d, That the 
 neutrality of these persons should continue after the oc- 
 cupation of their hospitals by the enemy, so that they may 
 stay or depart as they choose; 4th. That if they depart 
 they may take only their private property with them, ex- 
 cept in the case of ambulances, which they may remove 
 entire ; 5th. That a sick soldier iu a house shall be regarded 
 as a protection to it, entitling the occupant to exemption 
 from quartering of troops and from part of the war requisi- 
 tions; 6th. That wounded men shall, when cured, be sent 
 back to their own country on condition of not bearing arms 
 during the rest of the war; 7th. That hospitals and am- 
 bulances shall carry, in addition to the flag of their nation, 
 a distinctive and uniform flag having a red cross on a white 
 ground, and that their staff shall wear an arm badge of the 
 same colors, the delivery of which shall be left to the mili- 
 tary authorities ; 8th. That the details shall be left to the 
 commanders of the armies. The 9th and 10th articles are 
 formal and signatory. 
 
 55. In 1898 the War Department issued orders to the 
 following effect : 
 
 All persons connected with the Medical Department of the 
 army in the field, or referred to in Article 11 of the treaty, 
 shall wear habitually during the war, on the left sleeve of 
 the coat, midway between the shoulder and elbow, a brassasrd 
 or arm-badge, consisting of a red cross on a white ground. 
 
 All hospitals, ambulances, and field stations of the Med- 
 ical Department will habitually display the Eed Cross flag 
 accompanied by the national flag. 
 
 Permits, in duplicate, for civilians to be present with the 
 army, m the service of the Medical Department, may be 
 given by authority of a division commander ; one copy of 
 the permit will be retained by the person neutralized, and 
 
ON THE BATTLEFIELD. 37 
 
 its duplicate should be forwarded promptly to the Chief 
 Surgeon of the Army. 
 
 Persons neutralized under this authority will report 
 themselves at once to the Chief Surgeon of Division for 
 instructions. 
 
 The wearing of the arm brassard by any person not offi- 
 cially neutralized is prohibited. 
 
 The War Department recognizes for any appropriate co- 
 operative purposes the American National Eed Cross as the 
 civil central American committee in correspondence with 
 the International committee for the relief of the sick and 
 wounded in war. 
 
 56. Officially there is only one Eed Cross, that of the 
 Geneva Convention ; but many good people in certain coun- 
 tries, when the treaty was signed, formed themselves into 
 Eed Cross societies to collect funds and stores for relief 
 purposes when war should come; and these societies as- 
 sumed the Eed Cross as their flag and insignia. They 
 have, however, no legal or official status in connection 
 with the army, and are entitled only to such privileges as 
 the military authorities may desire to extend to them iu the 
 interest of the sick and wounded, 
 
 57. When the army goes into a comparatively permanent 
 camp, as in winter quarters, during sieges, or in the oc- 
 cupation of hostile territory, the sick and wounded need not 
 be sent away unless they accumulate beyond the capacity 
 of the hospital to accommodate them. Commanding ofiicers 
 generally approve of retaining the men in the field hospital, 
 as return to duty on recovery is better assured than from 
 distant hospitals. They therefore further the efforts of 
 the medical department in improving the condition of the 
 hospital. Lumber is obtained, and the tents are framed, 
 floored, and weather-boarded, while shelves, tables, and 
 
38 FIELD REPORTS AND PAPERS. 
 
 benches are put in, with suitable stoves or brick fireplaces 
 to warm the wards. Boardwalks are laid, and the grounds 
 fenced in and thoroughly policed. As thus established the 
 field hospital presents an air of permauence and stability ; 
 but it should be kept in proper drill, and ready at a few 
 hours' notice to be packed up and following the division 
 in the column of march. 
 
 OFFICIAL PAPERS. 
 
 58. The medical records of field service in time of war 
 have an importance which is not always recognized by those 
 who are responsible for their accuracy and completeness. 
 While facing the suffering of the battlefield the mind be- 
 comes careless of prospective considerations, and sometimes 
 looks upon the preparation of reports and papers as akin to 
 substituting the so-called red tape of bureaucratic methods 
 for the antiseptic dressings of the practical surgeon ; but 
 the value of these records may be at once appreciated when 
 it is realized that they are the corner-stone on which the 
 pension system is built. Defective records may cause 
 much suffering in the future by delaying or preventing the 
 establishment of just claims for relief. 
 
 59. The senior medical officer of each regiment co-operates 
 with company of&cers in providing the regimental com- 
 mander with the materials for his Field Return of killed, 
 wounded, and missing, which is filed in the oifice of the 
 Adjutant General, as the official record of the losses. The 
 senior medical officer is called upon also to forward to the 
 chief surgeon duplicate lists of wounded within two days 
 after an engagement. Outside of these battle returns the 
 only reports required from this officer are the morning and 
 monthly reports of sick and wounded of his regiment. His 
 
FIELD EEPOETS AKD PAPERS. 39 
 
 moiDing report is for the regimental commander, but a 
 duplicate is sent to the chief surgeon. His monthly report 
 should show those treated with the regiment ajid should 
 record as cases completed, so far as his report is concerned, 
 those that have been transferred to the Division hospital. 
 In large commands, as an army corps, a weekly report may 
 suffice to keep the chief surgeon informed as to the condi- 
 tion of the troops; but the medical officer on the staff of 
 generals of brigade or division may call for a copy of the 
 daily morning report. The monthly report forms a part 
 of the permanent record, and is transmitted to the Surgeon 
 General [16]. 
 
 60. The surgeon in charge of the field hospital reports 
 his sick and wounded daily to the chief surgeon for com- 
 parison with the reports from the regiments ; and monthly 
 to the Surgeon General through the chief surgeon. He is 
 accountable for the medical and hospital property and sup- 
 plies in use, signing all requisitions, and making annual 
 returns. He reports the personnel of the hospital corps 
 daily to the chief surgeon, and monthly to the Surgeon 
 General and chief surgeon [14]. As commanding officer 
 of the hospital corps, he keeps the accounts of the pay, 
 clothing, etc., of its members, including their final state- 
 ments in case of discharge or death, the executive officer 
 relieving him of the details of these duties. He is re- 
 sponsible also for the subsistence of his hospital and for 
 the proper expenditure of its hospital fund, the subsistence 
 officer aiding him in these duties. 
 
 61. The ambulance officer is charged with the care of the 
 pay, clothing, and subsistence accounts of his men, and is 
 held responsible for the care of the ambulances, wagons, 
 tents, horses, mules, forage, etc. 
 
CHAPTER III. 
 
 SANITARY CAEE OF CAMPS. 
 
 62. The site of a camp is of the first importance, because, 
 in the event of its insalubrity, no exercise of care in the 
 sanitary government can protect from evil consequences. 
 Ordinarily, in selecting a site the health and comfort of 
 the men is the first consideration; but when a military 
 object is in view, the ground must be selected and the 
 camp arranged for that object, other considerations being 
 merely secondary. 
 
 63. Dryness of site is essential to the healthfulness of a 
 camp ground. It depends on the inclination of the surface 
 and the ijorositj- and depth of the subsoil. The natural 
 drainage of a place is good when the surface sheds the 
 rainfall into neighboring watercourses, or when the surface 
 layers are so porous as to soak up the rainfall and drain it 
 off to lower levels by underground channels. The natural 
 drainage is bad, and the site damp and insalubrious, when 
 a level or slightly undulating clayey surface retains the 
 rainfall in shallow pools, or where the level of the subsoil 
 tvuter is near the surface. The subsoil water is that which 
 is found in digging shallow wells — rain-water which, having 
 penetrated a porous surface, is upheld below by a stratum 
 of impervious clay. 
 
 64. Moist soils, under their most favorable aspects, in- 
 duce catarrhs, sore throat, and other internal inflammations, 
 
OAIIP DISEASES, 41 
 
 r 
 
 develop consumptive and rheumatic tendencies, and, by 
 depressing the vitality of the system, render it an easier 
 prey to the attacks of other diseases ; they are also in warm 
 climates or seasons favorable to the development of the 
 mosquito, by which man becomes infected with the malarial 
 organism [75], the cause of intermittent, remittent, and 
 ' congestive fevers, enlargement of the spleen, congestion of 
 the liver, many neuralgic affections, and that broken-down 
 condition of the system found in individuals who have lived 
 for some time in marshy districts. 
 
 65. There are other points which enter into the con- 
 sideration of camp sites. Advantage in cold climates 
 should be taken of hills and woods as a protection against 
 wintry winds ; and in hot climates, of woods for shade, if 
 not so dense as to interfere with ventilation ; prevailing 
 winds should be observed, that the camp may be placed 
 to windward of swamps or other insanitary localities. In 
 the mountain districts of warm latitudes the nightly breeze 
 from hill to plain must be remembered in its bearing on 
 the healthfulness of sites. Canons are hot during the 
 day, oppressive at night by radiation from heated rocks, 
 and liable to inundation from rain-clouds on the mountains ; 
 the reflected glare from sand and rock is often distressing 
 and injurious to the men. A dusty site is hurtful to the 
 eyes, combined, as it usually is, with a garish light ; more- 
 over, dust, like mud, renders the best-disciplined troops 
 careless of their personal appearance and weakens the 
 hygienic government. Old camping-grounds should be 
 avoided on account of their filthy condition and the prob- 
 ability of their infection [76]. 
 
 66. Experience has shown that troops may be aggregated 
 in camps on a healthy site without the occurrence of dis- 
 ease among them. Camp diseases are therefore preventable 
 
43 CAMP DISEASES. 
 
 diseases. Among the diseases usually regarded as camp 
 diseases are : 
 
 67. Those occasioned by exposure to climatic or meteoro- 
 logical influences, such as catarrhs, bronchitis, inflammation 
 of the tonsils, larynx, or lungs, rheumatism, congestion of 
 the spinal membranes, simulating to some extent rheumatic 
 troubles, congestion of the bowels leading to diarrhea and 
 dysentery, ophthalmia, sunstroke, etc. Inadequate cloth- 
 ing and shelter induce a greater prevalence of these morbid 
 conditions among troops on active service in the field than 
 among men surrounded by the comparative comforts of 
 civil life ; and the attacks are generally of greater severity 
 on account of the more intense action of the cause and the 
 sometimes exhausted condition of the troops, but in other 
 respects there „s nothing special in these diseases when 
 they are found in a military camp. 
 
 68. Errors of diet, attributable to faulty cooking, indi- 
 vidual indulgence, imperfect mastication, and improper food, 
 are prolific sources of intestinal irritation which may end 
 in dysenteric ulceration. The term improper food includes 
 all articles which have suffered damage by imperfect preser- 
 vation, and meat which, while on the hoof, has been over- 
 •driven, badly fed, or affected with disease, or which has 
 been kept too long in the slaughter-house after killing, or 
 in the haversack after issue or cooking ; and to these must 
 be added many of the articles that are sold by sutlers and 
 traders. Organic impurities in the drinking-water, and an 
 excess of those salts which give hardness to a water, are 
 occasionally responsible for diarrheal attacks. When the 
 internal congestions which result from the malarial infec- 
 tion involve the intestinal mucous membrane, diarrheas are 
 produced. Foul odors, as from unpoliced sinks orunburied 
 carcasses, also occasion diarrheal efforts to rid the system 
 
CAMP DISEASES. 43 
 
 of the noxious matters -which have been absorbed from the 
 air. Moreover, any influence which interferes with the 
 normal action of the skin, as rapid cooling after cessation 
 of exercise, may be a cause of diarrhea. 
 
 69, Scurvy. Diet deficient in quantity predisposes the 
 soldier to disease by lowering the resisting powers of his 
 system. "When defective in quality from a sameness in- 
 volving a deficiency of the salts that are contained in fresh 
 vegetables and acid frujts, a taint of scurvy becomes mani- 
 fest. This shows itself first in loss of spirits and disin- 
 clination for exertion, muscular pains simulating rheuma- 
 tism, a slight tumefaction of the gums where they embrace 
 the teeth, a slight fetor of the breath, and, perhaps, when 
 specially looked for, some small spots of ecehymosis, like 
 flea-bites, on the skin of the calf or other parts of the lower 
 limbs. In all commands that have been confined to a salt 
 ration for some time, these symptoms should be carefully 
 looked for and promptly suppressed by an improved dietary. 
 When the possibility of scurvy is not held in view, such 
 cases are liable to be confounded with muscular rheumatism 
 or diarrhea, for the latter disease, occurring in a scorbutic 
 patient, is persistent and may for a time be held account- 
 able for the deteriorated condition. Later, when the gums 
 become swollen, spongy, and bleeding, the teeth loose, 
 and the skin covered with ecchymosed patches, hard swell- 
 ings, and foul ulcerations, there is no doubt of the char- 
 acter of the cases ; but the disease should not be permitted 
 to give such manifestations of its existence in a military 
 camp. 
 
 70. Intoxicants. Camp hygiene requires the absolute 
 banishment of alcoholic liquors from the lines. The medi- 
 cal and court-martial records of all camps where whiskey 
 could be procured furnish data sufficient for insistanee on 
 
44 AEMY ITCH. 
 
 its exclusion as the cause of much disease and many injuries 
 and violent deaths. 
 
 71. When a contagious disease appear* in a command, 
 it is important that it should be recognized at the earliest 
 possible moment, for overcrowding in camps with a want 
 of the proper facilities for cleanliness causes a rapid spread 
 of the disease. 
 
 72. Itch oe scabies usually makes its appearance on 
 the hands, in or about the clefts of the fingers, and from 
 this it spreads over the body and limbs, affecting chiefly 
 the flexures of th€ joints and other parts where the skin is 
 thin ; the head and face are seldom involved. It consists 
 of distinct reddish points with a minute bead of liquid at 
 the apex ; but as the intolerable itching leads to scratching 
 and subsequent inflammation, its vesicular character is often 
 obscured. It is caused by a minute insect, the acarus 
 scahiei, which burrows in the skm near the vesicles. When 
 the insect is killed the inflammation subsides immediately. 
 Sulphur ointment at night, with a thorough scrubbing in 
 the bath-tub in the morning, repeated on two or three suc- 
 cessive days, effects a cure. Clothing, bed-linen, and 
 blankets should be boiled to destroy their contagion. 
 
 73. A disease called aemy or camp itch must be distin- 
 guished from the parasitic scabies or itch of civil life. It 
 is developed in hot weather during an active campaign 
 when neither time nor facilities for personal cleanliness are 
 available. The over-stimulation of the skin during the 
 perspiration of hiirried marches, combiaed with the rough 
 contact of coarse-fibred underclothing, gives rise in some 
 sensitive constitutions to an eruption of minute papules 
 which itch intolerably, particularly during the night, when 
 the attention of the individual becomes fixed on his cutane- 
 ous sensations. This condition is known as prickly heat. 
 
ARMY ITCH. 45 
 
 In aggravated cases the papules are torn during the efforts 
 of the patient to find relief by scratching, and the surface 
 presents many dj-ied points of dark blood. Dust and dirt 
 accumulate on the irritated skin and intensify tlie irritation. 
 The pi'dU-iihiH carporls or body louse may ajipear under 
 conditions of filth and overcrowding, and the irritation of 
 its presenca augments the mental and bodily disquietude of 
 the affected individual. When any or all of these irritative 
 causes produce in some parts papules with darkened sum- 
 mits, and in others scabs and crusts of dried, purulent 
 matter with a thin, acrid liquid oozing from their cracks 
 and fissures, the disease is called camp itch. It affects the 
 chest, abdomen, and outer aspect of the limbs, while scabies 
 is generally found in the clefts of the fingers, the flexures 
 of the joint.s, the inner aspect of the limbs, and other 
 similarly protected parts. Rest in hospital with baths, the 
 removal of all sources of irritation, and lead lotion or some 
 antiseptic ointment, will usally control the disease. Dhobie 
 iteh is a name given to ringworm and other parasitic skin 
 diseases common in the Philippine Islands. Clothes sent 
 to a native laundry may come back infected. 
 
 74. Three species of pedlculi occasionally find favorable 
 conditions for their development on the uncared-for human 
 surface. One of them, that mentioned in the preceding 
 paragraph, will sometimes in a prolonged campaign appear 
 in a squ.ad or company, spreading from man to man by the 
 contact of blankets or baggage. Its body is whitish, elon- 
 gated, and somewhat flattened. It makes its abode and 
 deposits its ova or nits along the seams or folds of the inner 
 garments. The other species are rarely seen in military 
 commands. They are the pediculus capitis, which infests 
 the scalp, and the pediculus pubis, which may spread from 
 its nominal locality ovej- the whole of the surface except 
 
46 MALARIAL FEVERS. 
 
 the scalp. The one is smaller in size than the pedieulus 
 corporis, but is otherwise of similar appearance ; the other 
 is square-shaped, flattened, and provided with crab-like 
 claws. Both deposit their nits about the roots and stems 
 of the hair. Personal cleanliness with the application of 
 red precipitate or mercurial ointment, and the boiling or 
 burning of infected clothes, will speedily free the indi- 
 vidual from such undesirable companionship. 
 
 75. Malarial feveks are caused by the presence Of 
 microscopic parasites in the blood. This was discovered 'in 
 1880 by a French army surgeon named Laveran, while 
 studying malarial fevers at his station in Algeria. The 
 presence of these parasites, the plasmodia malaria}, in the 
 blood is now accepted as the only fact on which a positive 
 diagnosis should be based. The life history of the Plas- 
 modium outside of the human body has not been made out 
 with accuracy, but it is generally conceded that its germ is 
 transmitted to a healthy individual by the bite of a certain 
 species of mosquito which has previously sucked the blood 
 of a person affected with malarial disease. The mosquito 
 bite in this case is an infected wound [436] . 
 
 Formerly malarial infection was believed to be connected 
 with a fermentation of the organic matter in soils. For 
 the production of malarial manifestations there were sup- 
 posed to be needful: 1st, a certain amount of decaying 
 organic matter ; 2d, a certain proportion of moisture ; and 
 3d, a certain degree of heat. Under the combined influ- 
 ence of heat and moisture the organic matter undergoes a 
 fermentation during which the pernicious miasm was sup- 
 posed to be evolved. 
 
 This theory fitted well with much of our knowledge of 
 malaria. Dams, lakes, and ponds with an equable water 
 level and well-defined margins are not unhealthy, but 
 
MALARIAL FEVERS. 47 
 
 grounds that are alternately submerged and exposed are 
 malarious. The artificial draining of ponds and the ac- 
 cidental breaking of dams have occasioned disease in their 
 vicinity. Fever and ague prevail not during periods of 
 inundation, but during the subsequent periods of draining 
 and drying up, if the season be sufficiently warm. Shallow- 
 mill-dams that uncover a portion of their storage area dur- 
 ing the use of the water are more dangerous than those that 
 have depth enough to keep the area submerged. Shallow 
 creeks which open intt) salt water and are subject to tidal 
 influences are generally malarious. 
 
 Malaria was considered to be diffused into the atmosphere 
 with some difftculty. When it drifted with the wind its 
 course was along the ground, for in an unhealthy locality 
 it is more dangerous to sleep on the ground or on the ground 
 floor of a house than on a higher level. The wind, how- 
 ever, carried the infection but a short distance, and a growth 
 of trees between a pestilent marsh and a settlement has 
 frequently protected the latter from disease ; while, con- 
 versely, the removal of a screen of trees has been followed 
 by an invasion of malaria from the neighboring swamps. 
 But although most of the recorded observations on the at- 
 tributes of malaria are explicable by the theory of an ex- 
 halation from the soil during its fermentation, there are 
 some exceptional points. Thus, when organic matter and 
 moisture are present, the evolution of malaria should be 
 proportioned to the degree of heat, yet it is well known 
 that places which are deadly after sunset may be traversed 
 with impunity when the sun is high in the heavens. 
 
 It has now, however, been demonstrated that the Plas- 
 modium of Laveran is conveyed from the sick to the well 
 by a certain species of mosquito, the Anopheles ; and this 
 explains satisfactorily all the observations that have been 
 
48 MALARIAL EEVEES. 
 
 made on the propagation of malarial diseases. Marshy- 
 districts in warm climates and seasons are insalubrious be- 
 cause they present conditions favorable for the breeding of 
 the Anopheles. Thorough drainage and cultivation of the 
 soil lessen the prevalence of malarial fevers , because they 
 destroy these favorable conditions. The breaking in of 
 fresh ground for agricultural purposes, or its upturning in 
 building, road-making, etc., gives rise to disease because 
 shallow pools of water in the irregularities of the surface 
 of the upturned ground form favorite breeding-places for 
 the Anopheles. Infection occurs at night because this 
 mosquito flies only at night. It used to be said that malaria 
 loved the ground ; we now understand this to mean that 
 the Anopheles does not fly high. 
 
 The bite of this mosquito conveys no infection unless it 
 has previously fed on the blood of an infected person. The 
 Plasmodia are taken into the stomach of the insect and 
 thence they penetrate into the tissues of its body, where 
 they mature in the course of a week and give rise to a 
 swarm of germs which are drawn off into its salivary gland 
 and injected into the system of those who are afterward 
 bitten by this mosquito. One infected insect may convey 
 malarial disease to a number of men during the course of a 
 single night. 
 
 Experimenters have lived in- places notorious for their 
 malarial insalubrity and have suffered no harmful effects, 
 by simply protecting themselves from the bite of the 
 Anopheles. During their stay in the unhealthy locality 
 they exposed themselves in the open air only when the sun 
 was above the horizon, and exercised the utmost care that 
 every opening in their dwelling was carefully guarded with 
 mosquito netting. On the other hand, infected mosquitoes 
 have been sent to a non-malarious region where as a crucial 
 
MALARIAL JBVERS. 49 
 
 experiment they -were permitted to bite healthy individuals. 
 These were speedily seized with well-dehned malarial fever 
 and in their blood the Plasmodium was readily discovered. 
 
 The common mosquito, named Culex, does not carry 
 malarial infection. It is therefore desirable to be able to 
 distinguish between Culex and Anopheles. The former has 
 a thick body and a thin proboscis ; the latter a slim body, 
 a thick proboscis, and, generally, spotted wings. When 
 resting on a wall the tail of Culex hangs down parallel to 
 the wall, while the tail of Anopheles projects outward at 
 nearly a right angle from the wall. The larvse or wrigglers 
 of the two kinds may also be distinguished. Culex breeds 
 in water stored in barrels, tubs, cisterns, etc. , Anopheles 
 in rain-water collected in irregularities of the surface, 
 particularly in those containing greenish water-weed. 
 When at rest at the surface of the water the larvae of Culex 
 hang head downward, and when disturbed they wriggle at 
 once to the bottom. Those of Anopheles float fiat on the 
 surface, and when disturbed wriggle on the surface with a 
 backward skating movement. 
 
 Protection against malarial diseases is obtained by care 
 in the selection of a dry and well-drained camp site, and the 
 avoidance of all fatigues and exposures which would tend 
 to lower the vitality of the system. Troops on active field 
 service in malarious localities should carry mosquito netting 
 with them to close the ends of their shelter tents or other- 
 wise secure protection against the Anopheles. In camps of 
 a more or less permanent character the larvae of the 
 mosquitoes should be destroyed by sweeping out once or 
 twice a week all shallow puddles and emptying all collec- 
 tions of stagnant water which might serve as breeding- 
 places. Quicklime has been suggested as of value in kill- 
 ing the larvae. Kerosene oil is efl&cient by choking the air 
 4 
 
50 TYPHOID FEVEK. 
 
 tubes of the wrigglers. The oil should be applied by 
 painting the surface of the water twice a month with a rag 
 fixed on a stick as a paint brush. At permanent posts all 
 useless collections of water in which mosquitoes breed 
 should be filled up or drained away. Quinine destroys the 
 Plasmodium in the blood and is thus an efficient remedy. 
 It is sometimes given as a preventive when troops are to be 
 exposed on night duty in places known to be dangerous. 
 
 76. Typhoid fevbk is propagated chiefly by the in- 
 testinal discharges of an infected individual. It is a 
 specific disease affecting the individual but once, as in that 
 one attack it exhausts his susceptibility to its deleterious 
 influence. Every new regiment, particularly if raised in 
 a healthy country district, contains young men who are 
 susceptible to the disease, and their number gives a corre- 
 sponding susceptibility to the regiment. Such a command 
 will suffer more from its localized epidemic of typhoid fever 
 than one raised in the tenement districts of a city in which 
 the disease is constantly present, for many of the young 
 men from the unhealthy city have already undergone their 
 experience of typhoid fever. During the Civil War the 
 infectious nature of typhoid fever was not recognized. In 
 the large hospitals cases of this fever were treated in the 
 general wards. With a marching command the blankets 
 of a regimental or division hospital were baled for trans- 
 portation in the morning and at the close of the march were 
 distributed indiscriminately to typhoid-fever patients or 
 other invalids. No thought was given to the water supply 
 as a factor in the spread of the disease, although every 
 creek which furnished the supply of some part of a large 
 command was probably defiled by the drainage from up- 
 stream camps. With our present knowledge of the causa- 
 tion of typhoid fever we find no difficulty in accounting for 
 
TYPHOID FEVER. 51 
 
 the rapid spread and continued prevalence and fatality of 
 the disease among the volunteei- troops of that period of 
 our history. 
 
 In 1898, during the concentration of troops for the 
 Spanish-American War, typhoid fever was introduced into 
 the camps and spread as rapidly as during the Civil War. 
 This was owing to ignorance on the part of officers and 
 men of the dangers attending the neglect of proper sanitary 
 care in the disposal of excreta. The infection of typhoid 
 fever is contained in the excreta of an affected individual. 
 The sinks or privy pits became infected Waste ground in 
 the vicinity became soiled by men who did not use the 
 sinks. Sometimes the sinks were too shallow or too full 
 and overflowed during rains, infecting the soil in their 
 proximity, which afterward became dried into dust and 
 pervaded the atmosphere of the camp. Flies swarmed in 
 these infected places and brought infection to the food on 
 the mess tables. The tents, blankets, and clothes of the 
 men became soiled, dust-covered, and infected, and the 
 disease spread rapidly It was, however, as speedily con- 
 trolled by abandoning the infected camp and spending ten 
 days or two weeks on new ground before going again into 
 a camp intended to be cf some permanency. The infection 
 does not declare itself by decided sickness for ten days or 
 two weeks after it has been received. This is called the 
 pnriod of incubation. In moving from an infected camp 
 the infection is not wholly left behind. Sunlight and the 
 airing of tents, clothing and blankets on the new ground 
 tend to dissipate infection, but even with a thorough dis- 
 infection of these the germs of the disease would be carried 
 to the new camp in the persons of the men who became in- 
 fected in the old camp and had not yet passed through the 
 period of incubation. Every suspect during these ten days 
 
52 DTSENTEET AND CHOLEBA. 
 
 of probation should be kept under medical supervision and 
 be removed to a general hospital as soon as the specific 
 character of the disease has been defined [339]. In this 
 way the disease may be shaken off ; but if the sanitary care 
 which should have protected the first camp from typhoid 
 infection be not exercised in the new camp, the fever will 
 undoubtedly recur among the troops by the iatroduction 
 of a fresh case from some infected command or locality. 
 
 77. Dtsbntbey, like typhoid fever, has its infection ia 
 the discharges from the bowels, and when it prevails the 
 utmost care must be taken as to the disinfection of the 
 sinks, the general cleanliness of the camp, and the purity 
 of the water supply. A change to a new camping-ground 
 is always beneficial. 
 
 78. Choleka cannot be considered a camp disease, as it 
 is as prone to attack the civilian as the soldier. In fact, 
 the camp being mobile and under better discipline may 
 sometimes be preserved while neighboring cities are pros- 
 trated with the disease. All the measures suggested for 
 limiting the spread of typhoid fever are applicable in the 
 management of cholera cases. In the presence of an epi- 
 demic, the purity of food and drink requires every care. 
 With the exception of fruits that are protected by an outer 
 rind, no article of food should be eaten that has not been 
 subjected to heat in its preparation for the table. Disin- 
 fectants should be freely used in the sinks, as the dejections 
 of choleraic diarrhea are as infectious as the rice-water dis- 
 charges of defined cholera. If the camp site become in- 
 fected, security can be obtained only by promptly with- 
 drawing from the dangerous region. If troops fall back 
 before the advance of the disease or pass to one side of the 
 line of its advance, they will escape seizure, provided 
 judicious quarantine restrictions are imposed on intercourse 
 
YELLOW FEVER. 53 
 
 with infected localities. When, however, such a retreat is 
 iucompatible with strategic requirements, a line of sentinels 
 should be posted around the camp to cut off all unauthorized 
 communication. No person should be admitted within the 
 lines without undergoing quarantine examination ; no bag- 
 gage or supplies without being disinfected or passed by the 
 quarantine officer. Water-supply, if it comes from with- 
 out, or if a suspicion of contamination from without can be 
 harbored against it, must be boiled before being used, even 
 for police purposes ; while any pure supply should be placed 
 under guard for use as drinking water. Should it be im- 
 possible to procure such supply by other means, it ought 
 to be boiled, distilled, or filtered through germ-proof filters. 
 Police regulations should be scrupulously carried out. The 
 troops should be protected from all antihygienic influences. 
 There should be no unnecessary exposure to sun, rain, or 
 night air, and no drills or fatigue , duties other than to 
 furnish occupation and needful exercise. When the mili- 
 tary conditions permit, the camp should be viewed as en- 
 gaged in an active campaign against an insidious and im- 
 placable enemy, and the attention of every officer devoted 
 to superintending the conduct of his men with special 
 reference to this view. 
 
 79. Yellow Fever. The recent experiments of the 
 board appointed to investigate yellow fever at Quemados, 
 Cuba, Major Walter Reed, surgeon U. S, A., president, 
 have a most important bearing on the modes by which pro- 
 tection against yellow fever may be secured. A small 
 camp of non-immune young men, mostly belonging to the 
 hospital corps, was formed in an open field about a mile 
 from Quemados. After this camp had been occupied long 
 enough to show that yellow fever in its incubatory stage 
 was not present, five of the men permitted themselves to 
 
54 YELLOW FEVER. 
 
 be bitten by mosquitoes ( CiiZex fasciatus) which had pre- 
 viously been contaminated by being fed with the blood of 
 patients suffering from yellow fever. In from three to five 
 days thereafter each of these men became the subject of a 
 well-defined attack of the disease and was sent to the yel- 
 low-fever hospital. It was found that after the parasite 
 was taken into the stomach of the insect a certain number 
 of days had to elapse before the mosquito was capable of 
 reconveying the disease to man. This period, about twelve 
 days in summer and eighteen during the colder weather of 
 winter, represents the time required for the parasite to pass 
 from the insect's stojnach to its salivary glands. 
 
 In a second series of experiments four non-immunes were 
 injected with one or two cubic centimetres of blood from 
 yellow-fever patients. Within the usual time each of these 
 was attacked and sent to the fever hospital, while four of 
 the men who had suffered from infection transmitted by 
 the mosquitoes manifested no bad effect from a similar in- 
 jection of yellow-fever blood. Their mosquito-conveyed 
 infection had rendered them immune to the disease. 
 
 A third series of experiments was carried out to deter- 
 mine whether the disease can be conveyed by clothing and 
 bedding which have been contaminated by contact with 
 yellow-fever patients and their discharges. A small hut 
 was built with a door and two windows on the same side 
 to prevent any perflation of air, and well guarded against 
 mosquitoes by wire screens. The building was heated to 
 summer temperatures. It was kept securely closed during 
 the day, but in the evening Acting Assistant Surgeon R. P. 
 Cooke and two hospital corps men, all of them non-immunes, 
 entered and unpacked three boxes which contained sheets, 
 pillow-cases, blankets, etc,, taken from the beds of yellow- 
 fever patients in the Las Animas Hospital of Havana. 
 
YELLOW FEVER. 55 
 
 Many of these articles had been purposely soiled with 
 black vomit, urine, and faecal matter. Each was unfolded 
 and shaken to disseminate any infection that might be 
 present in them through the air of the room. These soiled 
 sheets, pillow-cases, and blankets were used by the experi- 
 menters in preparing their beds, while others were hung 
 around the room. The three non-immunes passed twenty 
 consecutive nights in this manner. During the day they 
 occupied a tent in the immediate vicinity and were kept in 
 strict quarantine. After this a fresh stock of soiled articles, 
 including pajamas, undershirts, nightshirts, sheets, blank- 
 ets, etc., taken from the persons and beds of fever patients, 
 was obtained, and two non-immune Americans occupied the 
 room for twenty-one nights and slept in the very garments 
 that had been worn by yellow-fever patients. At the end 
 of this period they went into quarantine and were released 
 five days afterward in perfect health. A third time this 
 experiment was repeated by two non-immunes for twenty 
 nights with similar results. 
 
 Meanwhile another small building was constructed with 
 doors and windows in opposite walls to give good ventila- 
 tion and with a wire screen extending from floor to ceiling 
 in the middle to divide it into two compartments. Every 
 article before admission into this room was carefully disin- 
 fected by steam. Fifteen infected mosquitoes were set free 
 in one compartment, into which a non-immune hospital 
 corps man entered and was bitten on three occasions. Four 
 days afterward he was removed to the yellow-fever wards. 
 The other compartment was occupied for eighteen nights 
 by two non-immunes whose health remained perfect. 
 
 The board therefore concluded that yellow fever is not 
 conveyed by fomites, and hence disinfection of articles of 
 clothing, bedding, or merchandise, supposedly contaminated 
 
56 SMALL-POX. 
 
 by contact witli those sick with the disease, is unnecessary ; 
 that a house may be said to be infected with yellow fever 
 only when there are present within its walls contaminated 
 mosquitoes capable of conveying the parasite of this dis- 
 ease; and that the spread of yellow fever can be most 
 effectually controlled by measures directed to the destruc- 
 tion of mosquitoes and the protection of the sick against 
 the bites of these insects. 
 
 The precautions now taken for the protection of the 
 troops serving in Cuba are stated in orders as follows : 
 
 1. The enforcement of the use of mosquito bars in all ban-acks 
 and especially In all hospitals. 
 
 3. The destruction of the larvae or young mosquitoes, commonly 
 known as "wiggle-tails " or " wlgglers," by the use of petroleum on 
 the water where they breed. 
 
 The mosquito does not fly far, and seeks shelter when the wind 
 blows; so it is usually, the case that every community breeds its 
 own supply of mosquitoes, in the water barrels, fire buckets, or un- 
 dralned puddles, post holes, etc. An application of one ounce of 
 kerosene to each fifteen square feet of water once a month will de- 
 stroy not only all the young but the adults who come to lay their 
 eggs. The water in any cistern or tank is not aflected in the least 
 for drinking or washing purposes if only it is drawn from below 
 and not dipped out. For pools or puddles of a somewhat perma- 
 nent character draining or filling up is the best remedy. It is rec- 
 ommended that the medical officer who makes the sanitary inspec- 
 tions at each post be charged with the supervision of the details of 
 these precautions. 
 
 80. Small-pox. — When an individual becomes affected 
 with headache and fever two weeks after he has been exposed 
 to the contagion of small-pox, his case should be regarded 
 as suspicious, particularly if there be much pain in the loins 
 and obstinate vomiting. On the third day of the fever 
 small reddish points appear on the forehead and nose. 
 
SMALL-POX. 57 
 
 Next day similar points are found on the neck, chest, and 
 arms, while those on the forehead have become darker in 
 color and larger, feeling like small shot under the skin ; 
 meanwhile, as the eruption comes out the fever abates. 
 These developments authorize the immediate isolation of 
 the patient under the care of special nurses, who should be 
 protected by fresh vaccine lymph, even though they bear 
 the scars of small-pox itself. The command should then 
 be inspected with the view of protecting by revaccination 
 those who have not recently undergone the operation. By 
 isolation is meant the transfer of the patient to a separate 
 ward, room, or tent, where he will have communication 
 with none save those in attendance, and where the inter- 
 course of the latter with the outside shall be so regulated 
 as to prevent the transmission of infection. 
 
 81, Vaccination is effected by punctures, scratches, or 
 abrasions made with a surgically clean lancet. When 
 lymph is taken from the vesicles of a healthy vaccinated 
 child on the eighth day of its vaccination the operation is 
 said to be arm-to-arm vaccination. This is the best way 
 of dealing with children under ordinary circumstances. 
 But when large numbers of persons have to be vaccinated 
 without delay on account of probable exposure to contagion, 
 fresh lymph must be obtained in quantity, dried on quills 
 or ivory points, in the form of crusts, or made up into 
 cones. Vaccine lymph derived from a vesicle on the arm 
 of a vaccinated person is said to be humanized ; when ob- 
 tained, as it generally is, by artificial cultivation on the 
 calf, it is called bovine lymph. In operating by puncture, 
 which is suitable only for persons with thick skins, a some- 
 what blunt lancet is run horizontally under the cuticle or 
 scarf skin for about 2 mm. Three such punctures are made 
 close to each other, and three others at a distance of 
 
58 SMALL-POX. 
 
 3 cm. from the first set. A little of the lymph is then 
 inserted into each puncture. If ivory points are used, 
 the lymph must be moistened with cool water, which has 
 been recently boiled, before insertion ; fragments of crusts 
 or cones must be rubbed up with a drop or two of water to 
 the consistence of cream. Instead of punctures, two sets 
 of light scratches may be made, each covering a space 
 about 5 mm. in diameter and 3 cm. apart, into which the 
 lymph is rubbed with the flat of the lancet, ivory point, or 
 quill. In the case of tender skins which bleed readily, it 
 is better to scrape the surface at the two points until the 
 cuticle is removed, and then rub in the lymph as into the 
 scratches. The slight wounds should be protected by 
 sterilized cotton held in place by a strip of plaster. The 
 outer aspect of the left arm is usually selected as the site 
 for vaccination. In exposing this site it is advisable as a 
 rule to drop the clothes from the shoulder rather than to 
 roll up the sleeves, for the latter if tight will by their 
 pressure engorge the arm, promote the oozing of blood, and 
 prevent absorption. The area to be vaccinated should be 
 sterilized by thoroughly scrubbing with soap and water, 
 using a scrub brush and following with alcohol. The skin 
 should be permitted to dry by evaporation before beginning 
 the operation. 
 
 82. On the third day after the insertion of the lymph in 
 a primary or first vaccination, a slight reddish tumefaction 
 is observable, which next day is tipped with a little clear 
 lymph. This vesicle increases in size until the eighth day, 
 when it becomes umbilicated or depressed in the centre and 
 surroimded by an areola of cutaneous inflammation. The 
 lymph is now mature and fit for use in other cases. By 
 the tenth day the inflammation extends an inch or more in 
 all directions from the vesicle, which loses its pearly color 
 
SMALL-POX. 59 
 
 and becomes turbid and purulent. At this time there is 
 usually a slight feveiishness, and the glands in the armpit 
 may be swollen. In a day or two the pustule breaks and 
 dries up into a brownish crust, the inflamed areola mean- 
 while disappearing. The crust falls off about the twenty- 
 first day, leaving a characteristic, slightly depressed cicatrix. 
 
 83. When one who shows scars of a successful vaccina- 
 tion is subjected to revaccination, the progress of the vesicle 
 as above described is often modified by the influence of the 
 primary vaccination.* The vesicle and its areola may be 
 smaller and the crust fall off at an earlier date. Vaccina- 
 tion protects from small-pox ; but as its influence fades in 
 time, it does not continue to protect completely, although 
 it renders the disease, which is then usually called vario- 
 liild, less protracted and less dangerous to the individual 
 than it otherwise would have been. So vaccination protects 
 from revaccination ; but as its influence fades, it does not 
 protect completely, the resulting vesicles being modified as 
 small-pox would have been modified had the individual 
 been infected with the matter of the small-pox pustule in- 
 stead of with that of the vaccine vesicle. These modified 
 results of revaccination must therefore be recorded as suc- 
 cessful operations because they exhaust the existing sus- 
 ceptibility to small-pox. 
 
 84. The convalescent from small-pox should be kept in 
 isolation until the skin is free from crusts. Infected cloth- 
 ing or bedding should be destroyed by fire or disinfected 
 by boiling, steam, sulphur fumes [336], or formaldehyde 
 [332] . Tents, when not required for further use as pest 
 hospitals, should be burned. Infected rooms are disinfected 
 by fumigating with sulphur or by cleaning away all dust, 
 washing with solution of corrosive sublimate or chlorid of 
 lime [333], and freely ventilating. 
 
60 SOAELET FBVEE. 
 
 85. Chicken-pox. — It is sometimes of importance to 
 distinguish between chicken-pox and small-pox or so-called 
 varioloid. The onset of both is by fever ; but in small-pox 
 the fever is severe and lasts for three days before the 
 papules appear, while in chicken-pox it is mild and pre- 
 cedes the eruption of vesicles by twenty-four hours only. 
 The vesicles of small-pox are umbilicated and take nine 
 days to mature ; those of chicken-pox are usually rounded 
 and begin to dry up by the end of the third day. Small- 
 pox lasts three or four weeks ; chicken-pox runs its course 
 in eight or nine days. The chicken-pox patient should be 
 isolated from ■ other children until the skin is free from 
 crusts or scabs. The clothes and bed-linen should be dis- 
 infected by boiling ; the room by thorough cleaning, swab- 
 bing with solution of corrosive sublimate, and free ventila- 
 tion. 
 
 86. Scarlet fever manifests itself from three to five 
 days after exposure to the contagion. Marked feverish- 
 ness, redness of the throat, and perhaps pain or dtflB.eulty 
 in swallowing are its first symptoms. At the end of 
 twenty-four hours an eruption of small scarlet dots appears 
 on the neck and chest, and afterward on other parts of the 
 surface, coalescing first into large, irregularly shaped 
 patches, and by the end of the second day into a generally 
 diffused efflorescence. The eruption lasts from four to six 
 days, during which the fever continues and the throat affec- 
 tion becomes aggravated, the fauces swollen, and the tonsils 
 covered with soft, yellowish sloughs. A scarlet-fever pa- 
 tient should be carefully isolated, no matter how mild the 
 disease may be in that particular case ; for although mild 
 cases are sometimes called scarlatina, their contagion is as 
 dangerous to others as that of the most aggravated case of 
 the disease. Isolation should be kept up until the des- 
 
MEASLES. 61 
 
 quamation of the skin has been completed. Bed-linen and 
 body-clothing should be boiled, and the room and all articles 
 that would be injured by boiling fumigated with sulphur 
 [336] or formaldehyde [332], the walls and floors being 
 subsequently treated with corrosive sublimate or chlorid of 
 lime [333] in solution. 
 
 87. EosBOLA. — It is sometimes impossible to distinguish 
 cases of this unimportant rash from mild cases of scarlet 
 fever. The appearance of the eruption is similar in both, 
 and in both there may be no other symptom on which to 
 base a diagnosis. In uncertain cases it is best to isolate as 
 if scarlet fever were under treatment. 
 
 88. Diphtheria. — When a patient has slight sore throat 
 with white spots or grayish-white patches on the mucous 
 membrane of the tonsils or adjoining parts, he should be 
 put in isolation as a case of diphtheria. The local symptoms 
 are sometimes preceded by feverishness and pains in the 
 back and limbs. The membranous patches may extend 
 over the pharynx and into the nasal cavity. The glands 
 of the neck become swollen and the breath extremely fetid. 
 Death may occur from suffocation if the larynx and trachea 
 are invaded. As the bacillus of the disease resides in the 
 discharges from the affected mucous membrane, all expec- 
 torated matters should be disinfected and all swabs and 
 cloths used in cleaning the mouth or throat should be 
 burned. The patient should be kept at rest in bed until 
 all symptoms of the disease have subsided, for death not 
 unfrequently occurs from syncope or heart failure. When 
 the case has terminated, the room and its contents should 
 be disinfected as after scarlet fever. 
 
 89. Measles. — About eight days after exposure to the 
 contagion, the patient becomes affected with feverishness, 
 cold in the head, and sometimes also in the chest. When 
 
63 EOTHBLN OR GEEMAN MEASLES. 
 
 these have continued for three or four days, the eruption 
 appears on the face, and in the course of four days more it 
 has spread over the neck, chest, abdomen, and limbs; but 
 by the time the later crops are appearing the earlier are 
 already fading. The eruption consists of small dots, which 
 coalesce into irregular-shaped patches of a dull red color, 
 associated with slight tumefaction, particularly on the face. 
 The patient should be isolated until the fine scales of des- 
 quamation have been completely shed. Clothing and bed- 
 ding should be disinfected by boiling, and rooms by thorough 
 cleaning, washing with sublimate or fumigating with sul- 
 phur or formaldehyde. 
 
 When a regiment consists of susceptible material — that 
 is, of young men who have not had the disease — its effi- 
 ciency may be utterly- destroyed for two months or more 
 by the introduction of the infection. Individually the 
 cases as a rule are by no means dangerous to life, but the 
 conditions of service in the field are such that a satisfactory 
 convalescence is impossible, and many men have subse- 
 quently to be discharged on account of persisting pulmo- 
 nary complaints. Under such circumstances the regiment 
 should be relieved from duty and provided with comfortable 
 quarters and ample hospital accommodation until it has 
 recovered from its attack. In this way only can it be 
 saved from the deadly inroads of pulmonary disease, which 
 are sure to follow the eruptive fever when its convalescents 
 are subjected to the hardships and exposures incident to 
 service in the field. 
 
 90. EoTHBLN or German measles bears the same rela- 
 tion to measles that roseola bears to scarlet fever, or chicken- 
 pox to small-pox. When these mild diseases occur epidem- 
 ically, there is no difficulty in showing their differences 
 from the dangerous eruptive fevers which they resemble ; 
 
CAMP DISEASES. 63 
 
 but when the first cases occur, the doubt as to their char- 
 acter often calls for careful isolation and treatment until 
 their true nature has been revealed by further observation. 
 91. Typhus fevek was once the scourge of military 
 camps and of all other places in which men were closely 
 crowded together. Some of the names applied to it, camp, 
 ship, prison, and hospital fever, indicate its association 
 with overcrowding. But of late years the sanitary knowl- 
 edge which has insisted on a certain air-space for each in- 
 dividual and a certain ration of air to revivify the blood in 
 his lungs [238] has done much to stamp out its contagion. 
 The experience of recent wars has demonstrated that typhus 
 fever can be generated at will, and that, if this fever is 
 generated in a military camp, it is due to gross negligence 
 or ignorance on the part of those in authority, for the dis- 
 ease does not spring unexpectedly into existence full armed 
 for destruction, but gives successive warnings of its coming, 
 each more emphatic than that which came before. When 
 a number of men are confined in a limited and poorly ven- 
 tilated shelter, the organic emanations permeate and adhere 
 to everything, and continually taint the air. Overcrowd- 
 ing of this kind is incompatible with cleanliness even where 
 facilities for cleanliness exist, but in such cases these are 
 generally absent; and in consequence the fermentation of 
 extraneous filth usually combines with the natural exhala- 
 tions to alter the quality of the air and the constitutions of 
 those who have to breathe it. The inmates lose vigor and 
 appetite ; they are subject to digestive disorders and head- 
 aches, and their sleep is unrefreshing. They become less 
 able to withstand the ordinary exposures of service,' and 
 the febrile action which is associated with their bronchitis 
 or other local disease is of an obscure yet prostrating char- 
 acter, as if the system did not have vitality enough to react 
 
64 CAMP DISEASES. 
 
 and tliro-w off the disease in a free perspiration, or a transu- 
 dation from the affected mucous membrane. Presently, 
 pneumonia appears to be the only disease that is developed 
 by exposure, and this pneumonia is of that low or asthenic 
 character which is called typhoid. If malarial fevers are 
 present they are never well-defined and vigorous intermit- 
 tents, but obscure remittents that are doubtfully treated 
 with quinine — they have so much the appearance of true 
 typhoid. If the command is suffering from an epidemic 
 of typhoid fever the mortality rate is exceedingly high, as 
 the patients sink into a state of prostration from which it 
 is impossible to rally them. Moreover, at such times cases 
 of sudden death in the persons of those who have not here- 
 tofore been ailing occasionally cause alarm in the camp. 
 These are apparently due to some cause which deranges the 
 blood, producing internal congestions, and perhaps cutane- 
 ous eechymotic spots. They are called congestive fevers if 
 the camp is malarious ; malignant measles if that disease 
 is prevailing ; and virulent typhoid if the regiment is under- 
 going its typhoid seasoning ; while the presence of epidemic 
 cerebrospinal meningitis or si^otted fever is feared by some, 
 and typhus fever by others. At such times also there is an 
 alarming suggestion of contagion in the hospitals and 
 quarters, even in diseases which, like pneumonia, are not 
 ordinarily regarded as having any contagious qualities. 
 Many regiments during the Civil War suffered from disabling 
 and needless experiences of this kind from an utter want 
 of knowledge of the principles of camp sanitation on the 
 part of those who should have possessed that knowledge. 
 Fortunately this generation of the contagious typhus miasm 
 was checked at an early period. The condition of the 
 command attracted the attention of superior authority, and 
 some officer of experience, sent as an inspector, appreciated 
 
SANITAET CAKE OF CAMPS, ETC. 66 
 
 the typhus-generating conditions to which the men were 
 subjected, and speedily effected their removal. Some of 
 these regiments were hutted in small squads of three to five 
 men under shelter- [94] or wedge-tent [96] roofs, others 
 were aggregated in larger squads in the Sibley tent [100], 
 and others again quartered by companies in extemporized 
 barracks or in rude buildings specially erected for their 
 use ; but in all such instances there was an utter disregard 
 of the necessity for •ventilation and cleanliaess in addition 
 to the overcrowding of the men. The tent-covered huts 
 were usually dugouts [106] ; the extemporized quarters 
 wholly unfit for crowded occupation, and the barrack- 
 buildings hastily constructed shells, enclosing three-tiered 
 rows of beds, with no special provision for the introduction 
 of fresh air, and all the crevices of their imperfect con- 
 struction carefully stopped up by the men. 
 
 92. It will be seen from this brief review of the diseases 
 which prevail among soldiers in active service that they 
 are not peculiar to military camps. Greater exposures 
 give greater promiaence to the diseases that result from 
 exposure. Dietetic errors arising from many causes and 
 combining with other influences which occasion intestinal 
 congestions give a notable prevalence, persistence, and 
 gravity to diarrheal diseases. Contamination of the soil 
 and surroundings of camp, including its water supply, 
 promotes the generation and propagation of the typhoid 
 germ among young men who are susceptible to its influence ; 
 and the close contact of adjoining squads and companies 
 affords the best facilities for the transmission of contagious 
 diseases. But none of this increased prevalence and grav- 
 ity is directly and unpreventably dependent on the aggrega- 
 tion of so many men in camps. The typhus miasm or con- 
 tagion, which intensifies the danger of every other affection, 
 5 
 
66 SANITAKY CAEB OF CAMPS, ETC. 
 
 and is in itself, when fully endowed with its virulence, a 
 more deadly enemy than all the others to which the camp 
 is subject, is not inherent in the system of military camp- 
 ing, but is a development from local overcrowding in indi- 
 vidual tents, huts, barracks, or hospitals. 
 
 93. The infantry line of battle camp affords about 4.5 
 square yards of ground as the site of the quarters of each 
 soldier; and when each man bivouacks, wrapped in his 
 
 The shelter-tent ol the Civil War. 
 
 blanket, on this area, there is ample space for free ventila- 
 tion ; but if the men be grouped in squads under the shelter 
 of tents or huts, a most unhealthy condition may exist 
 within. A large tent is a dangerous shelter; for assuredly 
 as many men will be packed into it as it can hold. If 
 fifteen or twenty men lie shoulder to shoulder during the 
 night rebreathing a deoxygenated air laden with unwhole- 
 some exhalations from the lungs and skin, disease will ia 
 time make its appearance in the squad, no matter how 
 thoroughly the streets and intervals of the camp may be 
 ventilated, for the evil is within and not without the shelter 
 canvas. The larger the squad and the smaller the supex'- 
 ficies allowed it under shelter, the greater will be the danger 
 of the speedy generation of typhus or crowd-poisoning 
 among the men. The shelter-tent carried by troops in a 
 campaign has this great advantage over more ostentatious 
 
SANITAKT CAKE OP CAMPS, ETC. 67 
 
 quarters, that it breaks up the company into small squads 
 and scatters the men over the company area. 
 
 94. The shelter-tent of the Civil War was made of cotton 
 duck, -weighing eight ounces to the linear yard. Two 
 pieces, each about 5 feet 6 inches square, were required to 
 construct a tent. Each piece had buttons and button-holes 
 which permitted of its being fastened to any other piece. 
 
 The wedge-tent. 
 
 The lower edge was furnished with a loop at each comer 
 and one at the foot of the central seam by which the piece 
 could be pegged to the ground. Pegs and uprights were 
 issued as part of the tent, but soldiers generally relied on 
 the camp-ground to provide them with extemporized sub- 
 stitutes. Each piece weighed 2 pounds 6 ounces; and as 
 usually carried it was rolled with the blanket into a long 
 cylinder, which was slung from the shoulder to the opposite 
 hip, where the ends were tied together with the g^y-rope. 
 The shelter tent now issued differs from that of the Civil 
 War in having a triangular flap attached to each half, so 
 that when these are approximated the head end of the tent 
 is closed in. 
 
68 
 
 SANITARY CARE OF CAMPS, ETC. 
 
 95. The common, ivedge-, or ^-tent, sometimes issued 
 during the Civil War, had a spread of 8 feet 4 inches at the 
 base, and a height and length of 6 feet 10 inches. The 
 entrance was a perpendicular cut to the bottom in the cen- 
 tre of its front, which admitted of each half being thrown 
 back to expose its interior. It had a sod-cloth along its 
 lower edge to prevent the entrance of air below. It had 
 no provision for ventilation, and when rendered impervious 
 in wet weather by the swelling of its fibres, the only en- 
 trance or exit for air was between the closed lapels of the 
 doorway. This tent afforded better protection than the 
 shelter-tent, and in mild weather made excellent quarters 
 for two or three men. 
 
 96. This tent was superseded by what is known as the 
 common tent, which is practically the wedge-tent raised 
 from the ground by a wall 2 feet high. It is provided 
 
 The common tent. 
 
 with two ventilating apertures, one la front and one in the 
 back end of the tent near the top on the right side. Each 
 aperture has a flap or curtain on the inside which may be 
 tied down when necessary. 
 
 97. The wall tent for officers is similar in construction 
 
SANITARY CARE OF CAMPS, ETC. 69 
 
 to the common tent, but has a wall 3 feet 9 inches in height 
 and has four breadths of canvas in its length. 
 
 98. The hospital tent is a -wall tent with six breadths of 
 canvas in its length. Height when pitched 11 feet; length 
 of ridge 14 feet ; width 14 feet 6 inches and height of wall 
 4 feet 6 inches. A fly or extra canvas roofing is provided 
 for wall and hospital tents. 
 
 99, Capt. E. L. Munson, assistant surgeon, TJ. S. Army, 
 recently brought to the attention of the department a 
 
 The Munson tent. 
 
 modification of the hospital tent, by which effective ventila- 
 tion is secured and the temperature of the interior in hot 
 climates is materially lowered. The principle is applicable 
 to all tents provided with flies. The canvas of the roof for 
 2 feet on each side of the ridge-pole is replaced by heavy 
 rope netting with two-inch meshes. The fly is made fast 
 over a ridge-pole placed 1 foot above the roof ridge and 
 extending 2 feet in front and in rear beyond the roof. 
 When several of these tents are pitched end on to each 
 other to form a hospital ward or pavilion, a continuous roof 
 is formed by the large flies, while the tents themselves are 
 4 feet apart, through which passageways lateral ventilation 
 
70 SANITARY CAEE OF CAMPS, ETC, 
 
 is assured and free access to each tent, without having to 
 pass through the other tent sections of the pavilion. In 
 the illustration the &y is thrown back to show the netting 
 on the near side of the roof. 
 
 100. The Sibley tent, formerly used in our service, was 
 a conical tent, 18 feet in diameter at the base and 13 feet 
 high. The upper end of the cone was cut off and bounded 
 by an iron ring which was hung by chains from the top of 
 the central supporting pole. This pole ended below in a 
 tripod, by moving the legs of which the tent could be 
 heightened or lowered according as the dryness or wetness 
 of the weather relaxed or tightened the canvas. Ventila- 
 tion was provided for by the circular aperture at the top, 
 which in wet weather was closed by a cowl. It was in- 
 tended for seventeen mounted men or twenty foot-men. 
 
 The conical wall tent. 
 
 101. The conical wall tent, now issued by the Quarter- 
 master's Department, is a development from the Sibley 
 
SANITARY CARE OF CAMPS, ETC. 71 
 
 tent. It consists of the cone of the latter raised on a wall 
 3 feet in height and the whole reduced in diameter to 16 
 feet and in height to 10 feet. The figure on page 70 shows 
 the interior with stove and stovepipe in position for cold- 
 weather use. 
 
 102. The shelter-tent, however, is usually all that our 
 troops have to rely upon for protection from the inclemen- 
 cies of the weather during field service. If the occupation 
 of the camp is to last for more than one night, and espe- 
 cially if the site or'weather be damp, the men should build 
 bedsteads of poles and forked uprights on which to spread 
 the hay, straw, grass, or whatever they may be able to 
 procure as a mattress. Any further stay on the same 
 ground should be marked by improvement in the condition 
 of the shelters and the company and regimental areas, the 
 character of which will depend on the available material 
 and the influences from which protection is sought. Ee- 
 liance can generally be placed on the ingenuity of a body of 
 men to make the most of the materials at command ; but 
 their efforts must as generally be checked by intelligent 
 supervision. In summer camps or those of warm climates 
 there is little danger of harmful results ; the men seek the 
 air and only such protection from the heat and glare of 
 the sun and occasional wind and rain storms as will not 
 interfere with the cooling influence of free ventilation. 
 Such camps usually consist of the shelter-canvas roofing 
 over walls of leafy willow-work, with a canopy of brush- 
 wood erected high above the tents to afford a better shade. 
 But in winter camps, or those of cold climates, the attempt 
 to preserve a certain degree of warmth in the interior of 
 the shelters is virtually an effort at the suppression of 
 ventilation. 
 
 103. The general opinion of army medical officers is in 
 
73 SANITARY CARE OP CAMPS, ETC. 
 
 favor of huts for occupation during cold weather; and 
 many of those who have written on the subject have put 
 themselves on record as insisting on 40 square and 400 
 cubic feet per man, with double walls, raised floors, ridge 
 ventilation, and warmed air supply, all of which require- 
 ments imply the presence on the camping-ground of specially 
 provided material and labor ; but huts built hy the troops, 
 and huts built for them, are two different things. In the 
 settlement of a large army in its winter quarters the amount 
 of transportation required for an attempt to house it as 
 might be desired is not always available; hence the men 
 must often rely upon their shelter-tents and such materials 
 as are afforded by the country in the vicinity of their 
 camping- ground. 
 
 104. In the establishment of winter camps during the 
 Civil War four men usually joined their shelter-pieces to 
 
 Army of Potomac log hut. 
 
 form a roof over low walls, generally in a well-timbered 
 country constructed of logs. The length of this roof was 
 10 feet 8 inches, and its spread 7 feet ; but as the canvas 
 had to be brought down over the outer face of the logs, the 
 interior of the hut was lessened correspondingly. The hut 
 
8ANITAET CARE OF CAMPS, ETC. 73 
 
 had an area in the clear of about 10 by 6 feet, or sufficient 
 for two double bunks with the narrowest of passageways 
 between them. But what with absentees, sick, and on 
 furlough, and the regular details for guard and picket duty, 
 it seldom happened that more than three men passed the 
 night in the four-pieced hut. A broad bedstead for three 
 men was accordingly built at one end, leaving a space at 
 the other of about 3 by 6 feet as a living-room, on the floor 
 of which the occasional fourth man spread his poncho and 
 blankets at night. 'The doorway opened into this space 
 from the street ; a cupboard or shelves were placed in the 
 angle near it, and an open fireplace in the opposite wall. 
 The preservation of the chimney was a source of much 
 labor and constant anxiety to the occupants of the hut, as, 
 although sometimes built of stone or brick, it was more 
 frequently a narrow wooden shaft, with layers of clay to 
 prevent its timbers from catching fire ; yet it was deserving 
 of all the attention bestowed on it, for when in good work- 
 ing order it gave a cheerful warmth to the interior while in 
 steady operation as an efficient means of ventilation. 
 
 105. The experience of our Civil War has shown that 
 under certain conditions these small and rudely constructed 
 huts may give wholesome shelter to their occupants dur- 
 ing the inclement season with far less risk of the develop- 
 ment of diseases due to local overcrowding, or the spread 
 of those propagated by specific causes, than the large army 
 tents and squad barracks of the European services. These 
 conditions are : 1st. The site of each hut should be free 
 from moisture ; the sides of the company streets and inter- 
 vals should be deeply trenched, and transverse cuts made 
 between these, uniting them and mapping out the sites of 
 the individual cabins ; surface drainage from higher grounds 
 should be intercepted and turned aside ; if rain fall during 
 
74 SANITARY CAEB OF CAMPS, ETC. 
 
 the period of preparation and building, the canvas should 
 be pitched to protect the sites ; otherwise they are better 
 exposed. 2d. The floor should be cleared of all herbage, 
 the soil well stamped with sand and gravel, and subse- 
 quently concreted ; but if the site be retentive of moisture 
 the floor should be raised about a foot from the surface by 
 being made of split or dressed logs closely set, or of lumber 
 which may be raised from time to time to air the underly- 
 ing surface. 3d. The shelter- canvas should be so fastened 
 that it may be unhitched with readiness when it is desirable 
 to sun the interior. 4th. The chimney should draw well, 
 as being the only means of securing ventilation. 6th. The 
 interior should be inspected daily to insure perfect cleanli- 
 ness. 6th. The camp-ground, as a whole, should be in 
 good condition, for a satisfactory cleanliness of the person 
 and quarters cannot be expected if the surroundings counter- 
 act all efforts .to this end. 
 
 106. When these requirements are not observed the log 
 shanty speedily degenerates into a den of filth and disease, 
 unfit for human habitation. The soldier in cold weather 
 is prone to burrow, and special attention must be directed to 
 guard against this tendency. In fact, a protest must be 
 entered against everything which is conducive to dampness 
 of the interior. The earth must not be banked up on the 
 outside of the logs ; the floor must not be dug out to bring 
 its level below that of the surrounding ground, nor must a 
 side- hill be dug into to form a part of the end or side walls 
 of the proposed hut. When a hut is converted into a half- 
 sunk cellar by a combination of excavation inside and 
 banking up outside, it is impossible in damp weather to 
 preserve a healthsome, dry interior; and irrespective of 
 diseases due solely to humidity, as catarrhs, sore throats, 
 rheumatism, etc., there is imminent danger of the develop- 
 
SANITARY CARE OF CAMPS, ETC. 75 
 
 ment of noxious germs from want of ventilation, for on 
 account of the low temperature the energies of the occupants 
 are devoted rather to excluding the cold than to ventilating 
 their quarters. Moreover, as the occupants begin to feel 
 the effects of their unwholesome dwellings they drop into 
 an apathetic condition in which all soldierly qualities are 
 lost. Their personal appearance and surroundings cease 
 to interest them, and they care only to pass the time in 
 their bunks when ^ey are not on the detail for duty. 
 The ignorance or carelessness of company and regimental 
 officers which permitted the construction of the dangerous 
 dugouts manifests itself as well during their subsequent 
 occupation : Inspections are perfunctory, filth accumulates, 
 and ultimately the typhus miasm gives added virulence to 
 the pre-existing causes of disease, and raises an alarm 
 which may fortunately put an end to the insanitary condi- 
 tions that are ruining the command [91]. 
 
 107. The shelter-tent is invaluable in summer, when the 
 men live in the open air and make use of the tent only as a 
 protection to their bedstead; but it covers too small an 
 area for comfort when, in winter, many hours of the day 
 have to be spent under it as in a living-room. The best 
 log hut which the troops can construct is limited in its area 
 by the means of roofing it ; and a small increase of area 
 under such circumstances makes all the difference between 
 compression and comparative comfort. Generally the wear 
 and tear of a summer's campaign renders the shelter-tents 
 unfit for service as a winter protection, and issues of new 
 shelter-canvas have to be made. This being the case, it 
 would contribute much to the health and comfort of the 
 troops if a special roofing-canvas were provided consisting 
 of two pieces — one, 14 by 12 feet, as a roof, and the other, 
 somewhat larger, as a fly to protect it. These would admit 
 
76 
 
 SANITARY CARE OF CAMPS, ETC. 
 
 of the construction of a log hut having an interior measure- 
 ment of 13 by 7 feet, and giving room by its length for a 
 double bedstead at each end, and an intervening moving 
 space between the doorway in the front wall and the fire- 
 place opposite. With the wall six feet high, which should 
 be its minimum, the hut would have a capacity of 700 cubic 
 
 winter hut for tour men— the canvas roof protected by a fly which is 
 fastened to a rail near the eaves. 
 
 feet, the air of which would be freely renewed by the 
 chimney-draught and the ventilating aperture in the roofing 
 canvas under the protection of the fly. Theoretical hygiene 
 may object to the area and air space of the proposed hut, 
 but the measurements are suggested advisedly, and are 
 based on a knowledge of the military tendency to close up 
 and occupy unoccupied space. When a hut affords possi- 
 ble bed and elbow room for one more man, that man will 
 immediately become an inmate, and the hut will no longer 
 be a hut for four, but for five, men. 
 
 108. Any tendency to crowding the huts on each other 
 should be strenuously opposed ; the minimum interval be- 
 
SANITARY CAKE OF CAMPS, ETC. 77 
 
 tween adjacent gables should be equal to the height of the 
 walls, six feet, while the passage between the rear walls 
 of adjacent rows should equal the height of the ridge, about 
 ten feet. If the company front be too small to afford this 
 space without undue narrowing of the street, the camp 
 should be formed in column of divisions. 
 
 109. Besides the trenching, which is intended to give a 
 dry site to individual huts, every effort should be made to 
 improve the genera]»surface of the camp. Surface depres- 
 sions which form pools in rainy weather should be drained 
 and filled up. The company streets should afford a firm 
 and dry footing when the men turn out at roll-calls. Path- 
 ways or sidewalks along the streets to the kitchens, officers' 
 quarters, sinks, etc., should, by trenching, grading, gravel- 
 ling, planking, or other means, permit of a dryshod per- 
 formance of the routine business of camp life even in 
 unfavorable weather. The perfection of this work will 
 depend on the permanence of the camp; but the main 
 features of the system of drainage should be worked out 
 at once, leaving improvements to follow as the stay is pro- 
 longed. 
 
 110. Company officers are responsible for the police of 
 the huts, kitchens, and company areas belonging to their 
 commands, and for the personal cleanliness of their men. 
 They should see that the interiors are kept scrupulously 
 clean, and that the canvas roof is removed from time to 
 time for thorough ventilation ; blankets should be aired on 
 every available occasion. 
 
 111. Personal cleanliness in winter quarters depends 
 considerably on the facilities provided for that purpose. 
 Huts should be built as lavatories, with safe drainage to 
 carry ofE the waste water either by surface trenching or 
 through a covered sink. A hot-water supply can be ob- 
 
78 SANITAKT CARE OF CAMPS, ETC. 
 
 tained by means of a boiler and barrels of water connected 
 by circulating pipes. 
 
 112. The regimental commander is responsible for the 
 condition of the camp as a whole ; and to enable him to 
 sustain this responsibility captains of companies are detailed 
 in rotation as superintendents of police, under the military 
 title of officer of the day. This officer has command of all 
 the guards and prisoners, and is responsible to his superior 
 officer for the order and cleanliness of the camp. He 
 makes use of the prisoners in policing the grounds ; and if 
 they are insufficient for the work, fatigue details are granted 
 him. As every day brings a fresh officer to superrutend, 
 the system is satisfactory with efficient officers. 
 
 113. With inexperienced troops and careless or incapable 
 hygienic government a good natural site can speedily be 
 rendered unhealthy by contamination of the soil with 
 organic impurities. Change of site may thus become 
 needful in a very short time, particularly in warm or moist 
 climates or seasons, for if police parties fail to remove the 
 dangerous material from the camp, the camp must be re- 
 moved from the dangerous material. Even in the best- 
 governed camps the occupation of winter quarters should 
 not be prolonged after the advent of warm weather, for 
 when the constant traffic on the company area and the 
 steady accumulation of refuse engendered by it are remem- 
 bered, soil contamination is seen to be merely a question of 
 time. 
 
 114. The regimental area should not only be regularly 
 and carefully policed, but the necessity for this work should 
 be reduced to a minimum by systematic arrangements for 
 the disposal of all the waste or refuse matters of the camp. 
 Moreover, the intervals between regiments should be pre- 
 served in as wholesome a condition as any other part of 
 
SANITARY CARE OF CAMPS, ETC. 79 
 
 the grounds ; the labors of regimental police parties should 
 overlap, rather than fail to meet. Besides cleaning up the 
 regimental area, general police details attend to the con- 
 dition of the sinks, remove kitchen refuse and stable 
 manure, repair defective trenching for surface drainage, 
 and keep the pathways passable during snowfalls and rainy- 
 weather. All gleanings from the surface should be collected 
 in heaps and carted to a selected dumping-ground at some 
 distance from the camp and its water supply. Covered 
 barrels for the reception of kitchen refuse should stand on 
 a wooden platform for the better protection of the surface 
 from contamination by decaying organic matters ; and their 
 contents should be carted away daily. Slaughter-house 
 offal and the carcasses of dead horses, mules, etc., should 
 be buried at the dumping-ground. 
 
 115. The sinks in an aggregation of regimental camps 
 are of necessity in front of the men's and in rear of the 
 officers' quarters; but in detached camps, where there is 
 choice of ground, they should be placed in such a position 
 that the prevailing winds will not carry odors over the 
 company areas. The sanitary discipline of camps requires 
 that every man should be punished who fails to make use 
 of the sinks. These are usually long trenches about eight 
 feet deep and two feet wide, with the excavated earth piled 
 on one side, whence a part of it, with quicklime or ashes, 
 can readily be thrown by the police party over the daily 
 accumulations. On the other side a long pole is laid hori- 
 zontally on forked uprights at a proper height for the con- 
 venience of the men. The whole is surrounded by a thick- 
 set hedge of brushwood, through which admission is given 
 by an oblique or valvular entrance. Small sinks for each 
 company are better than one of large size for the battalion. 
 When the stay in camp is prolonged beyond a day or two, 
 
80 SANITARY CAKE OF CAMPS, ETC. 
 
 the horizontal pole should be superseded by box-seats open 
 behind so that earth can be thrown in. While in winter 
 quarters the mouth of the trench should be completely- 
 boxed with covered seats, one side being hinged to admit of 
 layering the daily deposits with earth. When filled within 
 two feet of the surface, each sink should be replaced by a 
 new one, 'those disused being filled up and banked over to 
 mark their site. These siaks or privy pits often become 
 foci for the propagation of typhoid epidemics, and to pre- 
 vent this the most careful attention is necessary. 
 
 116. -D^-i/ ear^A cZose^s are preferable to earth pits. In these 
 the dejecta are received into galvanized iron receptacles, 
 covered with dry earth at the time of deposit, and removed 
 daily by scavengers, who replace the pails or receptacles by 
 carefully cleaned duplicates. But the most satisfactory 
 system for the removal of excreta from a permanent camp 
 is that by water carriage. With cases of typhoid fever, 
 dysentery, or camp diarrhea among the troops, the pits or 
 closets become infected and make their influence felt 
 throughout the whole of the camp. Disinfectants should 
 be used, but experience has shown that an efficient disin- 
 fection is difficult to carry out and requires constant iatel- 
 ligent supervision. Either the winter camp should be 
 removed to another locality or a sewerage system be in- 
 augurated. The objection to both of these propositions is 
 their cost. This question of cost is one which frequently 
 meets with much consideration, but the value of the object 
 in view should equally be considered. The first cost of a 
 system of sewers for a camp which is to be occupied for 
 several months is small compared with the expense result- 
 ing from an epidemic of typhoid fever. If water is brought 
 into camp, as it should be, in quantity sufficient to supply 
 bath-houses, kitchens, and quarters, it is a wise policy to 
 
SANITARY OAEB OF CAMP8, ETC. 81 
 
 make provision for the removal of the impure and waste 
 water and to utilize this discharge for the removal of the 
 excreta of the command. Disposal of excreta by crematories 
 has been tried but has not proved a success. 
 
 117. No satisfactory provision can be made to prevent 
 soil contamination from urinary excretion. During the 
 day the sinks are the receptacles for a large percentage of 
 such discharges ; but in bad weather their distance leads 
 the men to find some concealed place near their quarters, 
 often in the intervals between the huts, and at night all 
 parts of the area are liable to contamination. Unless oflB.- 
 eers are vigilant, certain angles about the huts will soon 
 begin to evolve ammoniacal odors. The plan of providing 
 night-tubs is objectionable, as they cannot be of use to all 
 without being too near to some. The medical officer should 
 indicate such places, if any, as may be used in addition to 
 the sinks, and the men be held to a strict observance of 
 camp sanitary orders. 
 
 118. The water supply should be jealously guarded by 
 the regimental medical ofQcers. If from a stream, care 
 should be taken that the drainage of one camp does not 
 contaminate the supply of another. Special points below 
 that' from which the water supply is derived should be in- 
 dicated for the washing of clothes, watering of horses, etc. 
 When wells' are used, their depth and distance from the 
 sinks should be carefully considered, as also the character 
 and incline of the strata through which they penetrate. 
 There is no time for chemical or bacteriological analysis to 
 determine the quality of water supplies in the field. The 
 water is a dangerous water when the taste or odor testifies 
 to the presence of vegetable organic matter, or when it is 
 known that sewage, even in small quantity, enters it. It 
 is useless to treat a water with alum, permanganate of pot- 
 
 6 
 
82 SANITARY CAEE OS CAMPS, ETC. 
 
 ash, or other purifying chemicals, because if it is of such a 
 character as to require this treatment it should be boiled. 
 Boiling a water for ten or fifteen minutes destroys all 
 infections, malarial, typhoid, dysenteric, and choleraic. 
 Soldiers should be taught to fill their canteens over-night 
 with well-boiled weak coffee as the water supply for the 
 next day's march. Filters are made which strain out the 
 germs of disease from an iufected water. Portable filters, 
 such as the Berkefeld, have been used by small commands, 
 and are useful on certaia marches and expeditions ; but it 
 is doubtful if they could be relied on ia time of war to 
 supply pure water to the troops of a large army. The 
 Waterhouse-Forbes sterilizer has given excellent results at 
 military posts iu Cuba and the Philippine Islands. In 
 this apparatus the heat given out by the boiled water iu 
 cooling is utilized in heating the entering fresh water. The 
 boiled and aerated water is delivered at a temperature only 
 4.5° F. above that of the entering water. This apparatus 
 is described in the Report of the Surgeon General for the 
 year ended June 30, 1899, pp. 216-226. 
 
 119, The Regulations provide for a satisfactory condition 
 of all camps by means of of&cial inspections ; but the army 
 looks to the medical ofiicer for its preservation from pre- 
 ventable diseases. He is the sanitary oflB.cer of the com- 
 mand, and must render a monthly sanitary report as called 
 for in the service of the post hospital [16] . The medical 
 ofB.eer is not confined to this regular sanitary report as a 
 means of brruging his recommendations to the notice of his 
 immediate commander and superior authority. When any 
 fault or error in the sanitary arrangements is detected, it 
 should be immediately reported for the action of the regi- 
 mental or other commander. 
 
 120. When troops are embarked on transports the utmost 
 
8ANITABT OAEB OF CAMPS, ETC. 83 
 
 care is enjoined by the Eegulations for the preservation of 
 the health of the men, for when thus crowded together in 
 narrow limits, with imperfect means of ventilation, the 
 absence of healthful exercise, and probably a defective diet, 
 a tendency to typhus and scurvy is readily developed. 
 Officers are required to enforce cleanliness as indispensable 
 to health. When the weather permits, bedding is brought 
 on deck every morning for airing. The men, in hot weather, 
 are not allowed to sleep on deck or in the sim ; and they are 
 encouraged and required to take exercise on deck, in squads, 
 by succession, when necessary. All the troops turn out at 
 a prescribed hour in the morning without arms or uniform, 
 and in hot weather without shoes or stockings, when every 
 individual is inspected as to his personal cleanliness ; the 
 same personal inspection is repeated thirty minutes before 
 sunset. On these occasions the medical officers are required 
 to examine the men to observe whether there be any ap- 
 pearance of disease. 
 
CHAPTER IV. 
 
 GENEKAL HOSPITAL SERVICE. 
 
 121. General hospitals are under tlie control of the Sur- 
 geon General. The surgeon in charge is in command of 
 the hospital and is not subject to the orders of local com- 
 manders other than those of the commanding officer of the 
 territorial department. They are established at points dis- 
 tant from the field of actual warfare. The first of these to 
 which the wounded man is transferred is usually that at 
 the base of supplies ; but his stay here is seldom of long 
 duration, as this hospital is in reality merely a resting and 
 shipping point on the route to places of greater security. 
 It is organized on the general hospital system, and may 
 indeed be viewed as the general hospital of the army to 
 which it is attached; but as its existence in a locality is 
 dependent on military movements, its accommodations and 
 appointments have usually more of the character of a field 
 than of a general hospital. It frequently consists of hos- 
 pital tents pitched end on to each other, four or five tents 
 forming a long pavilion accommodating twenty-four to 
 thirty patients, the pavilions, with wide intervals between 
 them, arranged on either side of a broad central street and 
 projecting at right angles from the street. The tents are 
 framed and floored as in the field hospitals of winter quar- 
 ters [57]. Associated with it are hospital boats or trains of 
 hospital ears, all of which are manned by assignments from 
 the Surgeon General's office. 
 
 122. A general hospital is practically an expansion of the 
 
GENERAL HOSPITAL SERVICE. 85 
 
 post hospital. The latter consists of an administration 
 building and one or two attached wards which may be 
 lengthened or shortened, within limits, to suit their capacity 
 to the requirements of the time and place. The former 
 consists of a series of long pavilion wards, each capable of 
 accommodating forty to sixty patients, with an administra- 
 tion building, kitchens, laundry, stables, repair-shops, etc., 
 and quarters for the oflQcers, employees, and 'guard, on a 
 scale proportioned to the size of the hospital. At the be- 
 ginning of our Civil War, hotels, churches, court-houses, 
 factories, and other large buildings were used as general 
 hospitals ; but the advantages of the pavilion system were 
 soon recognized, and extemporized hospitals became replaced 
 by special constructions. In these the wards were variously 
 arranged to secure a full allowance of ventilation and sun- 
 light for each, knd at the same time keep them within con- 
 venient distance of the oiRces and other buildings. In some 
 hospitals they were arranged in a line, with their gables 
 facing the front and rear, the administration building in 
 the centre of the line, and the other buildings disposed in the 
 rear. In others they were placed en echelon in the form of 
 a V, with the administration building at the apex, the 
 kitchens and dining-rooms in the interior, and the other 
 buildings closing in the base. In others, again, the pavil- 
 ions enclosed a circular or oblong space, the administration 
 building occupying a central position among the wards, and 
 the other buildings within the enclosure. Adjacent wards 
 were separated from each other by a clear space of about 
 thirty feet. The wards, kitchens, dining-rooms, and offices 
 were connected by means of a covered corridor or walk. 
 The plan of the Hicks Hospital, Baltimore, Md., submitted 
 on page 86, illustrates one method of arrangement. 
 
 123. Each ward of a general hospital was a ridge-venti- 
 
86 
 
 GENERAL HOSPITAL SEBVICE. 
 
 CE3 
 
 1=33 
 
 □a 
 I i» I 
 
 r^-i 
 
 QROtnn) PiAN OF Hicks Hospital, Baltihoke, Md.— 1, 1, 1, 1, wards; 2, ad- 
 ministration building ; 3, linen-room; 4, dispensary and operating-room; S, 
 dining-hall; 6, kitchen and laundry; 7, ward for detailed men; 8, knapsack- 
 room; 9, subsistence storehouse; 10, quartermaster's storehouse; 11, tank; 
 13, quarters for the guard; 18, stable; 14, wagon-house; IS, sutler's store; 16, 
 steward's quarters; 17, 18, offlcera' quarters (of which there are several not 
 shown on the plan); 19, guard-room; 20, guard-house near entrance gate ; 21, 
 workshop; 22, contagion-ward, — this was more distant than is represented. 
 The wards, dining-room, and administration building are connected by a 
 covered way. 
 
 fe 
 
 [rfri 
 
 Water-closet attached to lateral aspect of free end of a ward : a. Interior of 
 ward; 6, water-closet; o, lavatory and bathroom; c2, pantry; e, wardmaster's 
 room ; /, /, ventilating-hall and passage-ways. 
 
GENERAL HOSPITAL SERVICE. 
 
 87 
 
 lated pavilion from 145 to 187 feet long, 24 wide, and 14 
 to the eaves. The smaller length, for forty patients, was 
 generally preferred to the larger one, for sixty. At each 
 end of the ward there were partitioned off two small rooms 
 9 by 11 feet, with a six-foot passage-way. Those at the at- 
 tached end were used as a wardmaster's room and pantry; 
 those at the free end as a bathroom and water-closet. In 
 some instances the latter were cut off from the ward by a pas- 
 sage-way giving cro^s ventilation, and in others they were at- 
 tached to the lateral aspect of the pavilion at one of the 
 angles of its free end. The floors were raised at least 18 
 
 Ventilation and heating of a rldge-ventilated ward. 
 
 inches from the ground, and had free ventilation underneath. 
 The beds were placed at regular intervals from each other, 
 two occupying the floor space between adjacent windows. 
 During warm and mild weather the wards w6re ventilated 
 by the ridge. The opening, about one and a half feet wide, 
 extended the whole length of the building, and was pro- 
 tected by a ridge-roof which lapped well over it on either 
 
88 GBHTERAL HOSPITAL SERVICE. 
 
 side. During winter the ridge was closed and ventilation 
 by shafts and special fresh-air inlets was substituted. The 
 inlets were boxed channels from the side walls ^opening 
 beneath the stoves, which were each partially surrounded 
 by a jacket of sheet-iron or zinc. The air, more or less 
 warmed in its passage into the ward, became diffused and 
 was ultimately drafted through ventilating-shafts 18 inches 
 square which extended from the level of the tie-beams to 
 beyond the ridge. The heat of the stove-pipe was utilized 
 in promoting the escape of foul air through these shafts. 
 
 124. The size of a ward, as compared with the number 
 of occupied beds in it, is a matter of importance. Many of 
 the diseases which in former days increased the mortality 
 in hospitals were due to overcrowdiag. Erysipelas has be- 
 come infrequent, and hospital gangrene unknown [426], 
 since a proper amount of space has been assigned to each 
 bed. Typhus fever has also become a disease of the past, 
 as well as that typhus-like character which overcrowding 
 impressed on pneumonia and all other febrile diseases [91]. 
 The air space in the hospitals of the war was from 924 to 
 1,033 feet per bed; but all the beds were rarely occupied 
 at the same time. More space is required for suppurating 
 
 ' wounds, infectious diseases, and such as confine the patient 
 to bed than for trivial cases or convalescents to whom the 
 ward is merely a sleeping-room. When a liberal air space 
 is afforded, ventilation can be effected with less risk of creat- 
 ing a draught. If a ward give 3,000 feet of space [238] to 
 each patient, its air would have to be renewed only once per 
 hour to insure good ventilation; whereas, if it be crowded 
 with one man for every 500 feet of its capacity, the air 
 would have to be renewed six times in the course of an hour 
 to preserve its quality. 
 
 125. The administration building was usually two-storied, 
 
GENERAL HOSPITAL SERVICE. 89 
 
 and contained the general office, office of the surgeon in 
 charge, chaplain's office, dispensary, linen and store rooms, 
 lodging-rooms for officers, etc. The kitchen was divided 
 into two parts, the larger for the preparation of ordinary 
 diet, the smaller for extra diet. The dining-room seated a 
 number equal to two-thirds of the number of beds ; it com- 
 municated with the kitchen usually by the centre of one of 
 its sides. The subsistence and quartermaster's store-room 
 contained boxes and shelves for the various parts of the 
 ration, a room for clothing, and on its second story lodging- 
 rooms for the cooks; an ice-house was connected with it. 
 A knapsack-house received the effects of the patients while 
 in hospital. The laundry was a two-storied building, hav- 
 ing quarters for the laundresses on the second floor. Spe- 
 cial quarters, including dining-room and kitchen, were 
 provided for female nurses. The other buildings consisted 
 of quarters for officers; an operating-room and a dead- 
 house, both lighted by skylights, the former near the admin- 
 istration building, the latter in a retired part of the grounds; 
 a chapel, with library and reading-room attached; guards' 
 quarters, stables, repair-shops, etc. 
 
 126. When the water supply was not derived from the 
 mains of a city, steam was usually employed to raise it 
 from the wells, springs, or streams which formed its source, 
 and in this case the engine was generally situated near the 
 kitchen and laundry that the steam might be made available 
 in cooking and the power utilized in working the washing 
 and mangling machines. It was usually considered advis- 
 able to have some reserve tanks or cisterns kept always full 
 in case of danger from fire. 
 
 127. Kain-water is wholesome water if properly collected 
 and stored. The roofs or other shedding surfaces should 
 be clean ; if they are foul, the first fall of a shower should 
 
90 GENERAL HOSPITAL SBEVICE. 
 
 be run to waste by a cut-off, if a sedimenting cistern or 
 filter be not interposed between tbe watershed and the reser- 
 voir. Cisterns are usually constructed of brick, lined with 
 Portland cement, or of wood, generally cypress wood. Un- 
 less care is exercised in excluding the washings of the water- 
 shed, the cistern will soon accumulate a thick sediment of 
 foul mud, which must be cleaned out from time to time. 
 In warm weather, when the water-level in the cistern is 
 low, this sediment may seriously affect the quality of the 
 water. Underground cisterns, from their cooler situation, 
 are less prone to suffer from the fermentation of an accumu- 
 lated sediment. Moreover, the mineral or earthy matters 
 of which the underground cistern is constructed introduce 
 into the stored water certain bacteria which transmute am- 
 monia into nitric acid. These are called the micro-organ- 
 isms or bacteria of nitrification. Organic matter that may 
 be present in the water from the air-washing which it has 
 effected, or from foul accumulations on the watershed, in 
 the conductors, or in the cistern itself, is decomposed into 
 ammonia, and this is subsequently transformed into nitric 
 acid. The tendency of the water during its storage in the 
 cistern is to improvement ; but it is important to observe 
 that this does not hold good in wooden tanks, unless the 
 bacteria of nitrification are introduced, as by throwing into 
 the cistern a quantity of clean gravel. 
 
 128. Surface water, as from rivers, lakes, ponds, etc., is 
 often impure from filth washed from the watershed. The 
 subsoil water, tapped by shallow wells, is free from the tur- 
 bidity often found in surface waters ; but it is not generally 
 accepted as a wholesome water. If the soil be a clean sand 
 in an unsettled locality the water may be as good as any 
 filtered cistern water ; but if it be impure from the soakage 
 into it of the wastes of human life and occupation, the water 
 
GENERAL HOSPITAL SERVICE. 91 
 
 will be more or less tainted witli these impurities. The 
 water of deep wells is usually organically pure, but often 
 so charged with saline matters as to be undesirable as a 
 potable supply. 
 
 129. There is no easily performed chemical or other test 
 for organic matter in a water. If a quart bottle half filled 
 with the water at a temperature of 70° or 80° Fahr. be 
 shaken vigorously for a few minutes and then placed to the 
 nose, an organic odor may be detected in the air of the bot- 
 tle if the water is of Uoubtful or bad quality ; but bad waters 
 do not always have an odor. The best of the easy modes 
 of chemical inquiry is to hum the residue. Evaporate 100 
 CO. of the water to dryness in a platinum or porcelain cap- 
 sule ; then ignite the dish over the flame of a lamp. If 
 there be no blackening, or at most only a darkening of the 
 residue, which is speedily dissipated by a continuance of 
 the heat, the water is probably good. If the thin crust of 
 the residue blacken all over, and the carbon be afterward 
 dissipated with diificulty, the water has probably an excess 
 of vegetable matter. If, in addition to the blackening, 
 nitrous fumes are evolved, and the carbon sparkles in points 
 with the energy of its combustion, the water may be sus- 
 pected of containing organic matter of animal origin. The 
 organic matter found in drinking-water may be of a harm- 
 less or dangerous character ; but it must be conceded that 
 where there is much organic matter the likelihood of the 
 presence of dangerous matter is greater than where there is 
 little. 
 
 130. The presence of salts of lime and magnesia gives a 
 water the quality of hardness. Soap does not form a lather 
 with hard water until the lime and magnesia have been pre- 
 cipitated in the form of curdy salts of the fatty acids of the 
 soap. When a hard water is boiled, white flakes of car- 
 
92 GEKERAL HOSPITAL SEEVICB. 
 
 bonate of lime appear in it, and its temporary hardness is 
 removed. When the earthy salts are present in the water 
 as sulphates the hardness caused by them is called perma- 
 nent because it is not removed by boiling. Such waters in- 
 duce diarrhea, particularly in those who are unaccustomed to 
 their use. Soft waters contain but little of these earthy salts. 
 
 131. As water is frequently distributed by leaden pipes, 
 and sometimes stored in lead-lined cisterns, the possibility 
 of the solution of poisonous quantities of the metal must be 
 held in view. The symptoms are violent neuralgic pains 
 in the abdomen, simulating colic, but oftentimes affecting 
 also the limbs and trunk, with constipation and gradual 
 loss of strength. When lead is used for service-pipes the 
 water which has stood in the pipes over-night should be run 
 to waste before drawing a supply for use. Eain and other 
 soft waters act on lead with facility. When metal is used 
 for cisterns, iron, coated with asphalt paint or black varnish, 
 should be employed. Zinc, which forms the protective 
 coating of the iron in galvanized tanks and pipes, is acted 
 on by most waters, but without producing notable harmful 
 effects on the consumers. 
 
 132. When the vrater supply was adequate it was intro- 
 duced into the water-closets attached to the wards and into 
 the latrines for the use of convalescents and others. Water- 
 tight boxes, which were emptied and cleaned regularly, 
 were used in the absence of a water service. The earth- 
 closet, consisting of a closet-seat over a pail or other small 
 portable receptacle, with dry earth as a deodorant, was not 
 brought into general use until a few years after the war. 
 The drains and sewers of hospitals within municipal bounds 
 were connected with the general sewerage system. In other 
 cases the sewers of the hospitals found an outlet into some 
 neighboring stream or tide-water ; but where no satisfactory 
 
GENERAL HOSPITAL SEEVICE. 93 
 
 outlet was obtainable, tlie sewer termiiiated. in a cess-pool 
 from whicb liquids percolated or overflowed by a suitable 
 conduit into a natural incline leading from the hospital, and 
 solids were removed from time to time as they accumulated. 
 133. The sewerage system includes water-closet basins, 
 each with a water-seal to prevent the inflow of foul air 
 through their discharge-pipes, a soil-pipe leading downward 
 from the water-closets on the various floors and receiving 
 the waste-pipes from bath-tubs, kitchen traps, and other 
 water fixtures, and a drain connecting the lower end of the 
 soil-pipe with the sewer. Sewage is waste water which 
 contains human excreta. 
 
 Hopper-closet with water-seal. 
 
 134. Water-closets are of several forms and many varie- 
 ties. The hopper-closet is the simplest, because it has no 
 mechanical parts to get out of order. It consists of a fun- 
 nel-shaped bowl which leads the deposits into the water of 
 an S-shaped trap. Its efficiency depends on the quantity 
 of water available and the manner of its distribution from 
 the flushing rim over the curved sides of the basin. Pan- 
 
94 GENERAL HOSPITAL SERVICE. 
 
 closets and valve-closets are objectionable as liable to become 
 foul and out of order. In the plunger-closet the outlet from 
 the bowl is at the side instead of below, and is closed by a 
 heavy metal piston or cylinder which, on being raised, dis- 
 charges the contents into an S-shaped trap leading into the 
 
 Plunger-closet with water in basin and in S-trap and hub on soil-pipe side of 
 trap for attachment of vent-pipe. 
 
 soil-pipe. Leakage from the bowl sometimes occurs when 
 the plunger, on account of fouling, fails to completely 
 close the outlet. 
 
 135. Bath-tubs, wash-basins, and the fixtures of the laun- 
 dry are connected with the soil-pipe usually by lead pipes 
 one to two inches in diameter, trapped by a deep S-shaped 
 bend close to the aperture of outflow. Small overflow pipes 
 are generally provided, and these are either trapped them- 
 selves or connected with the main outflow on the near side 
 of the bend. Kitchen and pantry sinks have two-inch out- 
 flows provided with a strainer and trapped close to the bot- 
 tom of the sink. As the trap becomes sometimes choked 
 with sediment and accumulations of grease, it has usually a 
 
GBKBRAL HOSPITAL SERVICE. 95 
 
 screwed cap on its convexity by which it may be entered 
 and cleaned. Hot water often carries liquefied grease to a 
 considerabled distance along the outflow before it becomes 
 congealed. An occasional flushing with a solution of soda 
 or potash will tend to clear the two-inch pipe, and the 
 ammoniacal fermentation of water-closet discharges has a 
 similar scouring influence on the main drain. 
 
 136. Soil-pipes descend vertically through the building 
 from above the roof to the cellar. Each is open at the top 
 and ends below in a curve which connects it with the house- 
 drain. Water-closet outflows and the wastes of bath-tubs, 
 wash-basins, and kitchen trays, etc., join it by Y-shaped 
 branches. All junctions must be solidly made. Iron pipes 
 are joined by pouring melted lead into the sockets when the 
 lengths are in position, a small packing of oakum having 
 been previously introduced to prevent the liquid metal from 
 penetrating into the interior ; and when cold the lead is 
 driven securely home by a hammer and caulking-iron. 
 Lead is joined to iron by tipping the leaden pipe with a 
 brass ferrule, which is afterward caulked into the iron with 
 melted lead. 
 
 137. It is better to have these pipes in sight than boarded 
 up, as any flaw in the plumbing is more readily detected. 
 When a leak is suspected the peppermint test is recom- 
 mended fot its discovery. A fluid ounce of this volatile oil, 
 or a corresponding quantity of its essence, is poured into 
 the upper end of the soil-pipe, and a flush of water is sent 
 down after it. The odor of the oil is so penetrating that it 
 speedily makes itself felt at any leaky point or flaw in the 
 system of > pipes; but the search for its presence must be 
 conducted by one who has kept himself free from any recent 
 contact with the oil, and the man who made use of the test- 
 liquid must remain at his post until the end of the investi- 
 
96 GENEBAL HOSPITAL SEKVIOE. 
 
 gation, lest lie carry an odor -with him which would interfere 
 with the discovery of a leak. 
 
 138. The house-drain, of iron pipe six inches in diameter, 
 should traverse the building along the ceiling or walls of 
 the cellar, or, if it be needful to place it under the floor, it 
 should be laid in a concreted trench with a fall of at least 
 1 in 100, and a cover which can easily be removed for 
 inspection. Outside the walls the drain may be either of 
 iron or vitrified pipe. Iron should be used if the ground is 
 liable to sag, or if the drain passes within the drainage 
 area of a well-water supply, or near the roots of trees, which, 
 in their search for water, will penetrate the joints of vitri- 
 fied pipes and choke their interior. The term drain, which 
 custom has applied to this pipe, is sometimes misleading. 
 Drainage is the system by which the surface and subsoil 
 are relieved from an excess of moisture, and drains are 
 properly the tile-pipe or other channels by which this is 
 effected ; while sewers are the channels of the sewerage sys- 
 tem by which sewage is removed. Evidently the pipe in 
 question is rather a house-sewer than a house-drain. 
 
 139. At some convenient point, either inside or outside 
 the walls, this house-drain or sewer should be trapped by a 
 deep-sealed S-bend to cut ofE aU communication between 
 the air of the common sewers and that of the system of 
 pipes within the building. This trap should be well pro- 
 tected against freezing in cold weather. When rain-con- 
 ductors join the main drain on the near side of its trap they 
 require no special trapping, but if their junction be effected 
 on the far side they will, if untrapped, become ventilators 
 for the sewers, and may diffuse unwholesome gases through- 
 out the upper part of the building. 
 
 140. The water-closet system presents two guards against 
 the entrance of sewer air into a building — the main trap on 
 
GENERAL HOSPITAL 8EEVICE. 97 
 
 the house-drain, and the traps on the individual waste-pipes. 
 Should the former be forced by some sudden air pressure in 
 the common sewers, the foul air enters the soil-pipe, but on 
 account of its open upper end no pressure is brought to bear 
 on the interior traps. But the interior of the pipes on 
 the house side of the trap on the main drain may be so 
 coated with fermenting organic matters that the air con- 
 tained in them may differ bub little in quality from that of 
 the sewers. The open end of the soil-pipe above the roof 
 has of itself no ventilating or purifying influence. The 
 evaporation of the water in the trap of an unused bath-tub 
 or wash-bowl might therefore give entrance to very unwhole,- 
 some gases from the soil-pipe. It is advisable on this 
 account to have the whole system of pipes on the hither side 
 of the main trap as freely ventilated as possible. This is 
 accomplished by means of a Jresh-air inlet into the drain. 
 The inlet usually takes the form of a four-inch iron pipe 
 which extends from some distance above the surface of the 
 ground to the drain, tapping the latter at a convenient point 
 between the lower end of the soil-pipe and the main trap. 
 Its free end is covered with a cowl or raised cap to prevent 
 the entrance of foreign matter. The warmth of the soil- 
 pipe in the interior of the house and the aspiratory force 
 of the wind on the open mouth of its upper end above 
 the roof establish a constant current of fresh air through 
 it which materially lessens the danger attaching to acci- 
 dentally unsealed traps. Unsealing is sure to occur if the 
 plumbing fixture remains unused for a certain length of 
 time, depending on the warmth of the weather or room, and 
 the depth of the water in the trap. The remedy in this 
 case is obvious. 
 
 141. Sometimes, however, water-traps are unsealed by 
 (vhat is called siphonage. When the upper bend of an 
 7 
 
98 
 
 GENERAL HOSPITAL SERVICE. 
 
 S-trap becomes tilled, full bore, by a sudden dischaige of 
 water, the trap acts as a siphon, and may draw off so much 
 of the water as to leave itself with its seal broken. As 
 might be expected, small pipes and shallow seals are more 
 likely to be siphoned than large pipes and deep seals. 
 Again, the sudden rush of a discharge from a water-closet 
 through the soil-pipe may suck out the water-seal of a 
 neighboring trap. Both of these accidents are prevented 
 by means of a vent-pipe on the soil-pipe side of the trap, 
 which permits of the entrance of air in the one case to break 
 the siphon, and in the other to fill the vacuum- caused by 
 suction. Vent-pipes from traps unite into a single pipe, 
 
 S-trap— showing water-seal, screw cap 
 on convexity for convenience in clean- 
 ing, and vent-pipe to prevent siphoning. 
 
 Water-seal with rubber ball act- 
 ing as a valve. Bower's trap. 
 
 which may end above the roof like the soil-pipe, or open 
 into the latter at a point above the highest fixture. Me- 
 chanical devices are sometimes used to increase the efficiency 
 of the water-seal or guard against its loss. Thus, in Bow- 
 er's trap, a rubber ball is buoyed by the water against the 
 mouth of the pipe leading from the fixture. The discharge, 
 in passing, temporarily displaces it, but it immediately 
 resumes its guard, closing the aperture so long as enough of 
 water remains in the trap to float it into position. 
 
GENERAL HOSPITAL SERVICE. 99 
 
 142. LatAnes consist of a series of hopper or other closets 
 over a brick trench or iron receptacle containing water. 
 From time to time the plug which guards the outlet of the 
 receptacle is raised and the contents are flushed out through 
 an S-trap into the soil-pipe. 
 
 143. Sewers are generally built of considerable size, to 
 carry off the rainfall as well as the sewage ; and heavy rains 
 do much good from time to time in flushing out and cleans- 
 ing their channels. The rain-leaders from a building usu- 
 ally enter the house-drain on the near side of the trap [139] ; 
 but in climates where the winters are not severe they may 
 end in surface channels which carry the water through a 
 grating into a catch-box for gravel, the overflow passing 
 through a trapped drain to the sewer. 
 
 144. Ground areas on which rain-water would otherwise 
 accumulate are often drained by means of what is called 
 the hell-trap. A perforated metal plate permits the water 
 to enter a basin which lies underneath it, and when the 
 water rises to a certain height in the basin it overflows into 
 
 The bell-trap. 
 
 a central pipe which carries it into the house drain. A 
 hemispherical cup attached by its bottom to the under sur- 
 face of the plate makes a loosely fitting cover for the mouth 
 of the pipe, and by dipping into the water contained in the 
 basin prevents the escape of emanations from the drain. It 
 should be remembered that traps of this kind are readily 
 unsealed by evaporation. 
 
100 GENEEAL HOSPITAL SERVICE. 
 
 145. The surgeon in charge of a general hospital has full 
 and complete military command over the persons and prop- 
 erty connected with it. At small hospitals he is his own 
 executive officer ; but in large establishments an officer is 
 detailed to aid him in his supervision. The duties of this 
 officer are those of an adjutant to a commanding officer, 
 with those of subsistence officer and quartermaster super- 
 added. He has charge of the office and records, and of the 
 men detailed as clerks and orderlies ; he keeps the clothing 
 and other accounts of the detachment and of the detached 
 men ; he supervises the preparation of all regular reports, 
 promulgates all orders, and conducts the general correspond- 
 ence. He distributes the patients received for admission, 
 and looks after the general well-being of the establishment 
 as aid to his superior. The same reports and returns are 
 rendered and books of record kept as at a post hospital. 
 
 146. Several stewards, with clerical assistance, are re- 
 quired in the service of a large general hospital. One takes 
 charge of the books and papers relating to the military gov- 
 ernment of the establishment, — he is practically the ser- 
 geant-major of the'command; a second attends to matters 
 of subsistence; a third to quartermaster's property and the 
 issue of clothing; and a fourth to medical and hospital 
 property and supplies. A steward superintends the work 
 of the dispensary ; one has general charge of the operating- 
 room, wards, and dead-house ; one looks after the kitchen 
 and dining-room; and one attends to the laundry and the 
 work of disinfection. 
 
 147. Each ward surgeon is responsible for the profes- 
 sional treatment and general comfort of his patients; for 
 the police of his ward, the care of its property, and the 
 faithful discharge of their duties by his subordinates. He 
 makes a record of all cases of professional interest, and 
 
GENERAL HOSPITAL SERVICE. 101 
 
 sends a morning report to the executive officer, stating all 
 changes and recommending others, such as the return to 
 duty, furlough, discharge, or transfer of particular individu- 
 als. An officer of the day is detailed daily by roster from 
 the number of the ward surgeons. This officer must not be 
 absent from the hospital during his tour of duty. He ad- 
 mits patients in the absence of the executive officer, and 
 prescribes in cases of emergency in the absence of the ward 
 surgeons. He inspects the meals and visits the wards at 
 bedtime, and agafn after midnight, to regulate lights and 
 note the vigilance of ward attendants. The detaU for guard 
 is under his command to enable him to enforce discipline at 
 all times; but if the guard consists of a special body of 
 troops, its senior officer is held responsible for the general 
 police of the grounds and the preservation of order within 
 the limits of the command. 
 
 148. The chaplain, in addition to duties of a purely spir- 
 itual character, usually keeps a record of special patients, 
 with the post-office addresses of the nearest relatives; he 
 superintends the postal service, library, reading-room, and 
 cemetery. 
 
 149. Each ward is under the care of an acting steward or 
 private assigned as wardmastcr, who is responsible for the 
 comfort, diet, and medication of the patients, the perform- 
 ance of their duty by the nurses, the preservation of the 
 ward property, the regulation of the fires, lights, and venti- 
 lation, and the cleanliness of the bed-linen and clothing, 
 lavatory, bath, water-closets, etc. Two nurses are suffi- 
 cient for a pavilion of fifty beds when the cases are not of 
 an acute character; but three, four, five, or more may be 
 required, according to circumstances. These are detailed 
 from the allowance of hospital corps men and female nurses 
 provided for the hospital by the Surgeon General. 
 
102 GENEEAL HOSPITAL SERVICE. 
 
 150. The hospital fund of the general hospital differs in 
 no respect in its management from that of the post [14] . 
 Where hospital gardens are cultivated this fund is usually 
 capable of supplying all the needs of the extra-diet kitchen, 
 but, as already stated, the sum of forty cents per day per 
 patient is allowed for this purpose. One of the most im- 
 portant duties of the hospital steward is to see that the 
 hospital fund does not suffer from ignorance or want of 
 economy in the kitchen. 
 
 151. Special care is needful at a large general hospital to 
 guard agaiust danger from fire. Every member of the hos- 
 pital corps should at all times be on the alert for the gen- 
 eral protection. Full buckets and axes should be kept in 
 each building, with a suitable length of rubber hose for 
 attachment to the water service. These provisions suffice 
 for the suppression of fire when discovered in its incipiency ; 
 but to provide for the protection of patients and property 
 on an occasion of general danger, the whole command should 
 be organized and drilled, from time to time, as a fire 
 brigade. 
 
PART 11. 
 ANATOMY AND PHYSIOLOGY. 
 
 152. The body consists of a multiplicity of living tissues 
 aggregated into ofgans, each of which has its special func- 
 tion to perform in order to preserve the integrity of the 
 whole. These organs may be divided into three sets : 
 
 I. Those of locomotion consist of the bony skeleton, which 
 gives form and stability; the joints, which permit of motion 
 between the bones, and the masses of contractile flesh or 
 muscle, which effect the motion. 
 
 II. Those concerned in the processes of organic life con- 
 sist of an alimentary system, which renews the blood by 
 elaborating it from the raw material of food ; a nutritive 
 apparatus, which feeds the various parts by the circulation 
 of a liquid, the blood, and a depurative or excretory system, 
 consisting of lungs, skin, kidneys, etc., which removes from 
 the blood the impurities gathered in its course. 
 
 III. Those of the administrative system include the organs 
 of the senses and the nervous system, from which emanate 
 all the powers of vitality. 
 
 OHAPTEE I. 
 
 THE LOCOMOTOR SYSTEM. 
 
 153. Bone consists of animal tissue permeated with earthy 
 salts, chiefly phosphate of lime. The animal tissue may be 
 demonstrated by dissolving the earthy salts in dilute hydro- 
 
104 BONES, JOINTS AND MUSCLES. 
 
 chloric acid. Each bone is covered with a strong fibrous 
 membrane, the periosteum, in -which the blood-vessels of the 
 bone subdivide [194] before entering the bony tissues. 
 
 154, The muscles constitute the flesh or lean of the ani- 
 mal tissues. Each consists of a mass of parallel fibres 
 aggregated into bundles and bound together by a fine elastic 
 webbing which is called the areolar, cellular, or connective 
 tissue. Every fibre recognized by the eye is composed of a 
 vast number of microscopic fibrils, each of which is marked 
 with close-set, transverse lines ; and when the fibril con- 
 
 ■!i!liiiilil!i«i!ll| 
 
 Bundles of striated muscular fibrils. 
 
 tracts the lines come nearer to each other, as the coils of a 
 spring are closer when they are compressed than when they 
 are expanded. These markings are called striae ; and the 
 muscles that present them, striated muscles. All the volun- 
 tary muscles, or those under the control of the will, are 
 striated. Muscular fibres which contract independently of 
 the power of the will, such as those which move the intes- 
 tinal contents, are flattened, band-like fibres without striae. 
 155. At each end of a voluntary muscle the contractile 
 fibres become blended with strong fibrous tissue, which 
 interweaves with the periosteum of the bone and gives the 
 muscular fibres a strong attachment. In some instances, 
 as in the muscles of the forearm, the fibrous tissue assumes 
 the rounded form of a tendon or sinew. Generally one of 
 the two attachments of a muscle is more readily moved 
 than the other. A muscle which extends from the shoulder 
 
BONES, JOINTS AND MUSCLES. 105 
 
 to the forearm will, by its contraction, bend the elbow, and 
 raise the hand to the shoulder; but if the hand be made the 
 fixed point, as when we seize a bough or bar overhead, and 
 endeavor to raise the body by sheer strength of arm, the 
 same muscle, by its contraction, will raise the shoulder to 
 the hand. 
 
 156. Although the contractility of a muscle is ordinarily 
 exhibited only through the influence of the will, the ten- 
 dency to contraction is continually in force. When the 
 belly of a muscle is cut across, the fibres contract toward 
 their point of attachment, and a gaping wound is the result. 
 When a bone, as the arm-bone, is fractured, the muscles 
 which extend from above to below the fracture may, by 
 their contraction, cause the broken ends to override and 
 give rise to shortening of the limb. 
 
 157. The back-bone or vertebral column extends from the 
 skull down along the middle line of the back. If the fin- 
 gers be drawn along this line a number of bony prominences, 
 called spinous processes, will be felt, each of which belongs 
 to one of the bones composing the column. The motion 
 between adjoining bones is slight, but the combined motion 
 of the whole is considerable. In position in the body these 
 bones or vertebras constitute a pliant pillar about twenty- 
 seven inches long, rounded and smooth in front, irregular 
 from many projections behind and at the sides, and having 
 in its interior a long canal formed by the apposition of cir- 
 cular apertures in the individual bones. There are seven 
 vertebrae in the neck, or cervical region ; twelve in the back, 
 or dorsal region ; and five in the loins, or lumbar region. 
 They are held in position in the erect attitude, and moved 
 as required by powerful muscles inserted into their spinous 
 and other processes; and these muscles afford protection 
 from injury by acting as a padding to the column. Sus- 
 
106 
 
 BONES, JOINTS AKD MUSCLES. 
 
 pended in the canal of the column is the spinal cord, or that 
 portion of the nervous system from which are given ofP 
 most of the nerves that superintend 
 motion and transmit sensation. Aper- 
 tures are left between the vertebrae 
 along each side of the column for the 
 passage of nerves from the cord to the 
 various organs and tissues. 
 
 158. This flexible pillar is supported 
 upon a bone called the sacrum, which 
 is wedged into a triangular interval 
 between the hip-bones behind. It con- 
 tains within its canal the final breaking 
 up of the spinal cord for the nerve sup- 
 ply of the lower extremities. The sa- 
 crum is tipped below by a small bone, 
 the coccyx. See page 116. 
 
 159. The skull is divided into the 
 cranium and the face. The bony 
 plates forming the vault of the crani- 
 um consist of two layers of compact 
 tissue and a thin interlying layer of 
 spongy bone. The cranial bones are 
 united by close-fitting sutures, a series 
 of projections and notches on one bone 
 fitting into a corresponding series on 
 the adjoining bone. The brain or 
 organ of the intelligence and nervous 
 power is contained in the cranium, 
 and is continuous below with the 
 spinal cord through a large circular 
 
 opening in the base immediately over the canal of the ver. 
 tebral column. 
 
 Side view of vertebral 
 column : a, bodies of the 
 vertebras; b, cartilages 
 between vertebrae ; c, 
 apertures for nerves; d, 
 facets for ends of ribs; 
 e, facets for support of 
 ribs; /, spinous processes 
 projecting behind ; g, 
 prominent spine of sev- 
 enth cervical vertebra. 
 
BOKES, JOIKTS AND MUSCLES. 107 
 
 160. The bones of the face are very irregular in form, 
 and, with the exception of the lower jaw, are closely sutured 
 together. The rounded head of the lower jaw may be 
 felt in front of the lobe of the ear, and when the mouth is 
 opened the finger may be pressed into the back part of the 
 cavity of the joint [539]. 
 
 161. The cervical vertebrae are deeply embedded in the 
 muscles by which the movements of the head are effected. 
 These muscles surround and protect the Janjnx, or organ of 
 voice, the cartilages of which project in the middle line in 
 front. Opposite the prominence of the tlnjroid cartilage or 
 Adam's apple the air tube internally is narrowed to a tri- 
 angular chink, the glottis, by two folds of mucous mem- 
 brane, the vocal cords which vibrate in the passage of the 
 air current and produce the voice. Below the thyroid cai'- 
 tilage is a thick cartilaginous ring, the cricoid cartilage, 
 and below this the narrower flexible rings of the trachea or 
 wind2np6 stretch down behind the notch in the upper margin 
 of the breast-bone [232]. The o'sophagns, or gullet, lies 
 behind the larynx and trachea, and the large blood-vessels 
 and nerves are embedded on either side of these tubes. 
 One of the most noteworthy of the muscles of the neck is 
 the stemo-mastoid , which stretches as a firm, fleshy mass 
 from the junction of the breast-bone and collar-bone on 
 either side upward and backward to the bony prominence 
 behind the ear, its outline being distinctly marked on the 
 surface when the head is turned to the opposite side. 
 
 162. The dorsal vertebrae have connected with them the 
 bones which form the framework of the chest. These con- 
 sist of twelve riba on each side and the sternum, or breast- 
 bone, in front. The outline of the individual ribs and their 
 arrangement as a whole can usually be made out without 
 difBculty on the person. The seven upper ribs on each side 
 
108 BONES, JOINTS AND MUSCLES. 
 
 are attached in front to the margin of the sternum by means 
 of a cartilaginous prolongation of the bony tissue. Carti- 
 lage is an opaque, bluish-white elastic substance, familiarly 
 known as gristle. The cartilages of the eighth, ninth, and 
 tenth ribs curve upward on either side of the epigastrium, or 
 pit of the stomach, and unite with that of the seventh rib. 
 The eleventh and twelfth are called floating ribs, because 
 they have no fixed attachment in front. The cartilages 
 add greatly to the elasticity of the ribs, lessening the risk 
 of fracture and injury to the contents of the chest. The 
 movements of the ribs in inspiration are upward and out- 
 ward, enlarging the capacity of the chest in all directions. 
 The chest contains the lungs, heart, and great blood-vessels, 
 and the gullet on its way downward to the stomach. 
 
 163. The via ride or coUar-bone lies between the upper 
 part of the breast-bone and the point of the shoulder, where 
 it is united to a projection of the shoulder-blade, called the 
 acromion process. The triangular outline of the flattened 
 scainda or shoulder-blade can be defined by the eyes or by 
 the pressure of the fingers, its base forming part of the 
 breadth of the shoulder, and its apex reaching a little below 
 the eighth rib. Immediately below the junction of the 
 collar-bone and shoulder-blade at the point of the shoulder, 
 the bony tissue of the latter forms a shallow depression, 
 the glenoid cavity [541], in which the rounded head of the 
 arm-bone has free play for its movements. 
 
 164. The bony surfaces which move on each other, con- 
 stituting a joint, are bound together by strong fibrous tissue 
 which forms a capsule around them to prevent dislocation 
 while admitting of the needful degree of motion. Where 
 the strain is greatest the fibrous tissue is strengthened by 
 interlaced bands which are called ligaments. The joint- 
 ends of the bones are in the living body coated with a 
 
BONES, JOINTS AND MUSCLES. 109 
 
 layer of elastic cartilage, and this is covered over with a 
 thin, smooth membrane which gives a highly polished sur- 
 face to the interior of the joint and secretes a lubricating 
 liquid called synovia. The interior of the capsule has a 
 similar lining, while externally it is strengthened by the 
 apposition of neighboring muscles. The capsule of the 
 shoulder-joint is strongly supported by muscles : in front, 
 the pectoral muscles, which converge from the front of the 
 chest to be inserted into the inner side of the arm-bone 
 below the capsule; behind, the muscles which converge 
 from the scapular region to be inserted into the upper and 
 back part of the arm-bone ; and on the outer side forming a 
 cap to the joint, the deltoid muscle, which curves from the 
 clavicle and scapula above the joint to the outer side of the 
 arm-bone a little above its middle. Nevertheless the shal- 
 lowness of the glenoid cavity and the laxness of the cap- 
 sule which give to this joint its freedom of motion, render 
 it correspondingly liable to dislocation [541] . 
 
 165. The muscles mentioned in the last paragraph have 
 an interest in connection with fractures of the arm. The 
 deltoid raises the limb, pulling it away from the side; the 
 pectoral muscles act in the opposite direction; the scapular 
 muscles raise it. When the arm is broken just below the 
 line of the arm-pit, the front wall of which is formed by the 
 pectoral muscles in their passage from the chest to the arm, 
 these muscles drag the upper fragment inward, while the 
 deltoid draws the lower fragment, to which it is attached, 
 upward and outward. On the other hand, if the fracture 
 is above the attachment of the pectoral muscles, the upper 
 fragment will be displaced outward by the power of the 
 scapular muscles. 
 
 166, The humerus or bone of the arm consists of a cylin- 
 drical shaft expanded at its ends to enter into the formation 
 
110 BONES, JOINTS AND MUSCLES. 
 
 of the joints. The shaft, like that of all the long bones, 
 consists of a compact bony tissue hollowed along the centre 
 into a canal containing a fatty substance or marrow. The 
 ends are of spongy tissue covered with harder bone. The 
 upper end or head has a rounded surface on its inner 
 aspect for articulation with the glenoid cavity, and rough 
 prominences or tuberosities on its outer aspect for the attach- 
 ment of muscles. Toward its lower end the shaft becomes 
 flattened from before backward, to have greater breadth 
 for its hinge-like joint with the bones of the forearm; and 
 on either side of the articular surface is a projection or con- 
 dyle for the attachment of muscles. Both condyles can be 
 outlined by the fingers, but the inner is more prominent 
 than the outer. 
 
 167. The bones of the forearm are the radius on the outer 
 or thumb side, and the ulna on the inner or little-finger 
 side. The latter, at its upper end, is scooped out from 
 before backward into a semicircular surface which hinges 
 with the lower end of the humerus. When the forearm is 
 bent on the arm the back part of this semicircular notch 
 forms the olecranon process, or point of the elbow. The 
 upper end of the radius is small and rounded, but it may 
 be felt below the external condyle on the posterior and outer 
 aspect of the joint. The muscles on the back of the arm 
 extend or straighten the forearm at the elbow. The mus- 
 cles in front flex or bend it. One of these flexors, the 
 biceps, passes to the radius just below the elbow-joint; it 
 forms the fleshy mass on the front of the arm. Other flex- 
 ors stretch from the inner condyle along the front of the 
 forearm to operate on the fingers ; these become tendinous 
 as they approach the wrist. 
 
 168. In addition to accompanying the ulna in its hinge- 
 motion on the humerus, the radius has a kind of circular 
 
BONES, JOINTS AND MUSCLES. 
 
 Ill 
 
 motion on the ulna by which the hand is rotated. When 
 certain of the muscles on the front of the forearm contract, 
 the lower part of the radius is rolled over and in front of 
 the ulna, so that the hack of the. hand looks npirard or to 
 the front ; this is called pronation. When certain of the 
 posterior muscles contract, the motion is reversed, throwing 
 the palm upward or to the front ; this is called supination. 
 When the fingers of the observer are placed firmly on the 
 head of the radius, while the hand of the patient is alter- 
 nately pronated and supinated, the 
 rolling motion of the bone is easily 
 observed [623]. 
 
 169. Eight small bones, fitted close- 
 ly together in two rows, form the 
 wrist or caroms. The upper row ar- 
 ticulates with the lower end of the 
 radius; the lower row with the bases 
 of the five metacarpal bones. All 
 these joints are encrusted with car- 
 tilage and lined with synovial mem- 
 branes. The first metacarpal bone is 
 the uppermost of the three bones 
 which enter into the formation of the 
 thumb. The four other metacarpal 
 bones form the framework of the 
 palm of the hand. A.t the knuckles 
 they articulate with the bones of the 
 fingers. The four fingers consist each 
 of three pieces or phalanges jointed 
 together with hinge-joints ; the thumb has but two pha- 
 langes. 
 
 170. The tendons of the flexor muscles on leaving the 
 front of the forearm pass under a strong ligament at the 
 
 Bnck view of right 
 wrist and band: a, radi- 
 us; 6, ulna; c, bones oi 
 cai'pus ; d, ligaments, 
 shown only on left side 
 of illustration; e, e, row 
 of metacarpal bones; /, 
 g, h, 1st, 2d, and 3d pha- 
 
113 BOKES, JOINTS AND MUSCLES. 
 
 wrist into the palm of tlie hand, where they split up for 
 attachment to the various joints of the fingers. The ex- 
 tensors on the back of the forearm and wrist are arranged 
 in a similar manner. 
 
 171. Muscular and tendinous layers attached to the lum- 
 bar vertebrae, the hip-bones, and the ribs close in the ab- 
 dominal cavity in front and protect its contained organs. 
 The pelvis or floor of this cavity is formed mainly by the 
 two hip-bones, the upper margins or crests of which can be 
 felt curving from a sharp point in front, just above the 
 outer part of the flexure of the groin, outward and back- 
 ward toward the sacrum, which is wedged in between them 
 like the centre stone of an arch [page 116]. The pelvis 
 contains the bladder and the lower part of the intestine, 
 over which are packed away the mass of the intestines, the 
 kidneys, liver, spleen, stomach, etc. 
 
 172. These organs are separated from the contents of the 
 chest by the diaphragm, a thin but strong muscular and 
 tendinous partition attached to the inner surface of the cir- 
 cumference of the lower part of the chest. It forms the 
 floor of the chest or thoracic cavity and the roof of the 
 abdominal cavity. When the fibres contract, the tendency 
 of their action is to stretch the diaphragm tightly like a 
 drumhead between the two cavities, but when they relax, 
 as after an expiration, the partition bulges upward into the 
 chest. On account of this invasion of the thorax by the 
 dome-like convexity of the diaphragm, some of the abdom- 
 inal organs are situated within the lower part of the cage 
 of the ribs. The liver lies usually within the lower ribs 
 and cartilages of the right side. If the middle . finger of 
 the left hand, laid flat along one of these ribs, be struck 
 sharply and perpendicularly with the tips of the fingers of 
 the other hand, a dull or flat sound will be elicited as com- 
 
BONES, JOINTS AND MUSCLES. 
 
 113 
 
 pared with the resonant sound yielded by similar permission 
 over the higher parts of the chest where the air-filled lung 
 instead of the solid liver underlies the finger. When a 
 
 View of thoracic and abdominal organs; anterior walls removed, but the 
 relative position of the ribs, navel, etc., indicated: a, heart; 6, great vessels ; 
 c, c, lungs; d, d, diaphragm; e, liver; /, gall bladder; g, stomach; h, spleen: 
 u ascending colon ; J, transverse colon ; fe, coils of small intestine; Z, position of 
 ileo-C8BcaI valve at junction of small and large intestines; m, urinary bladder. 
 
 person lies on his back, the pressure of the other abdominal 
 organs forces the liver wholly within the ribs ; in the upright 
 or sitting posture its lower edge may be felt just below the 
 8 
 
114 BONES, JOINTS AND MUSCLES. 
 
 ribs, and if a deep-drawn breath be taken it will be farther 
 depressed. The stomach occupies the greater part of the 
 epigastrium, the space below the end of the sternum and 
 between the diverging cartilages of the ribs ; and on its left 
 side, covered by the lower ribs, is the spleen. The large 
 intestine traverses the right side from the fold of the groin 
 to the under surface of the liver, where it crosses the abdo- 
 men, between the umbilicus or navel below and the stomach 
 and spleen above, to the left side, which it occupies in its 
 descending course to its termination. The small intestine 
 is gathered into coils which fill the space corresponding 
 with the front of the abdomen below the navel ; but the 
 bladder, when distended, rises from its position in the pel- 
 vis into the lower part of this space. The kidneys are 
 attached to the rear wall of the abdomen, one on each side 
 of the lumbar vertebrae, so that their position corresponds 
 externally with the loins. These organs are covered with 
 a fine membrane, the peritoneum, similar to the • synovial 
 membrane [164] lining the joints, which permits them to 
 glide easily on each other during the constant changes of 
 position incident to the respiratory and other movements. 
 173. The umbilicus or navel is the remains of an opening 
 through which the blood-vessels of the fetus communicated 
 with those of the mother. At birth these vessels, constitut- 
 ing the umbilical cord, are tied and cut about an inch and a 
 half from the abdominal wall. The stump withers, and in 
 two or three days drops off, leaving a raw surface which, 
 on healing, contracts into the navel. In rare cases, when 
 the umbilical aperture is large, some portion of the abdom- 
 inal contents may be accidentally forced through it, form- 
 ing a soft swelling under the skin called a hernia or rupture. 
 It is treated by means of an abdominal belt, with a pad of 
 suitable size, to support the weak point. 
 
BONES, JOINTS AND MUSCLES. 115 
 
 174. Inguinal hernia is a protrusion through the passage 
 by which the vessels and nerves of the testicle communicate 
 with the interior of the abdomen. During straining or vio- 
 lent exertion, something is felt to give way, and a soft 
 swelling is found above and to the outside of the pubes 
 [175]. It may subside when the patient lies down, but it 
 reappears when he resumes the upright position; coughing 
 communicates a notable impulse to it. In aggravated cases 
 the protruded parts may be quite bulky, extending into the 
 scrotum. When they can be returned into the abdomen 
 by making the patient lie on his back, with his knees raised 
 to relax the abdominal muscles, the hernia is said to be 
 reducible. Any manipulation to aid its return must be ap- 
 plied with intelligence and gentleness. To press the pro- 
 trusion in an upward and backward direction with the hand 
 would merely flatten it against the small aperture through 
 which it had escaped. Gentle pressure should be made on 
 the tumor as a whole, but at the same time the effort of 
 the fingers should be to make the part that came down last 
 go vp first, vpward, outward, and backward, through the 
 aperture and along the track of the descent. A truss, con- 
 sisting of a steel spring to go around the lower part of the 
 body, and a pad to close and support the weak point, 
 should be applied as soon as the hernia is reduced. The 
 circumference of the body taken in inches, just below the 
 iliac crests, gives the size of truss that will fit a given case. 
 Suspensory bandages are used for support in irreducible 
 cases. Hernial protrusions constitute a grave danger to 
 life when they become inflamed. The unyielding aperture 
 constricts or strangulates the swollen parts, and the inflam- 
 mation ends in gangrene unless the constriction is promptly 
 relieved by a surgical operation. Eupture occurs also, but 
 with less frequency, at the middle of the groin where the 
 
116 
 
 BONES, JOINTS AND MUSCLES. 
 
 femoral vessels [193] pass from the abdomen to the thigh. 
 This is known as femoral hernia. The operation for the 
 radical cure of hernia, as now performed, is attended with 
 practically no danger and is generally successful. During 
 the past four or five years many operations of this kind 
 have been performed by military surgeons and many men 
 
 Bony pelvis and upper ends of thigh-bones: A, ilium united behind with B, 
 the sacrum ; a, the crest of the ilium, and 6, its spine ; C, the ischium, and e, its 
 tuberosity ; Z>, the pubes, and d, the pubic arch formed by the meeting of the 
 two bones ; e, the obturator foramen or opening, closed in the body by a strong 
 membrane ; E, three segments of the coccyx, the tip hidden by the pubic arch ; 
 P, the femur or thigh-bone; /, its head in the cotyloid cavity; p, its neck; A, 
 the great trochanter, and i, the small trochanter. 
 
 have been saved to the service who formerly would have 
 been discharged for disability. 
 
 175. The hip-hones form a strong arch, supporting the 
 body and giving attachment to the powerful muscles which 
 move the lower extremities. Each consists of three bones 
 soldered together into one irregularly shaped whole; the 
 iliimi forms the crest and massive side of the bone ; the 
 
BONES, JOINTS AND MUSCLES. 117 
 
 ischium constitutes its under portion, or that on which a 
 person rests in sitting; while the pubes joins in front with 
 the corresponding hone on the opposite side to form the 
 pubic arch. About the middle of the outer aspect of this 
 composite bone is a deep cavity, the cotyloid cavity, or 
 socket for the head of the thigh-bone. Dislocation is rare 
 at this joint, as compared with its frequency at the shoul- 
 der, on account of the depth of the socket, the greater 
 strength of the ligaments forming its capsule, and the 
 power of the overlying muscles. 
 
 176. The femur or thigh-bone has a strong cylindrical 
 shaft which expands below into an articular surface and 
 condyles [166] at the knee, and above into a round head on 
 its inner aspect, and a large tuberosity on its outer aspect. 
 The head is mounted on a neck by which it is projected 
 upward and inward from the axis of the shaft to the coty- 
 loid cavity. This carries the shaft clear of the hip-bone 
 and gives greater freedom of movement. The tuberosity, 
 the f/reat trochanter, can be felt on the outer aspect of the 
 joint, and when the foot or knee is rolled in or out, the 
 trochanter follows the motion. 
 
 177. The knee is a hinge-joint formed by the lower end 
 of the femur and the upper end of the tibia or principal 
 bone of the leg. The massive muscles on the front of the 
 thigh are inserted by a single tendon into the tibia just 
 below the joint; they extend the leg on the thigh. Inti- 
 mately connected with this tendon is a roundish bone, the 
 patella or knee-cap, which protects the joint in front. The 
 muscles on the back of the femur are inserted by tendons 
 on each side of the posterior aspect of the head of the tibia, 
 constituting the outer and inner hamstring muscles ; their 
 contraction flexes the leg. 
 
 178. The shaft of the tibia is three-sided, presenting one 
 
118 BONES, JOINTS AND MUSCLES. 
 
 of its angles along the front of tlie shin. At its lower end 
 it expands into an articular surface for the ankle-bone, 
 which it encloses and protects on its inner side by a projec- 
 tion called the internal malleolus. The yjJwZa -or outer bone 
 of the leg is much smaller than the tibia, to which it is 
 applied as a support or splint. Its upper end or head is 
 attached to the head of the tibia, where it may be felt just 
 below the outer aspect of the knee-joint. Its lower end 
 forms the external malleolus, which encloses and protects 
 the ankle-bone on its outer side. The muscles of the caU 
 are inserted by a strong tendon, the tendo Achillis, into the 
 point of the heel; they extend the foot at the ankle-joint. 
 The muscles beneath those of the calf become tendinous in 
 their lower part and pass under a ligament, between the 
 inner malleolus and the heel, to the sole, where they split 
 up into the flexor tendons of the toes. The extensors stretch 
 from the outer and fore part of the leg under a retaining 
 ligament in front of the ankle and along the upper surface 
 of the foot to the toes. 
 
 179. As the upper extremity is terminated by carpal, 
 metacarpal, and phalangeal bones, arranged as a prehensile 
 organ, the lower is terminated by analogous bones, tarsal, 
 metatarsal, and. phalangeal, modified to secure strength and 
 pliability. There are seven tarsal bones. The astragalus 
 or ankle-bone is rounded on its upper surface, which is re- 
 ceived into the concavity formed by the end of the tibia 
 and the two malleoli. It is supported on the calcaneum or 
 heel -bone; and these two articulate with the others which, 
 with the long metatarsal bones, complete the arch of the 
 foot. The phalanges are in general similar in their ar- 
 rangement to those of the fingers [169] . 
 
CHAPTEE II. 
 
 THE SYSTEM OF ORGANIC LIFE. 
 
 180. The blood is the essential part of the system of or- 
 ganic life ; the accessories are the organs which elaborate the 
 blood, those which distribute, and those which purify it. 
 Every portion of the body, from the bony framework up to 
 the delicate cerebral tissues, which give a material home to 
 thq, INTELLIGENCE itself, depends on the supply of blood for 
 its growth and well-being. 
 
 181. The blood consists of a colorless liquid serum, 
 plasma, or liquor sanguinis, and a vast number of micro- 
 scopic cells or corpuscles which give the liquid its red color. 
 The serum contains dissolved in it albumen, similar to that 
 constituting white of egg, fibrin, which, under certain con- 
 ditions, coagulates spontaneously, and some inorganic salts. 
 When blood is drawn from the body its fibrin consolidates 
 into a soft clot which entangles the corpuscles and serum 
 in its meshes. After some hours the clot becomes smaller 
 and firmer as the coagulated fibrin squeezes out the greater 
 part of the serum which was at first enclosed in it. If the 
 coagulation takes place slowly, affording time for the cor- 
 puscles to settle a little before becoming fixed in the con 
 solidating material, the upper surface of the clot may be 
 covered with a bvffy coat, a grayish-yellow layer of com- 
 paratively pure fibrin. Blood sometimes coagulates within 
 the body, as when an artery is tied [443] . 
 
 182. The cells which give color to the blood are called 
 the red corpuscles. They are circular flattened discs, yel- 
 
120 THE BLOOD AND ITS CIECULATION. 
 
 lowish and translucent, each like a minute, double-concave 
 lens. They consist mainly of a substance called hmmo- 
 glohin, which combines readily with oxygen, thus enabling 
 them to fulfil their mission, which is to carry oxygen to the 
 tissues for the oxidation and removal of used-up material. 
 
 183. White or colorless corpuscles are also found in the 
 blood, one for every four or five hundred of the red corpus- 
 cles. They are somewhat larger than the latter and contain 
 granular matter. In shape they are usually spherical, but 
 when closely watched they may be, seen to elongate their 
 substance in one or more directions ; and as the amosiba, one 
 
 Blood-corpuscles: a, red corpuscle, full view of one side; ft, profile view; c, 
 common mode of aggregation during clotting — like piles of coin ; d, a red cor- 
 puscle corrugated, probably old and ready to break down; e, amoeboid move- 
 ments of a white corpuscle ; /, a spherical colorless corpuscle. 
 
 of the lowest forms of living matter, moves in this way, 
 these movements are said to be amoeboid. They have the 
 power of penetrating the walls of the minute blood-vessels ; 
 and as they are always present in large numbers when 
 fibrin coagulates in- the tissues, they are supposed to be 
 concerned in the coagulation. 
 
 184. When the serum of the blood escapes through the 
 walls of the small blood-vessels, as a liquid through filter- 
 ing-paper, and accumulates in the tissues or cavities of the 
 body, it constitutes what is called an effusion. When the 
 white corpuscles penetrate the walls and the effused serum 
 becomes coagulated, the solidified matter is called an exu- 
 
THE BLOOD AND ITS CIRCULATION. 121 
 
 dation. The red corpuscles escape only through, accidental 
 breaks, and their presence in the tissues is known as an 
 extravasation of blood. 
 
 185. The Cieculation. — The living body is in a state 
 of constant change. There is a popular belief that the 
 body is renewed every seven years; but the finger-nails 
 require only a few months for their complete renewal. 
 Every organ undergoes change from day to day by the 
 removal of some of jts used-up tissue and its replacement 
 by fresh materials. A regiment may have now about the 
 same number of officers and men that it had a few years 
 ago, but the individuals that compose its numerical strength 
 are not the same ; those lost by discharge and death have 
 been replaced by recruitments. So the organs of the 
 human body are subject to processes of disintegration on 
 the one hand, and renovation by the blood on the other. 
 In every movement some minute particles of the muscles 
 become unfit for further service and have to be replaced ; 
 in every thought or mental impulse some part of the ner- 
 vous system becomes used up, as the plates of a galvanic 
 battery are dissolved to develop its power. To effect the 
 repair of this constant waste a constant circulation of the 
 reparative material is needful; but although this is pro- 
 vided by nature, the activity of the destroying influences 
 is so great that recurring periods of rest or sleep are re- 
 quired to permit of the perfect recuperation of the tissues. 
 
 186. The circulation of the blood is effected by the heart, 
 which drives it through the system ; the arteries, which con- 
 duct it to the tissues ; the capillaries, from which the repara- 
 tive operations are conducted, and the veins, which gather 
 up the blood and return it in an altered and impure condi- 
 tion to the heart. Before the blood starts again on its sys- 
 temio round it is driven to the lungs, where it becomes 
 
m 
 
 THE BLOOD AND ITS CIRCTJLATIOK. 
 
 purified. This accessory to the systemic circulation • is 
 called the pulmonary circulation. 
 
 187. To keep up these two currents of blood, the heart 
 is divided by a partition into two sides or chambers, the 
 left receiving and delivering pure or arterial blood, the 
 right receiving and delivering impure or venous blood. 
 These chambers are formed of muscular walls, which by 
 their contraction drive the blood into the vessels, as the 
 
 Diagram of the circulation. 
 
 hand, by its contraction on the rubber bulb of an atom- 
 izer, drives the air through its tube. The upper part of 
 each side forms a receiving-chamber or auricle for the 
 venous blood on the one side and the arterial blood on the 
 other. They become filled while the lower part of each, 
 the ventricle or delivering-chamber, is contracted in the act 
 of sending out its charge of blood. As soon as each ven- 
 tricle is emptied it relaxes, receives into its cavity the ac- 
 cumulated blood from the auricle, and again contracts to 
 
THE BLOOD AND ITS CIRCULATIOK. 123 
 
 drive out this fresh supply [267]. The two sides of the 
 heart act simultaneously, so that at the ventricular contrac- 
 tion the arterial blood on the left rushes off to the tissues, 
 and the venous on the right to the lungs. To prevent a 
 reflux into the auricles at this time, the communication 
 between the chambers is guarded by valves ; and to prevent 
 a return from the vessels during the subsequent relaxation 
 of the ventricles, the mouths of the former are, similarly 
 guarded. The left ventricle is thicker and stronger in its 
 muscular walls than the other chambers, as it has to drive 
 the blood to the uttermost parts of the system. The dis- 
 charging capacity of each ventricle is about two fluid 
 ounces. 
 
 188. The heart is conical in shape, and about the size of 
 the closed fist of the individual. It is imbedded between 
 the lungs, and sustained in its position by the many large 
 vessels which connect with its upper part. A strong fibrous 
 membrane, the pericardium, forms a loose sac around it; 
 and as the interior of this sac and the exterior of the heart 
 are both coated with a smooth serous membrane, the move- 
 ments are effected without friction. The heart lies behind 
 the middle of the sternum, extending from the central line 
 of the body about three inches toward the left, but only 
 half that distance toward the right. Its lower end or apex 
 corresponds with a point two inches below the left nipple 
 and one inch to its inner side (page 113). When the ear 
 is laid over the cardiac region the heart-sounds are heard. 
 They have been likened to the pronunciation of the sylla- 
 bles liibh-dup, and are separated from the next following 
 repetition by a well-marked pause. The first sound corre- 
 sponds with the contraction of the ventricles and the rush 
 of blood through the great arteries; the second is chiefly 
 caused by the sudden closing of the valves in these arteries 
 
124 THE ARTERIES. 
 
 when ventricular relaxation begins; and the pause corre- 
 sponds with the passage of the blood from the auricles into 
 the relaxing ventricles. 
 
 189. The great artery of the systemic circulation, the 
 aorta, begins at the upper part of the left ventricle, and, 
 passing upward behind the sternum for a short distance, 
 curves backward to the left side of the vertebral column. 
 From the upper aspect of the arch arise the vessels which 
 supply the head, neck, and upper extremities. 
 
 190. The carotid arteries run upward in the neck on each 
 side of the trachea and larynx, underneath the inner margin 
 of the sternomastoid muscle, giving ofE large branches for 
 the neck and face, and a large vessel, the internal carotid, 
 for the interior of the cranium. One of its branches, the 
 temporal, may be felt pulsating in front of the ear, just 
 above the articulation of the lower jaw, and a branch of 
 this, the anterior temporal, may often be seen pulsating as 
 it crosses the temple on a line from the upper border of 
 the ear to above the orbit. 
 
 191. The subclavian arteries run upward and outward 
 from the arch of the aorta behind the clavicle and over the 
 upper and outer surfaces of the first rib to the axilla or 
 armpit. The axillary artery is the continuation of the 
 subclavian as it passes along the inner side of the shoulder- 
 joint and upper part of the shaft of the humerus. The 
 artery below the insertion of the pectoral muscles [164] 
 is called the brachial ; it lies along the inner margin of the 
 biceps muscle, passing from the inner side of the humerus 
 in its upper part to the front of the bone at the elbow- 
 joint, where it divides into two branches, the radial and 
 ulnar. These branches descend the forearm, overlapped 
 by muscles, but near the wrist they become superficial and 
 are easily detected by the fingers. The radial is the vessel 
 
THE ARTERIES. 125 
 
 usually selected for ascertaining the rate and other charac- 
 ters of the arterial pulse. On reaching the palm the two 
 vessels reunite over the metacarpal bones, and from the 
 arch formed by their junction branches descend between 
 the bones, breaking up at the clefts into terminal branches 
 which course along adjacent sides of the fingers to their tips. 
 
 192. After completing its arch the aorta descends in the 
 thorax along the left side of the spinal column until, oppos- 
 ite the fourth lumbar vertebra, it breaks up into two large 
 vessels, the common iliac arteries. Each of these extends 
 downward and outward into the pelvis, where a large branch, 
 the internal iliac, is given off to the contents of the cavity, 
 its walls and the muscles connected with the outer surface 
 of the ilium. The continuation of the main trunk, under 
 the name of external iliac, reaches the middle of the groin, 
 where it enters the thigh and becomes known as the femoral 
 artery. 
 
 193. The pulsation of the femoral may be discovered by 
 the fingers from the middle of the groin downward for a 
 short distance. It then dips under the muscles and be- 
 comes lodged in a canal of fibrous tissue along the inner 
 side of the bone. At the junction of the middle with the 
 lower third of the thigh it passes backward into the poples or 
 ham, where under the name oi popliteal artery it descends 
 to below the knee-joint, where it divides into two tibial 
 branches. The anterior tibial artery penetrates to the front 
 of the leg between the heads of the tibia and fibula, de- 
 scends, covered by muscles, along the outer side of the tibia, 
 and under the name of the dorsal artery of the foot forms 
 an arch from which branches are distributed to the pha- 
 langes. The posterior tibial descends along the back part 
 of the leg, becoming superficial below, where it passes be- 
 tween the internal malleolus and the tendo Achillis [178] to 
 
136 THB ARTERIES. 
 
 reach the sole. Here it forms the plantar arch for the sup- 
 ply of the toes. 
 
 194. Each of the various arteries that have, been men- 
 tioned gives off branches to the parts in its neighborhood. 
 These divide and sub-divide until they reach a size but lit- 
 tle larger than the capillaries in which they terminate. 
 The small arterial vessels form a netvi^ork or vascular 
 framework, in which the tissties are bedded like the cellu- 
 lar substance of a leaf between the meshes of the veinlets 
 derived from the leaf -stalk. 
 
 195. The walls of an artery are so strong and elastic that 
 when empty they do not collapse, but remain open like 
 a rubber tube. They consist of an outer coat of tough elas- 
 tic tissue, a middle layer of muscular and elastic tissue, and 
 a smooth interior lining. When the heart throws its charge 
 of blood into the arterial tubes the walls of the latter yield 
 to the dilating force, but this yielding is momentary ; the 
 contractility of the muscular coat of the vessels, closing on 
 the contained blood, forces it onward to the tissues, back 
 flow being prevented by the valves in the aorta. 
 
 196. An organ or tissue does not require the same quan- 
 tity of blood at all times. The brain when actively en- 
 gaged requires more than when asleep ; a muscle in active 
 use requires more than when it is at rest. An increase in 
 the action of the heart provides more liberal supplies when 
 the requisition is made by the system as a whole ; but local 
 requirements are supplied by the contractility of the arte- 
 ries under the superintendence of the nervous system. 
 When an organ requires an increased supply its arteries 
 become larger by the relaxation of their muscular fibres. 
 Congestions or local determinations of blood [359] in cases 
 of injury or disease are effected by this action of the mas- 
 cular coat. Nervous impressions often operate on the size 
 
THE ARTERIES. . 127 
 
 of the vessels, as when the face becomes pale or flushes 
 under the influence of certain emotions. The contractility 
 oi the middle coat has also an important bearing on the 
 suppression of hemorrhage [440] . 
 
 197. If a part be deprived of its supply of blood for 
 a certain length of time, it will mortify. To lessen the 
 danger from accidental obstructions, the branches of one 
 artery communicate or anastomose with those of another. 
 When an artery, such as the axillary, has been wounded 
 and tied, the blood supply for the limb is kept up by 
 anastomosis. The direct route being blocked up, the 
 current passes through one or more of the branches given 
 off above the ligature, and these, by their connections with 
 those given off below the ligature, establish a collateral cir- 
 culation by which the parts below the obstruction are sup- 
 plied with blood. Anastomosis is more extensive in the 
 upper than in the lower extremity, and hence gangrene 
 after injury is less common in the hand than in the foot. 
 Where the anastomosing branches are large and the collat- 
 teral current readily established, there is danger of the re- 
 currence of bleeding from the lower or far end of a divided 
 artery, unless that end as well as the upper or near one be 
 closed by a ligature. 
 
 198. As the arteries subdivide into smaller branches 
 their walls become thinner, until they end in a vast number 
 of minute tubes which surround the elementary cells or 
 fibres of the various tissues with a freely anastomosing vas- 
 cular network. The vessels of this, the capillar?/ system, 
 are just large enough to permit the passage of the red cor- 
 puscles in single file. Their delicate walls permit the 
 plasma to exude into the tissues for the processes of growth 
 and repair ; the red corpuscles yield up the oxygen which 
 they have brought from the lungs for the oxidation or com- 
 
138 THE CAPILLARIES. 
 
 bustiou of used-up materials; heat is developed, and the 
 liquor sanguinis dissolves and washes back into the vascu- 
 lar current the carbonic acid and other more complex mat- 
 ters which result from the oxidation. These changes are 
 manifested in the blood by that darkening of its color which 
 distinguishes venous from arterial blood. 
 
 199. The veins collect the blood from the capillaries and 
 carry it back to the heart. The venous system is more 
 capacious than the arterial, for many veins have no corre- 
 sponding arteries, and all the smaller and some of the large 
 arterial vessels are accompanied by two returning veins. 
 The radial, ulnar, and brachial arteries, and those of the 
 leg, have each two companion veins; but from the axillary 
 and popliteal onward to the heart the arteries have but one 
 associated vein. 
 
 200. The veins of the upper extremity unite into a single 
 trunk, the axillary vein, which, on crossing over the first 
 rib behind the clavicle, becomes the subclavian vein. Be- 
 hind the sternoclavicular articulation the subclavian unites 
 with the internal jugular, the companion of the common 
 carotid artery, which returns the blood from the head, face, 
 and neck. The trunks formed by these two large veins 
 join behind the sternum, forming the superior vena cava, 
 which terminates in the upper part of the right auricle 
 (page 132). 
 
 201. The veins of the inferior extremity unite into a 
 single trunk, the popliteal, which becomes successively the 
 femoral, the external iliac, and the common iliac vein. By 
 the junction of the common iliacs is formed the inferior 
 vena cava, which runs upward on the right side of the aorta 
 and ends in the right auricle. 
 
 202. The inferior cava, in its passage upward along the 
 spine, receives blood from the kidneys, the testicles, and the 
 
THE VEINS. 129 
 
 abdominal walls ; but the blood from the organs of digestion 
 passes through the liver before entering the direct channel 
 to the heart. The veins from the intestines, the stomach, 
 and the spleen unite into one large vessel, the portal vein, 
 which enters the liver, subdividing, like an artery, into 
 smaller branches, and ultimately into a capillary system, the 
 blood of which is gathered up by a vein, the hepatic, and 
 passed into the inferior cava as the latter vessel passes up- 
 ward behind the postgrior border of the organ. There are 
 thus in the liver two series of blood-vessels — in fact, two cir- 
 culations ; the ordinary arterial circulation, ending in the he- 
 patic vein, and intended for the nutrition of the organ ; and 
 the portal circulation, also ending in the hepatic vein, but 
 intended apparently for the exposure of the venous blood 
 of the digestive organs to some special action prior to its 
 admission into the general circulation. As the veins of the 
 portal system contain much crude material absorbed from 
 the stomach and intestines, it may be inferred that the ob- 
 ject of passing their blood through the liver is to prepare 
 the crude material for future use as a part of the mass of 
 the circulating blood. 
 
 203. The veins which have no corresponding artery are 
 usually superficial in position ; and as the object of their 
 existence appears to be to furnish a route for the returning 
 blood when the deeper veins are temporarily occluded [205], 
 their intercommunicating branches are numerous and large. 
 The external jugular returns the blood from the exterior of 
 the head and certain parts of the face ; its branches unite to 
 a single trunk, which extends from just below the ear, down- 
 ward, across the sternomastoid, and then parallel to the pos- 
 terior border of that muscle, to the middle of the clavicle, 
 where it ends in the subclavian vein. 
 
 804. The superficial veins on the back of the fingers and 
 9 
 
130 THE TEIKS. 
 
 hand, and on the ball of the thumb and little finger, become 
 aggregated into three sets of vessels. Those on the outer 
 side of the forearm unite near the elbow to form a large 
 vein, the cephalic, v^hich courses up along the outer border 
 of the biceps muscle to join the axillary vein. Those on 
 the inner side form the basilic vein, which continues along 
 the inner border of the biceps to join the brachial veins. 
 Those on the front of the forearm unite to a single trunk, 
 the median, which runs upward to the bend of the elbow, 
 where it divides into two short branches, the median cephalic, 
 extending obliquely outward to join the cephalic, and the 
 median basilic, extending inwards to the basilic. In former 
 times when bleeding was extensively practised, the outer of 
 these communicating veins was usually selected for the 
 operation, as the inner one lies immediately over the brach- 
 ial artery, just above its point of division into the radial 
 and ulnar. The external saphenous vein collects blood from 
 the upper and outer part of the foot and the posterior as- 
 pect of the leg, and discharges into the popliteal. The in- 
 ternal saphenous vein passes along the inner aspect of the 
 
 Valves of veins : The arrow indicates the direction of the flow toward the 
 heart. 
 
 leg and the middle of the thigh to a little below the groin, 
 where it joins the femoral vein. 
 
 205. The walls of the veins are so thin that when filled 
 the color of their contents shows through them, and when 
 empty they collapse. Slight pressure closes them and ob- 
 structs their circulation. They have none of the contractil- 
 ity or elasticity that characterizes the arterial walls. After 
 
VARICOSE VEINS. 131 
 
 death the arteries are emptied by means of this contractility, 
 but the veins are found to contain hlood. The lining mem- 
 brane of the veins is pinched up at various points into folds 
 which act as valves, permitting the passage of blood toward 
 the heart, but overlapping each other and forming a parti- 
 tion across the tube when any pressure tends to force the 
 current back on the capillary system. When a muscle con- 
 tracts, the veins in its neighborhood are subjected to a pres- 
 sure which obliterate^ their channels ; but owing to the free 
 communication of their branches, the blood escapes into col- 
 lateral veins ; and this escape, by virtue of the system of 
 valves, is always in the direction of the heart. Muscular 
 movements thus accelerate the venous current. The heart 
 operates automatically. When the ventricles are filled they 
 contract to discharge the blood, and then relax to be filled 
 again. In the healthy condition the rapidity of the heart's 
 action depends on the inflow from the veins. Exercise calls 
 for more blood to the muscles, but this same exercise hastens 
 the return of the venous current and enables the heart to 
 meet the demand. When, for instance, one is rowing, the 
 deep veins are alternately filled and emptied by muscular 
 action at each sweep of the oars — filled from the capil- 
 laries, and emptied in the direction of the heart through 
 the superficial veins. 
 
 206. As the walls of the superficial vessels have little 
 support from adjoining textures, they sometimes yield to 
 the pressure of the contained blood, and become permanent- 
 ly dilated or varicose. The internal saphenous vein and its 
 branches are often thus affected, becoming large, tortuous, 
 and knotty. Some long-continued obstruction is generally 
 concerned in the causation, as the pressure of tight garters 
 or that of constipated bowels on the venous trunk within 
 the pelvis. The benefit to be derived from elastic stockings 
 
132 
 
 HBMOKEHOIDS. 
 
 in such cases is obvious. Bleeding from the rupture of vari- 
 cose veins should be restrained by compresses with a firmly 
 applied bandage. Hemorrhoids or piles are enlargements 
 of the veins around the anus and lower part of the bowel, 
 
 The Thokacic Organs : a, right lung divided into three lobes, and 6, left 
 lung into two lobes, their anterior margins thrown bacl£ to expose the deeper 
 parts; e, trachea with its cartilagino<is rings; d, right bronchial tube; e, right 
 auricle, receiving from above/, the superior vena cava, which is formed by the 
 junction of g, g., the right and left innominate veins, and each of these by the 
 confluence of A, h, i, i, the jugular and subclavian of its own side; j, the right 
 ventricle, giving issue to k, the pulmonary artery, which divides into two 
 branches, that for the right lung passing behind the other great vessels; I, I, I, I, 
 pulmonary veins, bringing oxygenated blood to m, the left auricle ; n, the left 
 ventricle, from which the blood is carried to the organs and tissues by o, the 
 aorta; p, p, g, g, carotid and subclavian arteries, given off from the arch of the 
 aorta. 
 
 due to the pressure of constipated bowels or to conditions 
 of the liver, which obstruct the passage of the blood through 
 the portal system [202]. 
 
 207. The venous blood returned to the right auricle by 
 the superior and inferior venae cavse, is retained in that 
 
ALIMEKTATION. 133 
 
 chamber only until the relaxing ventricle opens to receive 
 it. The distention of the ventricle is immediately followed 
 by its contraction, which drives the blood into the pulmo- 
 nary artery, the branches of which divide and subdivide 
 until they reach the terminal subdivisions of the air pas- 
 sages, where they end in a capillary system which sur- 
 rounds each air cell with a vascular network. Here the 
 blood undergoes changes which are the reverse of those 
 which take place injfche systemic capillaries. The red cor- 
 puscles exhale carbonic acid and absorb oxygen, and, as a 
 result, the blood loses its dark color and becomes a florid 
 red; heat is carried off by the watery vapor and the accom- 
 panying exhalations [248] . The oxygenated or arterialized 
 blood is gathered up by veins which complete the circuit 
 by joining the left auricle. 
 
 ALIMENTATION. 
 
 208. As the blood is subjected to a continuous loss of its 
 nutritive materials in the capillaries of the systemic circu- 
 lation, provision is made by nature to supply its elementary 
 principles. The materials of the blood are obtained from 
 the substances ingested as food. These are divided into 
 three classes — the nitrogenous, the non-nitrogenous, and 
 the inorganic. The nitrogenous contribute the albuminous 
 and fibrinous principles for the repair of the muscular sys- 
 tem. They include the albumin of fresh meat, the casein 
 of milk, the gluten of flour [611] and analogous principles 
 in other vegetables as peas, beans, mushrooms, etc. The 
 non-nitrogenous replace those elements of the tissues' that 
 are destroyed by oxidation during the production of force 
 and the development of animal heat. They include the 
 fats, starches, and sugars, all of which consist of carbon 
 
134 ALIMENTATION. 
 
 and hydrogen in a readily oxidizable form. Taken in ex- 
 cess of the immediate wants of the system, they are stored 
 up as surplus fat, to meet the emergencies of sickness or 
 impoverished diet. The inorganic consist of various salts 
 which are usually found already prepared by nature in the 
 substances that are used as food. In wheaten flour there 
 is nearly one per cent, of mineral matters, which are just 
 those that are required by the human system ; m fresh meat 
 and all other alimentary substances there is a similar sup- 
 ply of inorganic matter — common salt is perhaps the only 
 one of this class which is added specially to the diet. To 
 these three classes a fourth is sometimes added, comprising 
 such articles as have been called accessory foods — tea, coffee, 
 cocoa, alcohol, pepper, and other condiments ; but these are 
 stimulants rather than foods. Water is not usually re- 
 garded as a food, although it enters the system along with 
 the food and forms so large a percentage of the various 
 tissues of the body. Death occurs from its deprivation 
 more quickly than from the deprivation of food; men 
 have fasted for many weeks, but they will die for want of 
 water in as many days. 
 
 209. Each of the natural substances used as food con- 
 tains a proportion of all the elementary principles that are 
 needful to the formation of the blood supply. Wheaten 
 flour contains 10 to 15 per cent, of gluten, 60 of starch, 7 
 of sugar, and over 1 each of fatty and inorganic matters; 
 fresh meat yields 20 per cent, of albuminoids, varying pro- 
 portions of fat, and nearly 2 per cent, of salts; pork, 10 
 per cent, of albuminoids and a larger proportion of fat. 
 
 210. If any one of these substances contained the ele- 
 ments in the proportion in which they are required by the 
 human body, that substance would be a perfect food. Milk 
 is a perfect food for the child. It contains nitrogenous 
 
ALIMEKTATION. 135 
 
 matter in the form of casein, fat globules in the cream, and 
 lactose or sugar of milk and salts, chiefly phosphate of lime, 
 dissolved in its water. The requirements of the infant do 
 not vary from day to day, and the one food suffices for its 
 growth and development; but as it grows older, varying 
 conditions of exercise or repose call for more or less of the 
 nitrogenous elements, and varying conditions of external 
 temperature for more or less of the non-nitrogenous. Milk 
 then ceases to afford, the proportions fitted for all the con- 
 ditions in which the individual may be placed, and articles 
 of diet must be selected which in their totality give the 
 proportions required by the system. Great exertion calls 
 for a larger proportion of nitrogenous, great cold for a 
 larger proportion of fatty matters, while the starches and 
 sugars suffice for the wants of the system in the absence of 
 these special calls. Variety in diet, which is generally re- 
 garded as a matter of taste, originated in the necessities of 
 the system. 
 
 211. The total quantity of food necessary for support is 
 also measured by the conditions affecting the body. A 
 man who passes the day in hard labor or active exercise 
 requires tha.t full diet of which the army ration is an illus- 
 tration. If he be in hospital with some chronic discharge, 
 which acts as a drain upon the system, a full diet is also 
 needful. Ordinarily a patient in hospital requires much 
 less, particularly of the fatty elements, than is allowed by 
 the army ration; and the money value of the unused por- 
 tions of the ration constitutes the hospital fund. 
 
 212, When an excisi of food is taken, it is not absorbed, 
 but accumulates in the intestinal canal, undergoing changes 
 which tend to putrefaction. The acrid matters thus pro- 
 duced are taken up into the blood and induce a febrile con- 
 dition, or they irritate the intestinal canal and cause a 
 diarrhoea which brings about their expulsion. 
 
136 THE TEETH. 
 
 213. A deficiency of food occasions a feeling of f aintness 
 or sinking at the epigastrium, gnawing pain in the stom- 
 ach, headache, and weakness. Want of food is a common 
 and often unsuspected cause of sleeplessness. Patients in 
 hospital should never be dosed with opium when a cup of 
 beef tea with a cracker will remedy their complaint. When 
 the deficiency of food is continued, progressive weakness 
 and emaciation follow with increased liability to disease 
 and a special tendency to the scorbutic condition [69]. 
 
 214. Mastication and Swallowing. — When the pharma- 
 cist desires to extract the active principle from some root or 
 tough vegetable product, he slices, beats, or breaks it into 
 small portions that his menstruum may penetrate it and 
 dissolve out the valuable material. So nature operates in 
 dealing with the crude materials from which the elements 
 of the blood are to be extracted. To facilitate their reduc- 
 tion a liquid, the saliva, oozes from its secreting glands into 
 the mouth, to be incorporated with the triturated food which 
 it transforms into a soft pultaceous mass. The mouth, 
 
 fauces or throat, and oesophagus or gullet, are lined, like 
 the rest of the alimentary canal, with a membrane, whicli 
 secretes a thick viscid liquid called mucus, which lubricates 
 their interior, and enables the mouthful to glide easily into 
 the stomach. 
 
 215. If mastication be not thoroughly performed, the 
 stomach suffers ui the long run. Those who would be free 
 from dyspepsia should have good teeth and make good use 
 of them. Nature provides man with two sets of teeth. In 
 the milh or temporary set there are ten teeth in each jaw; 
 four incisors, or sharp-edged cutting teeth, in front, with 
 one sharp-pointed canine, or tearing tooth, on each side of 
 them, and two broad-crowned molars, or grinding teeth, on 
 each flank of the dental liae. The central incisors of the 
 
THE TEETH. 137 
 
 lower jaw appear about the sixth or seventh month, those 
 of the upper set closely following; the lateral incisors of 
 the lower about the tenth month, followed by the corre- 
 sponding upper teeth; the anterior molars shortly after the 
 end of the first year, the canine or eye-teeth at a year and 
 a half, and the posterior molars during the third year. 
 Teething is sometimes attended with considerable local irri- 
 tation, restlessness, loss of sleep and appetite, and even 
 symptomatic febrile action ; diarrheal troubles occasionally 
 
 Central incisor of Canine or eye-tooth Second bicuspid of 
 upper jaw. ct upper jaw. lower jaw. 
 
 alternate with inflammatory conditions of the skin covering 
 the buttocks or scalp, and sometimes convulsions are devel- 
 oped. Belief may often be afforded in such cases by lanc- 
 ing the gums when it is evident that the tooth is close to 
 the surface. 
 
 216. The permanent teeth are sixteen in number in each 
 jaw ; Four incisor and t\oo canine teeth supplant those of 
 the temporary set; four small or false molars, two on each 
 side, called also bicuspids, because they have two points or 
 cusps on their crown, replace the molars of the child; and 
 six large or true molars, three on each side, called also 
 multicuspids, because they have several points on their 
 crown to facilitate the grinding of food, make their appear- 
 ance behind the bicuspids. The lower teeth erupt before 
 
138 THE TEETH. 
 
 the corresponding teeth of the upper jaw; the first or an- 
 terior molars about the sixth year ; the central incisors at 
 the seventh; the lateral incisors at the eighth; the first 
 bicuspids at the ninth, and the second at the tenth year ; 
 the canines from the eleventh to the twelfth year ; the sec- 
 ond or middle molars at the thirteenth, and the third or 
 posterior molars, the wisdom teeth, as they are called, from 
 the seventeenth to the twenty-first year, or later. Some- 
 times young soldiers suffer considerably from pain and 
 
 Second molar of Wisdom tooth o£ Section of lower molar ; a, 
 
 upper jaw, upper jaw. dentine : 6, enamel ; c, crusta 
 
 petrosa ; d, pulp cavity. 
 
 swelling about the back part of the alveolar arch, due to 
 the incoming of a wisdom tooth. When the swollen gum 
 overlying the crown of the tooth is cut across, the symp- 
 toms will speedily subside. 
 
 217. Each tooth is divided anatomically into the crown, 
 which is visible in the mouth ; the neek, which is embraced 
 by the gum ; and the root, hidden by the gum and socketed 
 in the jawbone. The root of each of the incisors, canines, 
 and bicuspids is single and conical, the canine fang being 
 longer than the others. Each lower molar has two roots, 
 one in front and one behind, and each upper molar three 
 roots, two toward the outer and one toward the inner aspect 
 of the jaw; but the fangs of each wisdom tooth are usually 
 
THE TEETH. 139 
 
 consolidated into one which presents grooves or markings of 
 a division into three in the upper and two in the lower jaw. 
 
 218. The teeth are eoniposed of a substance called den- 
 tine, somewhat harder than bone. . This is crowned with a 
 dense white enamel and coated on the fangs with a thin 
 layer of true bone, which is here called crusta petrosa. In 
 the interior of each tooth is a cavity containing the dental 
 pulp, which consists of nerves and blood-vessels that enter 
 by an aperture at th* end of the fang. 
 
 219. Decay takes place by the softening and breaking 
 down of the dentine, at first into superficial cavities, which 
 afterward lay open the dental pulp and, undermining the 
 enamel, permit the caving in of the crown and the total 
 destruction of the tooth. The teeth may be preserved for 
 many years by the use of the tooth brush and by having all 
 cavities filled with gold or other durable filling at the hands 
 of a dentist. Speedy decay follows neglect in all cases, 
 although some teeth and some individuals are more liable 
 to suffer than others. The anterior molars give way soon- 
 est, and are frequently decayed before the posterior molars 
 have erupted. The pain associated with this decay is 
 sometimes so severe in its paroxysmal exacerbations as 
 to call for emergency treatment [398]. A crust of tartar 
 accumulates on those parts of the teeth that are not sub- 
 jected regularly to the use of the tooth brush. This de- 
 posit, which consists of a cement of lime and organic mat- 
 ter, adheres so firmly that it has occasionally to be scaled 
 off by a sharp steel instrument [402]. The margin of the 
 gum behind the front teeth of the lower jaw and the outer 
 surface of the posterior molars are favorite sites for its 
 accumulation. 
 
 220. The saliva contains a fermentative principle, ptya- 
 lin, which, when mixed with starch, changes that substance 
 
140 THE STOMACH. 
 
 first into dextrin and then into glucose [601]. The change 
 is immediate, so far as regards a small percentage of the 
 starch, but the fermentation is brought to an end as soon 
 as the mouthful reaches the acid liquids of the stomach. 
 
 221, The stomach, when distended, is a somewhat pear- 
 shaped bag occupying the epigastrium, its large end on the 
 left under the diaphragm, its smaller as pyloric extremity 
 on the right under the liver. [See illustration on page 
 113.] Its walls consist of flattened bundles of longitu- 
 dinal, oblique, and circular muscular fibres, with an exter- 
 nal peritoneal [172] covering and an internal mucous lin- 
 ing. Embedded in the last are many minute tubular follicles 
 from which, when required for digestion, the gastric juice, 
 an acid liquid containing a ferment, pepsin, oozes into the 
 stomach, as the perspiration sometimes oozes from the pores 
 of the skin or the saliva into the mouth during mastication 
 [267]. When a meal is taken, the gastric juice is freely 
 secreted and incorporated with the masticated food by the 
 contraction of the muscular walls of the stomach. Starch 
 and fat are unchanged in the stomach except for mechani- 
 cal division, but albuminous materials become dissolved 
 into a sour-smelling liquid called peptone, which is in part 
 absorbed by the veins of the stomach and in part escapes 
 at the pylorus along with the chyme or grumous liquid 
 which the stomach transfers to the intestine as the result 
 of its digestion. 
 
 222. The process of liquefying the albuminoids, which is 
 the object of gastric digestion, occupies from one to four or 
 five hours, according to the quantity and digestibility of the 
 food and the efiiciency of the preliminary mastication. It 
 can easily be understood why a mass of tough gluten and 
 unbroken starch cells, such as exists in sodden, unraised 
 bread will cause a sense of heaviness or oppression in the 
 
THE INTESTIKES. 141 
 
 stomach for some time after it has been eaten, ileats that 
 have been preserved in brine become hard and difficult of 
 digestion. An excess of fat also interferes with the action 
 of the gastric juice and prolongs the stay of the food in the 
 stomach. Veal and lamb require more time than beef or 
 mutton. Peas and beans, on account of their large propor- 
 tion of nitrogenous elements, make a greater call on the 
 powers of the stomach than the cereal grains. Poultry, 
 fish, and oysters are,quickly digested. 
 
 223. The contractile walls of the stomach keep it in close 
 contact with the food during the progress of digestion. 
 The pyloric end, leading into the intestine, is guarded by 
 a circular band of muscular fibres which permits liquids to 
 drain away, but prevents the passage of undigested food. 
 In the healthy condition there is no tendency to regurgita- 
 tion through the oesophageal opening, but in certain mor- 
 bid states of the stomach its contents are thrown out by 
 Vomiting. 
 
 224. The small intestine is a long narrow tube in which 
 the chyme is treated after its passage from the stomach. 
 It measures about twenty-five feet from its commencement 
 
 at the pylorus, under the cartilages of 
 the ribs of the right side, to its ter- 
 mination in the large intestine in the 
 right iliac region just above the fold 
 of the groin. [See page 113. j It is 
 gathered up into coils which are held 
 in position by folds of a membrane 
 called the mesentery. The walls con- 
 Foids of the mucous sist of a muscular layer, covered with 
 membrane, vai„ui^ peritoneum externally, and lined with 
 
 conniventea^ or the '^ 
 
 small intestine. a thick mucous membrane, arranged 
 
 loosely in many pleats or folds to ex- 
 pose a greater surface to the material which passes over it. 
 
143 THE LIVEK AND PANCREAS. 
 
 The mucous membrane, besides secreting mucus for the 
 protection of itself against matters of an acrid nature, is 
 provided with many small follicles which aid the liver and 
 pancreas in the digestion of starchy substances [228]. 
 Some of the intestinal follicles are aggregated into oval 
 patches, one or two inches in length and about half '' as 
 broad, their long diameter extending lengthwise of the 
 intestine. These, the patches of Peyer, are most numerous 
 in the lower part of the small intestine. They have a 
 special importance as being the site of tumefaction and 
 ulceration during the progress of typhoid fever [340] . 
 
 225. The spleen lies under the lower ribs of the left 
 side, close to the stomach. It is about the size of the fist ; 
 but as it is elastic and distensible its size depends chiefly 
 on the quantity of blood which it contains. One of its func- 
 tions is that of acting as a safety-valve to the blood current 
 for the supply of the digestive organs. When full and 
 actively engaged these organs require a larger blood sup- 
 ply than when empty ; and as the spleen is always smaller 
 when the stomach is full than when it is empty, it is sup- 
 posed to be a distensible cistern which serves to accommo- 
 date the blood when that liquid is not required for active 
 operations in the stomach and intestines. 
 
 226. The liver [page 113] secretes a dark-greenish liquid, 
 the bile, which is stored, when not required for use, in a 
 small pear-shaped receptacle, the gall-bladder, opening into 
 the intestine near the pylorus. This secretion acts as a 
 stimulant to the muscular coat of the intestines, inducing 
 those contractions which carry the contents onward from 
 the upper to the lower end, a movement known as the peri- 
 staltic or vermicular motion of the intestine [267]. The 
 bile is strongly alkaline, saponifying fatty substances, as 
 when oil is shaken up with liquid ammonia or caustic soda, 
 and rendering them soluble and susceptible of absorption. 
 
THE LIVER AND PANCREAS. 143 
 
 It is also an antiseptic, preserving the chyme from putre- 
 faction during its sometimes slow progress through the in- 
 testinal canal. 
 
 227. The pancreas or sweetbread secretes an alkaline 
 liquid containing a ferment, trypsin, which has the same 
 influence on starch that is possessed by ptyalin [220]. The 
 pancreatic juice operates also on the liquid albuminoids that 
 have escaped the action of the stomach, transforming them 
 into peptone ; and by its alkalinity aids the bile in reducing 
 the fats to a soluble condition. 
 
 228, The chyme diminishes in quantity as it approaches 
 the lower end of the small intestine. The peptone, dextrin, 
 glucose, and emulsified fats are absorbed by the veins of 
 the intestine, but chiefly by a set of vessels called lacteals. 
 The mucous membrane of the small intestine is so beset 
 with minute processes or villi as to resemble velvet. Each 
 of these processes contains a special absorbing vessel in its 
 centre. The vessels from adjoining villi imite, forming 
 larger vessels, which may be detected as whitish lines on 
 the intestine if digestion is in progress at the time of the 
 examination. The white color is due to minute globules 
 of emulsified fat in the chyle or liquid which the vessels 
 absorb. These vessels enter the folds of the mesentery, 
 where they pass through the substance of a number of 
 small bodies, each about the size of an almond. In these, 
 the mesenteric glands, a change takes place in the chyle. 
 It becomes capable of coagulating and many white corpus- 
 cles like those of the blood are found in it. After leaving 
 the glands, the vessels unite into two or three trunks, which 
 terminate in a large vessel, the thoracic duct, by which the 
 chyle is led upward along the front and left side of the 
 vertebral column to the left subclavian vein [200] near the 
 junction of the internal jugular. 
 
144 ABSORPTION. 
 
 229. Digestion and absorption take place in the large 
 intestine, for nutrient enemata are changed and taken up 
 by the vessels even from its lower part — the rectum. Dur- 
 ing the passage of the intestinal contents along the upper 
 part of the large intestine, the secretions that were con- 
 cerned in their digestion in the small intestine are absorbed, 
 leaving only a semi-solid mass of refuse and undigestible 
 material called /aces, which is excreted. A valve, the ileo- 
 coBoal [page 113], guards the entrance to the large intestine 
 and prevents backflow into the small intestine by any move- 
 ment of compression. Attached to the head of the large 
 intestine near this valve is the appendix, a small rudi- 
 mentary organ which is sometimes the seat of dangerous 
 inflammations. 
 
 230. The blood is thus seen to be supplied with its nutri- 
 tive material from the albuminoids, starches, fats, sugar, 
 and salts of the food, the crude results of the digestive 
 process finding their way into the circulation by the hepatic 
 vein after filtration through the liver, or by the lacteal ves- 
 sels after filtration through the mesenteric glands. The 
 lacteals are, however, only a part of a larger absorbent 
 system which pervades the whole body. This, the lym- 
 phatic system, consists of minute vessels which ramify in 
 the tissues, often following the track of the veins in their 
 junction one with another to form larger vessels. They 
 absorb from the tissues those matters that have been ex- 
 uded or formed during the nutritive or reparative processes, 
 and return them to the blood for further use as nutritive 
 material, or to be carried to the proper organ for elimina- 
 tion as refuse. Owing to the thinness of their walls and 
 the transparency of the lymph, as the liquid which they 
 contain is called, they are made out with difficulty unless 
 injected for the special purpose of displaying them. Some- 
 
EESPIEATION. 145 
 
 times, wheu inflamed, their tracks may be observed in the 
 living body, as when from a poisoned or festering sore on 
 the hand their red lines are found to extend along the fore- 
 arm and arm to the armpit. The flow of the lymph is oc- 
 casioned by muscular movements and valves which, as in 
 the case of the veins, direct the current onward to the 
 heart. The vessels anastomose freely with each other, and 
 at certain parts of their course are connected with small 
 glandular bodies which are usually aggregated in particular 
 localities, as the groin, armpit, neck, etc. The glands 
 effect a change in the character of the lymph, increasing 
 its coagulability, providing it with white corpuscles, and 
 preparing it for readmission into the blood by way of the 
 thora6ie duct. Matters which would poison the blood, if 
 admitted into its current, are retained in the glands, in 
 which they often set up a suppurative inflammation, which 
 leads to their own destruction. 
 
 EXCKETION. 
 
 231. Eespiration. — The lungs fill the cavity of the chest 
 with the exception of that part in the centre and toward 
 the left occupied by the heart. [See illustrations on pages 
 113 and 132.] Each is enveloped in a serous membrane, the 
 pleura, which lines also the interior of the walls of the chest 
 and the upper surface of the diaphragm, to facilitate the 
 motion of one part on the other. The space between the 
 pleura covering the lung and that lining the walls is called 
 the pleural sac or cavity ; but in health there is no pleural 
 cavity, for the lung lies in close contact with the walls 
 which protect it. 
 
 233. Each lung is composed of the branchings of an air 
 tube and the associated divisions of the pulmonary arteries 
 and veins which carry the blood to and from the organ. 
 10 
 
146 EESPIKATION. 
 
 The air tube or trachea divides behiad the sternum into 
 two branches or bronchial tubes, one for each lung. To 
 prevent its closure during movements of the neck, the walls 
 of the trachea are formed of narrow cartilaginous rings 
 closely set in a strong fibrous membrane. The ultimate 
 branches of the bronchial tubes end in minute air cells, 
 like grapes on the terminal twig of a vine, each cell sur- 
 rounded with a network of capillary vessels in which the 
 pulmonary arteries end and the pulmonary veins find their 
 origin. The air passages are lined with mucous membrane 
 covered with cells surmounted on their free ends with mi- 
 croscopic filaments, or cilise, which, by a constant swaying 
 motion prevent the secreted mucus from backing into the 
 air cells. 
 
 233. An upward and outward movement of the ribs, with 
 a concurrent downward movement of the diaphragm [172], 
 creates a partial vacuum in the lungs, which is immediately 
 filled by inflow of air through the larynx and trachea, con- 
 stituting the act of inspiration. No sooner is this com- 
 pleted than the diaphragm relaxes, the ribs fall, and the 
 capacity of the chest being thereby lessened, some of the 
 contained air is thrown out, constituting the act of expira- 
 tion. The alternation of these two movements constitutes 
 the act of respiration, which, in the normal condition of the 
 system, is performed from fifteen to eighteen times per 
 minute, or at the rate of one respiration for every five beats 
 of the heart. The motive power in quiet respiration is 
 mainly furnished by the action of the diaphragm; when 
 the breathing is more active the muscles which elevate and 
 depress the lower ribs become engaged; m. forced respiration 
 every muscle bearing on the thorax is called into action, 
 and even those of the face participate in the movement, 
 dilating the nostrils visibly to facilitate the ingress of the air. 
 
RESPIRATION. 147 
 
 234. The limgs have a capacity of over three hundred 
 cubic inches, but ordinarily the air movement into and out 
 of the chest does not exceed thirty cubic inches. This 
 quantity at each inspiration enters the lungs, mixing with 
 that already there, and at expiration the same quantity of 
 the mixed air is thrown out, the removal and replacement 
 sufficing to keep the contained air pure enough to oxygenate 
 or arterialize the current of the circulation. The diffusion 
 of the uiflowing air throughout the air cells occasions a faint 
 ruspirutory murmur, which may be heard by laying the ear 
 oh the chest. It is rougher or coarser over the trachea and 
 larger bronchial tubes than over the pulmonary tissue. The 
 sound in the one case is called hronchiul breathing, in the 
 other vesicular breathing. 
 
 235. The inspired air, if fresh, contains only a trace of 
 carbon dioxid, rarely amounting to .04 per cent., or 4 parts 
 in 10,000 of the air. The expired air is warmer than the 
 inspired air ; it is saturated with moisture, as may be seen 
 by breathing on some cold condensing surface ; and it con- 
 tains about 4.3 per cent, of carbon dioxid. 
 
 236. When the same air has been breathed and rebreathed 
 a number of times, it becomes unfit for respiratory use. 
 Those who inhale it suffer from headache, heaviness of 
 mind, and general discomfort. These effects are attributed 
 rather to the organic emanations of the used air than to the 
 carbon dioxid, for the latter, when derived from other 
 sources than human respiration, may be inhaled in large 
 proportions without harmful manifestations. 
 
 237. Fresh air contains about four volumes of carbon 
 dioxid in 10,000 ; but as the average man throws out from 
 his lungs .01 cubic foot per minute, or .6 cubic foot per 
 hour, the quantity in an occupied room is speedily increased 
 unless it be diluted and carried away by intermixture with 
 a steady flow of fresh incoming air. The air of bed-rooms. 
 
148 RESPIRATION. 
 
 barrack-rooms, and hospital wards becomes oftentimes ex- 
 ceedingly foul at night. Instead of four volumes in 10,000, 
 the air may be charged with twenty, forty, or more volumes. 
 The quantity of carbon dioxid found in breathed air gives a 
 definite expression to its vitiation. If half a fiuidounce of 
 lime water be introduced into a clean, dry, eight-ounce 
 bottle containing the air to be examined, and shaken up 
 vigorously for a minute or two, the appearance of a turbid- 
 ity from insoluble carbonate of lime in the liquid will in- 
 dicate the presence of eight or more volumes of carbon 
 dioxid in 10,000 volumes of the air examined. If no 
 turbidity be manifested, the air contains less than eight 
 volumes in 10,000. Ready methods of air analysis, such 
 as that just indicated, have not come into general use 
 because they convey no more information than may be 
 gathered by the sense of smell. A wholesome room should 
 not have more than six volumes of carbon dioxid per 10,000 
 of the air. When the carbon dioxid amounts to seven 
 volumes, a want of freshness is observed on entering from 
 the outer air ; and when nine or more volumes are present, 
 the organic odor is distinctly perceptible. 
 
 238. The inflow of fresh air to take the place of air viti- 
 ated by human occupancy is known as ventilation. Its ob- 
 ject is to so dilute the products of respiration that the carbon 
 dioxid of the air of the room shall not exceed six volumes in 
 10,000; and to effect this 3,000 cubic feet of external air 
 are required hourly per man. An aperture of seventy-two 
 square inches would furnish the needful supply if the inflow 
 proceeded at the rate of two feet per second ; but if the 
 aperture were considerably smaller, ventilation could be 
 effected only by the introduction of the air at such a rate 
 as would cause danger from draughts. A corresponding 
 aperture of exit must be provided. 
 
CUTANEOUS EXHALATION. 149 
 
 239. By natural ventilation is understood tHat which 
 takes place through doorways, windows, transoms, and the 
 seams of imperfect woodwork, and, if there be an open fire- 
 place, by the draught up the chimney. Heat is a powerful 
 aid to ventilation. As warm air is lighter, bulk for bulk, 
 than cold air, the warm air of a room rises to escape while 
 colder air seeks to enter below. Even when there is no fire 
 in the room the tendency of air vitiated by respiration is 
 upward, because it comes from the lungs warmer than the 
 surrounding air. When there are no special currents to 
 deflect it, the puff of tobacco smoke from the lips of a 
 smoker rises toward the ceiling. The natural exit for foul 
 air is in the upper part of a room. To ventilate satisfac- 
 torily by windows, the sashes should be lowered from the 
 top as well as raised from the bottom. But when ventila- 
 tion is effected by artificial means, the air may be drawn 
 off from any suitable point. 
 
 240. Cutaneous Exhalation.- — The body is enveloped 
 in a tough, close-fitting elastic covering, continuous at the 
 mouth, nostrils, and other apertures with the mucous mem- 
 brane of the interior. This covering consists of the skin 
 and an underlying layer of fatty tissue. Over the flexures 
 of the joints, in the eyelids, and other parts the layer of 
 fat is thin, that motion may not be impeded, while over the 
 abdomen a thickness of several inches acts as a protection 
 to the contained organs against injury from either violence 
 or cold. 
 
 241. The skin consists of two layers : The corium, derma 
 or true skin, which overlies the fat, is composed of closely 
 interlaced elastic fibres, with vessels, nerves, hair follicles, 
 small glands and channels for the passage of matters that 
 are to be thrown out of the system. The upper layer, 
 cuticle or scarf skin, consists of microscopic cells which 
 
150 CUTANEOUS EXHALATIOir. 
 
 grow from the surface of the true skin, and are shed in a 
 dried up or shrivelled condition from its own free surface. 
 The cells of the cuticle are composed of an albuminous 
 material, like the nails or hair, which are indeed out- 
 growths from its structure. Their horny nature may be 
 observed on the palms of the hands after unusual labor, 
 which by intermittent pressure has excited the cutaneous 
 growth. 
 
 242. The skin is well supplied with nerves, which are 
 distributed to small processes or papillae, projecting from 
 
 Perpendicular section of tlie skin, showing, », the epidermis, cuticle, or scarf 
 sldn; 6, a layer of dark-colored cells; c, the papillae on the surface of d, the 
 corium, derma, cutis vera, or true skin, and e, the fat cells underlying it ; /, a 
 perspiratory pore or aperture, g, the duct, and h, the coiled substance of a 
 sudoriparous gland ; i, the shaft of a hair, fc, its root, and I, sebaceous glands 
 communicating with the interior of the hair follicle. 
 
 the surface of the true skin like the villi [228] from the 
 mucous membrane of the small intestine. These papillee 
 are particularly numerous on the ends of the fingers, where 
 their arrangement in lines may be observed as parallel and 
 sometimes concentric ridges. The sense of touch is pro- 
 
CUTANEOUS EXHALATION. 151 
 
 portioned to their size and number. The points of a com- 
 pass, separated only one-twelfth of an inch, will be recog- 
 nized as two distinct objects by the tips of the fingers; yet 
 when separated two inches they will be felt to make but 
 one impression on the middle of the forearm, thigh, or 
 back. The cuticle gives protection to the sensitive papillae 
 by covering or sheathing them with an insensitive layer. 
 
 243. The skin is beset with hairs, each rooted on a small 
 papilla ab the bottom gf a follicle. From this root it rises 
 through the follicle to the surface and beyond. Small se- 
 baceous glands are packed in the interstices of the true 
 skin, their ducts opening usually into the hair follicles. 
 They secrete an unctuous matter, to prevent the skin from 
 being dried and cracked by exposure to the sun and air. 
 On the face, and particularly on the nose, their ducts some- 
 times become choked and their apertures, soiled by expo- 
 sure, appear as black points on the surface. Cautious pres- 
 sure will liberate the retained secretion in the form of a 
 tallowy cast of the duct. 
 
 244, But the elements in the structure of the skin by 
 which the purification of the blood is mainly effected are 
 the sudoriparous glands. These are small coiled tubules 
 which reach from beneath the true skin to the surface of 
 the cuticle, where their ducts terminate in minute pores. 
 They are surrounded by a vascular network from which 
 certain constituents of the blood are drawn" off and trans- 
 mitted to the surface to be dissipated as insensihle perspira- 
 tion or poured forth as a visible transudation. Condensed 
 perspiration or sweat is a sour-smelling liquid, containing 
 traces of saline and organic matter. The quantity of liquid 
 eliminated daily from the blood by means of these glands 
 depends on varying conditions as to exercise and external 
 temperature; but its average is about two pounds. The 
 
153 EXCRETIOISr BY THE KIDSTETS. 
 
 process is regulated by the nervous system; for in disorder 
 of the latter perspirations may occur in the absence of the 
 conditions which are ordinarily required for their produc- 
 tion, as when the skin is pale and cold in the prostration 
 of syncope [357] or approaching death. 
 
 245. Although the removal of water from the blood is 
 one of the prime functions of the skin, the cuticle performs 
 an important duty in preventing the general drying up 
 of the tissues by evaporation. Moreover, when the water 
 supply of the system is deficient, the skin may become an 
 absorbing instead of an eliminating organ. Immersion in 
 a bath of tepid water allays thirst. Even when the cir- 
 culation is almost at a standstill, and the patient uncon- 
 scious from a deficiency of water in the blood, he may be 
 rallied from his dangerous condition by the absorbing power 
 of the skin [460] . Nor is this power restricted to the ab- 
 sorption of water, for mercury may be taken up and the 
 system brought under its influence by means of vapor baths 
 or inunction. Absorption takes place readily from the sur- 
 face of the true skin; and before hypodermic medication 
 [305] came into use, the method of dusting or dressing a 
 blistered surface with the medicine to be absorbed was oc- 
 casionally practised. 
 
 246. Ubinaet Excretion. — The kidneys are two elon- 
 gated organs situated on the wall of the abdominal cavity, 
 one on each side of the vertebral column. The tissue of 
 the kidney consists of the ramifications of blood-vessels in 
 and around a series of fine tubes which drain the urine 
 from them. These tubules unite on the inner aspect of 
 each kidney into an elastic tube, the ureter, by which the 
 liquid to be thrown out is conveyed to the bladder. 
 
 247. The bladder [172] is a strong muscular sac, coated 
 in part with peritoneum and lined with mucous membrane. 
 
ANIMAL HEAT. 153 
 
 Its discharge tube, the urethra, passes from its lower and 
 fore part downward and forward beneath the pubic arch, 
 and then along the under surface of the penis. In passing 
 under the arch, the urethra penetrates a strong fibrous 
 membrane which closes in the bottom of the pelvis ; and 
 this membrane it is which forms the impediment sometimes 
 encountered in passing the catheter [319]. 
 
 248. Animal Heat. — When oxygen combines with car- 
 bon, carbon dioxi4,is produced, and heat is evolved during 
 the process, which is called oxidation or combustion. The 
 union of oxygen with carbon is followed by the same re- 
 sults, whether it takes place in the kitchen range or the 
 human system. In the ordinary fireplace much of the 
 heat that is produced passes off by the flue; so in the 
 tissues much of the heat produced passes from them into 
 the current of venous blood, and is thrown out by the 
 lungs. Water takes a prominent part in the regulation of 
 the animal heat. When a flame is applied to water in a 
 flask, the heat is communicated to the water and its tem- 
 perature rises until it reaches 212° F., when it boils; but 
 after this its temperature rises no more, although the water 
 still receives accessions of heat from the flame. Instead 
 of becoming hotter it becomes converted into watery vapor 
 or steam, and heat is absorbed during the process. Hence we 
 can understand that every breath which sends out watery 
 vapor into the atmosphere carries with it a certain amount of 
 heat. This is a cooling influence which is in constant opera- 
 tion to offset the continual heating influence of the oxidation 
 which takes place in the tissues. The water evaporated from 
 the skin is another cooling influence constantly in operation, 
 but susceptible of augmentation or decrease in accordance 
 with associated conditions. When, on account of exercise, an 
 
154 ANIMAL HEAT. 
 
 excess of heat is generated in the tissues, the breathing 
 becomes deeper that more watery vapor may be thrown out 
 at each expiration, and the perspiration is increased to cool 
 the body by its evaporation. When, on the other hand, the 
 vital actions are conducted so gently that there is no excess 
 of heat generated, the water which would otherwise be ex- 
 haled from the skin is drawn off without loss of heat by the 
 kidneys. These two organs supplement each other and 
 keep the temperature of the body at a normal of 98.4° F. 
 If, from any cause, as a chill to the surface, the perspira- 
 tory pores are closed, the heat of the body ceases to be dis- 
 sipated and in a little while the condition which we call 
 fever is developed. The influence of a diaphoretic, such 
 as Dover's powder, in reducing fever by inducing perspira- 
 tion, is thus understood. When a particular organ becomes 
 inflamed, the active changes going on in its substance aug- 
 ment its heat, and a symptomatic fever [374] is established. 
 When the action of the skin ceases because of a deficient 
 supply of water in the system, the blood becomes heated 
 and the circulation disturbed, leading to a condition which 
 has been called thermic fever, but which is generally known 
 as sunstroke [459]. 
 
CHAPTER III. 
 
 THE ADMINISTBATIVB SYSTEM. 
 
 249. The Administrative System consists of the brain, 
 spinal cord, nerves, and ganglia. The brain is the nervous 
 matter contained in the cranium ; it is connected directly or 
 intermediately with every organ and tissue as the headquar- 
 ters of the body to which all the reports called sensations are 
 rendered, and from which all orders for motion or action 
 based on those reports are issued. The spinal cord extends 
 downward through the vertebral canal, giving off branches 
 or nerves at intervals from its sides. The ganglia are small 
 fragments of nervous tissue found at intervals near the 
 spinal column, or in protected situations, as behind the 
 heart and around the large arteries of the abdomen. They 
 communicate freely with each other by branches called sym- 
 pathetic nerves,, and with branches of the cerebro-spinal 
 system ; and their distribution is along the tracks of the 
 arteries, going where the blood goes. 
 
 250. A large nerve consists of minute tubules enclosed 
 in a strong protective sheath, as the insulated wires of a 
 telegraph cable are enclosed in a non-conducting covering. 
 The branching of a nerve is like the splitting up of the 
 cable for the proper distribution of its contained wires. 
 Each tubule, representing a wire, ultimately reaches its ter- 
 minal station, where by its means messages may be con- 
 veyed to and from the brain. 
 
 251. The brain is a somewhat egg-shaped, pulpy body, 
 divided from before backward into two contiguous hemi- 
 
156 
 
 THE KEEVOUS SYSTEM. 
 
 spheres ; but the line of division does not extend all the 
 way down, for about its middle there is a broad bridge of 
 communication between the two sides. The surface presents 
 also grooves called sulci, and as these give the brain the ap- 
 pearance of consisting of a packed mass of irregular coiled 
 
 The Hemispheebs of the Brain: A, the right; B, the left, divided from be- 
 fore backward by a, 6, the longitudinal fissure, and connected by c, the bridge 
 uf transverse fibres called the corpus callosum. On the right side the convolu- 
 tions and sulci are shown ; on the left the upper part of the convexity of the 
 hemisphere has been cut away to show the gray matter d, d, dipping into the 
 sulci and appearing as islands, e, e, in the interior of the white matter ; the 
 elongated cavity with curved extremities is the lateral ventricle of that side. 
 
 tubing, the seeming coils are spoken of as the cerebral convo- 
 lutions. The exterior of the brain consists of gray, cineri- 
 tious, or vesicular matter, the interior of white or medullary 
 matter. The latter is a compact mass of nerve tubules con- 
 necting various parts of the gray matter with each other 
 and with all parts of the body. There are several cavities, 
 called ventricles, in the interior of the brain, their walls 
 
THE NEEV0U8 SYSTEM. 157 
 
 lined with gray matter. The brain -weighs about fifty 
 ounces, but the quantity of vesicular matter vai'ies with 
 the number of the convolutions and the depth of the sulci. 
 The intelligence appears to be proportioned to the quantity 
 of gray matter which envelops the white matter of the 
 brain. 
 
 252. The interior of the cranium is lined with a strong 
 fibrous membrane, the dura mater, which sustains and sup- 
 ports the brain, and^ supplies the nerves with a protective 
 covering as they pass through the bony apertures. Inter- 
 nally it is faced with a serous layer, the arachnoid, which 
 is reflected loosely over the convolutions, the two smooth 
 surfaces lessening the risk of injury from jolting, just as 
 the peritoneum [172] protects the abdominal organs from 
 injury by friction. Beneath the arachnoid and in close 
 contact with the brain matter is the pia mater, composed 
 of a fine network of nutrient blood-vessels. 
 
 253. The spinal cord is protected by a strong sheath, 
 which is lined like the dura mater. It consists chiefly of 
 nerve tubules, but a curved streak of gray matter extends 
 throughout its length on each side of its middle line. The 
 nerves which emerge in the cervical region divide on each 
 side into two sets, an upper and a lower. The former are 
 distributed to the head, neck, and interior of the chest, one 
 of them, the phrenic, being the medium by which the re- 
 spiratory movement of the diaphragm [172] is sustained. 
 The latter form an interlacement of large cords, called the 
 brachial plexus, which crosses the upper part of the armpit 
 with the axillary vessels, and is distributed to the upper ex- 
 tremity. The dorsal nerves supply the walls of the chest 
 and abdomen. The lumbar and sacral nerves are distrib- 
 uted to the pelvis and hips, but several of them unite on 
 each side into one large cord, the great sciatic nerve, which 
 
158 THE NEBVOUS SYSTEM. 
 
 extends along the back of the thigh, and breaks up into 
 branches for the supply of the lower extremity. 
 
 254. There are two kinds of nerve tubules: Nerves of 
 sensation, or sensory nerves, convey information to the gray 
 matter of the brain; nerves of motion, or motor nerves, trans- 
 mit from the gray matter the influence by which the mus- 
 cles are brought into action. When a sensory nerve is cut 
 across, the area of its distribution loses its feeling because 
 the information concerning its condition does not reach the 
 gray matter of the brain. When a motor nerve is severed, 
 the muscles which it supplied become paralyzed, because the 
 orders emanating from the gray matter do not reach them. 
 Most of the nerves contain both motor and sensory fila- 
 ments ; but some are purely motor, as the facial, a cerebral 
 nerve, which supplies the muscles of the head and face. 
 On its way out of the cranium it traverses the middle ear 
 [264] and when it becomes involved in certain destructive 
 diseases of that organ, the corresponding side of the face 
 loses the power of motion, becoming blank and expression- 
 less, but retains sensation, for the sensory filaments are de- 
 rived from another nerve. The motor filaments of the 
 spinal cord are aggregated in its anterior part ; the sensory 
 filaments in its posterior part. Hence the lower limbs 
 of a patient may be paralyzed and yet retain their sensa- 
 tion, because the posterior part of the cord has not suf- 
 fered from the disease or injury so much as the anterior 
 part. 
 
 255. The nerves from certain organs bring special in- 
 formation to the brain. The optic nerves transmit impres- 
 sions as to light or shade, color, form, size, distance; the 
 auditory nerves bring impressions of sound ; those of taste 
 and smell guard the entrance to the alimentary and respira- 
 tory tracts ; and from certain parts, as the tips of the fin- 
 
THE NBEVOTJS SYSTEM. 159 
 
 gers, come sensations giving definite ideas as to certain 
 properties of external objects. 
 
 256. The eye is protected by its deep situation in the 
 socket, by the projecting ridge of the frontal bone and the 
 quick movement of its upper lid. It is a small, globular- 
 shaped camera, covered in front by mucous membrane, the 
 conjunctiva. The rays of light enter through the cornea, 
 which is set into the front of the eyeball like a watch-glass 
 
 The rays from the object A B are brought to a focus on the retina at D, 
 where an inverted image is formed as In the camera of the photographer. 
 
 over the dial plate. Behind the cornea is a colored curtain 
 of muscular fibres, the iris, with a central aperture, the 
 pupil, which becomes contracted or dilated, according as 
 the light is strong or weak. The crystalline lens, situated 
 behind the iris, brings the rays to a focus on the retina, a 
 delicate expansion of the optic nerve. The whole is en- 
 closed, except on the corneal front, in a strong casing of 
 white fibrous tissue, the sclerotic coat. 
 
 257. When a camera is out of focus the lens is moved 
 forward or backward by a screw until the image is clearly 
 outlined on the ground-glass screen. In the eye a small 
 muscle increases the refracting powers to bring the rays 
 from near objects to a focus on the retina. This is called 
 the power of accommodation of the eye. 
 
 258. An individual should see distinctly at six hundred 
 yards a black centre, three feet in diameter, on a white 
 
160 THE NERVOUS SYSTEM. 
 
 ground, or at twenty feet a circular spot, four-tenths of an 
 inch in diameter, on a white card. An eye which responds 
 to this test is emTnetropic or normal. 
 
 259. In elderly people vision for distant objects remains 
 normal, but that for near objects is impaired. In readiag, 
 the sight has to be aided by convex glasses. This condition 
 is called presbyopia. 
 
 260. When the lens is too convex or the refracting media 
 of the eye too powerful, the rays from distant objects are 
 brought to a focus before they reach the retina. The spot 
 on the card must be brought nearer than twenty feet to be 
 clearly distinguished, or a concave glass must be placed 
 before the eye to diminish its refracting power. This is 
 the condition of myopia, or short-sightedness. 
 
 261. When the lens is too flat or the refracting media 
 too weak, the parallel rays from a distant object fail to 
 reach a focus until they have passed behind the retina ; and 
 briuging the object nearer increases the difB.culty. This, 
 the condition of hypermetrojna or long-sightedness, requires 
 convex glasses to aid the eye in focussing the rays. 
 
 262. When the cornea is irregular in its curvature, a 
 vertical line may be seen clearly, while a horizontal liue 
 crossing it is blurred or indistinct. This defect, astigma- 
 tism, cannot be remedied if the corneal surface is so faulty 
 as to distort the outlines of objects like a piece of poorly 
 made window-glass; but if there is merely a bulge or a 
 flattening at some particular point, special glasses may be 
 fitted. 
 
 263. Color-blindness is an inability to recognize certain 
 colors. When a man who is green-blind is presented with 
 a skein of worsted of that color and desired to pick from a 
 stock of various colors the skeins which correspond with it 
 in color, irrespective of shade, he will select and add to his 
 
THE NEBT0U8 SYSTEM. 161 
 
 green samples skeins of other colors, mostly neutral tints, 
 as grays, drabs, etc, , which seem to him to have the same 
 depth of shade as his test skein. When he is presented 
 with a roseate skein — one having a tinge of purple in its 
 redness — he will match it with shades of green or gray; 
 and when tested with a bright-red skein he will bring for- 
 ward light greens and browns as corresponding with it in 
 color. A red-blind man can see the purple but not the red 
 in the roseate test skein, and so selects light shades of blue 
 and violet as samples of the roseate color. When presented 
 with a bright-red skein, he matches it with shades of green 
 and brown that seem to the normal eye to be darker than 
 the test skein. 
 
 264. The external ear consists of a framework of pliant 
 cartilage bound to the bony parts by strong fibrous tissue. 
 At the bottom of the shell, or concha, is the opening of the 
 external auditory canal, which conveys the vibrations of the 
 air to the tympanum or drum of the ear. Its entrance is 
 beset with hairs to exclude insects, and its sebaceous folli- 
 cles [243] secrete a bitter waxy substance. This canal 
 extends inward and forward for about an inch, curving 
 slightly, so that its middle part is somewhat higher than 
 its ends [491] . The middle ear consists of a small cavity 
 in the interior of the temporal bone. It is lined with a 
 delicate mucous membrane, and any mucous secretion that 
 may gather in it drains off by a tubular passage, the Eu- 
 stachian tube, into the back part of the throat. Ordinarily 
 the walls of this tube are in apposition, but during swal- 
 lowing they become separated. In blowing the nose, air is 
 sometimes forced into the tympanic cavity, giving rise to a 
 feeling of distention in the middle ear, which is, however, 
 immediately relieved by the movement of swallowing. 
 When the Eustachian tube is obstructed, as frequently 
 11 
 
162 THE NERVOUS SYSTEM. 
 
 happens from the swelling of an ordinary sore throat, a 
 temporary deafness may be developed because air cannot 
 get into the tympanic cavity to support the drum of the 
 ear on its inner side against the pressure of the external 
 air on its outer side. The internal ear is a complex ar- 
 rangement of the nervous tissue by which the vibrations of 
 the tympanum are conveyed to the brain. 
 
 265. The olfactory nerve is distributed to the mucous 
 membrane covering the upper part of the interior of the 
 nose. It enters from the brain through apertures in a thin 
 plate of bone which forms part of the floor of the cranium 
 and the roof of the nasal cavity. 
 
 266. The tongue is the organ of taste, but some special 
 nervous filaments are distributed to the palate and fauces. 
 It is supplied also with nerves of common sensibility, which 
 enable it to detect extraneous matters in the food daring 
 mastication. It consists of longitudinal and transverse 
 muscular fibres, which by their contraction enable it to 
 assume almost any form. Its surface is roughened with 
 close-set papillae which are covered with mucous membrane. 
 A longitudinal furrow on its upper surface ends behind in 
 a depression near the base of the tongue; and from this 
 point some large papillae project outward' and forward, in 
 the form of a V. To impress the nerves of taste a sub- 
 stance must be in solution or soluble in the liquids of 
 the mouth. If the substance is insoluble it is recognized 
 only by the nerves of common sensation as insipid, gritty, 
 etc. 
 
 267. In the government of the army only such matters 
 as affect the general welfare are forwarded for the action 
 or decision of the War Department; minor and routine 
 matters are disposed of by subordinate commanders. So 
 in the human system, many sensations or reports are trans- 
 
THE NERVOUS SYSTEM. 163 
 
 mitted by the nerves, which are not of sufficient importance 
 to call for special action by the intelligence at headquar- 
 ters ; these are disposed of by what is called reflex action. 
 When the toes of a patient are tickled or pinched, the mus- 
 cles of his thigh and leg are brought into action, and the 
 foot is drawn away. This may be a voluntary act. The 
 sensation may be received and appreciated by the brain, 
 and in consequence a motor influence may be sent out to 
 effect the withdra-WB,l of the foot from the cause of the irri- 
 tation. But, on the other hand, it may be involuntary and 
 independent of sensation, as when it occurs in a paralyzed 
 limb. In such a case the gray matter of the spinal cord 
 takes note of the sensation, recognizes it as being not of 
 sufficient importance to be forwarded to the brain, and it- 
 self sends out orders t6 meet the needs of the case. Most 
 of the routine acts of life are regulated by this action of the 
 gray matter of the spinal cord. When an individual walks, 
 the pressure of his weight on the sole of the foot is trans- 
 mitted to the cord, and elicits the motor influence for the 
 continuance of the movement. When the ventricles of 
 the heart become filled with blood the sensory filaments 
 report the fact to the cardiac ganglion, and orders are 
 issued for immediate contraction. When there is an in- 
 sufficiency of oxygen in the lungs the ganglionic nervous 
 matter is informed, and, according to the necessities of the 
 case, a deep or shallow inspiration is taken [233] . When 
 masticated, food reaches the fauces the muscles of degluti- 
 tion are called into action. When food enters the stomach 
 its presence is announced and, from a special ganglion, the 
 standing orders for the needful increase in the supply of 
 blood and the prompt secretion of the gastric juice [221] 
 are carried out. Contact of the chyme with the intestinal 
 lining produces the vermicular or peristaltic movements 
 
164 THE NEETOUS SYSTEM. 
 
 [226], which carry the alimentary mass onward from coil 
 to coil. The functions of the kidneys, liver, skin, etc., are 
 all thus regulated and co-ordinated by reflex influence. 
 This system is sometimes called the sympathetic nervous 
 system, because by means of its connection with the cere- 
 bro-spinal nervous filaments the organs which it regulates 
 are to a certain extent brought into relation or sympathy 
 with the mind or will. The cheeks, for instance, flush or 
 pale, and the heart palpitates or fails under the influence 
 of mental emotions, and the will exercises a limited con- 
 trol over the respiratory movements. 
 
 268. Eeflex action from ganglionic or spinal nervous 
 matter relieves the gray substance of the brain from the 
 care of supervising the normal action of the organs and the 
 routine movements of the body, leaving its energies to be 
 expended in the exercise of the mind and will. That the 
 INTELLIGENCE finds euough to do in this way is shown by 
 the necessity for sleep. The brain is well supplied with 
 blood to repair its waste, part of which appears in the urine 
 as phosphates [317] ; yet the rapidity of the waste is such 
 that a certain number of hours in every twenty-four must 
 be given up wholly for recuperation. Nothing manifests 
 the independent character of the reflex acts so clearly as 
 their continuance during sleep, when the intelligence is pro- 
 foundly suspended. The heart beats, the chest heaves, the 
 arterialized blood circulates, the liver, kidneys, skin, etc., 
 perform their various functions under the controlling influ- 
 ence of the ganglionic system, and if the position of the 
 body or limbs be in any way uncomfortable, the gray nat- 
 ter of the spinal cord intercepts the message, and rectifies 
 the position without disturbing the sleeping intelligence. 
 
PAET III. 
 
 THE SPECIAL DUTIES OE THE HOSPITAL 
 COEPS. 
 
 CHAPTER I. 
 
 MANAGEMENT OP ACCIDENTS, WARD DUTIES, NURSINf;, ETC. 
 
 269. The Hospital Corps was organized for the purpose 
 of providing the Medical Department of the Army with an 
 efficient corps of nurses qualified not only to carry out the 
 directions of the surgeon in a hospital ward, but to assist 
 intelligently in the operating room, to give first aid in the 
 field and during emergencies, and in the disturbed condi- 
 tions of active service to sometimes take the place of a 
 medical officer with small detachments. 
 
 270. The private of the Hospital Corps on ward duty 
 should be an intelligent, careful, and even-tempered man, 
 well educated in his specialty of nursing. His duties as relat- 
 ing to the routine work of the ward are easily learned, but 
 a long experience is needful to fit him for those pertaining 
 to the treatment of the sick. Nursing camiot be taught in a 
 chapter of a handbook. It must be learned by experience 
 in the wards of a hospital. The nurse should be perfectly 
 familiar with the special arrangements for regulating the ven- 
 tilation and heating. If a patient is to be exposed during 
 the dressing of wounds or changing of clothes, sheets, or beds, 
 ventilators or windows which might cause a draught should 
 
166 NURSING. 
 
 be closed ; and all patients should be carefully protected 
 when it is necessary to flush a ward with fresh air to re- 
 move disagreeable odors. The temperature of the ward 
 should be kept about 70° F. ; in fever wards about 60°. 
 To cool the ward during hot weather wet sheets may be 
 hung in the entering air current. Cleanliness in a ward is 
 imperative . Every article soiled by use should be immedi- 
 ately removed and replaced, if necessary, by a clean one of 
 its kind. There should be nothing soiled in a well-kept 
 ward. The personal cleanliness of each patient should be 
 looked after by the nurse. The toilet of bedridden patients 
 should be made daily or ofteuer, during which the face, 
 neck, mouth, ears, hands, and nails should be cleaned. In 
 washing the body and limbs, when necessary, the water 
 should be about 96° F. unless otherwise directed, and the 
 patient protected from draughts during the process. In his 
 own person it is needless to say the nurse should endeavor 
 to keep himself surgically clean. Should his hands become 
 soiled during his attendance on any case, they should be 
 immediately washed and sterilized. The objects of good 
 discipline in the ward are order, regularity, and prompt 
 service, so tliat everything necessary to be done shall be 
 done quietly, without excitement, noise, or discussion. The 
 atmosphere of the ward should be one of quietude and 
 restfulness. The nurse should have tact to obtain obedience 
 from even querulous patients without argument or com- 
 mand. Patients suffering from fever are often irritable, 
 and as their senses are acute everything which stimulates 
 annoys. They should therefore be protected from the noisy 
 talking of convalescents, and even from strong light by 
 shades or screens. During the visit of the surgeon the nurse 
 stands by the bedside and listens attentively to the instruc- 
 tions given. He obtains the medicines from the dispensary 
 
NURSING. le? 
 
 and administers them as directed ; and in special cases feeds 
 the patient and attends to all his personal wants. He 
 should note carefully all changes in the symptoms for the 
 information of the steward and medical officer. Changes 
 in the pulse, temperature, and respiration are recorded in 
 most of the serious cases ; the frequency and character of 
 the discharges, the occurrence of cerebral disturbance, the 
 times and duration of sleep, and any complaint of pain or 
 any abnormal sengation felt by the patient should also be 
 carefully recorded. The more a nurse knows of the condi- 
 tion of a patient the greater is his value, for inexperience 
 and want of knowledge will often call unnecessarily for 
 assistance, while, on the other hand, they may consider as 
 unimportant some change which is of vital interest. 
 
 271. The private of the Hospital Corps, besides being 
 familiar with his duties in the ward, must be competent to 
 give first aid in emergencies. A seriously wounded or sick 
 man must be removed to hospital without delay except 
 when immediate treatment offers the only hope of saving 
 life. If the patient be insensible, place him on his back 
 with a support under his head ; remove his neckwear and 
 unbutton the clothing on his chest. Then sprinkle cold 
 water on his head, face, and chest, and put some to his lips 
 to ascertain if he has the power of swallowing. The nature 
 of the case should be made out, with a view to relieving 
 urgent symptoms and preventing injury during transporta- 
 tion. 
 
 272. If the injury be obvious, ascertain its character ; if 
 obscure, inquire of the bystanders what is known concerning 
 its history or cause. Personal examination of the patient 
 must be made with the utmost gentleness, lest harm be 
 done to some undiscovered injury. When facilities are 
 available the case should be treated as at the first dressing 
 
168 ACCIDEKTS. 
 
 station of field service [41, 365]. All symptoms observed 
 during tMs examination should be noted mentally for the 
 information of the medical officer, because some change 
 may take place in the condition of the patient before he 
 comes under medical supervision. 
 
 273. When there is much prostration, the patient's head 
 must be kept low ; and if he has lost so much blood as to 
 be notably weak or faint, efforts should be made to revive 
 him before removing him. to hospital. In no case while in 
 this exhausted state should he be placed on his feet or re- 
 quired to make exertion, however slight, in his own behalf, 
 lest he fall into the condition of syncope. If the case is 
 one of external hemorrhage, an ounce of brandy or whiskey, 
 with .020 morphin, should be admiuistered before placing 
 the patient on the litter ; but if the hemorrhage is internal, 
 faintness should be relieved by small doses, twenty or 
 thirty drops, of aromatic spirit of ammonia at short in- 
 tervals in a spoonful of water. 
 
 274. In moving a case of fractured thigh or leg, one per- 
 son should support the fractured parts ; and before trans- 
 porting the patient on the litter the foot of the injured 
 limb should be tied to the other, to prevent its rolling out- 
 ward by its own weight ; and support, as by a blanket rolled 
 into a cylinder, should be applied along the outer side of 
 the limb. 
 
 275. At the hospital the patient is prepared for bed by 
 removing his clothes, ripping the seams if necessary, 
 cleansing soiled surfaces, and applying dressings. The 
 under sheet of the bed should be drawn smooth and the 
 creases removed by traction first from one side, then from 
 the other, and fixing the ends securely under the mattress, 
 ~\Vlien the patient is unconscious or paralyzed the mattress 
 should be protected by a rubber cloth under the sheet and 
 
BATHS. 169 
 
 a folded blanket covered with a draw sheet should be placed 
 under the hips [314] . 
 
 276. To take oil" a shirt or undershirt : Pull it up from 
 the back, draw it over the head to the front, and then dis- 
 engage the arms. Reverse the movements in puttiug one 
 on. To take off a shirt or other body covering from a pa- 
 tient with a disabled arm : Baise the patient slightly and 
 draw the shirt from under him. Draw back the sound arm 
 and pull the sleeve jpff . Then draw the shirt over the head 
 to the disabled side and finish by pulling the sleeve off the 
 arm of that side. To put on afresh shirt: Draw the sleeve 
 up on the disabled arm, pass the shirt over the head ; put 
 the other arm in its sleeve and then adjust the body of the 
 shirt. The sleeve on the injured side may be unstitched 
 if necessary. 
 
 277. To change the patient from one bed to another: 
 The nurse places the head of the fresh bed at the foot of 
 the other. He stands on the right of the patient, bends 
 his knees, puts his right hand and arm under the upper 
 part of the thighs and his left around the back of the pa- 
 tient. Then he rises, lifting, with the body of his patient 
 on his chest and the arms around his neck. He then moves 
 by side steps to the other bed and lays him down by re- 
 versing the movements of taking him up. If the patient is 
 injured on the right side he must be taken up from the left. 
 Should his injuries be of such a character as to prevent this 
 mode of transfer, the methods of the Drill Eegulations 
 must be used. 
 
 278. Ordinarily the patient should have a bath before 
 being put to bed. A wai-m bath, from 86° to 98° F., 
 soothes the system, predisposing to sleep, while it cleans 
 the skin and promotes its activity. A cold bath, below 
 65°, and a hot bath, above 98°, are powerful influences; 
 
170 SUEGICAL OPERATIONS. 
 
 the former, when the immersion is short, is followed by- 
 warmth and tingling of the surface; the latter quickens 
 the pulse and respiration, congests the surface, and may- 
 induce faiatness. When, the hot bath is followed by free 
 perspiration its action is salutary ; but when it' occasions 
 fulness in the head, throbbing and giddiness, its iafluence 
 is harmful. The hot bath should be begun at 95° F. and 
 brought up to 99° by additions of hot water. Cold baths 
 are seldom used for the sick, as a certain vigor of constitu- 
 tion is needful to enable reaction [358] to take place. The 
 hot-air bath is often conveniently substituted for the hot 
 bath, as it may be given by the bedside, the patient sitting 
 on a cane-bottomed chair with a spirit-lamp beneath and 
 blankets draped around him from the neck to the floor to 
 confine the heated air 
 
 279. Should the accident or injury necessitate surgical 
 operation, preparations for its performance can be made 
 only by one who has a knowledge of what has to be done. 
 Preliminary to operation the surgeons, nurses, iastraments, 
 dressings, and patient must undergo a systematic prepara- 
 tion in order that the wound of operation may not become 
 infected with putrefactive or septic germs [326, 414]. 
 
 280. All persons assisting at the operation should wear 
 sterilized linen gowns, the hair covered with a sterilized 
 towel, and the hands rendered aseptic or free from germs. 
 All rings are removed, and the hands and forearms are 
 scrubbed for five minutes with soft soap and hot water, 
 particular attention being given to the nails ; after drying, 
 the parts are washed with alcohol and then in a solution 
 of bichlorid of mercury, 1 : 2,000, ia warm boiled water. 
 Some surgeons after washing with soft soap make the skin 
 mahogany brown with solution of permanganate of potas- 
 sium, subsequently decolorizing with a solution of oxalic 
 
SURGICAL OPERATIONS. 171 
 
 acid, and then lessening the irritation of the skin by wash- 
 ing in boiled lime-water. Others use diluted solutions of 
 formalin [332], while sterilized riihher gloves are worn by 
 some surgeons. Whenever during the course of the opera- 
 tion the sterilized hands of the operator or his assistants 
 have come in contact with some object not aseptic, they 
 should be bathed in the bichlorid solution before resummg 
 contact with the wound. 
 
 281. Dressings q^-e steamed in a sterilizer for twenty 
 minutes, after which they are removed with aseptic hands 
 to jars which have been scrubbed with soft soap and after- 
 ward with bichlorid solution. The contents of the jars are 
 covered with sterilized towels soaked in bichlorid. Every 
 knife or sharp-edged instrument is wrapped in gauze, to 
 preserve its edge from injury, and boiled for five minutes 
 in a one-per-cent. soda solution. Each is then removed 
 with aseptic fingers, and all are arranged in pans containing 
 boiled, i.e., sterilized water and covered with sterilized 
 towels. The needle of a hypodermic syringe is boiled with 
 the instruments ; but the barrel and piston are soaked an 
 hour in carbolic acid, five per cent. , in alcohol. Silk thread 
 or silver wire is wound on glass rods or spools and boiled 
 with the instruments or steamed with the dressings. Rub- 
 ber drainage tubes and catheters are boiled or steamed ; silk- 
 worm gut is boiled five minutes in alcohol ; and catgut is 
 soaked in ether for two days and then put in alcohol in a 
 firmly corked bottle, which is boiled in water for two hours. 
 Col. W. H. Forwood's method of sterilizing animal ligatures 
 is as follows : Use large, long test-tubes, say 10 inches by 
 1 inch, with pure rubber plugs and glass spools. Thor- 
 oughly clean and boil spools, tubes, and plugs. Wind 
 catgut ligature on glass spools, make the kangaroo tendon 
 into oval coils and place them in the tubes according to size 
 
172 SURGICAL OPERATIONS. 
 
 and kind. Immerse in ether fortior, U. S. P., forty-eight 
 hours, and then wash in ether. Immerse in alcohol with 
 ■Y^^T bichlorid of mercury (C. P.); boil twenty minutes in 
 a water or sand bath with the plugs out ; remove the tubes 
 while boiling and plug immediatelj'' (so as to form a vacuum 
 and remove air from ligatures), and then set aside twenty- 
 four hours. Renew alcohol with ^sVir bichlorid, and add 
 one per cent, of trikresol and store away ready for use. 
 (If there be no sediinent this renewal of alcohol will be 
 superfluous.) The ligature should be kept at least three 
 days, but it may remain any length of time in this solution 
 before use. On using, flame the tube, draw out the spools 
 or coils with sterile forceps and place them in a sterile 
 (boiled) ligature dish, with the fluid from the tube, or in 
 common alcohol with -j-jVir bichlorid. Ten years' experi- 
 ence has shown that this method increases the tensile 
 strength of the ligature and renders it absolutely sterile. 
 
 282. If possible, on the day before the operation the pa- 
 tient is given a bath ; the area of the operation is shaved, 
 washed with soft soap and water, rinsed off with boiled 
 water, washed with alcohol, and scrubbed with bichlorid 
 solution, after which the part is covered with aseptic gauze, 
 secured with a bandage. On the day of the operation the 
 patient is bathed and given a clean flannel shirt. The area 
 of the operation is then treated as on the previous day, and 
 the patient placed on the operating table and covered with 
 a sterilized sheet. 
 
 283. The operating-table should be covered with two or 
 three folds of blanket; overlaid by a disinfected rubber 
 cloth and provided with a low pillow for the head. If the 
 hands or feet of the patient have to be fixed out of the way 
 during an operation, the bandage used in making them fast 
 to some part of the table should be tied in a reef bow, as 
 
SURGICAL OPEEATIONS. 173 
 
 it may be needful to liberate them at a moment's notice if 
 dangerous effects from the anaesthetic are developed [289]. 
 Chloroform or ether [287] is then administered. In the 
 case of a nervous patient it is better to give the anaesthetic 
 in bed and then transfer him to the operating-table. He 
 is thus saved from the depressing effect of seeing the in- 
 struments and other preparations in the operating-room. 
 In all emergency operations, such as tracheotomy [494], 
 and in all operatiqps likely to be of common occurrence in 
 the service of the hospital, the nurse should be familiar 
 with the instruments required for each operation, so as to 
 have them in readiness. He should be familiar also with 
 the steps of the procedure, that he may be able to hand 
 each instrument or dressing when it is wanted. Prior to 
 operations of infrequent occurrence the surgeon should give 
 the nurse special instructions to qualify him as an intelligent 
 assistant. 
 
 284. When the necessary operation is an amputation of 
 the thigh the sterilized sheet is removed from the limb, 
 which is then emptied of blood by the application of Es- 
 march's bandage [286], and his hollow rubber tube with a 
 few turns of a roller beneath it is applied to control the in- 
 flow of blood by the arteries, or the screw tourniquet [442] 
 of some of the older instrument cases may be tightened over 
 the femoral below the middle of the groin [421] . On the 
 removal of the Esmarch bandage the surgeon cuts the soft 
 parts to the bone, and the flaps, or incised tissues, are in- 
 stantly gathered up in the hands of an assistant, who draws 
 them in the direction of the trunk, out of the way of the 
 saw Sometimes, instead of his lingers, the assistant uses 
 for this purpose a retractor, a piece of muslin two feet long, 
 and as wide as the diameter of the limb operated on. 
 This is torn for half its length down its middle, and the 
 
174 
 
 SURGICAL OPERATIONS. 
 
 two strips are made to embrace the bone at their point of 
 junction, so that by traction on the muslin the soft parts 
 are protected. During the application of the saw the as- 
 
 Amputation of the thigji. 
 
 sistant in charge of the limb is careful to do no more than 
 support its weight ; if he do more than this he will lock 
 the saw between the freshly sawn surfaces, and if he do 
 
 A bone-euttlng forceps. 
 
 less the unsupported part of the weight may splinter off 
 the under part of its upper fragment. On the removal of 
 the limb the surgeon smooths the edges of the bony stump 
 
 A spring or artery forceps. 
 
 with a scraper or strong-backed, blunt scalpel, and may 
 have to use a hone-cutting forceps to round off sharp angles. 
 The prominent arteries are then picked up by forceps or 
 tenaculum, and tied [444] ; and the tourniquet is gradually 
 relaxed to permit those that remain unligatured to indicate 
 
SURGICAL OPEEATIOKS. 175 
 
 their position by their leakage. When these ^re secured, 
 the tourniquet is removed, and the cut surfaces are well 
 washed with sterilized water until all oozing has ceased, 
 after which they are carefully bathed with an antiseptic 
 lotion, united by sutures [408], and dressed. 
 
 285. The provision for such an operation includes there- 
 fore a suitably prepared operating-table ; an anaesthetic and 
 handkerchief, cone and sponge, or special inhaler for its 
 administration, with a basin in case of vomiting, and a 
 
 A tenaculum. A scalpel. 
 
 hypodermic syringe with brandy and strychnine tablets in 
 case of need; supplies of antiseptic solutions such as of 
 bichlorid, carbolic acid, and formalin, and large supplies 
 of boiled water, both hot and cold ; sterilized towels and 
 dressings ; amputating knives, among them a double-edged 
 one or catlin if the forearm or leg be concerned in the 
 operation ; scalpels for incidental use and one with a strong 
 back, as a bone scraper; a bone-cutting forceps; several 
 artery forceps, tenacula, and ligatures with needles and 
 prepared silk or gut for sutures. 
 
 286. Esmarch's bandage is a broad, elastic roller, applied 
 from the toes or fingers upward, to compress the soft parts 
 and drive the blood before it toward the trunk. When the 
 bandage has reached a point three or four inches above the 
 site of the intended operation, a piece of strong elastic 
 tubing or fiat band, with hook and chain attachment, is 
 wound several times around the limb to cut off its circula- 
 tion, after which the bandage is removed and the limb is 
 ready for operation. The removal of the strong tubing, 
 which acts the part of tourniquet in this method, is often 
 
176 ANAESTHESIA. 
 
 followed by profuse oozing. To prevent it, some operators 
 close the wound and elevate the stump before entirely re- 
 moving the tubing ; others attempt to control it by the ap- 
 plication of hot water, 150° to 180° F. ; but perhaps the 
 best method is that which shortens the period of pressure 
 by the substitution of the ordinary tourniquet for the tub- 
 ing as soon as the principal arteries have been tied. 
 
 287. AnfBsthetics produce insensibility to pain Chloro- 
 form, ether, and nitrous oxide or laughing-gas are the anaes- 
 thetics chiefly employed. The last-mentioned is used by 
 dentists in the extraction of teeth ; the evanescent nature 
 of its effects renders it unsuitable for operations that re- 
 quire time for their performance. False teeth or tobacco, 
 if present in the mouth, should be removed before giving 
 a general anaesthetic. Chloroform and ether are used in 
 general surgery. They induce a condition of excitement 
 which is followed by insensibility. After a few inhalations 
 the face becomes flushed, and the pulse and breathing are 
 excited; the patient may be talkative and noisy, jovial or 
 quarrelsome, but is always incoherent, and often struggling 
 in his delirious fancies. Afterward muscular power and 
 sensation are lost, as evidenced by the inability of the pa- 
 tient to sustain the weight of his arm when it has been 
 raised by the surgeon, and his failure to wink when the 
 conjunctiva is touched. His breathing is quiet, and his 
 pulse full and regular, but perhaps somewhat slower than 
 natural. The object of the administrator is to prolong this 
 condition to the close of the operation ; if he give too little, 
 the patient may begin to struggle ; if he give too much, 
 stupor with stertorous breathing is developed. Usually the 
 movements incident to dressing the wounds arouse the pa- 
 tient ; failing this, consciousness is recalled by slapping the 
 forehead and chest lightly with a cold, wet towel. 
 
ANESTHESIA. 177 
 
 288. A larger quantity of ether than of chloroform is re- 
 quired to produce the anaesthetic effect ; its vapor is more 
 irritating, causing cough, feelings of suffocation, and dis- 
 ineliaation on the part of the patient to continue the in- 
 halation; it is highly inflammable, and hence dangerous 
 under certain conditions ; the excitement produced is more 
 violent, and its period more protracted, particularly if the 
 vapor be much diluted. The respiration under ether is less 
 regular, being often shallow and spasmodic. Its after- 
 effects — headache, confusion of mind, nausea, and general 
 malaise — are of greater intensity, and last longer than those 
 which follow the use of chloroform. The latter, therefore, 
 has many points in its favor ; but these are counterbalanced 
 by the greater risk of death : many more deaths from chlo- 
 roform than from ether have been reported. 
 
 289. Chloroform is best administered from a conical 
 sponge, or a soft handkerchief folded to a square of some- 
 what more than four inches. One or two drachms are 
 poured on, and the patient is told to breathe deeply, while 
 the sponge or handkerchief is held over his mouth and nos- 
 trils at such a distance as will permit a mixture of atmos- 
 pheric air with the^ indrawn current of anaesthetic vapor. 
 As soon as the handkerchief loses the freshness of the chlo- 
 roform odor, another similar quantity is sprinkled over it. 
 As the vapor is much heavier than air, there is no need of 
 oiled silk or other impervious covering to the upper surface 
 of the sponge or handkerchief. During the period of ex- 
 citement, the quantity of entering air should be diminished ; 
 but as soon as the patient sinks, with a deep breath or sigh, 
 into a condition similar to that of quiet sleep, the handker- 
 chief should be raised to admit of a freer entrance of air. 
 The free admission of air is important ; a small quantity of 
 chloroform vapor permeating the system to the exclusion of 
 
 12 
 
178 ANESTHESIA. 
 
 air is far more dangerous than a larger quantity adminis- 
 tered with proper precautions. If the patient show any 
 sign of returning consciousness, a freshening of the chloro- 
 form supply, or a lowering of the handkerchief to increase 
 the percentage of vapor inhaled, is required; and, on the 
 other hand, if the breathing begin to be stertorous, the 
 handkerchief may be laid aside for the time being. But 
 meanwhile the administrator must permit nothing to inter- 
 fere with his guard over the pulse and respiration of the 
 patient. The slightest irregularity in either dictates the 
 temporary withdrawal of the vapor. When chloroform 
 proves dangerous, it is usually by a stoppage of the heart, 
 sometimes of the breathing. When this happens, the oper- 
 ation must be suspended, fresh air admitted into the room, 
 the patient placed with his head considerably lower than 
 his body, his tongue pulled forward, and breathing encour- 
 aged by slapping the chest lightly with a cloth wet with 
 cold water, or artificial respiration must be employed. 
 The danger of vomiting is lessened by the administration 
 of thirty cubic centimetres of whiskey before beginning the 
 inhalation. In case vomiting occurs, the patient should be 
 rolled over on his side, that the vomited matters may have 
 free exit from his mouth. Death may occur from suffoca- 
 tion if these matters find their way into the trachea. 
 
 290. Ether is administered frqm a sponge covered on its 
 upper surface with a layer of oiled silk. Sometimes a 
 folded towel is rolled into the shape of a hollow cone, open 
 at the base for application over the mouth and nostrils ; the 
 ether is sprinkled over its interior. A cone of stout pack- 
 ing-paper is also occasionally used with a sponge fastened 
 in its apex. A half -ounce or more is poured on the sponge 
 at a time and the patient watched as in the case of chloro- 
 form. Danger in the case of ether usually arises from 
 
SURGICAL OPERATIONS. 179 
 
 failure of the respiration; less frequently from stoppage 
 of the heart. 
 
 291. In moving a patient back to bed after anaesthesia 
 his head should be kept low, and on no account should he 
 be permitted to sit up. Only a teaspoonful of water or 
 crushed ice should be given for several hours after the 
 anaesthesia. After all operations in which the abdominal 
 cavity has been opened, as in operations for gunshot or 
 other injuries, for appendicitis, for ovarian or other tumors, 
 great care should be taken to prevent vomiting. Nothing 
 should be given but water or other absorbable liquids for 
 several days after the operation. 
 
 292. The bed to receive the patient after a serious opera- 
 tion should be warmed, if necessary. The temperature and 
 pulse should be recorded. If the former should rise in the 
 course of a few days the surgeon will probably uncover the 
 wound of operation for inspection and redressing. Tight 
 stitches are relaxed and pus is removed. The wound should 
 be redressed also if there is much pain or if the discharge 
 from it has come through the original dressing. 
 
 293. The discharges from wounds, ulcerations, abscesses, 
 etc., have always a putrefactive or septic tendency; and 
 this should be constantly borne in mind by those who are 
 concerned in the management of surgical cases, that the 
 most perfect cleanliness, combined with antiseptic precau- 
 tions and free ventilation, may effectually prevent one 
 wound from being injured by the less favorable conditions 
 of another. Hospital attendants have, indeed, to make 
 perfect cleanliness their gviiding principle even for their 
 own welfare, for the discharges from mucous surfaces and 
 cutaneous or other ulcerations have, in certain diseases, a 
 contagious quality. Gonorrheal matter coming in contact 
 with the eyes, as from a tainted towel or finger, will light 
 
180 THE PULSE. 
 
 up a most violent and destructive inflammation [486], and 
 a hangnail or other trifling abrasion on the hand may permit 
 the introduction of the syphilitic virus. The nurse, there- 
 fore, in dressing septic wounds should be careful to protect 
 slight breaks in the skin of the hands, hangnails, etc , by 
 rubbing them with oil or covering them with collodion. An 
 accidental scratch or puncture should be treated as in [429]. 
 A one-per-cent. formalin solution is often used for disin- 
 fecting the hands [332] . 
 
 294. Local ancesthesia for subduing the pain in minor 
 operations is produced by throwing a spray of ether on the 
 part. The cold resulting from the evaporation of the 
 atomized ether benumbs the skin, and, if not too pro- 
 longed, is not followed by undesirable results. 
 
 295. The hydrochlorate of cocaine, in a four- or five-per- 
 cent, solution, is used in operations on mucous surfaces. 
 It is often used in operations on the eye. A few drops 
 paralyze the terminal branches of the nerves of sensation, 
 the effect lasting only five or ten minutes. It is used also 
 in operations on the mouth and throat, rectum, vagina, and 
 urethra ; twenty-four grains injected into the rectum have 
 proved fatal. It has no value as an anaesthetic when 
 applied to the skin. 
 
 296. The Record of a Case. In all important cases, 
 whether surgical or medical, certain observations should 
 be made by the nurse and recorded as part of the history 
 of the case. These observations relate to the pulse, respira- 
 tion, temperature, and sleep ; to food and medicines taken 
 into the system, and to matters excreted or passed out of 
 the system from the skin, lungs, bowels, or urinary bladder. 
 
 297. The Pulse. The expansion of the arterial tubes, 
 consequent on the sudden delivery into them of the contents 
 of the left ventricle, constitutes the pulse-wave as felt at 
 
THE RESPIRATION. 181 
 
 the wrist or elsewhere [196]. The pulse is usually taken 
 by pressing with the tips of the fore and middle fingers on 
 the radial artery a.s it passes over the lower end of the 
 radius internal to the prominence of that bone just above 
 the wrist joint. The beats occurring during a period of 
 sixty seconds should be counted, and at the same time ob- 
 servation should be made on its rhythm and other qualities. 
 The average pulse in the adult is about 70 or 76 per minute ; 
 in children it is more rapid; in infants, 110 or 120. A 
 natural pulse is of normal frequency, equal or regular, that 
 is, having all its pulsations similar and at equal intervals, 
 and neither hard like a cord nor soft or easily obliterated, 
 yet susceptible of a certain degree of impressibility by the 
 finger. As regards the number of beats per minute, the 
 pulse is said to be slow, frequent, or rapid ; the term quick 
 ■pulse has no reference to frequency, but to suddenness of 
 impulse. A pulse is irregular -when its beats lack uniform- 
 ity in strength or intervals ; intermittent when one beat is 
 omitted after a certain number of regular beats. A fill 
 pulse is one of large calibre; a. smnU pulse is generally 
 rapid and iveak or feeble, — thready or wiry if it be hard, 
 and fluctuating if soft. A febrile pulse is rajjid, full, and 
 hard if the patient be robust; rapid and small if he be 
 prostrated. Exercise increases the frequency of the pulse. 
 Its beats are more frequent when one is sitting or standing 
 than when lying. Weak pulses suffer greater acceleration 
 by exercise than strong ones. 
 
 298. The Respiration. The act of respiration may be 
 suspended voluntarily for a time; but the necessity for 
 breathing speedily overcomes any voluntary restraint by 
 spasmodic gasping efforts. When, notwithstanding these, 
 aeration fails to take place [234] , the blood tends to stag- 
 nate in the lungs, and is thrown back on the right ventricle, 
 
182 THE KESPIEATION. 
 
 causing the veins to become distended and the surface con- 
 gested and dusky. Meanwhile the circulation of venous 
 blood in the brain benumbs the consciousness of the indi- 
 vidual, whose struggles for breath become proportionately- 
 weaker. A person thus affected is said to be asphyxiated. 
 When the lungs are sound and the deficient aeration of the 
 blood is due to some mechanical interference with the inflow 
 of air or some narcotic influence on the brain, the continu- 
 ance of respiration by artificial means [471] is often of 
 value in saving life. But difficulty of breathing is fre- 
 quently due to causes which affect the integrity of the 
 lungs or air passages, and which cannot be favorably 
 affected by any method of artificial respiration. In pneu- 
 monia the air cells become filled with exudation [184] from 
 the capillary vessels, and the patient, in fatal cases, is to 
 all intents and purposes drowned in the plasma of his own 
 blood. In diphtheria the air tubes are narrowed and per- 
 haps occluded by the formation of false membrane within 
 them . In bronchitis the mucous membrane becomes swollen 
 and blocks up the tubes, or an excess of secretion may 
 produce the same effect. A slight inflammatory tumefac- 
 tion of the lining membrane of the larynx has frequently 
 caused death, for the air passage between the vocal cords 
 [161] is so narrow as to be easily closed up. In pleurisy, 
 or inflammation of the pleura, the pain of the inflamed 
 surfaces rubbing against each other makes the breathing 
 shallow, and later the lung may become compressed by an 
 accumulation of effused serum in the pleural cavity. A 
 punctured wound of the chest [452] admits air into the 
 cavity, and the lung becomes collapsed by the pressure of 
 the atmosphere ; during respiratory efforts air enters and 
 escapes, as in the case of a leaky bellows, by the leak 
 rather than by the regular passages. 
 
THE TBMPEEATURB. 183 
 
 299. In patients with fever, lung diseases, or great pros- 
 tration, the respiration should be counted. This is effected 
 by watching the chest or abdomuial movements by the eye 
 or by a gentle touch of the hand. 
 
 300. The Temperature. The natural temperature in man 
 is usually said to be 98.4° F., but it varies a little, being 
 more frequently above than below that point. When it 
 falls below 97°, the patient is in a state of collapse [357] ; 
 when it rises above 99.6°, he is feverish. Up to 102° the 
 fever is said to be moderate; above that degree it is high. 
 Death is imminent when the temperature reaches 106°. 
 
 301. Bodily temperatures are sometimes recorded in de- 
 grees of the Centigrade scale. The zero or freezing-point 
 of this scale corresponds with 32° F. ; and the boiling-point, 
 212°, of the latter with 100° Centigrade. Hence 180 
 Fahrenheit degrees = 100 Centigrade, or 1 = |. To change 
 Centigrade statements into the Fahrenheit scale, multiply 
 by 1^ and add 32. To change Fahrenheit into Centigrade, 
 subtract 32 and multiply the remainder by ^. 
 
 302. The clinical thermometer is a mercurial column, self- 
 registering by a detached portion of the mercury, and ac- 
 curately graduated for the short range of temperature likely 
 to be observed above or below the normal. A sudden jar 
 communicated to the hand which holds the instrument, 
 bulb downward, will send the index down when required. 
 When the patient is conscious and intelligent, the tempera- 
 ture is taken by placing the bulb of the thermometer under 
 the tongue, and having him close his lips around the stem 
 and breathe gently through his nose for two or three min- 
 utes, or until the mercury ceases to rise. The thermometer 
 should be sterilized before and after use [332, 333]. The 
 temperature may also be taken by placing the bulb in the 
 armpit and pressing the arm close to the chest during the 
 
184 
 
 THE TEMPERATUEE. 
 
 time of the observation. The rectum is a good situation for 
 obtaining the temperature in unconscious patients. 
 
 303. The normal temperature is subject to a daily fluctua- 
 tion of about a degree of Fahrenheit's scale. It is highest 
 in the evening, at from five to eight o'clock ; lowest during 
 the night or early morning, from two to six o'clock. The 
 hours of low temperature enhance the danger in cases of 
 low vitality. When fever is present, these fluctuations are 
 often distinctly marked. In the evening the patient be- 
 
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 Temperature chart, showing the morning and erenlng ohservations in a ease of 
 malarial fever malajler : quinine was given at the times marked *, and its influ- 
 ence is manifested in the succeeding fall of the temperature. 
 
 comes manifestly worse ; the flush deepens on his cheek, 
 the skin becomes hotter, and the cerebral disturbance ag- 
 gravated. These are called evening exacerbations. The 
 subsidence of this excess of fever after midnight is spoken 
 of as a remission. Evening exacerbations occur in all 
 fevers, even in those which, like typhoid, are regarded as 
 continued fevers. When the remission is strongly marked 
 or occurs daily at an unusual hour, the fever is a remittent; 
 and when, during the lull, the temperature drops to the 
 normal or below it, the fever is said to intermit. The tak- 
 
ABMINISTRATION OF MEDICINES. 185 
 
 ing of the temperature in febrile cases is an important duty. 
 It not only shows the progress of the fever and the influ- 
 ence of quinine or other anti-febrile remedies upon it, but 
 often enables the physician to prognosticate the result. A 
 line drawn across a ruled scale so as to show the morning 
 and evening temperature daily during the course of the 
 disease is called a temperature chart. 
 
 304. Administration of Medicines, etc. As regards the 
 administration of ^medicines measuring glasses are better 
 than spoons, because the latter vaiy in size. Atablespoon- 
 ful of a mixture should be regarded as equivalent to 15 c.c. ; 
 a teaspoonful to 4 c.c. One c.c. of water equals 15 drops, 
 but the volume of a drop depends on the physical qualities 
 of the liquid. A drop of castor oil occupies a very different 
 volume as compared with a drop of chloroform. When 
 drops are ordered they should be measured with a dropper. 
 A teaspoonful of a powder means that the spoon should be 
 smoothed off, not heaped up. All spoons and glasses used 
 in giving medicines should be perfectly clean and be cleaned 
 again after use. Medicines should be administered at in- 
 tervals as ordered ; but a patient should not be awakened 
 from sleep to take medicine unless the instructions require 
 this to be done. The nurse should know also the best 
 method and time for the administration of medicines, as, 
 for instance, that castor oil should be taken in a cup of hot 
 beef tea, cod-liver oil in black coffee, arsenic after meals, 
 and that the mouth should be rinsed out after iron. Medi- 
 cines that are unpleasant to the taste may be deprived of 
 much of their flavor by closing the nostrils while swallow- 
 ing them. He should also be aware of the special effects 
 of certain medicines ; as that quinine causes ringing in the 
 ears and deafness, bismuth brownish or dark-colored stools, 
 carbolic acid dark or olive-green colored urine, mercurial 
 
186 ADMINISTRATION OF MEDICINES. 
 
 preparations salivation, swollen gums, and foul breath, and 
 iodides and bromides occasionally catarrh and skin erup- 
 tions. Any unusual or bad effect from medicine admiais- 
 tered, such as nausea, vomiting, diarrhea, headache, etc., 
 should be noted and reported. 
 
 305. In cases in which the necessity for sleep is impera- 
 tive or aggravated pain has to be alleviated, morphine given 
 by the hypodermic syringe is frequently ordered. The 
 syringe is used also to introduce strychnine, ether, or other 
 stimulant when the heart's action is failing, or apomorphine 
 in poisoning when there is no other means available for 
 emptying the stomach. In using the hypodermic syringe 
 the exact quantity of the solution to be injected is drawn 
 into the barrel, the needle is adjusted, and the piston 
 pressed lightly until the appearance of the contained liquid 
 at the point of the instrument' shows that all air has been 
 expelled. Th^ skin is then pinched up between the fore- 
 finger and thumb and the needle is pushed into the subcu- 
 taneous cellular tissue. The injection should be made 
 slowly and gently, and after the withdrawal of the instru- 
 ment the finger should be kept on the puncture for a few 
 seconds. The arm or forearm is usually selected as the 
 most convenient site, avoiding the vicinity of the subcutane- 
 ous veins. The skin should be washed and disinfected with 
 bichloride solution before the puncture is made. 
 
 306. The appearance of the tongue often gives important 
 information concerning the condition of the digestive organs 
 and the general system. Naturally the tongue is clean, 
 red, and pliant. In malarial disease it is large, flabby, 
 coated with a bluish or grayish film, and indented on the 
 margin as if with the impression of the teeth. In dis- 
 ordered digestion it is cream-coated or covered with a yel- 
 lowish fur. When notable fever is present it becomes dry; 
 
ADMINISTBATION OF MEDICINES. 187 
 
 a moist tongue is always an improvement on a dry one. 
 In typhoid fever it is narrow, elongated, dry, with a dark 
 stain on the centre of its dorsum, and of a deep red color 
 at its tip and edges. Sometimes it cracks and bleeds, and 
 the blood dries into dark crusts called sordes, on it and on 
 the lips and teeth [339, 342]. 
 
 307. To give a weak patient a drink or liquid nourish- 
 ment the head and neck should be raised a little from the 
 horizontal by the .left arm of the nurse while the liquid is 
 spooned into his mouth ; or a glass tube may be used bent 
 at a right angle, one end in the mouth, the other one on a 
 lower level in the cup containing the liquid. 
 
 308. If a medicinal liquid has to be applied to the throat 
 by gargling it is well to gargle first with water to clear 
 away accumulated mucus. If the tonsils or other parts of 
 the throat have to be swabbed with a prescribed solution, 
 the patient, having gargled with water, is placed in a good 
 light, the tongue is depressed with a suitable instrument, 
 and the affected parts touched with the swab, which should 
 be withdrawn immediately. There should be no excess of 
 liquid in the swab to exude under the light pressure of 
 contact and run down into the larynx or trachea. If the 
 patient cough during or at the end of the proceeding, the 
 nurse should keep his face out of the line of the expelled 
 air to avoid receiving infection from the diphtheritic or 
 otherwise diseased throat. The swab should be burned and 
 the vessels used in gargling disinfected, after which the 
 nurse should wash and disinfect his hands and face. 
 
 309. Free vomiting is less distressing than dry retching. 
 A patient suffering from the latter condition should be 
 liberally supplied with tepid water or demulcent drinks, the 
 more so as their subsequent ejection facilitates the removal 
 of obnoxious matters from the stomach. During vomiting 
 
188 ADMINISTRATION' OF MEDICINES. 
 
 the nurse should support the head of the patient with one 
 hand on the forehead and the other behind. 
 
 310. Movements from the bowels should be noted, in- 
 cluding their frequency, color, consistence, the presence of 
 undigested food, of blood, mucus, etc., and any special 
 characteristics associated with the passage, as tormina or 
 cramps and tenesmus or distressing straining. Enemata are 
 usually given by means of a bulb syringe. The patient lies 
 on his side near the edge of the bed. The bulb and tubes 
 are filled with the liquid so that no air shall be introduced 
 into the bowel. The nozzle is then oiled and insinuated 
 into the rectum for about two inches, and by gradual com- 
 pression and relaxation on the bulb the injection is intro- 
 duced. A laxative enema consists of water at 96° F., with 
 enough of soap to make a lather, and with a little olive oil 
 or castor oil, as may be ordered, 260 to 300 c.e. of the 
 enema being injected and the patient required to retain it 
 as long as possible. The bed-pan or night-stool should be 
 at hand for the expected evacuation. If the object is to 
 wash out the bowel, water at 96° F. should be injected 
 untn it is found to be coming away by the side of the noz- 
 zle. In this case the mattress should be protected by rub- 
 ber sheeting with a folded blanket and draw sheet [276]. 
 An opiate enema consisting of starch, prepared as for the 
 laundry, to which the prescribed quantity of tincture of 
 opium has been added, is intended to be retained, and 
 should not exceed 100 c.c. in quantity. Kutrient enemata, 
 as prescribed by the surgeon, should also be small in 
 quantity. 
 
 311. A suppository of yellow soap is sometimes used to 
 promote a movement of the bowels. The soap is cut one 
 inch long and a quarter of an inch in diameter, tapered at 
 one end, moistened with water, and introduced into the 
 
ADMINISTRATION OF MEDICINES. 189 
 
 rectum. The movement usually takes place within ten 
 minutes after the introduction. Glycerin suppositories also 
 are used for the same purpose. 
 
 312. When the lower limbs are paralyzed, the condition 
 is called paraplegia ; this is occasioned by disease or injury 
 of the lower part of the spinal cord. Fracture or displace- 
 ment of the vertebrae may have severed the cord or caused 
 pressure upon it, or the pressure may be the result of in- 
 flammatory effusipn or exudation [184]. If the lesion be 
 somewhat higher in the loins, there will be involuntary 
 passage of urine and faeces. When the lesion is high 
 in the dorsal region, respiration becomes oppressed from 
 paralysis of the muscles concerned in expanding and con- 
 tracting the chest. When in the lower cervical region, the 
 upper extremities participate in the paralysis. When 
 above the origin of the phrenic nerves [253], death follows 
 immediately from paralysis of the respiration. 
 
 313. When paralysis is diie to disease or injury of the 
 brain, as concussion or compression [466], apoplexy [458], 
 etc., the loss of motion and sensation is one-sided, hemi- 
 plegia ; but as the respiratory nerves of the unafPected side 
 carry on the vital movements, death does not follow so 
 promptly as when the upper part of the cord is involved. 
 In hemiplegic cases the paralysis of the limbs is on the side 
 opposite to that which is diseased or injured, for the nerves 
 from each side of the brain cross over to the opposite side 
 as they leave the cranium to enter the spinal canal ; but as 
 the nerves which supply the head and face are cerebral 
 nerves issuing above this crossing of the tubules, the side 
 of the face which is paralyzed is that in which the lesion 
 exists. An apoplectic clot in the right side of the brain 
 paralyzes the right side of the face and the left side of the 
 body. 
 
190 BBDSOEES. 
 
 314. To change a soiled sheet under a paralyzed or help- 
 less patient : Turn him on his side ; roll the uncovered half 
 of the soiled sheet up lengthwise until the cylinder lies 
 close to his back. Have one-half of the fresh sheet rolled 
 into a similar roll and place its cylinder alongside of the 
 other, smoothing the unrolled half over the bed and tuck- 
 ing it away properly. Turn the patient on his other side 
 so as to bring him on the clean sheet ; remove the soiled 
 sheet, and unroll and smooth out the fresh one. Draw 
 sheets [275] are changed in the same manner, or the fresh 
 sheet may be fastened to the other with safety-pins and 
 the new sheet be drawn into place by the withdrawal of the 
 soiled one. 
 
 315. Bed-sores are usually found in patients who have 
 been confined to bed for a long period by exhausting dis- 
 eases, paralyses, compound fractures, etc. ; and their site 
 is the tissues subjected to pressure between the mattress 
 and some bone that is not well padded with soft parts, as 
 the sacrum and the prominences of the hip-bones, spine, or 
 ribs. The treatment consists of regularly inspecting the 
 back and other points of possible injury in a patient likely 
 to become affected in this way, and frequently changing 
 his position to relieve the threatened parts from continued 
 pressure. The skin should be kept dry and clean by wash- 
 ing with soap and water, or bathing with alcohol, or a 
 solution of corrosive sublimate, 1 : 1,000, and afterward 
 dusting with fine starch. The sheet on which the patient 
 lies should be kept free from creases and crumbs, and be 
 replaced by fresh linen as soon as it becomes soiled or 
 damp. Benefit may also be derived from the protection of 
 a piece of soft leather, spread with soap plaster, and the 
 judicious use of pillows. In unconscious or paralyzed pa- 
 tients, the skin should be kept free from the irritating con- 
 
CHAKACTERS OF URINE. 191 
 
 tact of discharges from the bowels or bladder ; but when 
 this is impossible, it should be protected by petrolatum. 
 When a sore has formed it should be relieved from all 
 pressure by air cushions or other suitable rings or pads, 
 poulticed if sloughing, and antiseptically dressed if dis- 
 charging only molecularly. When paralysis is due to 
 fracture of the spine [512] , bed-sores may be looked for in 
 the course of a few days, as in addition to the pressure 
 there is a loss of preservative nerve power in the parts. 
 Such cases requife every care in nursing to prevent the 
 sores from themselves becoming the active agent in causing 
 the death of the patient. 
 
 316, The urine consists of water holding in solution cer- 
 tain nitrogenous substances and inorganic salts. When the 
 muscles are used up by exercise they ar« repaired by the 
 albuminous principles of the blood, while their old and 
 degenerated material is absorbed in the form of complex 
 organic substances, which are finally converted into urea 
 and filtered oif through the kidneys. Some of the transi- 
 tion products in the decomposition of albuminous substances 
 are occasionally found in traces in the urine ; one of these, 
 uric acid, is constantly present. On the other hand, in 
 morbid states not only uric acid, but many of the less oxi- 
 dized products of the decomposition of the albuminoids may 
 be found in considerable quantities in the urine. 
 
 317. The inorganic salts of the urine, consisting of chlo- 
 rids, sulphates, and phosphates of the alkalies and of lime 
 and magnesia, are derived in great part from the food 
 [208] . Chlorids are constant constituents of most articles 
 of food. Sulphates originate in the decomposition of al- 
 buminous tissues, the sulphur of which becomes oxidized 
 in the body. Phosphates exist naturally in both animal 
 and vegetable foods ; they are derived also from the repara- 
 
192 CHARACTERS OF URINE. 
 
 tion of the bony tissues and the oxidation ol phosphorus in 
 the disintegration of the nerves and nervous masses. 
 
 318. The average quantity of urine secreted daily is about 
 fifteen hundred cubic centimetres, or fifty fluidounces. It 
 is decreased in warm and dry weather, when cutaneous and 
 pulmonary transpiration is active, for there is then less 
 water left in the system for elimination by the kidneys ; it 
 is decreased also in diseases characterized by profuse watery 
 evacuations from the bowels. It is increased in cold and 
 damp weather, when exhalations from the skin and lungs 
 are at a minimum, and in morbid conditions associated 
 with dryness of skin, excepting those inflammatory or 
 febrile diseases which tend to the suppression of all the 
 secretions. Normal urine removes from the system daily 
 about an ounce each of urea and salts and eight or ten 
 grains of uric acid in the form of urates. When freshly 
 passed it is slightly acid, but after a time becomes alkaline 
 from the transformation of its urea into carbonate of am- 
 monia. 
 
 319. For the introduction of the catheter the patient should 
 be on his back, head and shoulders slightly raised by pil- 
 lows, knees drawn up and separated from each other to 
 relax the muscles of the abdomen. The operator stands on 
 the left side of the bed, and, supporting the penis with the 
 fingers of his left hand, inserts the point of the instrument, 
 previously sterilized, warmed, and oiled, into the mouth of 
 the urethra. In doing this the body of the instrument is 
 almost horizontal, its concavity looking to the left groin. 
 As the point passes- down the urethra the handle is swung 
 round horizontally from the groin to the middle of the 
 abdonien and is then gradually raised to the perpendicular 
 and depressed between the thighs of the patient as the urine 
 begins to flow through it. A suitable vessel should be 
 
CHARACTERS OF URINE. 193 
 
 placed to receive the discharge and prevent unnecessary- 
 soiling of the bedding. A piece of rubber tubing fitted to 
 the mouth of the catheter and leading into the vessel is 
 sometimes useful. No force should be used in the opera- 
 tion, the catheter being, guided rather than pushed into the 
 bladder. Sometimes an impediment is offered by the point 
 of the instrument to the movement which brings the handle 
 to the perpendicular. This is best overcome by withdraw- 
 ing the instrument for an inch and letting it glide farther 
 mto the canal before attempting to raise the handle. A 
 large-sized catheter should always be employed for cathe- 
 terization unconnected with a strictured urethra. 
 
 320. When the urine is passed in large quantity [318] it 
 is usually j)ale in color ; when scanty, high-colored. Blood, 
 when present, may be identified by the appearance of the 
 red corpuscles under the microscope. A\Tien in small 
 quantity and diffused throughout the urine, it probably 
 comes from the kidneys; when in larger quantity or in 
 clots, and when it escapes more freely during straining at 
 the close of urination, it probably comes from the ureters 
 or bladder ; when it comes before the flow of urine, which 
 afterward becomes clear, its source is probably the lining 
 of the urethra. In some, acute malarial attacks the urine 
 is of the color of blood, although no red corpuscles can be 
 discovered by the microscope. Some substances, as rhu- 
 barb, beetroot, logwood, etc., may give rise to an appear- 
 ance as of blood in the urine. 
 
 321. The sperifir f/niviti/ of urine is usually said to be 
 1.020; but as this depends on the quantity of dissolved 
 solids that pass off in tlie liquid, it necessarily varies ac- 
 cording as the urine examined was secreted after fasting or 
 after the ingestion of food or drink. The specific gravity 
 is obtained by means of an nvinometer. The urine is placed 
 
 13 
 
194 CHARACTERS OF URINE. 
 
 in a tall cylindrical glass. A graduated stem, weighted 
 below by a small bulb containing mercury, is floated ia the 
 liquid and the specific gravity is read off where the stem 
 rises from the surface. In the absence of an accurate 
 urinometer the specific gravity may be taken by balanciag 
 a small glass vessel on the dispensing-scales and delivering 
 into it from a pipette ten or more cubic centimetres of the 
 urine. The weight of the urine divided by the number of 
 cubic centimetres indicates the specific gravity. If the 
 contents of a 25 c.c. pipette weigh 26.500, the specific 
 gravity is 25.600 h- 25 = 1.020. A notably low specific 
 gravity is suggestive of albuminuria or Bright' s disease ; a 
 high specific gravity, of diabetes, a disease in which sugar 
 is present. 
 
 322. When uriae is bloody it necessarily contains albu- 
 min ; but this substance in certain morbid states escapes 
 from the blood Lato the secreting tubules of the kidneys 
 along with the urea and salts which constitute the natural 
 excretion. Its presence in urine is suggested by the per- 
 sistence of air-bubbles on the surface of the liquid after it 
 has been poured from one vessel into another. To detect 
 it: Boil ten or fifteen cubic centimetres of clear filtered 
 urine in a test-tube and add a drop or two of nitric acid. 
 Heat throws down phosphates, which are dissolved by the 
 nitric acid ; the latter throws down urates, but these are 
 dissolved by the heat; when both reagents are applied, 
 nothing remains precipitated but the curdy flakes of albu- 
 minous matters. 
 
 323. Besides having a high specific gravity, as 1.040 or 
 over, urine which contains sugar is passed usually in in- 
 creased quantities. To ten or fifteen cubic centimetres in a 
 test-tube add a drop or two of a solution of sulphate of 
 copper and an excess of liquor potassse ; then boil the blue 
 
CHARACTERS OF URINE. 195 
 
 solution thus formed, when, if sugar be present, a red sub- 
 oxid of copper will be precipitated. 
 
 324. Urine when freshly passed is clear, but after a time 
 a sediment may gather in it. Reddish crystals of uric add 
 may be seen at the bottom of the containing vessel after 
 standing for twenty-four hours. Urates are more soluble 
 in warm than in cold water ; hence, when present in large 
 quantity, they may become deposited as a fawn-colored 
 powdery sediment after the urine has had time to cool. 
 The urates are in excess when the waste of tissue is great, 
 as in fevers and inflammations, or when the supply of nitro- 
 genous food is greater than is required [316], Phosphates 
 are deposited as the urine becomes alkaline by decomposi- 
 tion, because they are less soluble in an ammoniacal than 
 in an acid urine. They are whitish in color, and may be 
 distinguished from the urates by their failure to dissolve 
 on heating the liquid. They are usually present in excess 
 in cases of nervous depression or deficient vitality. The 
 gradual deposition of these insoluble or sedimentary mat- 
 ters under certain conditions within the bladder gives rise 
 to the formation of stone or gravel. 
 
 325. When a patient does not pass his urine the imme- 
 diate cause may be either suppression or retention. 
 
 Suppression of urine, in which the kidneys fail to secrete 
 and relieve the blood of urea and other refuse materials, is 
 a grave condition often seen when the secreting tissue is 
 disorganized; the blood becomes poisoned by the retained 
 matters, and, circulating iu the brain, gives rise to vrcemic 
 unconsciousness, convulsions, and death. In retcntioii of 
 urine the kidneys continue to purify the blood, but from 
 some local cause the accumulated urine is not expelled from 
 the bladder. It may arise from injury to the spinal cord 
 above the origin of the nerves which supply the bladder, or 
 
196 CONCERNING DISINFECTANTS. 
 
 from some stricture of the urethral passage, or even from 
 an overdistention of the bladder which temporarily par- 
 alyzes its muscular coat. Relief iu these iustances is 
 afforded by the introduction of the catheter. Retention 
 may be present, although the patient's complaint is that of 
 passing water all the time in driblets. The bladder may 
 be so distended that it overflows through the urethra, yet 
 cannot contract for the expulsion of the whole of its con- 
 tents. This condition is recognized by the tense swelling 
 and feeling of distress in the lower part of the abdomen. 
 In such cases it is better not to empty the bladder at once, 
 but to remove enough to give perceptible relief, and finish 
 the evacuation half an hour afterward. 
 
 326. Concerning Disinfectants. A member of the Hos- 
 pital Corps should be well informed concerning the strength, 
 uses, and mode of application of deodorants, antiseptics, 
 and disinfectants. When a living body dies or when or- 
 ganic matter is separated from its connection with vitality, 
 the germs or bacteria of putrefaction which are everywhere 
 present increase and multiply in the decomposing tissues. 
 The intention of nature in this process is to reduce the 
 complex organic substance to simple, inorganic forms, to 
 oxidize its carbon to carbon dioxid, its hydrogen to water, 
 and its nitrogen to the condition of ammonia or nitrates ; 
 but in the process many transitional products are formed, 
 and among them are foul-smelling gases and poisonous 
 substances which are called ptomaines. The former are 
 probably not in themselves harmful, but they indicate the 
 probability of the presence of harmful substances. The 
 latter are generally dangerous poisons. They are the cause 
 of the vomiting, violent diarrhea, cramps, and intense 
 prostration which so often follow the eating of tainted 
 meat [595]. Other dangerous germs may be associated 
 
CONCERNING DISINFECTANTS. 197 
 
 with the decomposing organic matter, such as those con- 
 stituting the infection of specific diseases, cholera, typhoid 
 fever, and dysentery, for instance. Deodorants are sub- 
 stances which decompose the foul-smelling gases, but they 
 do not necessarily destroy the bacteria which give rise to 
 these gases. AntisejAics retard or inhibit the growth and 
 multiplication of the bacteria, but do not kill them. Dis- 
 infectants destroy the bacteria utterly. All disinfectants 
 when used in insufficient quantity to kill the bacteria, i.e., 
 to act as germici3es, are antiseptics, but it does not follow 
 that all antiseptics are germicides if used in greater strength. 
 Common salt for mstance, has been used for ages as an 
 antiseptic or preservative, but it is not a disinfectant ; it 
 does not kill the germs. 
 
 327. In military practice disinfectants are to be used 
 only for a specific purpose ; in the absence of any infec- 
 tious disease they are not required and their expenditure 
 for purposes of general post sanitation is not authorized. 
 Sulphate of iron and other cheap deodorants and antiseptics 
 may be used when necessary, but the necessity for their 
 use is regarded as a reproach upon the sanitary police of a 
 post. 
 
 328. Surgeon General Sternberg, who has devoted much 
 time and careful laboratory work to the investigation of 
 the value of disinfectants, has arranged a series of twelve 
 as follows : 
 
 1. Fire. 
 
 2. Steam, under pressure (twenty pounds). 
 
 3. Boiling water. 
 
 4. Formaldehyde gas. 
 
 5. Chlorid of lime (in solution). 
 
 6. Mercuric chlorid (in solution). 
 
 7. Carbolic acid (five-per-cent. solution). 
 
198 COSrCEEKIKG DISIITFECTANTS. 
 
 8. Caustic lime ("quicklime"). 
 
 9. Dry heat (230° P. for two hours). 
 
 10. Sulphur dioxid. 
 
 11. Copper sulphate (in solution). 
 
 12. Zinc chlorid (in solution). 
 
 All these agents properly used are effectiTe for the de- 
 struction of the germs of tuberculosis, diphtheria, typhoid 
 fever, yellow fever, cholera, small-pox, measles, pneu- 
 monia, influenza, erysipelas, and, in general, of all infec- 
 tious diseases the germs of which do not form spores. The 
 five agents at the head of the list may also be relied upon 
 for the destruction of the spores of tetanus or lockjaw and 
 anthrax or splenic fever, called also malignant pustule or 
 wool-sorter's disease, which are the principal diseases in 
 which spores are present in the infectious material. Spores 
 are to bacteria what seeds are to a plant. The cold that 
 would kill a plant may be insufficient to harm the seed, 
 and correspondingly the agents that would kill bacteria 
 may not -be effective in destroying the vitality of their 
 spores. Most of the bacteria are reproduced by fission, 
 that is, by dividing into two, each of which again divides, 
 but some of the elongated rod bacteria called bacilli are 
 propagated also by spores. Fortunately this latter method 
 of propagation is rare among the germs of infectious diseases. 
 
 329, Destruction by fire should be resorted to only when 
 disinfection by other means would cost more than the value 
 of the articles, as in the case of soiled dressings, clothes, 
 and bedding, that are often so worn out as not to be worth 
 the trouble of disinfecting, mattresses and pillows that 
 would require the penetration of superheated steam to give 
 reliable results, and tents when the contagious disease that 
 called for their use is at an end. 
 
 330. Steam under pressure of twenty pounds gives a 
 
COKCERNING DISINFECTANTS. 199 
 
 temperature of 230° F., which destroys all spores with an 
 exposure of twenty minutes. Special apparatus is needful 
 for this mode of disinfection. 
 
 331. Boiling in water for half an hour destroys all infec- 
 tions, including the spores of anthrax. In fact, an ex- 
 posure for a few minutes to a temperature of 160° F., in 
 water, is fatal to the germ of cholera, typhoid fever, diph- 
 theria, pneumonia, and many other infectious diseases. 
 
 332. Formalde^de gas is now largely used instead of 
 steam and sulphur dioxid for the disinfection of clothing, 
 hospital wards, etc. The formalin of the Supply Table is 
 a forty-per-cent. solution of formaldehyde in water. A 
 one-per-cent. solution made by adding 25 c.c. of the strong 
 solution to a litre of water is used for disinfecting purposes. 
 The walls, ceiling, floor, furniture, and other articles in an 
 infected room or ward may be sprayed with this diluted 
 solution, after which the room should be closed for several 
 hours. A weaker solution, one-fourth of one per cent., is 
 used for sterilizing the hands and for surgical purposes. 
 For disinfecting with the gas a formaldehyde generator is 
 furnished. Most of these generators produce formalde- 
 hyde by the slow oxidation of methyl alcohol, one litre to 
 every 2, 500 cubic feet of space, with the room kept closed 
 for four to twelve hours before being aired for use. 
 Blankets, clothing, etc., should be spread out to expose 
 them fully to the gaseous disinfectant. 
 
 333. Solution of corrosive sublimate, one drachm to the 
 gallon of water, chlorinated lime, one ounce to the gallon, 
 solution of chlorinated soda diluted with nine volumes of 
 water, carbolic acid in a two-per-cent. solution, and trihresol, 
 also in a two-per-cent. solution, are efficient disinfectants 
 in certain cases. They may be used for washing the floors, 
 woodwork, walls, etc. , of rooms ; they may be used also 
 
200 CONCERNING DISINFECTANTS. 
 
 for the hands, and, with the exception of the sublimate 
 solution, for general personal use and for disinfecting soiled 
 linen before transferring it to the laundry. Stronger solu- 
 tions should be employed for the treatment of excreta or 
 for saturating the sheets in which a dead body is to be en- ■ 
 veloped pending the arrangements for burial. A suitable 
 strength is obtained by dissolving two drachms of corrosive 
 sublimate or four ounces of chlorinated lime in a gallon of 
 water, or by making a five-per-cent. solution of carbolic 
 acid. Any of these should be added, in volume equal to 
 that of the material to be disinfected, to each dejection m 
 cases of typhoid fever, cholera, yellow fever, and epidemic 
 dysentery, to the matters vomited in cholera, yellow fever, 
 scarlet fever, and diphtheria, and to the expectorations in 
 the two last-named diseases and typhoid pneumonia. The 
 disinfectant should be permitted to act on the excreta for 
 an hour, after which the contents of the vessel may be dis- 
 posed of, preferably by burial QuicldiTne prepared as 
 milk of lime, 1 part to 8 or 10 of water, may be used for 
 disinfecting excreta. As contact with metals decomposes 
 the sublimate solution, it should be used only in wooden, 
 earthenware, or other suitable vessels. 
 
 334. Privy-vaults or cesspools that have become infected 
 by the addition of discharges direct from the patient must 
 be treated liberally with milk of lime, chlorinated lime, or 
 strong solutions of sublimate or carbolic acid. 
 
 335. A dr-y or oven heat of 230° P. , continued for two 
 hours, is useful in dealing with infected garments whici 
 would be injured by immersion in boiling water or disin 
 fecting solutions. 
 
 336. FuTiiigation with sulphur has been extensively used 
 by municipal health of&cers in the disinfection of rooms, 
 particularly after small-pox, and by quarantine officers in 
 
CONCEKNING DISINFECTANTS. 201 
 
 purifying yellow-fever ships. This fumigation is directed 
 to the destruction of infection in. the crevices of the floors, 
 walls, etc., all of which should be carefully cleared of dust 
 before their exposure to the fumes. The dust thus col- 
 lected should be burned. Many articles may be conve- 
 niently disinfected without injury to their texture or color 
 during the fiunigation of the room in which the patient was 
 treated. Each article should be unfolded and freely ex- 
 posed to the sulphurous acid. The fumigation should last 
 for twenty-four hours, during which three pounds of sul- 
 phur should be consumed for every thousand feet of cubic 
 space. Articles of metal should be removed or covered 
 with grease to protect them from the fumes. Due precau- 
 tion must be taken against danger from fire, as by placing 
 the sulphur in iron vessels bedded in sand ; and the room 
 must be made as air-tight as practicable by closing all the 
 chinks. 
 
 337, Copper sulphate, in one-per-cent. solution and zinc 
 chlorkl in five- to teu-per-cent. solutions are reliable for the 
 destruction of germs in the absence of spores. These are 
 much below mercuric chlorid in germicidal efficiency, but 
 are better deodorants and are, therefore, useful in the sick 
 room for disinfecting the alvine passages. 
 
 338. Acute Infectious Diseases. The management of 
 acute infectious diseases may be illustrated by a brief de- 
 scription of typhoid fever, for the underlying principles are 
 the same in all cases. The nurse must be constantly at 
 hand to aid his patient, to protect him from harmful influ- 
 ences and unnecessary discomfort, to supply his allowable 
 wants, to carry into effect the special instructions of the 
 medical officer, and to keep the written record of the case. 
 He should have a clear understanding of what is known 
 concerning the ways in which the infection is spread, that 
 
202 
 
 TYPHOID FETER. 
 
 he may be able to protect 
 himself and others from 
 dangerous contact with 
 it, and to destroy it by 
 the efficient use of the 
 mogt appropriate disin- 
 fectants. Some diseases, 
 as small - pox, measles, 
 scarlet fever, and diph- 
 theria, must be kept in 
 strict isolation, and the 
 nurse should be respon- 
 sible that there is no un- 
 authorized communication 
 with his patient. When 
 a sick man is placed under 
 the care of a nurse who 
 has had no practical ex- 
 perience in the manage- 
 ment of the disease with 
 which his patient is affect- 
 ed, the hospital steward 
 or medical officer should 
 give him specific instruc- 
 tions to aid his knowl- 
 edge of general principles 
 in caring for the particu- 
 lar case. 
 
 339. Typhoib fever 
 usually begins with fever- 
 ishness, depression o f 
 
 spirits, muscular debility, and relaxation of the bowels. 
 
 The young soldier often suffers in this way for several 
 
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TYPHOID FEVER. 203 
 
 days -without reporting himself sick, attributing his con- 
 dition to some particular exposure or indiscretion in diet, 
 the effects of which will speedily subside. This ex- 
 plains why so few of the temperature charts or thermo- 
 graphs of typhoid fever show a rise from the normal of 
 98.4° F. Most of them begin with an evening temperature 
 of 103 or 104° on the third or fourth day, or even later, 
 of the declared disease, as in the accompanying illustration 
 from the record o^ a patient treated at Fort McPherson, 
 Ga., in 1898. In light cases the normal tendency of this 
 fever is to terminate favorably in the third week. During 
 the first week the temperature ascends by high steps in the 
 evening, which are not offset by the remissions which occur 
 in the morning. During the second week the temperature 
 oscillates, that of the evening continuing high. During 
 the third week the evening temperature falls to the normal 
 and convalescence begins. In a case of this kind the 
 tongue is furred or white-coated, with the edges and tip of 
 a brighter red than natural and with a tendency to dryness 
 at the base and centre. The skin is dry and husky; the 
 face slightly flushed and the eyes injected, particularly in 
 the evening, a bronchial cough being often associated with 
 this condition. Slight epistaxis occurs occasionally. The 
 bowels are relaxed, often tympanitic, or painfully distended 
 with air or gas, and tenderness with gxirgling is elicited by 
 slight pressure in the right iliac region where the ileum 
 empties into the large intestine. Bose-colored spots, tym- 
 panites, and tenderness and gurgling in the right iliac region 
 are the diagnostic symptoms of this fever. The cerebral 
 symptoms are restricted usually to frontal headache and 
 restlessness, sometimes excessive, constituting what is called 
 jactitation, followed by drowsiness and dulness of mind, 
 with at night an incoherent muttering. Rose-colored spots 
 
304 TYPHOID FEVEE, 
 
 appear about the beginning of the second week, generally 
 on the chest and abdomen, sometimes also on the back and 
 thighs. They are circular or somewhat oval, one to four 
 millimetres in diameter, rose-red in color, slightly elevated, 
 and with well-defined margins. They fade in the course 
 of a few days, but may be replaced by fresh crops. These 
 are regarded as the special eruption of this fever. In some 
 cases they are few in number, and may be overlooked un- 
 less careful examination is made. 
 
 340. Associated with these conditions of rising tempera- 
 ture during the first week, high temperature with rose- 
 colored spots on the skin during the second, and decliaing 
 temperature with fading of the spots during the third week 
 are certain lesions of the patches of Peyer [224] and of the 
 mesenteric glands connected with them. During the first 
 week they become congested, during the second swollen from 
 exudation, and during the third, corresponding with the 
 fading of the rose-colored spots and the declining tempera- 
 ture, the exudation becomes broken down and is absorbed 
 and the parts return to their natural condition. But as 
 successive crops of spots may appear on the skin, so succes- 
 sive tumefactions may occur in the patches of Peyer. The 
 patches first affected are those near the ileo-csecal valve 
 [229]. Subsequently those higher up in the ileum may 
 become tumefied, but if no ulceration takes place the un- 
 healthy action subsides during the third week and con- 
 valescence is established. 
 
 341. In less favorable cases in which the febrile action 
 fails to subside shortly after the fourteenth day, the con- 
 tinuance of the high temperature is sjnnptomatic of ulcera- 
 tion in the glandular patches of the ileum or indicative of 
 pulmonary complicatiorLS. Diarrhea becomes aggravated 
 and prolongs the duration of the case for several weeks. 
 
TTPHOID FBVEE. 205 
 
 witli rapid emaciation and exhaustion and much suffering 
 from tympanitic distention. Blood may appear in the 
 stools, and intestinal hemorrhage from the opening of an 
 artery in one of the ulcerated patches may cause collapse 
 and speedy death. Or an ulceration may perforate the 
 coats of the intestine and permit the escape of some part 
 of the intestinal contents into the cavity of the peritoneum, 
 bringing the case to a fatal ending by peritonitis. Both of 
 these accidents ar^ indicated by a sudden fall of the tem- 
 perature to below the normal, with collapse and cold per- 
 spirations. Eecovery may take place after the most 
 dangerous hemorrhages, but never after perforation and the 
 escape of the intestinal contents, unless the surgeon 
 promptly opens the abdominal cavity, repairs the injured 
 intestine, and washes out all trace of infection from the 
 peritoneal cavity with normal saline solution [351]. Pul- 
 monary complications are manifested by pain in the chest, 
 hurried breathing, and cough, the expectoration becoming 
 purulent and bloody or viscid and rust-colored. When 
 these conditions prolong the fever into the fourth week the 
 patient is greatly emaciated, pulse rapid and weak, and 
 prostration extreme. Notwithstanding the utmost care 
 bedsores [316] are likely to be developed at this time, and 
 these add greatly to the sufferings of the patient and to the 
 exhaustion which may be the immediate cause of a fatal 
 issue. At any time sudden death from failure of the heart's 
 action or from heart clot is a possible occurrence. 
 
 342. But the intestinal and pulmonary symptoms are 
 often masked or modified by the cerebral symptoms. The 
 patient is dull and stupid, and the condition of muttering 
 delirium, at first noticed only at night, becomes continuous. 
 
 Usually the delirium is quiet, but sometimes a delirious 
 patient is seized with a desire to get up and requires con- 
 
206 TYPHOID FEVEE. 
 
 stant watcliing, but seldom restraint, to keep him in bed. 
 Extensive congestion of the lungs may be present in a de- 
 lirious patient without expressing its existence by local 
 symptoms, and serious intestinal lesions may not be mani- 
 fested by pain or tenderness, although generally the stools 
 passed without the consciousness of the individual are loose, 
 frequent, and sometimes hemorrhagic. Meanwhile the 
 tongue becomes dry, brown, and fissured or dry, red, and 
 glossy, while the teeth and lips are black with sordes [306], 
 and the mouth coated with a tenacious glutinous mucus. 
 
 343. In protracted cases muttering delirium often alter- 
 nates with periods of stupor, from which the patient is 
 with difficulty aroused to his state of incoherency. Twitch- 
 ing of the muscles of the wrist and fingers, subsultus ten- 
 dinum, is often associated with this condition. In fatal 
 cases of this kind the patient is unconscious and greatly 
 prostrated, the pulse almost imperceptible, the eyes glassy 
 and half exposed, the lower jaw dropped, and the only 
 visible movements are those of respiration and subsultus. 
 
 344. In severe cases which have a favorable ending con- 
 valescence is tedious. Muscular strength and mental poWer 
 require a long period for the return of their former vigor, 
 during which the slightest indiscretion in diet may be fol- 
 lowed by a recurrence of diarrhea and increased tempera- 
 ture, indicating that the ulcerations of the intestine have 
 not as yet become wholly cicatrized. Bedsores which 
 have formed are slow to heal ; abscesses may be developed 
 in various localities, the parotid gland being frequently the 
 site of a dangerous suppuration ; and pain in the muscles, 
 simulating rheumatism, retards the return to health and 
 makes the patient a subject for care for several months. 
 
 345. This brief sketch of the possible progress of an at- 
 tack of typhoid fever shows the necessity for unremitting 
 
TYPHOID FEVEK. 207 
 
 care on the part of the nurse to protect the patient from the 
 many dangers which surround him, and to give him such 
 ease and comfort as are possible during the period of his 
 prostration. The patient during the mildest attack must 
 be regarded by the nurse as a child whose every action by 
 day or night must be super vised with intelligence to prevent 
 harmful results. 
 
 346. On admission the patient should be bathed and put 
 to bed, where he should be kept at rest, well covered, and 
 protected from draughts and garish light. A little beef 
 extract or other liquid nourishment should be given, the 
 nurse spooning it, if necessary, into the patient's mouth, 
 his head being raised slightly by. the left arm under the 
 pillow, after which the temperature, pulse, and respiration 
 should be observed and recorded, together with any nota- 
 ble symptoms as cough, epistaxis, presence of rose-colored 
 spots, etc. The ward physician gives full instructions to 
 the nurse concerning the food and medicine to be adminis- 
 tered, and these mstructions must be followed to the letter. 
 Some medical men treat this fever by trying to produce an 
 aseptic condition of the infected intestine, while others re- 
 duce temperature by febrifuges or by cold baths or pack- 
 ings, but whatever may be the method adopted, the life of 
 the patient depends on the care taken in sustaining his 
 rapidly failing strength by nourishment. On account of 
 the' inflamed and ulcerated condition of the patches of 
 Peyer liquid nourishment only should be given. Two or 
 three pints of milk may be allowed in divided doses during 
 the twenty-four hours, but if any curds appear in the stools 
 the quantity should be dimiiiished. The milk may be 
 mixed with lime-water or soda-water, or it may be pepton- 
 ized in many cases with advantage by means of the tablets 
 of the Supply Table. Whey or junket may also be given, 
 
208 TYPHOID FETEB. 
 
 and the diet may be varied by beef tea, mutton broth, 
 Wyeth's extract, barley water, gruel, etc. Every two 
 hours the patient should have something to support his 
 strength, and the time and quantity of each administration 
 should be noted on the record. Albumen water is a valu- 
 able nutrient, of which the patient seldom tires when sipped 
 from crushed ice or drawn through a bent tube [307] . It 
 is made by stirring up the whites of two eggs in a little 
 water, in which have been dissolved some pieces of sugar 
 impregnated with lemon flavor by having been rubbed on 
 the rind of a fresh lemon. Alcoholic stimulants may be 
 ordered to alternate with the nourishment, or both may be 
 taken together in the form of milk punch, eggnog, or wine 
 whey. In feeding the patient, the allowance for the time 
 should be freshly prepared and brought to the bedside. It 
 is needless to say that the hands of the nurse should be 
 scrupulously clean and the spoons, glasses, etc., glistening 
 in their polish. Any part of the allowance not used at the 
 time should be removed from the ward and the vessels 
 thoroughly cleaned for use on the next occasion. 
 
 347. Baths at a temperature of 68° to 72° F. are fre- 
 quently given to reduce temperature when it rises as high 
 as 103°. The bath is begun with water at 95°, cooled down 
 gradually by additions of cold water to 72°. The legs and 
 chest of the patient should be rubbed during his immersion 
 in the cold water. At the end of five or six minutes he shoiild 
 be placed in bed and covered lightly to rest before putting 
 on his shirt. A stimulant is usually given at this time. 
 The temperatui'e is taken and recorded, together with any 
 notable effects of the treatment. When the fevered patient 
 is very weak, cold sponging with water at about 50° may 
 be used instead of the bath. First the hands and arms are 
 sponged and rubbed dry, then the head and face, and after- 
 
TYPHOID FEVER. 209 
 
 ward the body and legs, or the wet pack may be used. A 
 blanket is spread on a bed and over it a sheet wrung out of 
 tepid water. The patient is placed on this with first the 
 sheet and then the blanket wrapped closely around him, 
 leaving the head and face uncovered. At the end of 
 ten minutes the patient is unpacked, rubbed dry, trans- 
 ferred to his own bed, and his temperature taken and re- 
 corded. 
 
 348. Irrespective of these baths, which are for remedial 
 purposes, the daily toilet of the patient should never be 
 omitted [270]. He should be sponged off for cleanliness 
 and comfort. When the tongue becomes dry and brown 
 the mouth should be washed out frequently with a piece of 
 linen moistened with glycerin and water. 
 
 349. The patient should not be permitted to get up for 
 any purpose. The bed-pan should always be used. Many 
 patients have died from fatal syncope in going to the water- 
 closet. The bed-pan should contain a disinfectant [333], 
 and after the disposal of its contents it should be cleaned, 
 disinfected, and placed in condition for future use. If the 
 bed becomes soiled by involuntary passages the rubber and 
 sheets should be removed, the patient cleaned and trans- 
 ferred to another prepared bed, and the ward ventilated 
 to get rid of the odor. The soiled bed and body linen 
 should not be carried from the ward to be placed in a 
 disinfecting solution, but should be disinfected by the 
 bedside. 
 
 350. An unconscious patient should be placed on his 
 side, altering position frequently to prevent bedsores [315] . 
 The quantity of urine passed must also be observed and 
 recorded, for retention may occur and the catheter [319] 
 be required. If the patient's mind is disordered he must 
 be carefully watched to prevent harm to himself or others. 
 
 14 
 
310 TYPHOID FBVBE. 
 
 When he is delirious the nurse should always have assist- 
 ance within call. 
 
 351. Collapse from profuse intestinal hemorrhage has 
 been successfully treated by the injection of hot normal 
 saline solution into the rectum or its transfusion into the 
 median basilic vein [204]. The solution is prepared by dis- 
 solving three of the tablets of the Supply Table in a litre 
 of distilled water, which is then sterilized by boiling and 
 cooled to 106° for transfusion. In a successful ease re- 
 ported from Fort Monroe, Va., a fountain syringe was used 
 with a glass pipette point attached to the end of the rub- 
 ber tubing for introduction into the vein. The syringe 
 was raised two or three feet above the patient. When 
 complaint was made of pain in the region of the heart 
 the syringe was lowered to lessen the rapidity of the trans- 
 fusion. 
 
 352. An unexpected fall in the temperature, with a rapid, 
 small, and weak pulse, sharp abdominal pain, and an anx- 
 ious and distressed expression of countenance, indicates the 
 occurrence of peritonitis from perforation of the bowel. 
 The medical officer should be notified immediately, as early 
 surgical intervention offers the only hope of saving the pa- 
 tient. Large quantities of sterilized normal saline solution 
 are required for the operation. 
 
 353. There are two tests which are of value in the recog- 
 nition of typhoid fever. One is Ehrlich's diazo-reaction, the 
 other is Widal's serum test. The steward or nurse may 
 be competent to get the diazo-reaction if the chemicals are 
 available. To 6 c.c. of urine in a test-tube add 5 c.c. of 
 sulphanilic acid solution, a few drops of a soltition of 
 sodium nitrite, and a few drops of ammonia liquor ; shake. 
 Normal urine remains yellowish and its froth whitish 
 under this treatment, but the abnormal urine of the ty- 
 
TYPHOID FEVEE. 211 
 
 phoid-fever patient becomes crimson, with a pinkish 
 froth ; but this reaction is given also by the uriae in certain 
 other diseases, such as measles, septic fever, and acute 
 tuberculosis. 
 
 354. Widal's test depends on the fact that the serum of 
 the blood of a patient suffering from typhoid fever causes 
 loss of motion, clumping or agglutination of the typhoid 
 bacilli, grown in laboratory cultures. The nurse may have 
 to provide the saiaple of blood for the bacteriological test. 
 The lobe of the ear is washed with soap and water and 
 afterward with alcohol. It is then pricked with a needle 
 which has been passed through the iiame of a spirit lamp 
 to sterilize it. Gentle pressure is made on the lobe to cause 
 a drop of blood to exude, and the exuded blood is touched 
 with a clean microscope slide on two or three points to 
 obtain as many well-separated blood spots for transmission 
 to the bacteriologist. If a glass slide is not at hand a clean, 
 well-calendered paper will answer the purpose of trans- 
 mitting the blood samples. 
 
 355. But besides the care of the patient in cases of 
 typhoid fever the important duty of protecting himself and 
 others from infeetion devolves upon the nurse. The bacilli 
 of typhoid fever reside in the stools of the patient ; they 
 are found also in the urine and the expectoration. Hence 
 all the discharges from a case of this kind should be re- 
 ceived into vessels containing a disinfectant [333]. Soiled 
 bed-linen or clothing should be soaked in a disinfecting 
 solution before being taken from the ward ; the floor and 
 furniture when tainted in any way should immediately be 
 mopped over with a suitable disinfectant and the person of 
 the patient, when necessary, sponged with a dilution of 
 chlorinated soda or formalin solution [332, 333]. The 
 wai'd, as in all infectious diseases, should be freely venti- 
 
313 TYPHOID. 
 
 lated. As the disease is propagated chiefly by the introduc- 
 tion of its infection into food or drink, care should be ex- 
 ercised in sterilizing the hands after contact with infected 
 articles, particularly before eating ; and obviously no food 
 or drink should be used in the room or ward save by the 
 typhoid patients. 
 
CHAPTER II. 
 
 SHOCK, REACTION, AND INFLAMMATION. 
 
 356. When the humaa body is injured without immediate 
 loss of life, certain effects may usually be observed; and 
 these are: 1, shock ov collapse ; 2, reaction; and 3, proc- 
 esses of repair. 
 
 357. Shock is a condition of nervous depression follow- 
 ing severe injuries. A similar condition caused by mental 
 impressions is generally called syncope or fainting. The 
 heart beats slowly or quickly, but with so little power that 
 it is unable to force the blood to the brain, as is manifested 
 by sudden pallor of the face, with accompanying giddiness, 
 faintness, noises in the ear, indistinctness of vision, and 
 unconsciousness. The patient should be laid on the ground 
 with his head low ; recovery may be hastened by sprinkling 
 a little cold water on the face, offering diluted ammonia or 
 its carbonate for inhalation, and giving a few swallows of 
 cold water or some convenient stimulailt. But when shock 
 is the result of injury, it is not so readily controlled. When 
 slight it is characterized by anxiety, tremors, pallor, and 
 faintness, and is relieved by rest in bed, reassuring words, 
 and some mild stimulant, as beef tea, coffee, weak toddy, 
 or aromatic spirit of ammonia in water. When severe, the 
 patient is semi-conscious and incoherent; countenance pale, 
 anxious, and shrunken; surface cold and bedewed with 
 moisture ; pulse weak, and respiration irregular and sighing. 
 Eecovery is promoted by placing the patient in bed with 
 his head low, and applying warmth to the extremities and 
 
214 COKQESTIOK AKD IKPLAMMATIOK. 
 
 pit of the stomach by hot bags or bottles and friction with 
 ■warm flannels, "whUe stimulants are given in small quantities 
 at short intervals. When there is reason to fear the ex- 
 istence of internal hemorrhage, as in injuries of the head, 
 chest, and abdomen, alcoholic stimulants should be given 
 with caution. 
 
 358, Eeaotion. — Severe shock may end in insensibility 
 and death by syncope, or in a condition of abnormal ex- 
 citement. As the duration of this reaction, as it is called, 
 is proportioned to' the previous depression, it is, of course, 
 desirable to lessen the intensity and duration of the shock ; 
 but this must be effected with caution lest the stimulants 
 used should intensify and prolong the subsequent reaction. 
 This condition is essentially one of fever, and is treated by 
 the means which tend to subdue fever [376] ; but as its 
 cause is not an abiding one, it usually subsides within 
 twenty-four hours or becomes merged in that fever which 
 is an accompaniment of the changes that are meanwhile 
 taking place in the injured parts. When, however, the 
 system at the time of the injury is debilitated, low delirium 
 and muscular tremors constitute the characteristic symptoms 
 of a condition which has been named prostration with ex- 
 citement, and which requires for its treatment careful 
 stimulation, with opiates to allay the nervous irritation. 
 
 359. Congestion and Inflammation. — As soon as re- 
 action begins, a local process of repair is set up, which is 
 neither more nor less than an exaggeration of the ordinary 
 nutritive forces of the part. The vessels enlarge and be- 
 come engorged with blood, making the part assume the 
 local characteristics of inflammation — redness, swelling, 
 heat, and pain. It is red from the accumulated blood ; 
 swollen from the engorgement of the vessels and the pres- 
 ence of the transuded liquid; hot from the destructive 
 
COKGESTIOX AND INFLAMMATION. 215 
 
 oxidation wMch the flow of oxygenated blood brings upon 
 the injured tissues ; and painful from compression of the 
 nerves of sensation by the tumefaction of the parts which 
 surround them. Should the capillary activity subside 
 promptly, leaving no trace of its presence, the part would 
 be said to have been congested, as when the ears or fingers 
 suffer temporarily from cold; but should the symptoms 
 persist and a rapid renewal of the deep-seated layers of the 
 cuticle take place, causing the older layers on the surface 
 to crack and peel off, or desquamate, an inflammation would 
 then be said to have existed. No well-defined line sepa- 
 rates congestion from inflammation ; the one is the begin- 
 niag of the other, and both are essentially an increased 
 activity of the ordinary processes of nutritive change in the 
 injured parts. During congestion, coagulable lymph exudes 
 from the vessels, constituting the material of repair. This 
 cements the surfaces of a closed wound and fills up the 
 vacuities of an open one with its granulations. It has but 
 little vitality, and its power of resisting harmful agencies 
 is correspondingly small. When a wound becomes infected 
 by bacterial organisms, as by the introduction of splinters, 
 fragments of clothing, or other foreign matter, by touching 
 with unclean fingers, by cleansing with water which has 
 not been sterilized by boiling, or even by exposure to the 
 air, the exuded lymph becomes transformed into a liquid, 
 pns, which is of no use as a reparative material, and which 
 drains away as a fetid discharge or is collected in cavities 
 called abscesses. 
 
 360. Manifestly, after the removal of the cause the in- 
 dications for treating a congestion are, first, to lessen the 
 quantity of blood in the engorged vessels ; and, second, to 
 promote the dispersion of the exudations that have escaped 
 into the injured tissues. 
 
216 CONGESTION. 
 
 361. The congested part should be kept at rest in an 
 elevated position ; those who have a felon on the finger 
 speedily discover that hanging the hand low aggravates the 
 suffering, and that raising it on the breast gives measurable 
 relief [396]. 
 
 362. Cold, applied by ice-bags, by evaporating lotions, 
 or by irrigation [414], acts by duninishiag the size of the 
 supplying vessels. Sometimes a cooliag astringent, as 
 liquor plumbi subacetatis, is added to the lotion to aid the 
 cold produced by evaporation. Ice-bags should have several 
 folds of linen between them and the skin to prevent frost- 
 bite. 
 
 363. Heat is applied by wet dressings, consisting of liht 
 or cotton thoroughly soaked, and covered with oiled silk to 
 prevent evaporation. Poultices are made of bread-crumbs, 
 oatmeal, linseed-meal, or other fariaaceous substances. 
 These should be boiled for a few miuutes to make the 
 poultice lighter than it otherwise would be. Heat, to be 
 efficient, must act on the parts adjoining the injury, relax- 
 ing them and preparing them to absorb blood which, with- 
 out their influence, would go to swell the accumulation in 
 the affected parts. An inflamed finger, for instance, is 
 relieved when the four other fingers and the hand as a 
 whole aid it in disposing of the blood that would otherwise 
 pulsate into its already-swollen tissues. The heat of a 
 poultice should always be tested before applying it to the 
 patient. Its heat should be retained by an oiled-silk outer 
 covering. Heat may be applied also by hot-water bags, 
 which should be wrapped in flannel before being placed in 
 position. 
 
 364. Blood is abstracted by leeches. These are placed in 
 a pill-box or wine-glass, which is inverted over the part to 
 which they are to be applied. If it is desirable that a leech 
 
IKFLAMMATIOK. 217 
 
 should bite on a particular spot, the part should be covered 
 with a piece of blotting-paper perforated at the spot, which 
 should be touched with a drop of blood or milk and water. 
 Leeches fall off when sprinkled with salt, which also makes 
 them disgorge the blood they have swallowed. Used 
 leeches should be kept apart from the others, as they fre- 
 quently become sick and affect their companions injuriously. 
 Bleeding from leech-bites may be kept up by warm fomentar 
 tions ; it may be stopped by touching the bites with col- 
 lodion or with a point of lunar caustic. 
 
 365, Cupping-glasses are also used for the abstraction of 
 blood, but the irritation icaused by them necessitates their 
 application at some distance from the congested part. 
 They are most frequently used for the relief of internal 
 congestions, hence the patient must not be incautiously 
 exposed during their application. The surface must be 
 moistened with warm water, that the skia may slide freely 
 under the edge of the cup and rise within it. The cup is 
 held in the left hand, its mouth inclined downward and 
 close to the part on which it is to be placed. The flame 
 of a spirit-lamp is permitted to play in its interior for a 
 second or two ; and as the right hand withdraws the lamp, 
 the left sets the cup on the selected spot. Immediately 
 the skin and subjacent tissues rise into the vacuum in a 
 convexity which momentarily becomes more and more turgid 
 with blood. The practice of putting a few drops of alcohol 
 into the cup should not be followed, as the skin may be 
 injured by the burning liquid ; and even with the spirit- 
 lamp flame the patient will suffer if the edge of the cup be 
 unnecessarily heated. The pressure of the atmosphere 
 drives the blood from the surrounding tissues into those 
 covered by the partial vacuum of the cups, and the congested 
 spots thus intentionally produced give more or less relief 
 
218 ISTBLAMMATIOlir. 
 
 to the congestion under treatment. This, which constitutes 
 dry cupping, is sometimes all that is needful, the cups being 
 permitted to act for a given time ; but when wet cupping is 
 desired, the cup first applied is removed as soon as the 
 others are in position, the scarificator is used, and the cup 
 replaced, after which the other cupping-sites are treated, 
 in succession, in like manner. The cup is detached by 
 pressing with the finger on the skin near its edge. The 
 spring scarificator should be held firmly in position on the 
 skin when the trigger is pulled; cuts of one-eighth inch 
 generally yield better results than those that are deeper. 
 The operation is finished by cleanijig the surface thoroughly, 
 bathing the lancet wounds with an antiseptic liquid, and 
 covering them with plaster so applied as to counteract any 
 tendency to gaping of their lips. 
 
 366. Counter-irritants act like cupping-glasses on, parts 
 adjacent to the congested area. Turpentine stupes, 
 mustard, or ammonia are frequently used over the throat 
 and upper part of the chest in croup ; and a large blister 
 is sometimes beneficial over the affected side in congestion 
 of the lung and on the back of the neck when the brain is 
 implicated. Caustic issues, hot water, tincture of iodine, 
 and other substances are often used as counter-irritants. 
 These applications are called rubefacients when they redden 
 the skin, and vesicants when they raise the cuticle by an 
 underlying effusion, 
 
 367. The turpentine stupe is simply a flannel cloth wrung 
 out of hot water and sprinkled with turpentine. 
 
 368. Mustard, made into a soft paste with a little tepid 
 water, is spread on a piece of linen or cotton and applied 
 with a piece of tissue-paper, gauze, or fine cambric inter- 
 posed to prevent the irritant from adhering to the skin ; it 
 is kept in position until the surface is reddened, after which 
 
INFLAMMATIOK. 319 
 
 a piece of soft lint is used as a protective. When left too 
 long in contact with the skin, mustard causes paiaful 
 ulcerations. If mild rubefaction only is required, the paste 
 should contain one or two parts of wheat flour. 
 
 369. Ammonia is commonly employed in the form of the 
 official liniment ; or a wiae-glass may be filled with pledgets 
 of lint soaked in diluted ammonia, and inverted for one or 
 two minutes over the selected part. 
 
 370. A fly-blister is made by spreading cerate of can- 
 tharides on adhesive plaster, linen, or paper. The skin 
 should be sponged with vinegar before the blister is applied, 
 and there should be no tissue-paper facing such as is used 
 in the case of mustard. The application is removed as 
 soon as vesication takes place, or at the end of ten or twelve 
 hours, even in the absence of vesication. In the latter case, 
 the use of a bread poultice will usually raise the cuticle. 
 Indeed, in children and persons with delicate skins, the 
 substitution of a poultice for the cerate at the expiration 
 of three or four hours is the better practice. If speedy 
 healing be desired, the effused liquid is drained off by one 
 or two punctures and the part dressed with cotton or an 
 antiseptic ointment ; if the blister is to be kept open, a cir- 
 cular portion of the cuticle is cut out, but not removed, and 
 the surface dressed with an irritant ointment, as a petrola- 
 tum dilution of the ceratum cantharidis. The immediate re- 
 moval of the cut portion is attended with much pain ; it is 
 better, therefore, to permit it to be thrown off naturally. 
 
 371. For making small counter-irritant sores, technically 
 called issues, potassa or potassa cum calce is generally used. 
 A circular aperture the size of the portion of skin to be in- 
 flamed is cut in a piece of adhesive plaster, which is applied 
 to the part. Potassa is rubbed on the unprotected spot for 
 a minute, after which the plaster is removed and the part 
 
220 INFLAMMATIOIT. 
 
 washed with, vinegar. Potassa cum, calce is made into a 
 paste with alcohol and applied for ten or fifteen minutes 
 over the aperture, vinegar being used, as in the other case, 
 to wash away the alkali that may be sticking to the de- 
 stroyed surface. These escharotics excite so much conges- 
 tive action in the skin as to cause its superficial layer to be 
 thrown off as a slough, leaving an ulcer which may, like a 
 blistered surface, be healed or variously irritated according 
 to the requirements of the case. 
 
 372. Sot water is readily available as a counter-irritant. 
 Its heat is best applied by means of the head of a hammer 
 or other smooth, metallic body. The hammer, immersed in 
 water at 120° T., dried and held in contact with the skin 
 for two or three seconds, acts as a rubefacient ; and if the 
 contact be prolonged for ten seconds, vesication will usually 
 be produced. Tincture of iodine, croton oil, and tartar 
 emetic ointment are frequently used for their counter-irritant 
 properties. 
 
 373. Besides these local applications for lessening conges- 
 tion and rfemoving effusion, general measures are sometimes 
 available and useful. Purgatives are valuable in congestive 
 conditions, particularly of the brain. They stimulate the 
 intestinal canal and the organs connected with it ; and the 
 afilux of blood to these organs lessens by just so much the 
 engorgement of -the blood-vessels in the congested brain. 
 The large watery evacuations produced by Epsom, Glauber, 
 and Eoehelle salts relieve the turgescence of the vascular 
 system by withdrawing part of the liquid constituents of 
 the blood, but without inducing that extreme prostration 
 which, in blood-letting, follows a loss of the red corpuscles. 
 The action of diaphoretics on the skin and of diuretics on 
 the kidneys operates advantageously when the congestion 
 to be relieved does not affect the skin in the one instance or 
 
SYMPTOMATIC FBVEB, 221 
 
 the kidneys in the other. In both there is a temporary 
 afflux of blood to these organs, which is relieved respectively 
 by a free perspiration or a profuse secretion of urine. 
 Nauseants, as tartar emetic and ipecacuanha, operate on 
 the whole system and incidentally only on the congested 
 part. The vital energy of every organ and tissue of the 
 body is diminished that the energy which threatens the 
 congested organ with danger may be lessened. 
 
 374. Symptomatic Fever. — When an injury is severe, 
 reaction is generally associated with and aggravated by a 
 febrile condition, which is usually referred to as traumatic, 
 syiwptomatic, or inflammatory. The skin is hot and dry, 
 the face flushed, eyes injected, pulse quickened, breathing 
 accelerated, tongue white and coated, appetite impaired, 
 except for cooling liquids, bowels constipated, urine scanty 
 and high colored; and there are pains in the loins and 
 limbs, headache, restlessness, confusion of thought, and 
 sometimes delirium, particularly at night. At the onset 
 the patient may feel chilly, but there is never a decreased 
 temperature ; on the contrary, even while chilliness is pres- 
 ent, the thermometer may show the bodily heat to be two 
 or more degrees above the normal. In fact, a chill means 
 a sudden rise of body temperature. The patient becomes 
 so heated that his surroundings feel cold to him ; a slight 
 current of air or an exposure of some part of the body may 
 cause a rigor in which there is shivering with chattering of 
 teeth, pallor of countenance, and blue lips and nails. The 
 febrile heat results from increased activity of the nutritive 
 processes going on in the injured part. The greater heat 
 developed there raises the average temperature of the blood, 
 as the heat of the water-back of a kitchen range raises that 
 of the contents of the hot-water cylinder connected with it. 
 This excess of heat distributed throughout the body "Btimu- 
 
222 CHEOlfIC INFLAMMATION. 
 
 lates tlie oxidizing or destructive function of the blood, so 
 that all the tissues are wasted with unusual rapidity, thus 
 adding to the febrile heat and aggravating the abnormal 
 condition of the patient. The chill is succeeded by a feel- 
 ing of burning heat ; but if the onset of the fever be violent, 
 the febrile heat may not be preceded by a chill. 
 
 375. The measures which are of value in subduing this 
 febrile condition consist of rest, quiet, low diet, and the 
 agencies already indicated as useful in quieting the local 
 action, such as purgatives, nauseants, and diaphoretics, 
 which depress the vitality of the whole system, and certain 
 remedies which reduce the temperature and pulse without 
 causing much general depression. 
 
 376. Rest has a powerful influence in quietiug the heart's 
 action. The pulse is more rapid when one is standing than 
 when sittiag ; more rapid when sitting than when at rest 
 ia bed ; and during exercise its rapidity is proportioned to 
 the exertion [297]. 
 
 377. Quiet, which may be regarded as a variety of rest, 
 implies the withdrawal of all stimulating impressions. The 
 patient should be kept in a cool, well- ventilated room, and 
 protected not only from glare, noise, and other physical 
 influences, but as much as possible from all that would 
 interfere with tranquillity of mind. 
 
 378. By low diet is not meant a restriction to so many 
 ounces per day, for a fevered patient has usually but little 
 desire for food, but the careful avoidance in the diet of 
 everythiug of a stimulating nature. Milk, eggs, oysters, 
 tea, toast, beef tea, broths, farinas, and jellies constitute 
 its elements. 
 
 379. Chronic Inflammation. — Sometimes, and chiefly 
 in. people of weak vitality, congestion does not entirely 
 subside after the healing of a wound, the filling up of an 
 
CHKONIO INFLAMMATION. 223 
 
 abscess cavity, or the repair of an injury. The area re- 
 mains red and somewhat swollen; but as the pressure is 
 slight, there is but little pain ; and as the nutritive changes 
 in the part are not active, there is neither local heat nor 
 iniiammatory fever. The fault in the constitution, which 
 is the main cause of the persistence of the congestive action, 
 must be remedied by tonics, stimulants, and diet, with ap- 
 propriate treatment when called for by a tubercular, rheu- 
 matic, syphilitic, or other specific taint in the blood. Local 
 treatment usually consists of stimulant applications to ex- 
 cite the nutritive forces of the part to that energy of action 
 which will remove the exuded matters from a congested 
 area, or repair the damage that may have been caused by 
 suppuration or ulceration. 
 
 380. Active exercise promotes the nutritive changes in a 
 healthy part ; the same end, in a chronically inflamed part, 
 is induced by what may be called passive exercise. Fric- 
 tion and massage or shampooing are the methods by which 
 this is attempted. The former is a misnomer, for the 
 manipulation intended is not a quick, superficial rubbing 
 that would speedily abrade the skin, but a firm, equable 
 pressure reaching to the deeper tissues and applied in the 
 direction of the venous flow so as to aid the onward move- 
 ment of the blood. The latter adds to the so-called fric- 
 tion a pommelling, kneading, and slapping of the parts, 
 which should never be continued long enough to excite pain. 
 These methods of stimulation are used to remove the exu- 
 dations which, in sprains and contusions, interfere with 
 the natural movements of the affected parts. Pressure 
 enters into these manipulations as a part of the passive ex- 
 ercise ; but it is sometimes applied continuously to promote 
 absorption, as by means of a weight or compress on an en- 
 larged gland or buho, or by strapping with strips of plaster 
 
234 CHKONIC IKFLAMMATION. 
 
 in the case of a swollen testicle. The oleaginous sub- 
 stances which enter into the composition of liniments are 
 of value mainly in lessening friction and preventing abrasion 
 during the rubbing which is associated with their use ; but 
 the turpentine, ammonia, and other stimulants that are 
 frequently employed have each a special value independ- 
 ent of the method of their application. All the substances 
 that are used as counter-irritants in acute inflammation 
 [366-372] may be utilized as local stimulants in chronic 
 cases ; but while, as counter-irritants, the site of their ap- 
 plication is at some distance from the inflamed part, as 
 stimulants their site is the part itself, or so close to it as 
 to involve it in the stimulant action. Solutions of nitrate 
 of silver, sulphate of zuic, sulphate of copper, and other 
 irritant substances, so diluted as not to over-excite the 
 parts, are in constant use to change the character of the ac- 
 tion in indolent sores and in chronic inflammation of the 
 mucous membranes of.the eye, throat, urethra, rectum, etc. 
 Tincture of iodine is frequently employed for the dissipa- 
 tion of the effusions and exudations that impede motion 
 after the inflammation which caused them has subsided, 
 because, in addition to its local stimulus, it is taken up 
 into the system, where it acts as a powerful excitant to the 
 processes of absorption ; and with the same view iodid of 
 potassium is often administered internally, particularly in 
 scrofulous and rheumatic swellings. In using tincture of 
 iodine, the part having been painted once daily for three 
 days should be permitted to remain three or four days be- 
 fore a further application is made. In the chronic inflam- 
 mations and exudations of syphilitic disease mercury is 
 frequently prescribed in small doses to affect the system 
 gradually and gently. Gray powder, the chlorid, and 
 iodids are used internally for this purpose, with or without 
 
HECTIC FEVEH. 225 
 
 the external application of mercurial ointment or vapors. 
 A mercurial vapor bath is administered by adjusting a 
 blanket around the patient from his neck to the floor as he 
 sits undressed upon a cane-bottomed chair under which, in 
 a porcelain or other suitable vessel, are twenty or thirty 
 grains of calomel. The heat of a spirit-lamp is made to 
 volatilize the calomel, forming a mercurial vapor which 
 condenses on and is absorbed by the skin. The bath lasts 
 fifteen or twenty minutes, and at its conclusion the patient 
 is put to bed wrapped in the blanket which was used to 
 confine the vapors. 
 
 381. Hectic Fevek. — In cases of long-continued sup- 
 puration, as in large abscesses and tuberculosis of the lungs, 
 hectic fever usually supervenes. The patient is weak, 
 emaciated, and pale, but toward evening his face becomes 
 flushed and his temperature rises to fall again toward 
 morning after a profuse perspiration. He should be made 
 to sleep in flannels to avoid becoming chilled. After free 
 perspiration the patient should be dried, avoiding exposure, 
 and in changed underclothing be transferred to a fresh and 
 warm bed. 
 
 16 
 
CHAPTEE III. 
 
 SPECIAL INFLAMMATIONS. 
 
 382. Burns. — When heat is applied to the body by radi- 
 ation, as from a glowing fire, some of the minute scales that 
 form the cuticle have their vitality impaired. Congestion 
 follows and tho nutritive energies of the part become inten- 
 sified ; but in the course of a few days the action subsides 
 with the completion of a new layer of cuticle and the scal- 
 ing off or desquamation [359] of the old one. This is known 
 as ruhef action — the action produced on the skin by mustard, 
 liniment of ammonia, tincture of iodine, etc., when used as 
 counter-irritants. When produced thus intentionally rube- 
 faction requires no treatment except protection by some soft 
 material; but when it results from accident the congestive 
 reaction may go beyond rubef action ; and as it is undesir- 
 able that it should do so, means should be adopted to re- 
 strain it. Lead lotion is commonly used for this purpose, 
 with tincture of opium to allay the burning. Exposure to 
 the air increases the congestion and aggravates the pain; 
 hence the value of dusting the part with flour or starch, 
 covering it with cotton-wool, or smearing it with bland un- 
 guents, such as palm-oil, oxid of zinc ointment, or petrola- 
 tum, to which the addition of carbolic acid is of benefit, as 
 it tends, like opium, to benumb the sensibility; alkaline 
 liquids, as carron oil and strong solutions of carbonate of 
 soda, are also used for this purpose. 
 
 383. When the heat is greater, and generally in the in- 
 juries called scalds, the vitality of the surface layer of the 
 
BURNS. 227 
 
 skin is impaired as in rubefaction, but the reactionary con- 
 gestion is so much more intense that the effused serum ac- 
 cumulates beneath the injured cuticle, raising it into a 
 blister. This is vesication — the action of cantharides, am- 
 monia, acetic acid, etc., when applied for purposes of 
 counter-irritation. Every care must therefore be taken to 
 preserve the injured surface from influences that would in- 
 tensify the congestion. If the burned surfaces are numer- 
 ous or extensive they should be uncovered, one by one, or 
 part by part, tcf lessen exposure and prevent irritation. 
 Blisters, when flaccid, should not be opened, but when 
 distended they should be punctured to relieve tension 
 and lessen the risk of accidental rupture. They are then 
 protected by any of the applications mentioned as useful in 
 the case of rubefaction [382] except flour and starch, which 
 would become caked into an irritant by the exuding liquids ; 
 antiseptic absorbent cotton is probably the best; but what- 
 ever the application, it should be left undisturbed for sev- 
 eral days unless its removal is called for by excessive dis- 
 charge or putrescent odors. By the end of a week or ten 
 days a delicate new cuticle is formed, over which the old 
 shrivels up and peels off; but the entrance of putrefactive 
 germs from an inefficient protective or antiseptic dressing 
 will lead to suppuration if the degenerated matters drain 
 from the surface, to viceration if they are absorbed, and to 
 sloughing if they are thrown off as a solid mass. In any 
 of these events the healing of the primary injury may be 
 delayed for weeks. If the whole thickness of the skin is 
 involved m a burn, protective or cooling applications should 
 be used at first to moderate the reactionary congestion ; next, 
 soothing poultices or warm-water dressings to promote the 
 ulceration which is to separate the slough; and lastly, the 
 applications called for by the characters of the granulating 
 
328 BURNS AND SCALDS. 
 
 sore. The cicatrix in burns of this depth becomes power- 
 fully contractile, so that it will in progress of time, and 
 according to its situation, evert the eyelids, distort the 
 features, draw the head to one side or the other, and flex 
 the joints, producing deformities and disabilities that are 
 as difficult to prevent as to cure. 
 
 384. In all burns except those of a trivial nature there 
 is more or less disturbance of the general system. Shock 
 [357] is proportioned to the extent of the burn as well as to 
 its intensity ; thus, there may be as complete a collapse in 
 a case of scalding as in a case of charring, if the former in- 
 volve a larger extent of the surface. Sometimes shock ac- 
 companies very trifling burns, in which case it is usually 
 due rather to the circumstances attending the injury than 
 to the injury itself, and is easily removed by stimulants; but 
 when due to the latter it is often prolonged, two or three 
 days elapsing in severe cases before reaction is established. 
 
 385. Burns by Gobrosive Acids. — The skin when 
 corroded by oil of vitriol, nitric or hydrochloric acid should 
 immediately be washed with a strong solution of carbonate 
 of soda or other alkali, and subsequently treated as a burn. 
 When the eyes are injured, the alkaline solution should 
 contain about ten grains of the carbonate to an ounce of 
 water. Olive or castor oil should afterward be used to 
 protect the disorganized conjunctiva. Stimulants and opium 
 are called for if there is much shock. 
 
 386. Scalds, etc., of the Throat. — Children are 
 sometimes scalded or burned in the mouth and throat by 
 steam or boiling water, acid, or strongly alkaline liquids, as 
 solutions of ammonia or washing soda. Usually the 
 mucous membrane of the lips and mouth only is injured; 
 but occasionally the larynx is involved. Eedness and 
 gvvelling of the mouth and throat, with difficulty in 
 
FROST-BITE. 229 
 
 swallowing, hoarseness, and accompanying fever, follow 
 the accident. The immediate danger in such cases arises 
 from closure of the rima glottidis [161] . If the local symp- 
 toms are due to acids or alkalies, the appropriate antidote 
 [563] should be used as a mouth-wash, and taken into the 
 stomach if there is reason to suppose that any of the dan- 
 gerous liquid has been swallowed. 
 
 387. Feost-bite.— The frost-bitten part is cold, 
 shrunken, bloodless, and without sensation. The immediate 
 object of treatment is to restore the circulation in the affected 
 region; but the reaction must be cautiously induced lest 
 the subsequent congestion run into gangrene or sloughing. 
 The frozen part should be thawed out by friction with a 
 mixture of snow or ice and water. Only when reaction is 
 fairly established should the patient be moved into a warm 
 room. After reaction is established, the lighter grades of 
 frost-bite require no treatment except protection. In cases of 
 greater severity, increasing congestion should be restrained 
 by cooling lotions ; but if sloughing threatens, these should 
 be replaced by soothing poultices, with stimulants of resin 
 and turpentine when the action becomes indolent, and 
 charcoal or other deodorizing antiseptics when called for 
 by the gangrenous condition. When the toes, fingers, or 
 larger portions of the extremities are destroyed, they do not 
 become separated from the living parts in such a manner as 
 to leave the latter in good condition for the formation of a 
 rounded stump; on the contrary, as the interior parts suffered 
 less than the exterior from the killing influence of the cold, 
 more of them are preserved ; and when the separation takes 
 place they, including the bones, project beyond the level of 
 the superficial tissues that remain. This necessitates sur- 
 gical interference. 
 
230 CHILBLAINS AND CONTUSIONS. 
 
 388. Chilblains are chronic congestions produced by 
 cold in constitutions of impaired vitality. The patient 
 should be well fed and exercised to' give vigor to the sys- 
 tem. This, with the protection of the congested parts from 
 changes of temperature, will alone effect a cure; but local 
 applications, as of camphor, turpentine, or tincture of iodine, 
 are called for, chiefly by the intolerable itching. When 
 sloughing takes place, poultices with resin cerate or turpen- 
 tine should be used until the surface is ready to granulate. 
 
 389, A Contusion or bruise is the injury that results 
 from a sudden crushing of the parts. There is swelling, 
 with numbness, dull aching pain, and shock. The swelling 
 results from exudation and extravasation [184], the dark 
 color of the bruise being due to the latter. Where the tis- 
 sues are lax, as about the eyelids and scrotum, the swelling is 
 greater, in proportion to the injury, than where they are less 
 distensible. Evaporating lotions or ice should be applied to 
 restrain the outflow from the vessels. Ordinarily, in a few 
 days the swelling decreases and the discoloration fades. 
 Absorption is promoted by rubbing equal parts of tincture of 
 arnica and water, with equable pressure, . over the contused 
 parts ; or soap liniment with tincture of opium may be used 
 if there be much pain. Contusion of the testicle is accom- 
 panied with much shock and tendency to syncope. Con- 
 tusion of the abdomen, as from blows, the kick of a horse, 
 or passage of a wheel over the body, is sometimes followed 
 by nausea, vomiting, and great prostration, although there 
 may be no laceration of the abdominal viscera. In cases 
 of suspected internal injury stimulants should be given 
 with caution, lest hemorrhage be increased. A full opiate 
 dose, the careful removal of the patient to hospital and per- 
 fect rest afterward, constitute the treatment of the emer- 
 gency ; purgatives are contraindicated. 
 
SPRAINS. 231 
 
 390. A Speain is a stretching or tearing of the fibrous 
 bands and expansions that surround a joint or of the mus- 
 cular and tendinous tissues concerned in the movements of 
 the body. When a sprained joint is examined immediately 
 after the injury, the absence of dislocation or fracture is 
 readily discovered; but if some hours have elapsed, there 
 may be so much pain, swelling, and interference with mo- 
 tion as to render the diagnosis uncertain until the inflamma- 
 tory action has bgen to some extent controlled. Evapo- 
 rating, lead, opiate, arnica, and other lotions have a value 
 only when acting in concert with immobility. Splints and 
 slings should be applied when needful to restrain the joints 
 of the upper extremity; but when the ankle or knee is 
 injured, the patient should be put to bed with the limb 
 elevated on pillows; and after the subsidence of the inflam- 
 mation, the utmost caution must be exercised in resuming 
 the use of the injured limb. Sprains of the ankle often 
 disable for months on account of chronic inflammation 
 kept up in the joint by its unadvised use. A sprain seems 
 a minor injury, and patients fail to recognize the necessity 
 for absolute rest until they learn by experience that it 
 would perhaps have been better for them if there had been 
 a dislocation or fracture, as they would then have submitted 
 to the necessary confinement. Slight sprains of the ankle 
 or knee, associated with little inflammatory action, are some- 
 times put up in an immovable dressing, as the starch, sili- 
 cate, or gypsum bandage [503-506], and the patient per- 
 mitted to move about on crutches; but when the injury is 
 at all severe, the acute inflammation should be controlled 
 before having recourse to these dressings. Stiffness of the 
 joint during convalesuence from sprain of the ankle is re- 
 moved by friction or massage, and effusion by tincture of 
 iodine or other counter-irritants [380]. 
 
332 ABSCESSES. 
 
 391. Sprains of the loins are sometimes so severe as to 
 simulate more dangerous injuries, as fracture of the spine; 
 but the patient is usually able, with more or less difficulty, 
 to straighten himself up, and the spinous processes present 
 no irregularity. Blood in these cases sometimes appears 
 iu the urine, indicating an injury to the kidneys; but this 
 is not often followed by any inflammation of that organ. 
 Hemorrhage may also take place iato the spinal canal, 
 occasioning paralysis of the lower extremities and iaereas- 
 ing the resemblance to fracture. Paralysis may also super- 
 vene from effusion of serum iato the canal, due to the 
 spread of the inflammation from the sprained tissues to the 
 membranes of the cord. The necessity for perfect rest in 
 severe sprains of the loins is therefore imperative. This is 
 aided by suitable measures to allay inflammation [375] in 
 the early period, and counter-irritants and resolvents after- 
 ward. 
 
 392. Abscess. — When the degenerated matter of an exu- 
 dation accumulates in a liquid form in the interior of a 
 tissue it constitutes an abscess. The walls of the cavity 
 which contains the matter are thickened from exudation, 
 and external to this there is usually a swelling from effusion 
 of serum, and, if the skin be implicated, a redness from 
 congestion. Superficial abscesses are seen in connection 
 with minute punctured wounds from splinters, the presence 
 of which gives rise to the suppuration which eventually 
 casts them out. During the hard stage of the inflammatory 
 swelling, the progress of suppuration should be promoted by 
 large poultices, but as soon as a fluctuating spot is detected, 
 that is, a soft spot which feels to pressure with the finger 
 as if it contained liquid, an incision should be made to lib- 
 erate the matter. If no incision is made, the abscess cavity 
 becomes enlarged by absorption until the surface is reached ; 
 
BOILS AND CARBUNCLES. 233 
 
 but in this case the patient has to suffer for a longer period, 
 and owing to the larger size of the cavity more time is 
 required for its healing, and the likelihood of scarring is 
 increased. Granulation is conducted under stimulant, anti- 
 septic, or such other dressings as may be called for by its 
 condition. 
 
 393. Boils. — A boil is a hard, knobby, painful swelling 
 developed under the skin, which is more or less congested. 
 It enlarges, and ajj the end of a week its centre becomes 
 pointed and ruptures, giving issue to a liquid oozing, and 
 showing through the aperture a yellowish slough which is 
 too soft to be pulled out by a forceps, even if it were free 
 from all adhesions to the interior. In a few days the 
 slough breaks down and is discharged, the cavity granu- 
 lates, and in progress of time the coagulable lymph which 
 formed its walls becomes absorbed. Boils usually come in 
 crops. The treatment for abscess is not suitable here, 
 because the matter cannot be cast out by incision, and poul- 
 tices increase the size of the interior slough. The boil is 
 best treated by merely protecting it from injury by adhesive 
 plaster, and dressing with resin ointment when the slough 
 is separating. 
 
 394. Some large and flat boils are called blind because 
 they do not open to discharge a slough. After increasing 
 for a week or ten days they slowly subside, leaving a hard- 
 ness at their site for a long time ; or, at the period of their 
 culmination, a small purulent point may be discovered, 
 which, instead of opening for the discharge of a slough, 
 dries into a yellowish scale. Poultices and incision are of 
 no benefit. The part should be simply protected by plas- 
 ter. Any discoverable errors in diet or mode of life should 
 be corrected. 
 
 395. Cabbuncles are large and tedious boils which occur 
 
234 WHITLOW. 
 
 generally on the back of the neck in debilitated constitu- 
 tions. The subcutaneous tissues are involved in the con- 
 gestion, which is of a livid color and attended with much 
 pain and constitutional irritation. The local treatment 
 consists of poultices or warm-water dressing, with after- 
 ward a free crucial incision and applications of resin or 
 turpentine to promote the evacuation of the cavity. Some- 
 times the opening is made by potassa [371]. If left to 
 itself, the carbuncle is opened by. ulceration at two or more 
 places, which uncover the underlying slough as they increase 
 in size. A nutritious diet is always, and stimulants gener- 
 ally, required to effect the cure. 
 
 396. In a whitlow or felon, which is usually occasioned 
 by a prick on the end of a finger, the exudation is bound 
 down by the strong membrane covering the bone or the 
 fibrous tissues which hold the tendons of the finger in their 
 place. The consequent pressure is a source of severe throb- 
 bing pain even when there is but little redness or swelling. 
 The patient is deprived of sleep, and his whole system dis- 
 turbed, by the intensity of his suffering. The hand should 
 be enveloped in a large poultice, and kept in an elevated 
 position; opium or Dover's powder should be given to allay 
 pain and promote the subsidence of the congestion ; but if 
 the symptoms are not favorably impressed within twenty- 
 four hours, a free cut should be made down to the hone to 
 relieve alike the tension in the part and the suffering of the 
 patient. To wait until the accumulated matter reached the 
 surface by ulcerative action would be to invite the destruc- 
 tion of the part and many weeks of disability, as the matter 
 finds it easier to spread upward into the palm of the hand 
 along the tendons than to come to the surface. 
 
 397. A GUMBOIL, or alveolae abscess, is a suppuration 
 connected with the fang of a tooth. A congestion with a 
 
GUMBOILS. 235 
 
 slight exudation of lymph occurs at the deep end of the 
 fang. As this lymph is locked in on all sides by bone, 
 there is intense pain, which soon becomes throbbing. If at 
 this stage the tooth be extracted, the matter escapes and 
 the trouble is at an end ; but it is not always advisable to 
 sacrifice a tooth on account of the temporary iniiammation 
 at its root. Occasionally the matter finds its way between 
 the fang and the socket, and escapes gradually at the neck 
 of the tooth. The usual course, however, is for the matter, 
 by its pressure, to cause absorption of the bony tissue in 
 which it is confined, until an aperture is made which per- 
 mits it to escape and accumulate between the surface of the 
 jaw-bone and the gum. Accordingly, when any soft, boggy 
 swelling is observed on the gum, it should be immediately 
 incised to permit the matter to escape. For the time being 
 the gumboil is at an end ; the swelling subsides and the in- 
 cision heals ; but very frequently the healing is not perfect. 
 There often remains a minute aperture on the site of the 
 incision, and from it matter occasionally exudes. Some- 
 times the aperture becomes blocked up, and there may be 
 a little pain and swelling before the accumulated matter 
 finds its way through the fistulous opening. To effect a 
 cure in this instance, the decayed root must be removed. 
 If the matter of the original gumboil be not liberated when 
 it has penetrated through the bone and reached the gum, 
 it will generally cause much swelling, and finally break 
 within the mouth by the thinning of the walls of the 
 abscess cavity; but sometimes the matter dissects its way 
 into the tissues of the cheek, causing much swellicg of the 
 face and subsequent disfigurement by the scar of its open- 
 ing. This should be avoided by the liberation of the 
 matter while it is yet confined between the gum and the 
 bone. A small drill has recently been added to the dental 
 
236 TOOTHACHE. 
 
 case [402]. With this instrument immediate relief may 
 be given by drilling through the outer wall of the socket 
 and thus affording an exit for the matter at the end of the 
 fang. 
 
 398. Ulceration of a bone is called caries. The same 
 term is applied to the decay by which cavities are formed 
 in the dentine [218] of the teeth. Toothache is one of the 
 symptoms of this decay. When the cavity is small and 
 does not penetrate to the dental pulp, it should be carefully 
 cleaned out with absorbent cotton on the end of a suitable 
 instrument, and then plugged with cotton moistened with 
 carbolic acid, to allay sensitiveness. Afterward, when the 
 cavity has lost its 'tenderness, it should be dried and filled 
 with gutta-percha, softened by a heat which should not be 
 greater than the skin of the wrist or back of the hand can 
 bear without pain. When the cavity is large and the pulp 
 exposed, as evidenced by the extreme sensitiveness of the 
 bottom of the cavity, the relief of the toothache requires 
 the extraction of the tooth or the killing of the nerve. To 
 effect the latter purpose, a mixture of equal parts of laun- 
 dry soap and arsenious acid is used. The cavity having 
 been carefully dried, a small piece, about the size of a pin- 
 head, of the arsenical soap is introduced into it and held 
 in position for twenty-four hours by a filling of cotton-wool. 
 This intensifies the pain for several hours, but afterward 
 relief is experienced. Care should be taken that the action 
 of the arsenic is confined to the cavity. Gutta-percha or 
 oxyphosphate cement is safer than cotton dressing because 
 the arsenic cannot leak out and cause inflammation of the 
 gum and necrosis of the alveolar process. The oxyphos- 
 phate cement is composed of glacial phosphoric acid and 
 oxide of zinc made into the form of a paste, which hardens 
 quickly. Instead of the arsenical soap a mixture of arseni- 
 
TOOTH EXTEACTIOK. 237 
 
 ous acid and carbolic acid or oil of cloves may be used ; one 
 hundredth part of a grain of the arsenic with a drop of 
 either of the liquids. A piece of cotton, about the size of 
 a pinhead, is soaked in the mixture, inserted and sealed as 
 above. Carbolic acid on cotton-wool is used to allay any 
 remaining tenderness, after which the cavity may be plugged 
 with gutta-percha, as a preservative, until the services of a 
 dentist are obtained, which should be within two weeks 
 after the temporary plugging. 
 
 399. When a tootH has to be sacrificed because of a gum- 
 boil or a large cavity of decay, a suitable tooth-forceps 
 should be selected Forceps are made of different sizes and 
 shapes ; but every one should be strong and unyielding in 
 its jaws and handles, and should move easily at its joint, 
 without being in the slightest degree loose-jointed; the 
 jaws should fit accurately to the neck of the tooth to be 
 extracted, and should flare out toward their joint, so as to 
 cap the crown of the tooth without compressing it. The 
 jaws of an upper-tooth forceps are usually in line with the 
 handles, while those of the lower-tooth forceps are set at a 
 considerable angle. Forceps for single-fanged teeth [217] 
 have the extremity of their jaws gently curved and plain ; 
 those for the upper molars have a ridge on the face of the 
 outer blade for catching hold of the crotch between the outer 
 fangs ; those for the lower molars have a similar ridge on 
 both blades to fit on each side into the crotch; a pointed 
 cow-horn forceps is designed for lifting out the lower molars. 
 The various forceps at the command of the intending oper- 
 ator should be carefully studied as regards their adjustment 
 to the teeth and the direction of the traction to be employed. 
 The operating-chair should be solid, with a convenient grasp 
 for the hands of the patient, and a low neck-rest, that his 
 head may be thrown well back. 
 
238 TOOTH EXTEACTION. 
 
 400. The operator stands on the right sic?e when an upper 
 tooth is to be extracted ; on the left when a left lower tooth 
 is the subject; and behind, operating over the face of the 
 patient, when a right lower tooth is to be removed. The 
 fingers of his left hand should steady the jaw near the 
 affected tooth and afford counter-force during the extrac- 
 tion. In laying hold, the blades are closed lightly on the 
 tooth and the points are pushed well home on the neck 
 beneath the gum, keeping their long axis in line with that 
 of the tooth. The blades are then closed firmly on the 
 tooth so as not to slip, yet not to crush in the sides of a 
 hollowed tooth. A steadily increasing pull is then made, 
 with a slight rotary movement if the tooth is single-fanged, 
 and an equally slight lateral or forward and back movement, 
 when the tooth will come away. In extracting molars, the 
 traction is combined only with an outward and inward 
 movement ; any attempt at rotation would break the fangs. 
 Care should be taken that the extracted tooth do not slip 
 from the forceps into the throat of the patient. 
 
 401. If the tooth break during the attempt at extraction 
 an effort may be made to remove the stump, but it should 
 not be prolonged if not promptly successful. The patient 
 may be solaced with the information that his toothache will 
 subside, as the dental pulp has now been removed, or, if 
 the relief of a gumboil was intended, that the matter will 
 now find exit by the central canal and sides of the fang. 
 Stumps rarely call for extraction save at the hands of a 
 dentist to prepare the gums for artificial teeth. As the 
 dental nerve is destroyed, they are seldom the subject of 
 toothache. A steel lever is useful in their extraction, as is 
 also a shorter gouge-like instrument ; these, which are called 
 elevators, are inserted between the socket and the stump; 
 but the greatest care must be taken lest they slip and injure 
 the mouth, tongue, or throat. 
 
CORNS. 239 
 
 402. A small dental case is provided by the Medical De- 
 partment for use at military posts where the services of a 
 qualified dentist cannot be obtained. By its means a care- 
 ful and neat-handed operator can insert a stopping that will 
 last for years. It contains a mirror for examinations, a 
 scaler for removing tartar, an explorer for examining cavi- 
 ties, chisels for trimming their edges, and excavators for 
 cutting out decayed dentine, with forceps for handling 
 absorbents, etc., and a supply of prepared gutta-percha. 
 Heavy socket-handies are provided for holding the instru- 
 ments. A spatula is used in fi^Uing large cavities, and 
 hurnishers when the cavities are small. The gutta-percha 
 stopping requires to be cut into pellets proportioned to the 
 size of the cavity to be filled. These are warmed on a 
 piece of porcelain over a lamp-flame, taking care not to 
 overheat them. They are then worked into the cleaned 
 and dried cavity with warm instruments. Moisture in the 
 cavity will defeat the intention of the operation. The 
 dental case contains also the small drill mentioned in 
 paragraph 397. 
 
 403. CoENS. — Continued pressure causes absorption and 
 ulceration ; intermittent pressure stimulates growth. Corns 
 are an illustration of the effects of intermittent pressure; 
 but it often happens that the stimulation induces inflamma- 
 tion and suppuration. When acutely inflamed, the part 
 should be poulticed or treated with water dressing, covered 
 with oiled silk, and subsequently punctured to liberate the 
 matter, removing the corn at the same time, if this can be 
 readily accomplished. The proper treatment for uninflamed 
 corns, whether hard, as over the prominences of the toes, 
 or soft, as on their contiguous surfaces, is to keep them 
 closely trimmed, particularly toward the centre, and to 
 wear shoes that do not chafe or press upon the part or crowd 
 Jhe toes together. Care of the feet is of greater benefit in 
 
240 BLISTBKS ON THE FEET, CHAFIKGS. 
 
 the cure of corns than more energetic and painful methods 
 of eradication. 
 
 404. Bunions are caused by the pressure of narrow-toed 
 shoes. ITaturally, the toes spread away from each other, 
 but the narrow-toed shoe crowds them on the middle toe as 
 a centre, the great toe being deflected outward and the 
 little toe inward, while the root of each forms a prominent 
 angle on the side of the foot. This angle, unsupported by 
 adjacent structures, receives the pressure of the boot or 
 shoe, and its skin becomes first thickened by the stimula- 
 tion, and then painfully congested by its continuance. If 
 this protest against the unsuitable footgear be disregarded, 
 effusion takes place beneath the skin and forms a water-pad, 
 as it were, for the protection of the joint. Under a contin- 
 uance of the pressure the effused serum becomes replaced 
 by purulent matter, which escapes by the ulceration of a 
 small aperture through the overlying cuticle. The cure of 
 the bunion requires the removal of the cause, the relief of 
 the congestion by a poultice, the absorption of the effusion 
 by iodine paint, or the granulation of the suppurating cavity 
 under appropriate dressings — soothing, if the granulations 
 be unprogressive from inflammation, and stimulating, if 
 unprogressive from indolence. 
 
 405. Blisters on the Feet. — In the early days of a 
 march soldiers sometimes suffer from blistering of the feet, 
 particularly the heel, developed by chafing in ill-fitting 
 shoes or such as have not been broken in to the form of the 
 feet. The blister should be drained and protected next day 
 by a piece of rubber plaster. 
 
 406. Chafing in the Groins is also a frequent annoy- 
 ance on the march. It should be treated in camp by wash- 
 ing the excoriated surface and applying a lotion of acetate 
 of lead, and on the march by the use of oxid of zinc oint- 
 ment. 
 
CHAPTER IV. 
 
 WOUNDS. 
 
 407. A WOUND is an injury inflicted by mechanical vio- 
 lence on the living body — hence a bruise is a wound ; but 
 the term is usually restricted to a separation of parts. An 
 incised wound is one made by a cutting instrument ; in a 
 lacerated wound the tissues are torn apart ; and in a con- 
 tused wound they are broken by some irregularity on the 
 surface of the bruising instrument or by the violence of its 
 application. Sometimes a contused wound presents the 
 appearance of an incision, as when the scalp is split open 
 by a club. A punctured wound has great depth as com- 
 pared with its other measurements. A bayonet wound is a 
 characteristic punctured wound ; a sabre rut is a contused 
 incision ; gunshot wounds are contused lacerations. 
 
 Incised Wounds. 
 
 408. The requirements of treatment in the case of wounds 
 are : To arrest hemorrhage ; to remove shock ; and to adjust 
 the separated surfaces and to so retain them until the exuded 
 lymph or granulations have acquired strength enough to 
 withstand the separating tendencies of the ordinary move- 
 ments of the part. Close contact cannot be effected if any 
 foreign matter, such as splinters of the weapon, sand, or 
 earthy particles, fragments of clothing, or even coagulated 
 blood be lodged in the wound. These must be picked away 
 by the forceps or fingers, or washed off with a plentiful 
 
243 INCISED WOUNDS. 
 
 supply of sterilized water or bicMoride solution. The skin 
 of the neighboring surface should also be cleaned, and, if 
 necessary, shared, and washed with a disinfecting solution. 
 The part is then placed in that position which will relax 
 the injured tissues and permit the sides of the wound to be 
 brought together, and the edges are stitched at half -inch or 
 other suitable intervals if plaster alone will not hold them 
 in position. A slightly curved needle is pushed through 
 the skin at about one-fourth of an inch from the edge of the 
 
 Closing a wound by suture. Securing apposition by plaster. 
 
 strips. 
 
 wound, and thence through the opposite tissues, drawing 
 after it the suture thread, which is then tied in a reef or 
 surgeon's knot [444] and cut off short. The thread used 
 for this purpose should be thoroughly aseptic. 
 
 409. Strips of plaster are applied across the line of the 
 wound at short intervals or between the sutures, if any have 
 been inserted. They should be long enough to extend 
 several inches on each side of the wound, and they hold 
 better when slashed two or three times with the scissors for 
 half an inch longitudinally at each end. In applying each, 
 and particularly the first one, which should be across the 
 centre of the line of wound, one-half of the strip should be 
 placed in position on one side of the wound ; and when it 
 
LACERATED WOUNDS. 243 
 
 adheres firmly, traction should be made on the unapplied 
 half with one hand while the other draws toward the wound 
 the tissues on which the plaster is to be laid, that it, when 
 applied, may the better retain the sides of the wound in 
 apposition. A very good way of applying plaster strips is 
 shown in the accompanying illustration. When a clean 
 incised wound has been drawn together by plaster or sutures, 
 the only dressing required is a protection from the air and 
 from changes of temperature. Some folds of lint or sub- 
 limated gauze may Ife laid over it and retained by a band- 
 age ; and if the wound is situated near a joint, the occa- 
 sional movement of which would tend to draw the edges 
 apart, a suitable splint should be applied to restrain its 
 motion. A cradle or light curved framework is sometimes 
 placed over a wound to relieve it from the weight of the 
 blankets. The sides of such a wound will in forty-eight 
 hours be so firmly united that each suture may be snipped 
 at the side of its knot and removed bj' seizing the knot be- 
 tween the points of a dressing forceps ; but the plaster and 
 splint should be left until the union is strong enough to 
 sustain the ordinary strain incidental to their situation. 
 In removing the strips of plaster, each should be raised 
 from one end to the line of the wound, then from the other 
 end to the same line, after which its middle may be de- 
 tached; in a large wound the centre strip should be re- 
 placed by a fresh one before the support of the others is 
 withdrawn. Wounds which progress thus favorably are 
 said to heal hj prbnanj union or by the first intention. 
 
 Laceeated Wounds. 
 
 410. It is sometimes difficult to bring the sides of a 
 lacerated wound into that close contact which is needful to 
 
244 LACERATED WOUlirDS. 
 
 primary union. When tlie edges are brought together, 
 there may be interstices and cavities in the interior -which 
 the most carefully arranged compresses will fail to obliter- 
 ate Moreover, there may be loss of substance, not only 
 in the interior, but of the surface, which will prevent the 
 edges from coming together. Such a wound does not bleed 
 so much as an incised one, but it requires the exercise of 
 greater care to secure the freedom of its irregular surfaces 
 from the presence of foreign matter. After it has been 
 thoroughly cleaned the wound should be closed by stitches 
 and slips of plaster, with small pads or compresses of folded 
 lint to preserve its sides in contact, and a splint, if needful, 
 to restrain motion. The object is to obtain primary union 
 of as much of the wound as possible. 
 
 411. The presence of lymph [230] or of a thin layer of 
 coagulated blood between the surfaces does not interfere 
 with this union ; but when there are considerable cavities 
 within the wound, union in this adhesive way does not take 
 place. The lymph lying next to the living surface becomes 
 converted into living granulations, and that which is more 
 remote, lying in the centre of the cavity or interstice, breaks 
 down into a liquid which drains from the wound. The 
 formation of granulations progresses gradually, until ulti- 
 mately the two sides come into apposition, and adhesion 
 takes place by what is called secondary union in contradis- 
 tinction to that by primary adhesion. 
 
 412. When the loss of tissue involves the superficial 
 parts, constituting what is called an open wound, repair is 
 effected by granulation ; and when this process has brought 
 the reparative material in the wound up to the level of the 
 surrounding surface, a delicate skin, soon becoming thicker 
 and stronger, spreads from the edges over the surface and 
 completes what is called the cicatrization of the wound, 
 
LACERATED WOUNDS. 245 
 
 413. If, however, the granulations be injudiciously- 
 treated by warm, moist, and relaxant applications, such as 
 poultices, they may lose their fresh red color and their 
 power of exuding adhesive material; so that, when op- 
 posite surfaces come together in the interior, they are un- 
 able to unite, and when the proper level in the open wound 
 is reached, they fail to cicatrize, rising, instead, above the 
 level as a fungous growth, constituting what has been called 
 proud flesh. The sluggish granulations must be touched 
 freely with lunar caustic or sulphate of copper. This de- 
 stroys their superficial parts, and the action set up in the 
 capillaries of the deeper parts in order to throw off the 
 cauterized slough leaves them in fitter condition for adhe- 
 sion or cicatrization, as the case may be. 
 
 414. When a wound is infected, owing to imperfect 
 cleansing at first, to subsequent injudicious handling, or to 
 exposure, it becomes red, hot, swollen, and painful, and 
 the discharge from it profuse and acrid — in fact, it festers ; 
 and if the swelling should block up the track by which the 
 discharges escape, or if the wound itself be of such a char- 
 acter that the generated matter tends to become bagged in 
 some cavity or infiltrated in the subcutaneous or intermus- 
 cular cellular tissue, a serious condition will result. The 
 germs of putrefaction which have gained access to the 
 wound produce during their development and propagation 
 poisonous principles which are called ptomaines [326]. 
 These are absorbed into the blood and cause an intoxication 
 of a septic character [415], which, however, ceases when 
 the matter is removed and the wound treated aseptically. 
 The wound should be freed from all putrefying matters ; 
 and if this cannot be accomplished by flushing it with anti- 
 septic solutions, a special opening should be made to facili- 
 tate their escape. When it has been thoroughly cleaned it 
 
346 CONTUSED WOUNDS. 
 
 may be again dressed with antiseptics, which are to be re- 
 newed as soon as materially contaminated with the dis- 
 charges. Irrigation, which was formerly employed as a 
 method of continuously cooling an inflamed wound, is one 
 of the means by which the putrefactive tendency may be 
 neutralized It is effected by placing a vessel containing a 
 supply of the liquid to be used on a plane a foot or two 
 higher than the wound and siphoning its contents through 
 a rubber tube, delivering in or on the wound. The flow 
 through the tube must be regulated by a clip or some ex- 
 temporized means of pressure. 
 
 415. If, however, the putrefactive germs get into the 
 blood and multiply in it, the septic intoxication [414] , which 
 is easily remedied, becomes a dangerous septiccemia or sep- 
 tio fever. This condition may arise from a prick with a 
 needle or other sharp instrument, making an infected or 
 poisoned wound. 
 
 416. A dangerous condition similar to that of septicsemia 
 occurs when the germs in the blood become blocked in the 
 capillaries of some of the organs and form the foci from 
 which abscesses are developed. This is called pyaimia. 
 A severe chill with a sudden rise in the temperature of the 
 patient indicates the occurrence of this condition. 
 
 Contused Wounds. 
 
 417. A part which has been severely contused may be 
 several days or weeks before the discoloration consequent 
 on extravasation of blood is effaced and the tissues return 
 to their healthy condition [389]. So in a contused wound 
 time must elapse before the severed surfaces are in a condi- 
 tion to unite. There can therefore be no union by first in- 
 tention, and sutures are useless in view of the swelling that 
 would necessitate their removal in the course of a few 
 
FIRST AID IN GUNSHOT WOUNDS, 247 
 
 hours as reaction progresses. Plaster strips suffice to pre- 
 serve adjustment after the wound has been cleaned. On 
 account of the lowered vitality of the injured tissues it is 
 of importance to disinfect thoroughly and protect a severe 
 contused wound. Without an efficient antiseptic treat- 
 ment, the germs of putrefaction would find in the extrava- 
 sations and exudations of the injured tissues the most 
 favorable conditions for their growth and propagation, and, 
 as a result, a violent action would be set up, attended with 
 much loss of substance by sloughing, a rapid spread of the 
 inflammation by the acrid products, and the danger of con- 
 stitutional infection by the absorption of germs into the 
 blood. On the other hand, with an efficient antisepsis the 
 injured tissues break down and are absorbed or drain away, 
 leaving the wound free to granulate and heal like the cavities 
 and interstices of a wound that is merely lacerated. 
 
 Gunshot Wounds. 
 
 418. Gunshot wounds are treated like other contused 
 lacerations; but the battlefield produces them in such 
 numbers as to render imperative the adoption of a system 
 for their satisfactory management. 
 
 419. FiEST AID concerns itself with shock, hemorrhage, 
 and the application of protective dressings. 
 
 420. Shock is, as in other wounds, usually proportioned 
 to the severity of the injury ; but sometimes the excitement 
 of victorious battle counteracts the depressing influences of 
 a serious wound, while, when the mind is affected by defeat 
 and the body exhausted by fatigue, a comparatively trivial 
 injury may exercise a powerful impression. When shock 
 is severe, place the patient on his back with his head low; 
 check hemorrhage, if it exists ; loosen belts and clothing, 
 
348 FIRST AID IS GUNSHOT WOUNDS. 
 
 and give 5 c.c. of aromatic spirit of ammonia or 20 c.c. 
 of whiskey, with cheering words before removal from the 
 field. 
 
 421. Bleeding. ^ — Oozing is usually restrained by the 
 dressing which is intended for the protection of the wound. 
 Venous bleeding is suppressed by graduated compresses 
 [439] on the wound ; and if from a limb, by a bandage ap- 
 plied firmly from the toes or fingers up to and over the 
 compresses. Arterial bleeding is controlled by compresses, 
 in wounds of the head, hand, and foot ; but when the jet 
 comes from the thigh, leg, arm, or forearm, a tourniquet 
 [442] or rubber bandage [286] should be applied to the 
 main arterial trunk. If the blood springs from the neck 
 or the walls of the chest or abdomen, torsion [441] or the 
 ligature [443] is used ; failing this, efficient pressure with 
 the fingers must be employed until the hospital is reached. 
 The comtnon carotid is reached by pressing the finger deeply 
 into the neck in a backward and inward direction at the 
 anterior margin of the sterno-mastoid muscle ; the facial as 
 it curves from the neck to the face over the base of the 
 lower jaw about an inch in front of its angle ; the subclavian 
 may be flattened against the first rib by pressing the thumb 
 downward into the hollow behind the collar-bone; the 
 axillary by placing the thumb in the armpit and pressing 
 outward against the humerus ; the brachial in the upper 
 part of its course by a similar outward pressure, but im- 
 mediately above the elbow the pressure must be from be- 
 fore backward; the radial and ulnar arteries are reached 
 by the fingers along the outer and inner sides of the fore- 
 arm near the wrist ; and bleeding from the palmar arches 
 is controlled by graduated compresses backed by wooden 
 splints. The femoral artery is reached below the middle 
 of the groin by pressure with the thumb backward against 
 
FIRST AID IK GUNSHOT WOUNDS. 249 
 
 the femur ; the popliteal by pressure from behind against 
 the knee-joint ; the anterior tibial in the lower part of its 
 course by pressure along a line drawn from the head of the 
 fibula to midway between the malleoli ; the dorsal artery of 
 the foot along the outer side of the extensor tendon of the 
 great toe ; the posterior tibial in the hollow between the 
 inner ankle and the heel. 
 
 422. When the hemorrhage has been very great, the pa- 
 tient is completely prostrated. His face and lips are pale, 
 countenance shrunken, skin cold and bedewed with drops 
 of perspiration ; his pulse is rapid, small, weak, and flut- 
 tering, perhaps almost imperceptible ; his breathing quiet, 
 but frequently interrupted by a long, sighing expiration ; 
 his voice is weak and whispering, and his limbs powerless 
 or at times tossed about in sudden, aimless movements. If 
 he is conscious, he calls for water to allay his thirst ; but 
 he is often unconscious or unobservant of what is passing, 
 muttering occasionally to himself in a low delirium. A 
 case of this kind, occurring in the field, must be carried 
 with the utmost care by hand-litter to the hospital, admin- 
 istering stimulants by the way, and continuing the treat- 
 ment on the litter until the returning strength of the 
 patient authorizes his removal to bed. 
 
 423. The object of a primary or field dressing is to 
 protect the wound. The contents of a first-aid packet 
 should be used in accordance with its printed directions, or 
 the wound should be covered with layers of sublimated lint, 
 cotton, jute, etc., and secured with plaster or the triangular 
 bandage ; but if the wound is already soiled it should be 
 freed from foreign matters and be made antiseptically clean 
 before being dressed. 
 
 424. The proper size for a triangular bandage is from 
 forty to fifty inches along the base and twenty to twenty- 
 
250 FIEST AID IN GUNSHOT WOUNDS. 
 
 four inches from the centre of the base to the apex. A 
 piece of linen, muslin, or other suitable material of this 
 shape and size fulfils many of the requirements of first aid 
 in surgical emergencies. It may be folded in the form of 
 a cravat for application to the head, neck, or limbs, as well 
 as for fixing splints or other protective appliances. In 
 bandaging the hand, the injured member is laid. upon the 
 open triangle, the fingers toward the apex, and the wrist 
 or forearm over the middle of the base ; the apex is then 
 turned upward over the hand, and held in position by 
 crossing the ends of the bandage over it, and tying them 
 around the wrist. The/ooi is bandaged in a similar manner, 
 the ends being secured around the ankle. On the same 
 principle the stump after the amputation of a limb may be 
 treated, or dressings retained upon any part of the head. 
 It may be applied to the chest by fastening the ends around 
 the body and drawing the apex over one or the other 
 shoulder down in front or behind to be made fast to the 
 girdle formed by its base ; to. the pelvis by encircling the 
 body and bringing the apex up between the thighs in front 
 or behind to be fastened to the girdle. For the shoulder a 
 strip may be torn lengthwise from the base of the triangle, 
 passed around the neck on the injured side, and fastened 
 in the uninjured armpit ; the small triangle remaining is 
 made fast by its base around the arm of the injured side, 
 and its apex is carried up over the shoulder to be secured 
 to the strip already applied. For wounds of the hip or 
 thigh two triangles are required — one is folded and applied 
 as a girdle around the body, the base of the other is passed 
 around the thigh, and its apex brought up and made fast 
 to the girdle. As a sling for an injured upper extremity 
 one-half is laid over the breast and shoulder of the unin- 
 jured side, so as to bring the midlength of its base under 
 
IKFECTED WOUNDS. 251 
 
 the hand and its apex beyond the elbow to be supported ; 
 the other half is carried up over the shoulder- of the injured 
 side and its ends are tied on the nape of the neck. The 
 point or apex of the triangle is then smoothed out, folded 
 snugly around the elbow, and made fast. 
 
 425. When bones are fractured, place the limb in as 
 natural and easy a position as possible and apply a bandage 
 or padded splints for comfort during 
 transportation. JRifles, swords, scab- 
 bards, pieces of wood, lath, or shingles, 
 branches or twigs, may be used as 
 splints, and clothing, blankets, hay, 
 straw, grass, or moss as padding. Col- 
 lar-hone or shoulder-blade : put the fore- 
 arm and hand in a sling and bind the 
 arm to the body. Humerus : apply two 
 splints, one in front and one behind, 
 
 . sung for forearm. 
 
 when the break is m the lower part; 
 otherwise, on the inner and outer sides; and support 
 the arm in a sling. Forearm : place thumb up and ap- 
 ply a splint along the outer surface to the wrist and 
 along the inner surface to the ends of the fingers; sup- 
 port by sling. Bones of leg and th'ujh : apply splints 
 on each side. For the thigh the outside splint should ex- 
 tend from the armpit to beyond the foot. A blanket made 
 into two rolls, with a trough for the limb between them, is 
 useful. Bind the injured limb to the sound one. 
 
 Infected Wounds. 
 
 426. Wounds are occasionally assailed by germs of greater 
 virulence than those of putrefaction, particularly when 
 many patients are crowded together under the same roof. 
 
253 ARROW WOUNDS. 
 
 Eeysipblas and hospital gangrene both result from the 
 infection of the wound by specific germs through the 
 medium of a foul atmosphere, taiated fingers, iristruments, 
 sponges, etc. Each of these germs produces its respective 
 disease : the one a violent inflammation, which spreads far 
 from the original wound along the skin and its underlyiug 
 tissues, causing the accumulation of purulent matters at 
 various points, with much disorganization of the affected 
 parts and a corresponding amount of febrile action; the 
 other an equally violent Ltiflammation which, although 
 spreading with less rapidity, exercises a more deadly action 
 on the parts involved, causing their mortification or death, 
 and is associated with a low or typhoid form of fever. To 
 avoid these infections, the wounded should be treated in 
 the open air or in tents rather than in crowded rooms ; and 
 the nurses in attendance on such cases should not be per- 
 mitted to come near the general surgical wards. 
 
 427, Akkow wounds are punctured wounds with more 
 or less of contusion, but they differ from bullet penetrations 
 in being always infected with germs. Both the arrow-head 
 and its shaft are always unclean ; the former is often made 
 fast with animal fibres, and the latter painted with blood 
 or vegetable juices. Wounds penetrating the cranium, 
 chest, or abdomen are- therefore exceedingly dangerous. 
 The head of the arrow should be removed, if possible ; but 
 the projecting flukes make this difficult. First aid is re- 
 stricted to cutting away the shaft a few inches outside the 
 entrance and taking care that no movement of the patient 
 shall bury the head deeper in the tissues. But the sooner 
 the effort is made to remove the arrow-head the greater 
 will be the chances of success, for the fastenings of many 
 arrow-heads become loosened in the moist tissues, so that 
 traction on the shank removes it, leaving the head within. 
 
INFECTED WOUNDS. 253 
 
 If needful, the wound must be enlarged for the passage of 
 a long-limbed forceps, and only when the head has been 
 secured between the blades should traction be made on the 
 shank and forceps as a whole. Cases may occur when the 
 best, if not the only possible, way of removing the missile 
 is to push it onward in its line of direction, meeting it, for 
 extraction, with an incision through the tissues which it 
 must of necessity penetrate. Sometimes, in the exitement 
 of battle with Indian foes, the wounded man will seize the 
 shaft of the arro^ and drag it from the wound, in which 
 case the head is usually left in the tissues, and the difficul- 
 ties attending its removal are much increased. 
 
 428. Wounds which become infected with the germs of 
 erysipelas or hospital gangrene [426] are in truth poisoxed 
 WOUNDS ; but this title is usually reserved for those that 
 are inoculated with the poisonous agent by the instrument 
 which inflicted them. The scratches or punctures acci- 
 dentally received in examining or dissecting the dead body, 
 or in operating on the living, are often poisoned as well as 
 those caused by the sting of a hornet or nettle, the bite of 
 a rabid dog, or the fangs of a venomous serpent. The 
 gravity of these depends on the nature of the virus or germ 
 introduced, The wound in itself is generally a minor con- 
 sideration — a mere abrasion often proving more dangerous 
 than a free laceration, as the oozing of blood from the 
 latter tends to the removal of the infectious material. 
 
 429. Dissection wounds sometimes heal as readily as if 
 uninfected; in other cases the scratch inflames and sup- 
 purates, leaving an ulcer which heals by granulation or by 
 forming a thick scab, as in the case of the vaccine virus ; 
 in a third set of cases the inflammatory action is not eon- 
 fined to the wound, but involves all the neighboring tissues, 
 as of the finger and hand, while red lines of inflamed 
 
 23 
 
354 IKFECTED WOUNDS. 
 
 lymphatic vessels reach upward to the armpit, the glands 
 of which become implicated in the swelling and suppura- 
 tion. Dissection wounds are especially dangerous when 
 the virus implanted is derived from a patient who has died 
 of blood poisoning, erysipelas, or inflammation of the peri- 
 toneum or pleura The fever which accompanies them is 
 usually of a low or typhoid type. The treatment of dis- 
 section, as of all poisoned wounds, looks to the removal or 
 destruction of the poison before it has time to be absorbed. 
 Prompt action is therefore essential. A constriction should 
 be placed around the finger or hand above the injured point, 
 which should be immediately washed in a germicidal liquid, 
 incised to promote bleeding, and sucked vigorously to re- 
 move the septic matter. After this, if the matter is known 
 to be of a specially dangerous character, lunar caustic 
 should be freely applied and the part wrapped up in a 
 large soothing poultice. In the absence of nitrate of silver, 
 any powerful escharotic may be employed, as the caustic 
 alkalies, sulphuric or nitric acid applied by means of a 
 wooden probe, a drop of boiling oil, or a small fragment 
 of chlorid of zinc paste made by moistening and mixing 
 one part of the salt with two of flour. 
 
 430, Tetanus or Lockjaw is a dangerous infection of 
 wounds, usually such as have been contaminated by con- 
 tact with the soil. It begins with a stiffness of the jaws, 
 which is speedily followed by muscular spasms similar to 
 those caused by strychnine [594], The first indication of 
 lockjaw should be reported to the surgeon immediately. 
 
 431. The BITE OF a rabid dog should be treated as a 
 dangerous dissection wound. When lunar caustic is not at 
 hand, the wound, after laceration, free bleeding, and vigor- 
 ous suction, should be cauterized with a steel rod, probe, 
 or other suitable instrument, at a dull red heat. Experi- 
 
INFECTED WOUNDS. 255 
 
 ence has shown the efficiency of solid nitrate of silver, when 
 promptly and freely applied ; but the terrible and deadly 
 nature of hydrophobia has begotten a distrust of any but 
 the most heroic measures. Hence a thorough excision of 
 the bitten part is by some recommended, to be followed by 
 caustic or the actual cautery. 
 
 432. Serpent bites must be promptly sucked, excised, 
 and cauterized, an encircling ligature meanwhile having 
 been placed on the cardiac side of the wound ; some prac- 
 titioners have used' alcohol, ammonia, or tincture of iodine 
 locally to neutralize or decompose the virus. The effect 
 of the poison depends on its virulence in the individual 
 case. Sometimes the part inflames, the inflammation 
 spreading like erysipelas along the subcutaneous cellular 
 tissue, and affecting the glands by way of the lymphatic 
 vessels. The patient may die after several weeks of sup- 
 puration and suffering, or recover after many months with 
 a limb more or less impaired by destructive inflammation. 
 In the most virulent cases, the patient dies in a few hours 
 from disorganization of the blood, the body becoming 
 swollen, ecchymosed, and undergoing rapid decomposition. 
 If there is much depression during and after the local treat- 
 ment, alcoholic stimulants should be freely administered. 
 
 433. The bites op tarantulas and the stings of scor- 
 pions, CENTIPEDES, ETC., are frequently spoken of m the 
 Western service of our army, but are rarely seen. When 
 they occur, they must be treated on the same general prin- 
 ciples as other wounds of this class. The application of 
 diluted ammonia or liquor potassse to the injured point is 
 recommended by some for the neutralization of the poison, 
 
 434. The trifling wounds caused by the stings or bees 
 or wasps are best treated by suction, which usually with- 
 draws the stingy or touching with diluted ammonia, after 
 
256 GLANDEES. 
 
 whieli the local inflammation is subdued by means of lead 
 lotion or cold-water dressings. Mosquito bites cause a 
 temporary stinging or burning at the injured points, but 
 this is of small consequence compared with the danger of 
 malarial fever [75] or of yellow fever [79], the infection 
 of which may be conveyed by the insects. 
 
 435. GriiANDEKS.^The inflammatory discharges from a 
 glandered horse or mule produce disease in man when they 
 come in contact with a wound, an abraded skia, or even 
 with the unbroken mucous membrane of the nose or lips. 
 The contagious nature and the invariable fatality of the 
 disease call for the utmost care in dealing with its suspected 
 occurrence in the horse. The earliest sign consists of a 
 steadily flowing watery or slightly mucous discharge from 
 the nostrils, with swelling of the glands under the jaw of 
 the affected side . This may continue unchanged for several 
 months, the mucous membrane being dark purplish instead 
 of faintly pink as ia health or bright red as in ordinary 
 catarrhal inflammation ; but usually the discharge becomes 
 thick, viscid, discolored, bloody, and offensive, the mucous 
 membrane ulcerated, and the lymphatic glands of the face 
 tumefled or transformed into putrid sores. The glands on 
 the inside of the thighs are next involved, and speedily the 
 whole body is converted into a mass of putrefaction. In 
 some cases the disease begins by swelling and ulceration of 
 a few of the glands of the extremities ; the lymphatic ves- 
 sels connected with these become swollen and corded, and 
 implicate the other glands with which they communicate. 
 These knots of enlarged glands, called farcy buds, ulcerate 
 in their turn, and the matter discharged from them is as 
 infectious and dangerous as that from the glandered mucous 
 membrane. In man, the two modifications of the disease 
 are usually combined j whether the disease begins as 
 
GLAKDEES. 257 
 
 glanders or as farcy, the other modification is speedily de- 
 veloped. 
 
 436. When a suspicious case appears in a stable, the 
 affected animal should be isolated and cared for until ex- 
 pert testimony has decided upon its destruction as a danger- 
 ous focus of infection, or its treatment, — for farcy in its 
 early stages has been successfully treated. Those having 
 care of the animal should not sleep under the same shel- 
 ter with their charge; all unnecessary contact should be 
 avoided, and aftei' unavoidable contact, either with the 
 animal or surrounding objects which might be infected, the 
 greatest care should be given to washing away every trace 
 of such contact ; the danger in the breath of the animal 
 should be fully appreciated, and exposure to its impetus 
 during the sneezing or coughing, which frequently occurs, 
 should especially be shunned. Disinfectant solutions [326] 
 should be freely used. 
 
CHAPTER V. 
 
 HEMOKBHAGE FROM WOUNDS. 
 
 437. Capillary hemorrhage consists of a general ooz- 
 ing of red blood from the surface of the wound. It is con- 
 trolled by clearing away all clots, freely exposing the part 
 to the air, and elevating it ; by affusion with cold or hot 
 water [286] or the application of ice ; by the use of styp- 
 tics, which coagulate the blood in the cut ends of the ves- 
 sels, and by bringing the sides of the wound together when 
 they can be so bandaged as to prevent the bagging of ac- 
 cumulating blood. 
 
 438. Liquor ferri subsulphatis, or Monsel's solution, is 
 the styptic commonly used ; the persulphate is too irritant 
 for this purpose. It is applied locally by means of a dossil 
 of lint ; it is inhaled from an atomizer in bleeding from the 
 lungs, and administered in 3 to 6 minim doses in hemor- 
 rhage from the stomach or bowels. Tannin is applied 
 locally in solutions of suitable strength ; dissolved in alco- 
 hol and ether and mixed with collodion, it forms a styptic 
 collodion used for sealing the edges of wounds. Alum in 
 solution, turpentine, tincture of catechu, tincture or infu- 
 sion of matico, and other astringents are also frequently 
 employed by mopping the bleeding sufrace with a pledget 
 of lint or cotton which has been soaked in the styptic 
 liquid. Epistaxis or bleeding from the nose is treated by 
 any of these methods aided by compression of the facial 
 artery [421]. Ordinarily in full-blooded individuals nose- 
 
HEMORKHAGE. 259 
 
 bleeding is salutary and easily stopped; but in broken-down 
 constitutions and in heart disease it ia sometimes persistent 
 and dangerous. Bleeding from the socket of an extracted 
 tooth may be controlled by removing all clots from the cav- 
 ity, packing into it, bit by bit, a long strip of dry lint, a 
 quarter of an inch wide, placing a small-folded compress 
 over this, and keeping the jaws tightly closed on the whole 
 for several hours. 
 
 439. Venous hbmokkhage is dark-colored, and flows in 
 a steady stream. Ptessure with the finger or with gradu- 
 ated compresses is the best means of controll- 
 ing this species of hemorrhage. Graduated 
 compresses consist of small pads of folded 
 
 A graduated lint, cotton, Or Other suitable material. The 
 ™ *°^' smallest is placed on the bleeding-point; 
 others are laid over it, the outermost being the largest, 
 so that when the whole is bound in position by means of 
 a bandage the pressure is transmitted to the bleeding 
 vessels. If the bleeding is from a limb, a bandage should 
 be applied from the toes or fingers to the level of the 
 wound, prior to placing the compresses in position. A 
 tight bandage around the limb above the wound increases 
 venous bleeding. 
 
 440. Arterial hemorrhage is florid red in color and 
 escapes from the wound in spurts or jets. A small arte- 
 rial point may be recognized on a profusely oozing surface 
 by the impulse of the escaping blood and the bright- 
 ness of its color. Nature operates in three ways to pre- 
 vent fatal consequences from the division of these vessels : 
 by the contraction of the divided ends, the coagulation of 
 the blood, and the influence of the injury on the heart and 
 nervous system. When an artery is divided its muscular 
 coat contracts on the instant, narrowing and withdrawing 
 
260 HEMOEEHAGB. 
 
 its cut end into the tube of the outer coat, and carrying the 
 interior lining along with it. A gash with a sharp knife is 
 followed by a spirt of blood which escapes before the inner 
 coats have had time to contract; but this immediately sub- 
 sides to a capillary oozing unless some comparatively large 
 vessel has been wounded. When the cutting iustrument is 
 blunt the bleeding is relatively less, because the irritation 
 caused by the coarse edge stimulates the vessels to contract. 
 Some vascular tumors which could not be excised on account 
 of hemorrhage have been successfully removed by the 
 ecraseur, a strong wire cord which is looped over the tumor 
 and made to cut its way through. Contused and lacerated 
 wounds bleed less than incised wounds : an arm has been 
 torn off by machinery without notable hemorrhage from 
 the lacerated axillary artery. The closing of the divided 
 vessels, which is begun by the contraction of the interior 
 coats, is completed by the formation within them of a plug 
 of coagulated blood ; for the retracted and roughened ends 
 favor the deposition of coagulum. The tendency to faint- 
 ing [357] which follows a wound conduces to the suppres- 
 sion of bleeding by diminishing the force of the heart's 
 action. 
 
 441. Artificial means for arresting hemorrhage are based 
 upon those employed by nature. Douching with cold or 
 hot water, or exposure to the air, stimulates the cut vessels 
 to greater contraction, and is suitable to the cases of small 
 vessels that do little more than ooze. Continued pressure 
 with the finger upon a bleeding-poiut will restrain hemor- 
 rhage until the vessel becomes plugged with coagulum; this 
 pressure may be combined with the use of styptics. When 
 the spurting vessels are small, bleeding may often be stopped 
 by torsion, by which is meant seizing the bleeding-point 
 between the blades of a forceps and twisting it three or 
 
HEMOBEHAGE, 261 
 
 four times, thus converting that particular part of the wound 
 into a laceration, which does not bleed. When the vessel 
 is larger and yields a dangerous jet, the finger must be 
 placed upon it to prevent loss until better means of control 
 have been adopted. These consist either of placing a 
 tourniquet or elastic bandage [286] on the limb above the 
 wound as a temporary expedient, or of applying a ligature 
 around the open mouth of the vessel as a permanent 
 
 measure. 
 
 « 
 
 442. The Jield tourniquet consists of a pad to be placed 
 over the artery and a strap and buckle to secure it in posi- 
 tion. This may be extemporized by 
 a roller for a pad, fastened by a loop- 
 bandage [501] ; or by encircling the 
 limb with a handkerchief over a 
 smooth stone for a pad, and tighten- 
 ing the handkerchief by giving seve- 
 ral turns to a short stick which has 
 been slipped between it and the skin 
 on the opposite side of the limb to the 
 stone. The latter was the original of 
 
 The screw tourniquet. ° 
 
 the screw tourniquet that is yet in use, 
 and which consists of an encircling band that may be tight- 
 ened by the separation of two metal plates consequent upon 
 the turning of a screw. The screw and plates are usually 
 placed over the artery, with a large roller beneath the lower 
 plate, to give a trustworthy pressure along the arterial 
 track. 
 
 443. But the tourniquet is merely a provisional arrest, as 
 during transportation to hospital or while awaiting the 
 arrival of expert assistance or the needful instruments. 
 Permanent closure of the bleeding vessel must be effected 
 by the ligature; and when an artery of some size is divided 
 
262 HEMORRHAGE. 
 
 it is not enough to tie its upper or bleeding end — its lower 
 end should also be secured to prevent hemorrhage from it 
 after the establishment of the collateral circulation [197] . 
 When an artery is tied firmly with a small round cord of 
 ligature silk or carbolized catgut, its inner coats are cut 
 across at the point of stricture and retract on account of 
 their contractility, leaving only the tough external tunic in 
 the grasp of the ligature. In the course of one or more 
 
 Ligation of an artery: The ligature has cut the middle and internal coats 
 which are retracted on each side within the arterial tube ; a conical plug of co- 
 agulum has been formed on the side towards the heart. 
 
 days, depending on the quantity of tissue devitalized by the 
 pressure of the ligature, the whole of this tissue becomes 
 absorbed and the loop is free to be withdrawn by traction; 
 but this does not usually happen until the cellular coat on 
 the upper side of the ligature has been sealed by exuded 
 lymph and the canal of the vessel closed for some distance 
 by a fibrinous coagulum. There is, therefore, no recur- 
 rence of the bleeding when the ligature is withdrawn as 
 in the case of silk, or when it is liquefied and absorbed as in 
 the case of catgut. Ordinary catgut is too readily softened 
 and absorbed when imbedded in the living tissues; but 
 when specially prepared, as by soaking for a long time in 
 carbolized oil, it becomes harder, and resists the action of 
 the tissues until time has been afforded for the consolidation 
 of the artery. 
 
 444. In operating, the bleeding mouth of the vessel is 
 transfixed with a tenaculum or seized with a spring or 
 artery forceps [284], and drawn out from the mass of tissue 
 
HEMORRHAGE. 263 
 
 in which it is imbedded, after which an assistant passes the 
 ligature around it and ties it firmly in a reef knot or that 
 modification of a reef knot sometimes called the surgeon's 
 knot. In tying the reef knot, the middle of the ligature is 
 applied to the artery immediately in advance of the points 
 of the forceps or curve of the tenaculum, and its free ends 
 are brought loosely around on the other side of the artery 
 and crossed from one hand to the other, forming a ring 
 through which one end is passed to form a single knot. 
 This knot is drawn tightly on the artery, the traction on the 
 
 The reef knot. The surgeon's knot. 
 
 ligature on both sides being made as close to the vessel as 
 possible in order not to drag it out of its position. The 
 inner coats give way under the pressure of the tightened 
 ligature ; but as the single knot would speedily slip, it must 
 be guarded by a second, made as before by crossing the 
 ends to form a ring, slipping one end through the ring and 
 drawing on the ends ; but in crossing the ends for this sec- 
 ond single knot, that which lies in front of the first knot 
 must be placed in front of the other, else the second knot 
 will not hold securely. Sometimes, in tying the second, 
 the first knot will become relaxed, to prevent which the tip 
 of the finger of an assistant should be pressed upon it until 
 the second is about to be run home; but the first may be 
 made to hold better until the second is tied by passing the 
 end through the ring twice, constituting the surgeon's knot, 
 instead of once, as in casting the sailor's or reef knot. If 
 
264 HEMOSEHAGE. 
 
 the ligature is of catgut, both ends are cut ofE short at the 
 knot, which is left in the wound to be absorbed; if of silk, 
 one of the ends is cut short off and the other is brought out 
 at the lowest part of the wound, so that it may act as a drain 
 for the passage of liquids exuded after the lips of the wound 
 have been brought into position and sutured. 
 
 445. The hemorrhage which takes place from a wound at 
 the time of its infliction and ceases spontaneously or with 
 the aid of surgical art, as described above, is called primary. 
 This hemorrhage, whether arterial, venous, or capUlary, 
 must always be completely stopped before a wound is closed, 
 lest it should continue and become infiltrated between the 
 muscles or penetrate into neighboring cavities, forming a 
 clot which would give rise to extensive inflammation by its 
 subsequent disintegration and decomposition. The greater 
 the shock attending the injury, or the greater the faintness 
 from blood already lost, the greater must be the care given 
 to this point, because, as the patient rallies from the shock 
 or syncope and the impulse of the heart becomes stronger, 
 there is greater danger of a recurrence of the bleeding. It 
 is well, therefore, when there is much nervous prostration, 
 to wait for marked indications of returning strength before 
 finally closing the wound. 
 
 446. The bleeding which occurs during reaction, when 
 the clots which have formed ia the mouths of the vessels 
 are driven out by the increased force of the circulation, is 
 called intermediary hemorrhage. When care has been taken 
 in the first instance, this seldom amounts to more than a 
 mere oozing which may stain the overlying dressings. 
 
 447. But danger from hemorrhage has by no means 
 ceased when reaction has been established, for at the end of 
 several days the establishment of a collateral circulation 
 [197] may give rise to bleeding if the lower end of the 
 
HEMORRHAGE. 265 
 
 divided artery was left unguarded by a ligature [443] ; 
 ulceration or sloughing may lay open an artery or vein the 
 coats of which have been contused ; or a ligature may come 
 away, leaving the vessel imperfectly guarded by coagulum 
 and exuded fibrin, so that what is called secondary hemor- 
 rhage may occur, and be even more dangerous than the 
 primary bleeding, on account of the greater difficulty of 
 securing an injured vessel in a wound that has been more or 
 less altered by adhesions and granulations than in one that 
 is recently inflicted. Secondary hemorrhage, if slight, may 
 be controlled by pressure or the injection of styptic solu- 
 tions ; but if profuse it must be temporarily restrained by 
 the application of a tourniquet or other pressure to the main 
 trunk above the wound until competent surgical assistance 
 has been obtained to open the wound and secure the bleed- 
 ing vessels. 
 
CHAPTER VI. 
 
 "WOTWDS OF THE HEAD, NECK, AND TRUNK. 
 
 448. The gravity of wounds op the head- depends on 
 the amount of injury sustained by the nervous masses. 
 Contused wounds should be treated, as in other parts of the 
 body, to moderate inflammation and promote the absorption 
 of extravasated blood or exuded inflammatory products. 
 Incised wounds sometimes bleed freely, and require a com- 
 press. Plaster strips, not sutures, should be used to retain 
 the edges in apposition, even when the wound is lacerated 
 and the scalp torn from the underlying bone. Preliminary 
 to this, the hair must be removed by close cropping and 
 shaving. 
 
 449. Dressings are retained on the scalp in various ways. 
 In applying a single roller or bandage for this purpose, the 
 end is placed on the forehead and one or two firm horizontal 
 turns are made, ending on the temple, where the superim- 
 posed layers are fastened together by a pin or stitches ; the 
 bandage is then carried from this fixed point over the vertex 
 and under the chin as often as may be required, and the 
 end and crossings stitched for greater security. The double 
 roller is made by stitching together the free ends of two 
 single rollers. In applying it to the head, horizontal turns 
 are made to fix in their place those turns that are carried 
 over the cranium to cover its dome. This, the recurrent or 
 capelline bandage, is a relic of the olden time, when to do a 
 thing secundeTn artem was considered of more importance 
 than to do it so that it should fulfil the indications in the 
 
WOUNDS OF THE HEAD. 
 
 267 
 
 case under treatment. A simpler retentive appliance is 
 the four-tailed bandage. This is a piece of muslin a yard 
 long and six or eight inches wide which has been torn 
 lengthwise into two strips of equal width, except in about 
 
 Single roller for the head. 
 
 Four-tailed bandage on chin. 
 
 six inches of its middle part. The untorn portion is applied 
 to the vertex ; the posterior tails are tied under the chin 
 and the anterior tails under the occiput. 
 
 450. A narrower four-tailed bandage than that for the 
 head is useful on the chin; the upper tails are tied on the 
 back of the neck, or crossed there and tied under the chin, 
 and the lower ones are carried to the vertex. The six- 
 tailed bandage for the head is made on the same principle. 
 The central part is applied to the vertex, the middle tails 
 are made fast under the chin, the anterior tails beneath the 
 occiput, and the posterior ends on the forehead. But a 
 handkerchief used as a triangular bandage is the simplest 
 and often the best form of retentive appliance. The centre 
 of the base or long side of the triangle is applied to the 
 forehead, the apex or opposite corner falling over the occi- 
 put, where the ends of the base meet and are tied firmly 
 
368 wotrNDS of the keck and chest. 
 
 together, or are brought forward after crossing, and made 
 fast on the forehead. 
 
 451. In cases of cut-thboat there is often much bleed- 
 ing, which should be controlled by continued compression 
 with the finger if the bleeding is venous, by torsion or the 
 ligature if arterial. When the cut is below the larynx, the 
 head, neck, and chest may become swollen from the escape 
 of air into the cellular tissue (emphysema) ; this is not usu- 
 ally a dangerous complication. The wound should be closed 
 by many stitches, and its lips supported by long strips 
 of plaster, stretching downward and outward toward the 
 collar-bone and shoulder; but if the patient is unable to 
 breathe through the natural passage the ■wound should be 
 left open, with its sides approximated by a forward inclina- 
 tion of the head. When the pharynx is involved, nourish- 
 ment must be administered by means of the stomach-tube 
 [565]. In suicidal cases the patient should not be left alone. 
 
 452. Wounds of the chest penetrating the cavity and 
 injuriag the lung are usually attended with shock; and 
 when there is serious internal hemorrhage the patient sinks 
 into a condition of great prostration and final collapse ; but 
 however desirable it may be to ascertain the full extent of 
 the injury, the finger or probe should not be used in the 
 examination. Penetration of the wall is usually associated 
 with the entrance of air through the wound, distending the 
 cavity and preventing the filling of the lung during inspi- 
 ration. Blood iu the pleural cavity, htemothorax, gives a 
 dull sound on percussion over the collected extravasation ; 
 air in the pleural cavity, pneumothorax, gives a tympanitic 
 or drum-like sound over the intruded air When the lung 
 is penetrated, blood appears in the sputa, and an admixture 
 of air gives a frothiness to liquids that escape from the 
 wound; the cellular tissue of the chest often becomes infil- 
 
WOUNDS OF THE ABDOMEN. 269 
 
 trated with air, constituthig the condition called emphysema. 
 If the penetration is small, as a stab, and inflicted with a 
 clean instrument, it may heal as readily as a simple non- 
 penetrating wound, even although there may be extravasated 
 blood within the pleura and an injury to the lung ; but if 
 the wound become infected by injudicious handling, by the 
 exposure incident to its open or gaping character, or by the 
 lodgment of any foreign matter, as a bullet or fragment of 
 clothing, a violent inflammation of the pleura and lung will 
 result. 
 
 453. The treatment of the non-penetrating wound is that 
 of flesh wounds in any other situation; and that of pene- 
 trating wounds differs only in the addition of precautions 
 to restrain internal hemorrhage and moderate the subse- 
 quent inflammation. During collapse, stimulation must be 
 attempted with caution, lest it aggravate the hemorrhage ; 
 during reaction, perfect rest and quietude must be enjoined. 
 
 454. Wounds of the abdomen which do not penetrate 
 into the abdominal cavity require greater care in their 
 management than corresponding wounds of the chest. This 
 arises from the greater likelihood of foreign bodies escaping 
 detection among the muscular tissues, the greater difBculfcy 
 of obtaining coaptation of the deeper parts of the wound, 
 the greater danger of extravasated blood burrowing between 
 the muscles, and, corresponding with all this, the greater 
 tendency of such wounds to suppurate and occasion con- 
 stitutional disturbance. In treating them, foreign matter 
 should be carefully removed; bleeding should be entirely 
 stopped before the edges are approximated, and this should 
 be effected by the ligature if the flow is copious, or by 
 torsion, styptics, cold or local pressure if slight; on no 
 account should the wound be closed and compresses applied 
 with the view of controlling hemorrhage, lest the blood find 
 
270 WOUNDS OF THE ABDOMEN. 
 
 its way into the intermuscular spaces; compresses should 
 be used, however, to insure coaptation of the deeper parts, 
 and the edges should be closed by sutures or strips of plaster 
 while the body is retained in that position which most facil- 
 itates closure. In punctured wounds it is often difficult to 
 decide whether the cavity has been penetrated; in such 
 cases, exploration by the finger or probe is not permissible. 
 Hemorrhage must be stopped before the wound is closed, 
 as otherwise blood, if the wound penetrated, would collect 
 ia the peritoneal cavity. When penetration is evidenced 
 by protrusion of the viscera, the case must be brought 
 immediately to the attention of the surgeon. 
 
CHAPTER VII. 
 
 THE CAUSATIVE CONDITIONS OF INSENSIBILITY. 
 
 455. Insensibility may arise from : Injury to the brain by 
 external violence ; apoplectic conditions, or those connected 
 with congestion of the brain; and syncopic conditions, or 
 those connected with a diminished circulation of blood. 
 
 456. Concussion op the bbain varies in intensity from 
 a momentary stunning, which leaves the patient temporarily 
 confused, weak, and tremulous, to a state of continued in- 
 sensibility with feeble but easy breathing, an almost imper- 
 ceptible pulse, pale countenance, and cold, clammy skin. 
 The occurrence of vomiting in a case of severe concussion is 
 accounted a favorable sign, as the patient usually rallies 
 after it. The patient should be put to bed and be warmly 
 covered ; warmth should also be applied to the extremities ; 
 and should the power of swallowing be retained, the removal 
 of intense depression may be cautiously attempted by small 
 doses, twenty or thirty drops, of aromatic spirit of ammonia. 
 A purgative enema should be administered ; and if insensi- 
 bility continue for some hours, the catheter should be used. 
 When reaction takes place, cold cloths or evaporating lotions 
 should be applied to the shaven scalp, with perfect rest, 
 quiet, an unstimulating diet, and an occasional laxative. If 
 serum be effused or lymph exuded during reaction in a case 
 of concussion of the brain, these morbid products, confined 
 within the bony case, give rise to symptoms of compkession. 
 If a blow on the head lacerate some of the blood-vessels 
 
272 COSTGESTIOK OF THE BEAII>f, APOPLEXY. 
 
 within the skull, the resultiiig hemorrhage occasions a grad- 
 ually increasing pressure on some part of the brain; or i£ 
 the blow fracture the skull and drive a portion of the bone 
 inward, the brain suiters immediately from the pressure of 
 the intruding fragment. The symptoms and treatment of 
 compression are those of apoplexy, for the latter is caused 
 by the pressure of a hemorrhage or effusion which depends 
 on disease instead of on external violence. 
 
 457. In CONGESTION OF THE BEAiN the arteries bring an 
 excess of red blood and the capillaries become engorged. 
 The symptoms are headache, fever, great restlessness, and 
 delirium ; and not until effusion has taken place and exercises 
 a compression on the brain does the delirium subside into 
 the insensibility and profound stupor of the apoplectic state. 
 The gradual progress of the case indicates, in this instance, 
 the conditions to which the insensibility must be attributed. 
 458. Apoplexy. — Insensibility, as a direct result of 
 active congestion, is gradual in its development; but as an 
 indirect result it often occurs suddenly, particularly in 
 elderly persons, in whom the walls of the cerebral arteries 
 have undergone weakening and dilatation. The strain on 
 these weak points during a congestion of even a trivial char- 
 acter may be such as to occasion their rupture and a sud- 
 den extravasation of blood into the substance of the brain. 
 Pressure is exercised on the brain by this extravasated blood, 
 and is manifested by the same symptoms as the pressure 
 from an indriven portion of a fractured skull or the com- 
 pression arising from blood extravasated as a result of vio- 
 lence. The patient is unconscious, his face flushed, pupils 
 insensible to light and perhaps of different sizes, pulse slow, 
 hard, and full, breathing slow and somewhat irregular, the 
 inspiration snoring and the expiration puflB.ng; generally 
 the feature^ are drawn to one side, indicating the existence 
 
SUNSTROKE. 273 
 
 of paralysis [313]. The treatment consists in loosening 
 the clothing about the neck and chest, and applying cold to 
 the head, which, with the shoulders, should be kept elevated 
 by pillows; hot water with mustard to the feet and legs, 
 and the placing of a drop or two of croton oil on the tongue, 
 with a purgative enema if the bowels are not opened in the 
 course of an hour. Cloths or other absorbing material 
 should be adjusted under the patient with a rubber sheet to 
 protect the mattress [275] ; and if the insensibility has 
 lasted for some time, a catheter should be introduced to 
 evacuate the bladder [319]. 
 
 459. SuNSTEOKB is the result of heat, over-exertion, and 
 an insufficient supply of water. If the water needful in 
 the system be not replenished from time to time as it is 
 dissipated in vapor from the lungs and skin, evaporation 
 will cease ; the skin, instead of being bedewed with mois- 
 ture, will become dry ; and the blood, altered by its loss of 
 water and its excess of heat, will tend to stagnate in certain 
 organs, as the lungs and brain. At first the patient may 
 have merely a sense of oppression in the chest, or of head- 
 ache, with increasing confusion of thought ; but his limbs 
 will speedily begin to tremble, and ultimately sink un- 
 der him as he falls insensible. His pulse is quick, com- 
 pressible, and small, sometimes intermitting; his breathing 
 short, shallow, and interrupted by deep-drawn sighs; his 
 lips are livid; he clutches spasmodically at his chest, as if 
 to remove something that oppresses ; and he may be seized 
 every two or three minutes with violent convulsions which 
 stretch him out stiff and rigid for a few seconds, and then 
 gradually relax, with hesitating twitches which forebode a 
 recurrence. A man in this condition will die very shortly ; 
 or he will recover consciousness in a short time, if properly 
 treated, becoming perfectly well in a few hours or days; or 
 18 
 
274 SUNSTSOKE. 
 
 some accident may occur to the brain during its congested 
 condition, particularly if he be elderly and the subject of 
 degeneration of the walls of the cerebral arteries, and in 
 consequence of that accident he may remain unconscious for 
 many days, and have paralysis or other indications of injury 
 to the nervous system. 
 
 460. Manifestly, the sooner a sunstruck patient is treated 
 and recovered from his unconscious and convulsed condition 
 the less will be the risk of injury to the brain. He should 
 be immediately carried to the nearest shade, where his outer 
 clothing should be removed. If he still retain the power of 
 swallowing he may take as much water — not iced water — 
 as he will drink ; but if he is so insensible that no effort is 
 made at swallowing when a few drops of water are placed 
 in his mouth, his surface should be assiduously mopped 
 with dripping wet cloths, the moisture of which, while cool- 
 ing by its evaporation, wiU be absorbed by the vessels of 
 the skin, and will tend to relieve the abnormal condition of 
 his circulation, so that in a short time the power of swal- 
 lowing may be recovered. If, however, the patient fall 
 into a comatose state, he must then be treated as a case of 
 apoplexy [458]. 
 
 461. Iced water should not be given to a person suffering 
 from heatstroke. The cooling produced by it is merely 
 local. It cools the fauces and the stomach, and is in small 
 quantities grateful to the palate ; but its influence in lessen- 
 ing the temperature of the body generally is no greater than 
 that of the same quantity of water at the ordinary summer 
 temperature. Ingested water operates during its exhalation 
 from the lungs and skin, but to get there it must first be 
 absorbed into the circulation by the minute vessels of the 
 stomach. Cold contracts these vessels and interferes with 
 absorption. A person in ordinary health who desires to 
 
EPILEPTIC STUPOB. 275 
 
 experience the feeling of local cooling may take a glass of 
 iced water, as he can afford to wait for its absorption until 
 the subsidence of the temporary chill ; but one who is dying 
 for want of water should by no means have the absorbing 
 powers of his stomach rendered inactive by the tempera- 
 ture of the water supplied to him. 
 
 462. Epileptic Stupok. — An attack of epilepsy consists 
 of loss of consciousness and convulsions. It varies in 
 severity from a momentary lapse of mind, with barely 
 appreciable spasms, or twitchings of the features, to a vio- 
 lent paroxysm lasting two or three minutes. When severe 
 the patient becomes suddenly pale, falls forward on his 
 face, sometimes with a loud, quick scream, and is iramedi- 
 ately seized with a rigid spasm which lasts for ten or twenty 
 seconds, and is followed by rapid contractions and relaxa- 
 tions of the muscles, which contort the features and jerk 
 the body and limbs with much violence. These last for a 
 minute or two, during which the face becomes congested, 
 the pupils dilated, and the lips covered with foam, which 
 may be tinged with blood if the tongue has been injured by 
 the spasmodic action of the lower jaw ; there may be also 
 involuntary discharges from the bowels and bladder. A 
 long-drawn sigh ends the fit, and the patient sinks into a 
 stupor which may last for several hours and be mistaken for 
 apoplexy on account of its heavy breathing and puffing ex- 
 pirations. The history of the case is, however, distinctive : 
 The patient is perhaps recognized as an epileptic subject, 
 or his present condition of stupor may be known to have 
 been preceded by convulsions ; the presence of foam on his 
 lips is suggestive of the epileptic struggle, and the absence 
 of paralysis tends to confirm this diagnosis by excluding 
 apoplexy as a cause. 
 
 463. In treating an epileptic a handkerchief or a gag of 
 
276 CONVULSIONS — ALCOHOLIC STUPOR. 
 
 wood should be placed in the mouth of the patient to pro- 
 tect his tongue ; the neck and chest should be freed from 
 all constrictions ; and no more restraint should be used than 
 is required to guard against accidents. After the fit he 
 should be placed in bed to recover from its exhausting 
 effects. 
 
 464. Convulsions, with temporary loss of consciousness, 
 occurring in young children who are not known to have dis- 
 ease of the brain, are usually due to the irritation of teeth- 
 ing or to some disorder of the digestive organs, as the 
 presence of indigestible matters or worms. The patient 
 should be placed across the lap of a nurse, and while ice- 
 cold water is applied to the head, the feet and legs should 
 be immersed in a pail of hot water. Meanwhile the gums 
 should be examined ; and if a rising tooth is found to be the 
 occasion of much redness and swelling, a free cut should be 
 made over it, lengthwise of the gum, to relieve the pressure. 
 If there is no tumefaction of the gum, an enema of soap- 
 suds should be administered, or an emetic of ipecacuanha, 
 if there be a history of some indigestible substances taken 
 into the stomach. 
 
 465. Alcoholic stupor is distinguished from apoplexy 
 mainly by the condition of the pulse and pupils — the former 
 is rapid, small, and soft, the latter dilated ; moreover, there 
 is no contraction of the facial muscles or other indication 
 of paralysis ; and cold water freely applied to the head has 
 usually some influence in arousing the patient from his 
 lethargy. In an unknown case the odor of alcoholic stimu- 
 lants in the breath should not be permitted to have weight 
 as evidence, because apoplexy or brain injury is by no 
 means inconsistent with the presence of alcohol in the 
 system. In every case of doubtful causation, the patient 
 should be taken into hospital and treated as if suffering 
 
DELIEIUM TREMENS — INSElirSIBILITT FROM COLD. 277 
 
 from congestion of the brain until his actual condition is 
 unmistakably revealed. Even when his stupor is known to 
 have been occasioned by his own vicious habits, he should 
 be treated as sick until the recovery of his intelligence. To 
 confine a man in this comatose condition in a guard-ceil 
 merely exposes him to danger; it is no punishment, for 
 punishment can be inflicted only when the individual is sen- 
 sible of its application. 
 
 466. The treatment consists of cold to the head and an 
 emetic of mustard, if the patient have not already vomited 
 freely. If the pulse become weak and the skin cold and 
 clammy, hot coffee should be administered, or small doses 
 of aromatic spirit of ammonia in water, with frictions and 
 warmth to the general surface. 
 
 467. Delirium Tremens. — Prolonged alcoholic excess 
 leads to a condition of nervous prostration characterized by 
 muscular tremors and delirium. The patient is constantly 
 anticipating some fancied evil or annoyance, which keeps 
 him in a state of nervous inquietude, talking anxiously 
 and with more or less incoherence. He is usually easily 
 controlled and diverted from his intentions, but he must be 
 watched closely for fear of accidents. Milk and beef 
 essence should be given as food, with bromid of potassium 
 or chloral, or morphine by hypodermic injection, to quiet 
 the nervous system and induce sleep. For Opium Narcot- 
 ism, see par. 586. 
 
 468. Insensibility prom Cold. — Exposure to extreme 
 cold acts like opium in exercising a benumbing influence on 
 the sensations, leading from drowsiness to a stupor so pro- 
 found that the system fails to recognize the necessity for 
 breathing. If the body is stiff, the tissues should be relaxed 
 by friction with cold water, after which artificial respiiation 
 
278 HEAT EXHAUSTIOlir. 
 
 offers tlie only prospect of resuscitation. Even when the 
 insensibility has merely embarrassed but not arrested the 
 respiratory movements, the return of warmth to the body 
 must be gradually effected, lest the patient die in the 
 delirium of excessive reaction. Only such stimulants as 
 hot cofEee, beef tea, and aromatic spirit of ammonia are 
 admissible. 
 
 469. Cases of insensibility associated with cerebral con- 
 gestion, and arising from causes which interfere with the 
 respiratory function, such as strangling, choking, smother- 
 ing, drowning, etc., are referred to under the heading of 
 Artificial Eespiration, paragraphs 476-481. 
 
 470. Heat Exhaustion. — Insensibility from exhaustion 
 is a common occurrence on forced marches, particularly 
 among raw troops. Ordinarily the order of march provides 
 for a rest at the end of every hour to refresh the men, to 
 permit those who have fallen behind to recover their posi- 
 tion ia the ranks, to readjust accoutrements, and to replen- 
 ish water supplies when occasion offers; but on a forced 
 march, those who have fallen behind have no opportunity 
 afforded them of rejoining their company. They struggle 
 on through the heat and dust until they become utterly 
 exhausted and drop unconsciously by the roadside, face 
 pale, lips bloodless, pulse rapid and feeble, respiration 
 sighing, and the muscular system affected with the tremors 
 of prostration. Eecovery in these cases is speedy when 
 the conditions are favorable. The removal of the patient's 
 belts and burdens, rest in the recumbent position in the 
 shade, cold water to the head and face, upward frictions to 
 the limbs, and stimulants and water as required, generally 
 suffice to re-establish his powers. Frequently, however, 
 these cases of heat exhaustion are complicated with conges- 
 
HEAT EXHAUSTION. 279 
 
 tive tendencies, manifested by dryness of skin, pulmonary 
 oppression, headache, and convulsive seizures [459]. In 
 such instances alcohol is contra-indicated ; water alone, or 
 with a few drops of aromatic spirit of ammonia, is the 
 proper remedy. 
 
CHAPTER VIII. 
 
 ARTIFICIAL RBSPIEATION. 
 
 471. A person at the point of death from asphyxia [298] 
 may be recovered by keeping up movements of the chest 
 that will alternately compress and expand the lungs ; but 
 no method of doing this is efficient unless the tongue of the 
 patient be prevented from, blocking up the air passage. Dur- 
 ing insensibility it tends to fall backward in the throat and 
 close the upper end of the larynx. It must be seized, 
 pulled forward, and held ia that position by an elastic 
 
 Silvester's metliod: Inspiration. 
 
 band, string, or tape passed around its base and under the 
 chin, by a pencil placed across its base and lodged in posi- 
 tion behind the back teeth, or by the fingers of an assistant 
 
ARTIFICIAL EESPIKATION-. 281 
 
 enveloped in a dry handkerchief to prevent them from 
 slipping. 
 
 472. In Silvester's method the patient is placed on his 
 back, with a pillow or roll of clothing under his shoulders 
 to elevate them and carry the chin away from the breast- 
 bone. The operator kneels at his head, and, taking hold of 
 an elbow in each hand, makes the inspiratory movement by 
 drawing the arms outward away from the chest, and then, 
 continuing the motion, forcibly upward over the head of 
 
 Silveat«>i''3 method: Expiration. 
 
 the patient. This drags .the lower ribs upward and out- 
 ward, expands the chest, and causes the entrance of air. 
 The expiratory movement is made by passing the arms 
 down again along the side and front of the chest, and making 
 pressure on them when in that position, to force the ribs 
 downward and drive the air out of the lungs. This com- 
 pletes the respiratory movement, which should be repeated 
 at the rate of fifteen times per minute, until natural respi- 
 ration returns or the case is abandoned. 
 473. In Marshall Hall's method the patient is placed 
 
282 ARTIFICIAL EESPIEATION. 
 
 on the floor or ground with the face downward, his fore- 
 head resting on one arm, and a roll of clothing supporting 
 his chest. While in this position the weight of the body 
 compresses the ribs and expels the air from the chest — an 
 artificial expiration which is deepened by making pressure 
 on the lower ribs. Then the operator, with one hand on 
 
 Marshall Hall's method: Expiration. 
 
 Marshall Hall's method : Inspiration. 
 
AETIFICIAL RESPIRATION. 283 
 
 the patient's free arm near the shoulder, and the other 
 placed under or in front of the corresponding hip-bone, rolls 
 the body from face downward to its side and a little beyond. 
 An assistant aids in this movement by handling the head 
 and underlying arm. When the body has been thus rolled 
 somewhat more than half round, the chest becomes relieved 
 from superincumbent weight, and a certain volume of air 
 enters. After resting a second or two in this attitude of 
 inspiration, the g^tient Is returned to the prone position, and 
 pressure made along the ribs to imitate the expiratory act. 
 
 474. Other plans have been advocated, such as that of 
 compressing the abdominal walls as if the object were to 
 drive the contents of the abdomen upward into the chest. 
 This forces the diaphragm upward and empties the lungs, 
 after which the sudden withdrawal of the pressure per- 
 mits of inspiration. Whichever method is used, it is 
 well, during its progress, to attempt to stimulate the res- 
 piratory powers by holding ammonia to the nostrils and 
 slapping the chest alternately with cloths wrung out of cold 
 and hot water. As soon as natural breathing has been 
 restored, efforts should be made to promote the circulation 
 by rubbing the limbs in the direction of the trunk; to 
 restore the warmth of the body by the use of warm clothing, 
 blankets, hot flannel, bottles, or bricks, and to stimulate the 
 vital actions by small doses of aromatic spirit of ammonia. 
 
 475. The conditions which call for artificial respiration 
 are those in which the lungs are sound but deprived of air, 
 either mechanically or by the substitution for air of some 
 gas or vapor which is not directly poisonous, or when res- 
 piratory action has ceased on account of some narcotic influ- 
 ence exercised on the brain. These include : 
 
 476. Strangulation by cord, ligature, or other compres- 
 sion on the neck or windpipe. 
 
284 ARTIFICIAL EESPIKATION. 
 
 477. Smothering from the mechanical closure of the nos- 
 trils and mouth by any substance, or even by interference 
 with the movements of the chest, as when one has been 
 imbedded to the neck in a sand-slide. In these cases the 
 mechanical cause must at once be removed, together with 
 articles of clothing which might interfere with the move- 
 ments of the chest. If the mechanical cause has occasioned 
 other injury than strangulation or smothering, artificial 
 respiration may be of no value, as when in hanging the 
 cervical vertebrae have been dislocated or fractured ; but if 
 there be no evidence of this, and particularly should there 
 be a spasmodic quivering of the muscles or the faintest 
 indication of pulsation of the heart, efforts should be made 
 without loss of time to arterialize the venous blood by imi- 
 tating the movements of respiration. 
 
 478. Choking from the pressure of something in the gullet. 
 When a man becomes suddenly suffocated while eating, the 
 fingers should be immediately passed over the base of the 
 tongue, and as far down as can be reached, to bring away 
 any foreign substance that may be there [495] ; after which 
 artificial respiration is in order, if necessary. 
 
 479. Drowning by immersion in water : No time should 
 be lost in removing the body from the water; and except 
 in inclement weather, resuscitation should be attempted on 
 the spot. The upper or body clothing should be removed, 
 and, as the air tubes are frequently choked with indrawn 
 water, the patient should first be placed face downward on 
 the ground, and his body raised by the hands of the oper- 
 ator clasped underneath the abdomen to cause the intruded 
 water to escape, partly by drainage and partly by the 
 upward pressure on the lungs occasioned by the constriction 
 of the abdomen. The mouth and nostrils are then cleaned 
 and artificial respiration is instituted. Meanwhile the lower 
 
ARTIFICIAL RESPIRATION. 285 
 
 garments should be removed, and the surface dried and pro- 
 tected with blankets or shawls. 
 
 480. Asphyxia froin coal-gas, charcoal fumes, or the exhala- 
 tions of vats, pits, or mines. Care must be taken in recover- 
 ing the body that the rescuer, if overcome by the harmful 
 atmosphere, may be promptly withdrawn. The noxious 
 gas in such cases consists mainly of carbonic acid, carbon 
 dioxid, sometimes associated with carbonic oxid, carbon 
 rnonoxid. The former suffocates by preventing aeration of 
 the blood, while the latter has a directly poisonous influ- 
 ence; but as coal-gas contains less than ten per cent, of the 
 poisonous oxid, there is a prospect of favorable results if 
 treatment by artificial respiration and cold affusion be 
 promptly instituted. 
 
 481, Insensibility from ether or chloroform [287], carbonic 
 oxid, from ojiinin [586], or from exposure to extreme cold 
 [468]. The escape of water-gas gives rise to most of the 
 deaths from carbonic oxid ; the gas contains thirty or forty 
 per cent, of this insidious poison. When opium is the cause 
 of danger, artificial respiration aims to prolong life until 
 the poisonous influence has been eliminated or counteracted 
 by other means. 
 
 482. Signs of Death. — There is no positive sign of 
 death except the occurrence of decomposition in the tissues 
 of the body. This is the statement of a scientific fact; but 
 at the same time there is practically no diflBculty in deter- 
 mining the presence of death long before putrefaction sets 
 in. The evidence of death consists of the concurrent exist- 
 ence of several conditions : 1. The continued cessation of 
 breathing, as determined by a polished surface held over 
 the lips and nostrils; 2. The continued absence of any 
 movement of the heart when closely watched for by the 
 ear and touch; 3. Eelaxion of the muscles, passing into 
 
286 ARTIFICIAL BESPIEATION. 
 
 rigidity at the end of three or four hours ; 4. The glazing 
 of the eyes; 5. The progressive cooling of the body from 
 its normal living temperature to that of the surrounding 
 atmosphere. Many single tests of the presence of death 
 have been suggested. Perhaps the best of these is the tying 
 of a string around the end of a finger or lobe of the ear : no 
 change takes place on the dead body ; but if there be any 
 vital movement in the vessels the point beyond the ligature 
 becomes more or less congested. In the wrist test a splint 
 is placed in front to protect the radial and ulnar arteries ; 
 a cord is then tied tightly around the spliut and wrist to 
 block the veins on the back of the hand. These veins grad- 
 ually become filled with blood if the heart's action and cir- 
 culation have not wholly ceased. The hypodermic injection 
 [305] of a few drops of a strong solution of ammonia has 
 also been recommended. If the body be not dead the 
 ammonia will produce on the skin, over the point where it 
 was injected, a bright red patch, on the surface of which 
 raised red spots wUl appear; but in absolute death a brown 
 dark blotch will be developed. 
 
CHAPTER IX. 
 
 FOREIGN BODIES IN THE EYE, EAR, ETC. 
 
 483. Foreign bodies lodging in the eye cause much red- 
 ness and distress. If they are not visible on careful inspec- 
 tion of the globefthey should be looked for behind the 
 upper eyelid. To do this a probe is laid along the lid from 
 the root of the nose outward, and pressed lightly against 
 the upper part of the ball ; at the same time the lid is 
 
 Everting the upper eyelid. The conjunctival vessels are congested. 
 
 pulled away from the globe by traction on the eyelashes, 
 and the patient is told to look downward, when the lid will 
 be tilted over the probe behind it, fully exposing its con- 
 junctival surface. The intruding substance should be 
 brushed away with a camel's-hair pencil or pledget of lint; 
 if it be partly embedded in the mucous membrane it should 
 be lifted out with the flat surface of a blunt-edged lancet. 
 A drop of olive or castor oil instilled into the eye will 
 relieve the irritation. 
 
 484. Eye-drops, such as solutions of nitrate of silver, 
 atropin, etc., are not dropped into the eye, but instilled or 
 insinuated. The patient turns his face upward, and the 
 
288 FOEEIGK BODIES IK THE EYE, EAR, ETC. 
 
 operator, having depressed and partly everted the lower lid 
 with the fingers of one hand, brings a drop hanging on the 
 end of a glass rod, tube, or dropper into gentle contact 
 with the mucous membrane, from which it flushes over the 
 surface of the eyeball. 
 
 485. When a par.ticle of extraneous matter is embedded 
 in the conjunctiva the blood-vessels become enlarged, form- 
 ing a close-set network such as is represented in the illus- 
 tration just submitted. The enlarged vessels give rise to a 
 feeling as if sandy particles were lodged on the surface of 
 the membrane. Usually the removal of the irritant cause, 
 the seclusion of the patient in a shaded room, a dose of 
 aperient medicine, and the use of cold lotions will speedily 
 allay the congestive action ; but if the redness and other 
 symptoms persist after these measures have been tried for 
 a day or two, a drop of a solution of nitrate of silver, one 
 or two grains to the fluidounce of water, instilled morning 
 and evening, will generally be efficient. 
 
 486. Sometimes, however, the eyelids become swollen 
 and puffy, closing over the eyeball, yet allowing the tume- 
 fied, red, and inflamed mucous membrane to protrude be- 
 tween them and giving issue to a free discharge of puru- 
 lent matter. As this matter is infectious, the greatest care 
 must be used to prevent the spread of purulent ophthalmia 
 by infected fingers, towels, etc. The disease is apparently 
 due sometimes to atmospheric changes, in which case both 
 eyes of the patient will suffer simultaneously; at other 
 times it results from the infection of gonorrheal discharges, 
 and in these cases one eye is usually first affected, and is 
 seriously endangered before the other receives the conta- 
 gion. Eest, quiet, low diet, and aperient medicines are 
 required as constitutional remedial agents, whilst the local 
 measures consist of repeated syringing and warm f omenta- 
 
FOKEIGK BODIES IIT THE EYE, EAE, ETC. 289 
 
 tions to clear away accumulated matter, scarification of the 
 tumefied membrane if it project much through the fissures 
 between the lids, and the introduction of a solution of 
 nitrate of silver to stimulate the enlarged vessels to contract. 
 Neglect in a case of this kind may lead to total loss of vision 
 by sloughing of the cornea, as that part of the eye is de- 
 pendent on the conjunctiva for its supply of nutriment. 
 
 487. When men have been exposed for a considerable 
 time to a garish light, as that reflected from stretches of 
 sand or snow, the retina or sensitive membrane of the eye 
 may become temporarily strained and unable to take cog- 
 nizance of ordinary impressions. This condition, which 
 has received the name of snow-blindness, usually requires 
 no other treatment than rest in the shade for a few days to 
 enable the nervous matter to recover it's normal functions. 
 Sometimes, however, the local reaction which takes place 
 becomes developed into a general inflammation of the eye, 
 requiring special surgical attention. 
 
 488. Foreign bodies in the nose. — Young children some- 
 times push beans, buttons, or other small objects into the 
 \iose, and are tmable afterward to withdraw them. They 
 may sometimes be removed by a vigorous effort to blow 
 through the blocked-up nostril or by sneezing artificially 
 induced ; failing this, they must be withdrawn by a fine for- 
 ceps or blunt hook, afterward washing out the cavity with 
 warm water in which a little common salt has been dissolved. 
 
 489. Sometimes, in southern climates, uncleanly children 
 or intemperate adults become affected with maggots in the 
 nasal cavities. These cause much local irritation, loss of 
 sleep, fever, and ultimately delirium. They may be cleared 
 out by making the patient inhale half a drachm of chloro- 
 form and immediately thereafter syringing out the cavities 
 with a warm solution of common salt, repeating the opera- 
 
 19 
 
290 
 
 FOKEIGK BODIES IN THE EYE, EAK, ETC. 
 
 tion at intervals of a few hours, until all the maggots have 
 been removed. 
 
 490. Foreign bodies in the ear. — Insects cause great dis- 
 tress, and should be immediately dislodged by filling the 
 canal with warm oil or gently syringing with warm water. 
 The latter procedure generally suffices to remove small 
 bodies, such as beads, seeds, etc. ; if it fail, the case should 
 be left for fully qualified surgical skill. Plugs of cotton- 
 wool may be withdrawn by forceps after dissolving their 
 waxy adhesions by instilling a few drops of olive oil. Wax 
 should not be picked out, but softened by instillations of oU 
 at night and syringing with warm water next morning. 
 
 491. The ear should never be syringed with cold water; 
 the water used should always be distinctly warm to the 
 fingers. The patient, or an assistant, holds the edge of a 
 
 Syringing the ear. 
 
 cup or receiver closely to the side of the neck below the 
 lobule. The operator takes hold of the upper and back 
 part of the ear with the fingers of one hand, pulling it 
 upward, backward and slightly outward to straighten the 
 canal, while he lays the nozzle of the syringe just within 
 its entrance and pushes the piston gently and slowly home. 
 Two or three two-ounce syringefuls generally suffice to 
 
FOREIGN BODIES IN THE EYE, EAE, ETC. 291 
 
 cleanse the canal. After syringing, the water should be 
 permitted to drain from the ear, which should be dried 
 with the twisted comer of a towel or fragment of liut. 
 
 492. Foreign bodies in the trachea. — When buttons, beads, 
 seeds, small coins, etc., enter the larynx or trachea of chil- 
 dren, efforts at removal should be restricted to coughing 
 while the patient is held with the head and body inclined 
 downward. 
 
 493. In cases o| impending suffocation from foreign 
 bodies in the larynx, the windpipe is opened through the 
 membrane between the thyroid and cricoid cartilages [161]. 
 
 494. Tracheotomy has sometimes to be performed on 
 account of the blocking up of the larynx with diphtheritic 
 membranes. For this operation the neck of the patient is 
 put on the stretch by a small, hard pillow underneath. 
 The incision is made over the upper part of the trachea, 
 exposing its rings. These are drawn up by a sharp hook 
 attached to the cricoid cartilage, and the opening is made 
 by cutting through a few of the rings from below upward. 
 The operator and his assistants should avoid contact with 
 infectious matters expelled through the opening by a sud- 
 den fit of coughing. The tracheal tube is then introduced 
 and fixe4 'witii tapes. The inner tube should be removed 
 frequently, cleaned in a solution of bicarbonate of soda, 
 and touched over with glycerin before reintroduction. 
 
 495. The foreign bodies which stick in the pharynx are 
 usually fish-bones. If the bone can be seen, or felt by the 
 tip of the finger, when the tongue is depressed, it should 
 be removed by the fingers or forceps. If it be too low 
 down for this procedure, large mouthfuls of half-chewed 
 bread should be swallowed to carry it along. It must be 
 remembered that the tearing of the mucous membrane will 
 for some time afterward give rise to the impression in the 
 
292 FOEEIGIf BODIES IS THE STOMACH. 
 
 mind of the patient that the bone has not been dislodged. 
 Large bodies, such as fragments of meat causing choking, 
 must be im mediately removed -with the fingers. 
 
 496. Foreign bodies in the stomach. — When a child has 
 swallowed any of the small bodies mentioned, the alarm 
 of friends should be quieted and the patient fed for a day 
 or two on oatmeal, puddings, etc., after which a laxative 
 dose of castor-oil should be given, with instructions to look 
 for the foreign body in the intestinal discharges. 
 
CHAPTER X. 
 
 FEACTURES. 
 
 497. A fracture, surgically, is a break in the tissue of a 
 bone. It is simple when the bone is broken at one point; 
 comminuted when broken into more than two fragments; 
 impacted when one fragment is wedged into the other ; com- 
 pound or open when a wound penetrates from the surface to 
 the plane of the fracture ; and complicated when it is asso- 
 ciated with other serious injuries, as contusion, laceration, 
 etc. A fracture may be comminuted and the soft parts 
 contused and lacerated, yet if the skin be unbroken, extrav- 
 asated blood and effused serum are absorbed and satisfactory 
 repair goes on ; but in a compound fracture which becomes 
 infected by its exposure to the air, violent inflammation, 
 burrowing suppurations, and sloughing cause much suffer- 
 ing and danger. 
 
 498. The symptoms of fracture are pain, swelling, loss 
 of power, deformity, unnatural mobility, and crepitation. 
 There is nothing characteristic in the first three, as they 
 may be present in bruises and dislocations; but angular 
 deformity in the case of a long bone manifests the nature 
 of the injury as definitely as the mobility in a part that 
 ought to be solid, or the crepitus or grating when the broken 
 fragments are moved on each other. All fractures of the 
 long bones are more or less oblique ; and the shortening and 
 difiSculty of retaining the fragments in their proper relations 
 to each other are proportioned to the obliquity ; the lower 
 fragment, as being the more movable, is the one displaced. 
 
294 FEACTURES. 
 
 499. A fracture should be treated as soon as possible after 
 the accident, because when swelliag and muscular contrac- 
 tion have occurred it is more difBcult to bring the broken 
 ends into accurate contact (coaptation). When a bone lies 
 so near the surface that the fingers can recognize it, it is 
 easy to ascertain whether coaptation has been effected; but 
 when the bone is well covered with muscles, the recognition 
 of a proper setting is more difficult, and must depend upon 
 the removal of all observable deformity. 
 
 500. Splints are used to keep the broken ends in contact 
 until union is effected. They are of wood, pasteboard, per- 
 forated felt, gutta-percha, strong leather, sheet-tin, or ziue, 
 or any other material which possesses the proper strength, 
 and can be cut to suit the necessities of the case. The 
 angles formed by the meeting of the sides and ends should, 
 in all splints, be rounded off; the edges of metal splints 
 smoothed, and of wooden ones bevelled. Pasteboard, 
 leather, and gutta-percha must be softened in hot water be- 
 fore they can be moulded to the part for which they are 
 intended. Gutta-percha requires practice for its successful 
 application, inasmuch as a slight excess of heat transforms 
 it into a sticky, unmanageable mass. It should be folded 
 in muslin which extends beyond its ends, and immersed in 
 hot water while held by the free ends of its muslin wrapper 
 until the needful plasticity is attained. In the absence of 
 anything better, a handful of selected straw may be cut to 
 the proper length and quilted between the folds of soft cloth, 
 
 501. All splints, of whatever material, must be padded 
 before being put to use over the fractured bones. Several 
 layers of sheet wadding are cut to give the needful thick- 
 ness of pad on the face of the splint. These are retained 
 in position by being folded with the splint in muslin as a 
 packet is folded in paper, the free ends being brought back 
 
FRACTURES. 295 
 
 and stitched together behind, leaving the front of the pad 
 smooth and unwrinkled. Oakum, patent lint, and cotton 
 batting are also used for this purpose, but they do not make 
 so smooth a pad as the sheet cotton. When the bones have 
 been brought into their proper place the splints are applied 
 and retained in position by a bandage, or preferably by 
 strap-and-buckle fastenings, because they leave the limb 
 partly in sight, and can be relaxed or tightened with facil- 
 ity. The loop bandage answers in the absence of straps ; a 
 length of about three feet is cut from a roller, and doubled 
 lengthwise on itself; this is passed around the splinted 
 limb and the free ends are drawn tightly through the bight; 
 these ends are then separated from each other and tied 
 firmly at their meeting on the opposite side of the limb. 
 
 502. In applying a roller for the retention of splints or 
 any other purpose, each turn is made to overlap that which 
 preceded it ; and when the increasing thickness of the limb 
 prevents the roller from lying flat and at the same time 
 preserving the overlap, the difficulty is overcome by what 
 is called reversing. The upper border of the turn is folded 
 obliquely over the forefinger of the left hand, while the 
 roller in the right hand is made to describe a half turn on 
 its long axis, after which the circular movement is contin- 
 ued until the point is reached where the next reverse has to 
 be made. If a roller which encases or encircles a limb is 
 likely to become wetted, it should be applied lightly, else 
 the contraction which follows the wetting will make it 
 harmfully tight. 
 
 503. Sometimes the bandage itself is made to act the part 
 of a splint by saturating it with some substance, such as 
 starch, soluble glass, or plaster of Paris, which will endue 
 it with a solidity and resistance sufficient for the purpose. 
 Whichever of these materials is employed, the limb is first 
 
296 
 
 FRACTURES. 
 
 lightly encased in a moistened roller, and its hollows and 
 inequalities filled with cotton batting, after which the so- 
 called immovable dressing is applied. A colored tape should 
 be placed longitudinally beneath this dressing to act as a 
 guide for the knife, scissors, or cutting pliers used in its 
 
 Eerersing roller on leg. 
 
 Many -tailed bandage over 
 starched splints. 
 
 subsequent removal. The unyielding character of these 
 dressings renders them applicable only in fractures in which 
 there is no danger of the development of inflammatory 
 swelling. 
 
 504. Starch is prepared as for laundry use. The ban- 
 dages to be used are unrolled, soaked in the starch solu- 
 tion, re-rolled, and applied as an ordinary roller. Strips 
 of saturated bandage may be laid on longitudinally to 
 strengthen the casing, after which another circular or spiral 
 starched roller is used, or a many-tailed bandage may be 
 employed. This latter consists of strips cut long enough 
 to go once and a half round the limb. These are arranged 
 on a towel or pillow, the upper one being laid down first, 
 
FRACTURES. 297 
 
 and each successive strip overlying that which preceded it 
 by half its width. The strips are then brought beneath the 
 limb, around which they are applied as shown in the cut. 
 The starch bandage takes from twenty-four to thirty-six 
 hours to set. Should it become loose by the subsidence of 
 any swelling existing at the time of its application, it must 
 be cut along the line of colored tape, its edges trimmed, and 
 the casing again closed and sustained in position by an 
 ordinary roller. , 
 
 505. A saturated solution of the silicate of soda may be 
 used in the same manner as the starch solution. It sets 
 slowly, but makes a light and firm support. 
 
 506. Plaster of Paris is of use as a support in fracture by 
 virtue of its setting readily when mixed with an equal vol- 
 ume of water. Usually when thus mixed it consolidates 
 in three minutes; common salt hastens, mucilage or glue 
 retards, the consolidation ; white of egg beaten up with the 
 plaster gives it greater tenacity. To form a splint of this 
 material, several thicknesses of washed muslin are folded to 
 the required shape; these are immersed in and saturated 
 with the liquid plaster, refolded to the proper shape, 
 smoothed, and applied to the part, which is held in position 
 until the plaster sets. When a limb is to be encased the 
 dry plaster is first rubbed into the bandages which are to 
 be used, and the limb is wrapped in cotton wadding, which 
 is kept in place by an ordinary bandage ; after this the pre- 
 pared rollers are soaked in water and applied in circular 
 turns without reverses; some of them may be cut into 
 lengths and laid on longitudinally to give greater strength 
 to the casing. The dresser should protect his finger nails 
 from the plaster by greasing them. To clean the hands 
 afterward : Eub them with wet salt and then wash. 
 
398 SPECIAL FKACTUEES. 
 
 507. Union between the broken ends of a bone does not 
 usually begin to take place until about ten days after the 
 injury, so that any malposition detected during this period 
 is susceptible of rectification. Three to six weeks are 
 required for a firm cementation of the ends, the time de- 
 pending on the size of the injured bone and the accuracy 
 of the coaptation ; small bones, as those of the fingers, 
 unite more readily than larger ones. 
 
 SPECIAL FEACTUBBS. 
 
 508. Feactukb of the skull may occur without notable 
 symptoms other than those of the concussion [456] which 
 might be present irrespective of the fracture ; and they may 
 get well without at any time giving symptomatic evidence 
 of their existence. Sometimes a fissure or depression may 
 be felt through the scalp, and, when the base is the seat of 
 injury, there is occasionally a watery discharge from the 
 ears, a continued bleeding from them, or the appearance 
 of blood extravasated beneath the conjunctiva. As soon as 
 the patient rallies from the concussion, his head should be 
 shaved and cold applied, purgatives administered, and rest 
 and quiet enjoined. Should symptoms of compression be 
 present from, the m,oment of the injury, there is probably 
 some displacement of bone; should compression be devel- 
 oped with increasing intensity some tirtie after the injury, it 
 probably results from hemorrhage within the cranium. 
 
 509. When the fracture is compound [497], its edges may 
 be discovered by exploration with the finger ; and if any part 
 of the bone is found to be driven inward, a cautious at- 
 tempt is made by the surgeon to remove the fragment or 
 raise it to its proper level. Slight symptoms of compres- 
 sion may sometimes be removed by relieving the brain of 
 
FRACTURES OF THE SPINE. 299 
 
 this pressure ; but in these fractures the compression, when 
 severe, is usually caused by an associated hemorrhage, and 
 is unaffected by the restoration of the bone. 
 
 510. When the brain is laid open, foreign matter should 
 be gently removed and the wound cleaned with an antisep- 
 tic solution, after which a compress should be laid over it 
 and retained by a bandage to prevent protrusion of the 
 brain substance. 
 
 511. The arch is the most common site of feactube of 
 THE LOWEK JAW. Crepitus and irregularity in the line of 
 the teeth readily indicate the nature of the injury. A 
 pasteboard splint is moulded to the front and under surface 
 of the jaw, and bound in position by a four-taUed bandage 
 [450]. The splint below and the teeth of the upper jaw 
 above preserve the proper relations between the fragments. 
 
 512. The SPINE is fractured by falls from a great height 
 or the fall of a heavy weight on the body when bent. The 
 injury is usually attended with profound shock. Its symp- 
 toms depend on the situation of the fracture and the pres- 
 sure on, or damage to, the spinal cord. Local violence may 
 break off one or more of the spinous processes that pro- 
 ject behind, without much injury to the contents of the 
 spinal canal; but when the bodies of the vertebrae are 
 involved in the fracture, there is usually paralysis of those 
 parts of the body which receive their nerves from the cord 
 below the seat of injury. Any necessary movement of the 
 patient should be made with the utmost care, to avoid 
 increasing the injury to the cord or its membranes. To 
 turn him over on his face for a thorough investigation of 
 the fracture would invite such a displacement of the lower 
 portion as might cut the cord in two. 
 
 513. In these fractures there is severe pain, with swelling 
 and other signs of contusion, irregularity of the spinous 
 
300 FRACTURE OF THE KIBS. 
 
 processes, and possibly crepitus on movement. When the 
 cord is injured in the loins, the lower extremities are par- 
 alyzed, the urine retained, and the faeces passed involun- 
 tarily ; when in the dorsal region, the symptoms include, in 
 addition, a tympanitic swelling of the abdomen, due to 
 paralysis of the muscular coat of the intestine ; and when in 
 the neck, the upper extremities become paralyzed. Frac- 
 tures of the spine have generally an unfavorable ending, 
 reached sooner or later according as the site of the injury 
 is in the upper or lower part of the column. Above the 
 third cervical vertebra death may be immediate, from in- 
 jury to the phrenic nerves, which preside over the respi- 
 ratory movements of the diaphragm ; in the lower part of 
 the cervical region, the patient lives only a few days; in 
 the dorsal region, he may linger for two or three weeks, 
 and in the lumbar region for one or two months, greatly 
 distressed toward the end by increasing bed-sores. The 
 patient should be put to bed in the position which gives 
 him least discomfort, and the catheter must be used regu- 
 larly to prevent distention of the bladder. 
 
 514. The EiBS are frequently fractured by blows, falls, 
 or the counter-pressure of opposing forces, as when a wheel 
 passes over the chest. The middle ribs are most liable to 
 injury, as the upper have a better protection from the over- 
 lying soft parts, and the lower have a greater elasticity. 
 Fracture is detected by pressing the finger along the skin 
 over the line of the rib supposed to be injured, or by plac- 
 ing the hand on the part while the patient makes an effort 
 at coughing. It is treated by confining the chest in a 
 bandage — either several turns of a broad roller, or a closely 
 fitting jacket fastened by straps and buckles or eyelets and 
 laces — to keep the parts at rest and throw the burden of 
 the respiratory movements on the abdominal muscles. 
 
FRACTURE OF THE HUMERUS. 301 
 
 515. When the collar-bone is fractured near its mid- 
 dle, the inner fragment remains in its place, but the outer 
 is dragged downward, forward, and inward by the weight 
 of the extremity. A wedge-shaped pad is fitted, base up- 
 ward, into the armpit; the arm is brought slightly inward 
 across the chest, and the elbow and humerus are pressed 
 upward so as to force the point of the shoulder upward 
 and backward. A long roller is then applied to retain the 
 limb in this positiion. A few turns are passed around the 
 chest to fix the end, after which the arm is included with 
 the chest in each turn ; the roller is then carried below the 
 elbow and over the opposite shoulder, and the operation 
 finished by some circular turns to fix the whole. The vari- 
 ous turns should be stitched here and there to prevent dis- 
 placement. 
 
 516. When this bone is fractured near its outer extremity, 
 there is little tendency to displacement, and all that is 
 needful is to keep the arm bound to the side and to support 
 the forearm in a sling. 
 
 617. The flatness of the shouldek-blade preserves it 
 from fracture, but occasionally the acromion process is 
 broken off. The patient complains of a great sense of 
 weight, and the roundness of the shoulder is lost; but the 
 deformity disappears when the arm is pushed perpendicu- 
 larly upward so as to raise the broken fragment. In treat- 
 ing this injury, a cushion is placed between the elbow and 
 the side to relax the deltoid, and the arm is kept at rest in 
 this position by being bandaged to the side and having the 
 elbow and forearm supported in a short sling. 
 
 518. A transverse fracture of the humerus above the con- 
 dyles looks like a dislocation backward of the radius and 
 ulna at the elbow [544], because there is an unnatural 
 prominence behind the joint, with a depression above it, 
 
302 FEACTURB OF THE HUMEKUS. 
 
 and the front of the forearm is shortened ; but it differs 
 from a dislocation in that if the arm be fixed and traction 
 made on the forearm, the unnatural appearance will be 
 removed and the grating of the fractured ends may be per- 
 ceived. Treatment: Eeduce by traction, and preserve in 
 position by a roller bandage applied around the lower part 
 of the arm and the upper part of the forearm ; use two 
 padded splints — one straight, in front of the humerus, the 
 other bent at a right angle, with one part behind the 
 humerus and the other below the forearm. Fasten by 
 buckle or loop bandages, and support the elbow and forearm 
 in a sling. 
 
 519. Sometimes from the nature of the violence the outer 
 or inner condyle is broken off, causing a prominence which 
 may simulate dislocation. Crepitation may be felt when 
 the inner condyle is fractured by grasping the prominence 
 and at the same time moving the forearm backward and 
 forward; when the outer condyle is fractured, crepitation 
 is best elicited by alternately pronating and supiaating the 
 hand [168]. In treating these fractures, keep the forearm 
 at a right angle with the arm, the back of the hand turned 
 upward and the fingers bent if the inner condyle is involved, 
 and the palm upward and the fingers straight if the outer 
 condyle is the subject; then apply a roller around the lower 
 part of the arm and upper part of the forearm, and over 
 this a padded rectangular splint of pasteboard or other suit- 
 able material, placing one part behind the humerus and the 
 other below the forearm, and securing all with a roller. 
 The injured limb should be supported ia a sling. 
 
 520. When swelling comes on quickly in fractures near 
 the elbow, it is well to support and rest the limb, and to 
 apply evaporating lotions to subdue inflammation before 
 splinting the injured bone. 
 
FBACTURE OF THE RADIUS. 303 
 
 521. When the shaft of the hone is broken, there is no 
 difficulty in recognizing the injury. The inability of the 
 patient to raise his arm, its mobility when handled, crepi- 
 tation, and angular deformity sufficiently announce its na- 
 ture. When the fracture is in the low&r 'part a splint 
 should be applied in front and another behind ; but if the 
 fracture is about the middle, the splints should be placed on 
 the inner and outer sides. When the fracture is in the 
 u^er part, the upper fragment may be dragged outward 
 and the lower fragment inward, or vice versa, according as 
 certain muscles are broken off with the one or left attached 
 to the other [166]. In either case traction should be made 
 on the lower fragment untU all shortening of the limb is 
 removed, when three splints should be applied, one along 
 the front, a second behind, and the third on the outer 
 aspect of the arm. A wedge-shaped pad is then placed 
 along the inner aspect, with its thick end in the armpit 
 if the upper fragment be displaced inwai'd, so that when 
 the arm is afterward bandaged to the side the pressure of 
 this pad may keep it in its place; but if the lower frag- 
 ment be displaced inward, the thick end of the pad should 
 be below and its apex in the armpit. In bandaging the 
 arm to the side the roller should be applied firmly over the 
 fragment which has the outward tendency and lightly over 
 that which tends inward. 
 
 622. The weight of the arm in all these fractures of the 
 humerus should be supported by a sling; but care should 
 be taken that it does not press the elbow upward, lest it 
 give rise to shortening of the bone in cases in which the 
 line of fracture is oblique. 
 
 523. Fractures of the kadius are characterized by loss of 
 the power of voluntarily effecting the movements of prona- 
 tion and supination [168] ; the hand is supported by the pa- 
 
304 PRACTUKB OF THE ULNA. 
 
 tient in the prone position. When the fracture is in the mid- 
 dle or lower third, it may be felt by the finger ; if it be in the 
 upper third, where the bone lies deeper in the muscles, it 
 may be detected by grasping the upper part of the forearm 
 in one hand, pressing the thumb firmly on the head of the 
 radius, on the outer aspect of the posterior prominence of 
 the elbow, and alternately supinating and pronating the 
 injured limb with the other hand. The fracture is revealed 
 by the grating of the fractured ends on each other and by 
 
 Fracture at wrist. 
 
 the failure of the head of the bone to participate in the 
 rolling motion given to the lower fragment. When the 
 fracture is near the wrist— Colles' s fracture — its site be- 
 comes swollen by effusion into the sheaths of the tendons, 
 which gives the injury the appearance of a dislocation, the 
 more so that this same swelling interferes with the motion 
 of the fingers; but crepitus readily distinguishes between 
 the fracture and the dislocation. 
 
 624. Fracture of the ulna may usually be discovered by 
 drawing the finger along the edge of the bone on the poste- 
 rior and inner aspect of the forearm. There is a depression 
 at the seat of the fracture on account of the lower fragment 
 settling toward the radius. 
 
 525. Fracture of both hones is readily recognized by the 
 unnatural mobility, the angular deformity, and the grating 
 of the fragments. 
 
 526. In splinting these fractures, the forearm should be 
 bent at a right angle to the arm to equally relax the mus- 
 
FEACTUKE OF THE PELVIS. 305 
 
 cles on the anterior and posterior aspects, and the hand 
 should be kept midway between pronation and supination, 
 i.e., with the thumb upward and the little finger down- 
 ward, because, if union were to take place with the hand 
 prone, the power of supination would be restricted, and if 
 with the hand supine, pronation would be impaired. If 
 both bones are broken, the hand should be kept in line with 
 the forearm; if the radius alone is fractured, the hand 
 should be slightly depressed; and if the ulna alone is in- 
 jured, the hand Should be raised. Two splints are re- 
 quired, one for the back and one for the front of the fore- 
 arm, the former reaching only to the wrist, the latter to the 
 roots of the fingers. These splints should be broader than 
 the breadth of the forearm, that the bandages may not com- 
 press the bones laterally; and they should have a thicker 
 padding along the centre of their length than on the margins, 
 that they may make pressure on the space between the shafts 
 of the two bones and keep the fragments parallel. They are 
 fastened by the buckle, loop, or common roller bandage, after 
 which the forearm is supported in a sling. 
 
 527. The metacarpal bones extend from the wrist to 
 the roots of the fingers. Their fractures are treated on a 
 pasteboard or other splint applied to the palmar aspect and 
 extending along the forearm to the ends of the fingers. It 
 should be well padded, particularly in the hollow of the 
 palm. 
 
 528. Small splints on feactuebd fingers may be fas- 
 tened by strips of rubber plaster. 
 
 529. The pelvis [175] is fractured only by great vio- 
 lence, as in falls from a height to rocky ground or the fal 
 of a horse on its rider. It is often difficult to detect the 
 fracture, the existence of which must be assumed from the 
 nature of the causative violence, the inability of the patient 
 
 20 
 
306 FBACT0EB OF THE THIGH-BON'E. 
 
 to support himself, a feeling of laceration at the fractured 
 part when any exertion is made, and the absence of any- 
 other obvious explanation of these symptoms. The legs of 
 the patient should be bound together to prevent motion, and 
 the utmost care used in transporting him to bed lest dis- 
 placement be augmented or the pelvic viscera injured by 
 splinters. The catheter should be introduced and retained 
 for some days, to lessen the danger of extravasation of 
 urine in case of possible injury to the bladder, as the escape 
 of urine into the peritoneal cavity would be followed by 
 fatal peritonitis, and into the cellular tissue of the pelvis 
 by diffuse inflammation, sloughing, and abscesses. The pa- 
 tient should be placed iu bed in the position in which he 
 is most comfortable, usually on his back, with his knees 
 flexed and supported by pillows under them. 
 
 530. Fractures of the thigh-bone close to the hip-joint 
 occur mostly in aged people, from slight shocks, as in mak- 
 ing a misstep. When they occur in younger people they 
 
 Fractured thigh treated by straight splint. 
 
 are usually the result of great violence, and are often com- 
 plicated with other injuries requiring the most intelligent 
 surgical treatment. In these fractures there is, as in most 
 of the dislocations of the hip- joint, a shortening of the limb, 
 and inability on the part of the patient to move it; but it 
 may be readily lengthened by traction, rotated, or otherwise 
 moved by the surgeon. When the patient lies on his back 
 
FBACTUBE OF THE THIGH-BONE. 307 
 
 the foot is usually everted, that is, rolled outward on the 
 heel so as to carry the toes away from the central line of 
 the body. Crepitus may be felt by placing one hand over 
 the great trochanter [176] and giving a rotatory motion to 
 the limb with the other. The patient is placed on a hard 
 mattress, and a roller is applied from the toes to above the 
 knee to support the tissues and prevent swelling from the 
 bandage to be subsequently applied higher up. The ordi- 
 nary wire mattress js too yielding for use in such cases, but 
 when supported beneath by wooden slats it answers the 
 purpose excellently. The splint employed should be long 
 enough to extend from the lower ribs to three or four inches 
 beyond the foot, and it should be provided with two holes 
 near its upper and two notches at its lower end. The limb 
 having been extended, by traction, to its proper length, the 
 splint, well padded, particularly at the ankle, is applied on 
 the outer side. A roller, fixed by several turns around the 
 ankle, is looped around the foot and through the notches at 
 the end of the splint to keep the foot in position; this 
 bandage is then carried upward beyond the knee. Exten- 
 sion and counter-extension are effected by the application 
 of what is called the perineal band. A large smoothly folded 
 and well-padded handkerchief is applied to the crotch of 
 the injured side, and the ends carried, one in front, the 
 other behind, the hip to the holes in the splint, through 
 which they are passed and tied firmly together. By this 
 means the splint, and with it the part of the limb below 
 the fracture, is kept down in its proper place. A small 
 wooden splint is applied to the inside of the thigh ; and 
 afterward a broad bandage is passed around the pelvis and 
 brought down the thigh to aid in keeping the apparatus in 
 position. 
 
 531. Fractures of the shaft of the femuk generally 
 
308 FKACTUEE OF THE THIGH-BOlirE. 
 
 override each, other from half an inch to two inches, owing 
 to the contraction of the powerful muscles connected with 
 the bone. American surgeons usually treat this injury in 
 the straight positipn by short thigh-splints and extension by 
 weights. A roller is applied from the toes to the ankle ; a 
 strip of plaster two and a half inches wide is then made to 
 adhere firmly to each side of the limb from the fracture to 
 the ankle, but each strip is cut so long that the lower ends 
 
 Fractured thigh in coaptation Rpljnts ; extension by weights. 
 
 may overlap, forming a loop about four inches beyond the 
 sole of the foot; the roller is then carried upward to the 
 level of the fracture. A flat wooden foot-piece, three inches 
 wide and four or five long, is firmly attached within the 
 loop of adhesive plaster, and to it is made fast a cord which 
 passes over a pulley to sustain the extending weights. The 
 weight of the body of the patient affords the counter-extend- 
 ing force, which may be increased by raising the foot of the 
 bed on blocks, or by means of a perineal baud, extending 
 upward and made fast to the head of the bedsteads Four 
 padded splints are applied to the thigh, and kept in posi- 
 tion by loop or buckle bandages ; and support is further 
 given to the limb by sand-bags, particularly on the outer 
 aspect, to prevent eversion of the foot. 
 
 532. Some surgeons treat fractures of the thigh-bone, 
 particularly of its upper part, in a slightly flexed position, 
 the body being somewhat raised in bed, the thigh and leg 
 supported on a double inclined plane, and the foot, to pre- 
 
FRACTURE OF THE LEG. 309 
 
 vent its eversion, made fast to a suitable foot-piece [534]. 
 Small splints are applied by buckle bandages to the anterior 
 and lateral aspects of the thigh. Smith's anterior splint 
 acts the part of a double inclined plane for suspending the 
 
 Smith's anterior splint. 
 
 limb in the flexed position. It consists of a framework of 
 stout wire, which is applied to the anterior aspect of the 
 limb; short strips of strong muslin or bandage are attached 
 to the wires, and pass beneath the limb, to form a cradle 
 for its support. The splint is then bound on firmly by 
 
 / 
 
 Smith's anterior splint applied. 
 
 roller bandages, and the whole suspended as shown in the 
 accompanying illustration. The thigh attachment for sus- 
 pension should be near the seat of the fracture ; the leg 
 attachment about half way between the knee and the ankle. 
 533. In FRACTURES OF THE LEG, uot including gunshot 
 fractures, both bones are usually broken, and in their lower 
 third, their weakest point. Any break in the anterior bor- 
 der of the tibia can readily be detected by the fingers; but 
 
310 FEACTUEE OF THE LEG. 
 
 ■when the fracture is near the ankle-joint the strong muscles 
 of the calf may draw the lower fragments and heel back- 
 ward,- or, if the fracture be oblique, the foot may be dis- 
 placed outwardly or inwardly. In these cases the absence 
 of dislocation is known by the removal of the deformity 
 under the influence of slight traction. When the fibula 
 alone is broken, as is sometimes the case from a twist of 
 the foot, crepitus may be felt by firmly grasping the parts 
 and moving the broken ends on each other. 
 
 534. When, in fracture of either or both bones, there is 
 little deformity, the plaster of Paris, or starch bandage 
 strengthened by a pasteboard splint, may be immediately 
 applied. When the fracture is in the upper third of the 
 leg, the upper fragments are prone to be tilted forward, 
 particularly when the muscles of the anterior aspect of the 
 thigh are put on the stretch by bending the knee. The 
 straight is, therefore, the best attitude for the treatment of 
 such fractures. A roller is applied to the limb, which is 
 then placed on a straight wooden splint, somewhat hollowed 
 on its upper surface, and extending from the middle of the 
 thigh to the heel ; after which a pasteboard or gutta-percha 
 splint is moulded to each of the lateral aspects. When the 
 
 Double inclined plane for fractures of lower extremity. 
 
 fracture is below the upper third, the flexed position of the 
 limb is considered to give better results. The double 
 inclined plane for this purpose ends below in a foot-piece, 
 
FRACTURE OF THE LEG. 311 
 
 and has a screw beneath the knee-joint by which the angle 
 of elevation may be altered to suit the necessities of the 
 case or to permit of passive motion to the -joint when the 
 confinement of the limb has continued for a long time. 
 The fracture-box is often used for the treatment of these 
 fractures, and is particularly useful in gunshot injuries, 
 and those which are associated with wounds of the soft 
 parts. It consists of a bottom which extends from the 
 knee to the sole, two sides which are hinged so that they 
 
 Fracture box for the leg. 
 
 may be approximated over the contained limb, and a foot- 
 piece fixed at an appropriate angle. A soft pillow is laid 
 in the box, or oakum, bran, etc., may be used for this pur- 
 pose; the injured limb is then deposited in it, and the 
 necessary pressure exerted by tying stout tapes or strips of 
 bandage around its yielding sides. If bran is used, a soft 
 muslin cloth should be laid in the box in the first instance, 
 that its ends may be folded securely around the limb and 
 fastened to prevent the leakage of its contents. 
 
CHAPTER XI. 
 
 DISLOCATIONS. 
 
 535. A dislocation is a displacement of tlie bones form- 
 ing a joint; the ligaments are stretched or ruptured, and 
 the articulating surfaces of the bones more or less separated 
 from each other. The bone dislodged is usually that on 
 the lower or distal side of the joint; the other remains in 
 its place. 
 
 536. Dislocation is characterized by pain, swelling, loss 
 of power over the part, and deformity from the unnatural 
 position of the dislodged bone. Deformity in fracture may 
 be removed by pulliug the parts gently into their proper 
 place, but it returns when the traction ceases ; dislocation 
 offers a fixed resistance to efforts of this kind ; but once the 
 deformity is removed by the application of a greater force, 
 it does not return. Moreover, deformity in fracture is asso- 
 ciated with a mobility in parts which should be rigid, while 
 in dislocation there is rigidity of parts which are naturally 
 mobile. Ordinarily, therefore, there is little difficulty in 
 determining whether an injury is a fracture or dislocation, 
 particularly if the examination is made before inflammatory 
 swelling is developed. Counter-extension, extension, and 
 manipulation are required to reduce a dislocation. Counter- 
 extension is the force applied to the upper bone to fix it in 
 its place, so that the extensional force applied to the lower 
 bone may be wholly utilized in drawing it away from its 
 unnatural position. Manipulation tilts the lower bone into 
 
DISLOCATION OF THE LOWER JAW. 313 
 
 its place by direct pressure or by some suitable movement of 
 the limb, when the extending and counter-extending forces 
 have freed the bones from their unnatural position. The 
 extending force should be steady, and gradually increased 
 until its object is accomplished. The use of pulleys for 
 multiplying power is seldom required in the recent injuries 
 which constitute surgical emergencies; and chloroform is 
 rarely needful, as the primary shock suflSciently relaxes the 
 muscles. 
 
 537. When a dislocation is complicated by fracture close 
 to the head of the dislocated bone it is always difficult, and 
 sometimes 'impossible, to effect its reduction. 
 
 538. After a dislocation has been reduced, the joint 
 should be supported by a sling, bandage, or splint for a 
 week or more until the risk of recurrence has been obviated 
 by the recovery of the lacerated or stretched ligaments. 
 
 539. The lower jaw is dislocated by opening the mouth 
 too widely, as in yawning, etc., or by a downward blow on 
 the chin while the mouth is half open ; both sides are usu- 
 ally displaced, sometimes only one. The head of the bone 
 slips from itg natural position, immediately in front of the 
 ear, over and in front of the eminence which forms the 
 anterior margin of its articular cavity. The mouth is locked 
 in the half -open position ; speech and deglutition are effected 
 with difficulty, and there is a dribbling of saliva from over- 
 secretion by the stimulus of pressure on the salivary glands. 
 To reduce : Two pieces of soft wood, each about as thick 
 as the thumb, are placed, one on each side, between the 
 upper and lower posterior molars, and are held in this 
 position by an assistant standing behind the patient. The 
 operator then places his fingers under the arch of the bone 
 and raises it, gradually increasing the power, by which 
 means the head of the bone is tilted downward and back- 
 
314 DISLOCATION OF THE LOWER JAW. 
 
 ward over the articular eminence, when the muscles of 
 mastication immediately return it to its cavity with a snap. 
 In the absence of an assistant, the operator may insert his 
 thumbs into the patient's mouth, and press the posterior 
 lower molars downward, while with his fingers he raises 
 
 A Dislocated Lower Jaw : The condyloid process a of the lower jaw has 
 slipped over the articular eminence b fi'om its natural position in the articular 
 cavity c which lies in front of the canal of the ear. The alveolar arch d is thus 
 projected forward and the mouth is open because the coronoid process, e, strikes 
 against the lower edge of the malar bone / ; gis the angle of the jaw and h its 
 ramus. 
 
 the chin ; but in this case the thumbs should be guarded by 
 strong leather gloves. A chin bandage [460] should be 
 worn for a few days to support the joint. 
 
 540. The most common displacement of the inner end of 
 the CLAVICLE is that in which it is thrown forward from its 
 articulation with the sternum or breast-bone by violence 
 applied to the front of the shoulder. The most common 
 displacement at the outer end of the bone is the removal 
 from it, in a downward direction, of the acromion process 
 of the scapula by direct violence, as by falls or blows on 
 the shoulder. The nature of the injury, in either case, is 
 easily distinguished by the unnatural projection of the end 
 of the collar-bone as it lies beneath the skin. Both luxa- 
 tions are reduced by placing the knee, as a fixed point, 
 
DISLOCATION OF THE SHOULDER-JOINT. 
 
 315 
 
 between the patient's shoulder-blades and drawing the 
 shoulders steadily backward while an assistant in front of 
 the patient makes pressure to direct the end of the bone 
 into its place. After reduction the retentive apparatus 
 used for fracture of the clavicle [515], with a pad over the 
 displaced end of the bone, should be used to preserve the 
 parts at rest. 
 
 541. Dislocations of the shoulder- joint are more com- 
 mon than those of all the other joints of the body taken 
 together ; and whal; is called the down- 
 ward displacement of the head of the 
 humerus into the armpit is by far the 
 most frequent of the shoulder luxa- 
 tions ; in fact the others are extremely 
 rare as compared with it. The in- 
 jury is easily recognized: The round- 
 ness of the shoulder is lost; its apex 
 is formed by the projecting acromion, 
 beneath which may be felt a depression 
 caused by the absence of the head of 
 the bone from the glenoid cavity of 
 the scapula; the patient supports his 
 forearm, as in fracture, with the hand 
 of the uninjured side; but the arm is rigid, generally 
 in line with the long axis of the body, but with the elbow 
 projecting somewhat from the side. The long axis of the 
 bone is seen to extend from the elbow to the armpit, in 
 which situation its round head may be felt, particularly if 
 at tlie same time an eifort be made to raise the elbow. [In 
 the accompanying illustration the shaft of the humerus is 
 too perpendicular ; it should have had a decided outward 
 slope. ] Eaising or lowering the elbow is difficult and causes 
 great pain, but a slight forward and backward movement 
 
 Dislocation downward 
 of the tiumerus at the 
 shoulder, the head of the 
 bone lying below the 
 glenoid cavity of the 
 scapula. 
 
316 
 
 DISLOCATION OF THE SHOULDER- JOINT. 
 
 may sometimes be effected without much inconvenience. 
 This projection of the elbow may indeed be looked upon as 
 a reliable sign of dislocation if it persist when the hand of 
 the patient is laid upon his uninjured shoulder. The fingers 
 tingle and become numb from pressure by the displaced 
 bone on the large nerves traversing the axillary space, and 
 the limb may soon become swollen from interference with 
 the circulation. 
 
 542. When recent, this dislocation is easily reduced. An 
 assistant holds the body of the patient fixed; another 
 makes traction on the elbow in the line of the bone, at first 
 downward and outward, and 
 afterward more directly out- 
 ward by gradually raising the 
 elbow, to draw the humerus out 
 of its abnormal position, while 
 the fingers of the operator in 
 the armpit press outward and 
 upward to help the head over 
 the edge of the glenoid cavity; 
 and as soon as this is accom- 
 plished the muscles restore the 
 bone with a snap to its natural 
 position. 
 
 543. Various modes have 
 been suggested of accomplish- 
 ing reduction when assistance 
 is limited to one person, as, 
 is seated on a low chair on which the operator places 
 his foot so as to insert his knee into the axilla; with 
 one hand he fixes the shoulder, and with the other grasp- 
 ing the elbow he draws the humerus downward, at the 
 same time endeavoring, by pressing it inward, with his 
 
 Beducing a downward disloca- 
 tion of the humerus at the shoul- 
 der-Joint. 
 
 for instance: The patient 
 
DlSLOCATIOlf OF THE ELBOW- JOIKT. 317 
 
 knee as a fulcrum, to tilt its head over the edge of the 
 articular cavity. Again : The patient lies on his back on 
 the ground while the operator, seated by his injured side 
 and facing him, makes traction on the hand and forearm, 
 and with his unbooted foot in the axilla directs the head of 
 the bone to its cavity. Or : The armpit of the patient is 
 hooked over the top bar of a wooden fence and the operator 
 makes traction on the displaced bone, the inertia of the 
 
 Dislocation backward of the radius and ulna at the elbow. 
 
 patient on the other side of the fence affording the counter- 
 extending or resisting force, while the breadth of the top 
 rail, under these conditions, lifts the head of the bone over 
 the edge of the cavity. In muscular subjects it may be 
 needful to clove-hitch [546] a skein of yarn or some other 
 strong soft material to the arm, by which to make the 
 necessary traction. After reduction the arm must be sup- 
 ported in a sling for several days. 
 
 544. The most frequent of the dislocations at the blbow- 
 joiNT is that in which both bones of the forearm are carried, 
 backward and project beyond the lower end of the humerus. 
 The deformity is similar to that in fracture of the lower end 
 of the arm-bone, but it cannot be removed, as in that case, 
 by gentle traction ; the forearm and arm are fixed in their 
 abnormal relation to each other, and cannot be unlocked 
 without the intelligent application of suitable force. One 
 assistant fixes the humerus, another makes traction on the 
 
318 DISLOOATION 01' THE HAND. 
 
 forearm in the direction of its length, and the operator, 
 placing the fingers of one hand in front of the forearm close 
 to the elbow, and those of the other on the projection behind 
 the joint, endeavors to pull the bones away from their posi- 
 tion against the lower end of the humerus. Or: The 
 patient being seated on a chair, the operator rests his foot 
 on it and places his knee in the bend of the injured elbow, 
 pressing against the front of the radius and ulna to dislodge 
 them ; one hand fixes the humerus while the other makes 
 traction on the forearm, and, after the knee-pressure has 
 been kept up for some time, bends the forearm around the 
 knee to bring the articulating surfaces into contact. The 
 joint and forearm must afterward be supported in a sling. 
 
 545. Dislocation of the hand from the lower end of the 
 bones of the forearm is an extremely rare injury, at one 
 time supposed to be more common because fracture of the 
 lower end of the radius [523] was frequently mistaken 
 for it. 
 
 546. The thumb has three joints — one opposite the upper 
 part of the ball, one on a level with the web, and a third 
 
 Formation of the clove-hitch. 
 
 in the free portion. All are liable to luxation, but the mid- 
 dle joint most frequently meets with this injury, the lower 
 bone being usually thrown backward on the upper. To 
 apply a suitable extending force it is sometimes needful to 
 use a skein of thread or a strong tape made fast to the 
 thumb by a clove-hitch, with a few turns of a wetted roller 
 
DISLOCATION OF THE HIP-JOINT. 319 
 
 applied beneath to protect the skin. The clove-hitch is 
 made by forming two loops as in the cut, and then placing 
 that on the right over or in front of the other, so as to form 
 a double loop ; when traction is made on its ends this loop 
 around the thumb does not slip. 
 
 547. The joints of the fingers, when dislocated, are 
 reduced in the same manner as those of the thumb. 
 
 548. Dislocations op the hip-joint are accidents which 
 require the best gurgical intelligence for their treatment. 
 In presenting them briefly in this place, it is not suggested 
 that members of the hospital corps should be prepared to 
 undertake their management, but merely that they should 
 have that amount of knowledge of the conditions involved 
 which will enable them to give intelligent assistance to the 
 operator in his efforts at reduction. This knowledge, under 
 the pressure of an emergency which coincides with the 
 absence of better surgical skill, may be of much benefit to 
 the patient. 
 
 549. The head of the femur may be thrown out of its 
 cavity in any direction, but systematic writers on surgery 
 divide dislocations at the hip-joint into five classes : 1, 
 Upward on the dorsum or outer aspect of the ilium; 
 2, upward and backward into a notch between the ilium 
 and ischium; 3, upward and forward toward the pubes; 
 4, downward and forward below the pubes ; and 5, anom- 
 alous dislocations which do not properly belong to any of 
 the four classes stated. Sixty per cent of the dislocations 
 of the hip-joint belong to the first class ; twenty-five to the 
 second; the remaining fifteen to the other classes. 
 
 550. When the head of the bone is thrown upward on 
 the dorsum of the ilium, the hip bulges from the unnatural 
 position of the bone, the limb is shortened, the knee rolled 
 inward and advanced across the lower third of the opposite 
 
320 
 
 DISLOCATIOSr OF THE HIP- JOINT. 
 
 thigh, and the foot inverted, with the great toe resting on 
 the top of the arch of the opposite foot. The patient can- 
 not move the limb, nor can the surgeon straighten it or 
 withdraw it from the other. The head of the bone is 
 directed backward and the trochanter forward. The injury 
 
 Pislocation upward on 
 the ilium. 
 
 Dislocation upward and 
 backward. 
 
 is distinguished from fracture of the neck of the femur by 
 nversion, immobility, and the absence of crepitus. 
 
 551. When the head of the bone rests on the ischiatic 
 notch there is less shortening and the knee is less advanced ; 
 the limb is rotated inward and the great toe rests on the 
 root of the toe of the opposite foot. The head of the bone 
 is directed backward and the trochanter forward. 
 
 552. When the head is thrown upward and forward 
 toward the pubes there is also shortening; but the knee 
 and foot are rotated outward and drawn away from the 
 opposite limb; the roundness of the hip is lost, and the 
 
DISLOCATION OF THE HIP-JOINT. 
 
 321 
 
 head of the bone, which is directed forward, forms an 
 easily discovered tumor in the groin on the outer side of the 
 femoral artery. 
 
 553. The downward dislocation is also characterized by 
 the limb being carried away from that of the opposite side; 
 
 Dislocation upward and forward. 
 
 Dislocation downward. 
 
 but in this instance there is lengthening ; and although the 
 foot is advanced, there is neither inversion nor eversion. 
 The head of the bone is directed inward and the trochanter 
 outward. 
 
 554. In dislocation upward the operator places his foot 
 in the perineum as a counter-extending force ; he passes the 
 loop of a skein of worsted, which is attached by a clove- 
 hitch to the lower part of the thigh of the patient, over his 
 neck, so that by stretching himself backward he may bring 
 a considerable extending force to bear on the dislocated 
 bone ; and when these forces have been continued for some 
 time he endeavors with both hands to rotate the knee out- 
 21 
 
322 DISLOCATION' OF THE HIP-JOINT. 
 
 ward so as to tilt the head of the bone into its cavity. But 
 generally in these dislocations chloroform has to be admin- 
 istered and steady traction by pulleys used for the purposes 
 of extension. For instance, in the upward dislocation the 
 patient lies on his back; a sheet is folded to form a perineal 
 band, the ends of -which are made fast to some immovable 
 object so situated that its resistance shall be exercised in 
 line with the long axis of the femur ; a skein of worsted is 
 
 Seduction of upward dislocation. 
 
 then clove-hitched above" the knee, or a suitable leathern 
 band buckled on this part, and hooked on to the system of 
 pulleys, which are so arranged that the extending force may 
 also be in line with the long axis of the femur. When these 
 forces have brought the head of the bone down to its proper 
 level, the operator rotates the knee slightly outward to 
 complete the reduction; or if difftculty be experienced in 
 effecting this, he passes a towel beneath the thigh close to 
 the hip-joint, and tying its ends together, places the bight 
 over his neck and endeavors by raising his body to lift the 
 head of the bone into its cavity while using his hands on 
 the pelvis as a counter-force. 
 
 555. In the upward and backward dislocation the patient 
 lies on his side and the extending and counter-extending 
 forces are directed in a line across the middle of the sound 
 thigh. 
 
 556. When the head of the bone is thrown toward the 
 
msLocATioisr of the hip-joint. 
 
 323 
 
 pubes, the patient is placed on his sound side ; counter- 
 extension by the perineal band is upward and forward in 
 front of the line of the body, and extension downward and 
 backward behind the line of the body ; a towel is used to 
 lift the bone into its place. 
 
 657. In the downward dislocation the patient lies on his 
 back ; the pelvis is fixed by a sheet which is made fast to 
 
 Reduction of upward and backward dislocation. 
 
 some immovable object on the sound side; another sheet is 
 passed into the perineum and its ends are carried up between 
 the body and the counter-extending girth, after which they 
 
 Reduction of upward and forward dislocation. 
 
 are attached to the pulleys ; extension is made in an upward 
 and outward direction as regards the position of the patient; 
 and when these forces have been sustained for some time, 
 
324 DISLOCATION OF THE KJ^TEE-JOINT. 
 
 the operator from the sound side passes his hand beneath 
 the patient's sound ankle, and, grasping the ankle of the 
 injured limb, draws it toward him, thereby throwing the 
 head of the bone outward into its place. 
 558. In all these dislocations a long straight splint [530] 
 
 Reduction of the downward dislocation. 
 
 must be applied on the outer side, after reduction, and 
 retained for two or three weeks to support the joint and 
 prevent motion. 
 
 659. The patella or knee-cap is sometimes driven out- 
 ward, less frequently inward, from its position in front 
 of the knee-joint. Keduction is effected by bringing the 
 limb forward on the body to relax the muscles on the ante- 
 rior aspect of the thigh, and then pressing the bone inward 
 or outward, as may be required, to restore it to its place. 
 
 560. Dislocations at the knee-joint are dangerous from 
 the violence needful to cause them and from their inflam- 
 matory consequences. The nature of the injury is easily 
 distinguished. Keduction is accomplished bj' extension 
 from the ankle and counter-extension from the thigh to 
 separate the bones, with pressure by the fingers of the oper- 
 ator outward, inward, forward, or backward, as may be re- 
 quired to bring the head of the tibia into its proper place. 
 
 561. The most frequent of the dislocations of the ankle- 
 
DISLOCATIOK OP THE ANKLE-JOINT. 325 
 
 JOINT is that in which the foot is twisted outward, so that 
 its inner edge rests on the ground. The lower end of the 
 tibia forms a projection on the inner aspect of the joint, 
 and there is a depression on the outer aspect about two 
 inches above the joint where the thinner bone, the fibula, 
 generally gives way. This accident has often been called 
 "Pott's fracture," after the surgeon who first described the 
 true condition of the parts involved. It is treated by exten- 
 sion to the foot, counter-extension to the leg or thigh, and 
 manipulation to return the bones to their natural relation- 
 ship. The leg is then placed on an inclined plane with 
 a foot-piece, or otherwise supported until the fractured 
 fibula becomes united and the ruptured ligaments healed. 
 
 562. Other dislocations at the ankle and of the bones of 
 the FOOT are rare or so complicated by the violence which 
 caused them that the displacement of the bones is only one, 
 and often a secondary one, of the conditions that require 
 surgical treatment. 
 
CHAPTER XII. 
 
 THE MANAGEMENT OF CASES OF POISONING. 
 
 563. The strong acids and alkalies can hardly be called 
 poisons. When taken accidentally, they seldom reach the 
 stomach, as their presence in the mouth discovers the acci- 
 dent and leads to the immediate rejection of the mouthful. 
 When taken intentionally, however, the stomach is involved. 
 There is intense thirst with burning and agonizing pain, 
 nausea, and vomiting of matters mixed with darkened blood 
 and portions of mucous membrane. After much suffering 
 the patient becomes exhausted, his pulse rapid and weak, 
 skin cold and clammy, leading to death by collapse. 
 Sometimes the shock of the injury [358] is so great that 
 death may occur with little suffering. In other cases, par- 
 ticularly when ammonia has been used, death may occur 
 from suffocation caused by tumefaction of the larynx. The 
 corrosive agent should be immediately neutralized. Mag- 
 nesia answers best for the strong acids, as it is bland in 
 itself and disengages no gas to distend the injured stomach ; 
 but in its absence chalk, whiting, washing or baking soda 
 may be used, or even soap and water, as the fatty acid of 
 the soap does not interfere with the antidotal power of its 
 alkali. When potash, soda, or ammonia is the corrosive 
 agent, vinegar, lemon juice, aromatic sulphuric acid, etc., 
 suitably diluted, must be administered. Subsequently, the 
 whites of two or three eggs should be given in water, or in 
 their absence, milk, olive oil, or mucilaginous drinks, as 
 
MAKAGEMENT OF CASES OF POISONING. 327 
 
 gruel, acacia water, or linseed tea. The intense suffering 
 should be alleviated by subcutaneous injections of morphine, 
 and the patient sustained during threatening coUapse by 
 injections of brandy, warmth^ and friction. 
 
 564. Poisons, from the point of view of those who are 
 called upon to rescue the patient, may be divided into three 
 classes. 
 
 I. Local irritants which produce an irritation or inflam- 
 mation of the alimentary canal. 
 
 II. Those which combine with the local irritation a cer- 
 tain action on some other part of the system. 
 
 III. Those which exert their influence on the nervous 
 system with little or no local action on the alimentary canal. 
 
 565. In every case of poisoning the first object of treat- 
 ment is to rid the stomach of the deleterious agent, and 
 meanwhile, if possible, to prevent its absorption. If free 
 vomiting is occasioned by the poisonous agent itself the use 
 of warm water may suffice to secure its removal ; otherwise 
 evacuation is best accomplished by the lavage-tube or stom- 
 ach-pump, because the use of these instruments is not at- 
 tended with the exhaustion that is prone to follow repeated 
 vomiting. To wash out the stomach by siphon action the 
 lavage-tube is warmed, oiled, and introduced while the 
 patient is supported in the sitting posture. Its tip, in be- 
 ginning its descent, should be in contact with the back part 
 of the pharynx. When introduced it is connected with a 
 funnel, the latter filled with warm water and held below 
 the level of the patient's stomach. When all is ready the 
 funnel is raised that its contents may flow gently into the 
 stomach, and when the latter is distended it may be 
 emptied by lowering the funnel below the level of the 
 stomach. This flushing with warm water should be re- 
 peated several times. Should any solid matters block the 
 
338 MANAGEMEH-T OF CASES OF POISONING. 
 
 stomach, apertures of the tube they may be cleared out by 
 raising the funnel. The stomach-pump consists of a barrel 
 and piston, the nozzle of the former fitted on its end with* 
 a flexible stomach-tube and on its side with another tube 
 for conveying the pumped liquids into a receiving basin ; 
 but the valves of the pump are so constructed that the action 
 of the instrument may be easily reversed, thus enabling the 
 operator to pump liquids into as well as out of the stomach. 
 Water should be alternately pumped in and removed until 
 it comes away clear. When the lavage-tube or pump is not 
 at hand, mustard or sulphate of zinc should be preferred as 
 emetics, because they act promptly and with little straining 
 or depression. The dose is one or two teaspoonfuls of the 
 former, or two grams of the latter, in a tumblerful of 
 warm water, vomiting being afterward solicited by tickling 
 the fauces and driuking large quantities of tepid water. 
 Ipecacuanha, in two-gram doses, may also be used. Sul- 
 phate of copper, from its irritant properties, is likely in 
 many cases to increase the poisonous effect if it be not 
 efficient as an emetic ; and tartar emetic induces too much 
 prostration to be used in cases which so often tend to death 
 by the supervention of collapse. Hydrochlorate of apomor- 
 phine, .006, may be given by hypodermic injection [305] 
 when the patient is unable to swallow. 
 
 566. The prevention of absorption is effected by the ad- 
 ministration of a chemical antidote which will combine 
 with the poison in the stomach to the formation of a sub- 
 stance which is insoluble or inert. • This may often be at- 
 tempted pending the evacuation of the stomach. Tannic 
 acid, for instance, unites with the poisonous alkaloids, and 
 also with tartar emetic, forming insoluble compounds. It 
 is well, therefore, in treating poisoning by vegetable sub- 
 stances, to make the patient drink 260 c.c. of water con- 
 
MAKAGEMENt OF CASES OF POISONING. 329 
 
 taining a gram of tannin, or freely of an infusion of green 
 tea, particularly if there is any delay in procuring the 
 stomach-tube or emetic. The tannin is given in the ex- 
 pectation of holding the deleterious agent prisoner until it 
 can be removed ; but the necessity for its removal is not 
 obviated, for the tannin compound is soluble and poisonous 
 under certain conditions that might be present in the ali- 
 mentary canal. So in the case of poisoning by salts or oxids 
 of the metals, ai^enic and antimony excepted, it is well to 
 have the patient swallow the whites of two or three eggs 
 diffused in water, for albumen forms insoluble compounds 
 with most of these poisonous substances. If eggs are not 
 at hand, milk or flour and water may be used as less efficient 
 substitutes, as the casein of the one and the gluten of the 
 other have a chemical action somewhat similar to that of 
 albumen. But as these compounds also are liable to be 
 dissolved under certain conditions, those produced with 
 corrosive sublimate and sulphate of copper being, for 
 instance, soluble in an excess of albumen, it is proper to 
 get them out of the stomach as speedily as possible. 
 
 567. When the poisonous substance is known, the chem- 
 ical antidote is sometimes indicated with precision. Thus, 
 when nitrate of silver has been swallowed, a solution of 
 common salt destroys its causticity by precipitating the sil- 
 ver as an insoluble chlorid ; when oxalic acid has been used, 
 chalk or whiting neutralizes its irritant qualities by convert- 
 ing it into an insoluble oxalate ; carbolic acid and sugar of 
 lead are rendered inert by the use of a soluble sulphate 
 such as Epsom or Glauber's salt; phosphorus is converted 
 into a harmless phosphid by sulphate of copper, and arsenic 
 is deprived of its poisonous properties by the hydrated oxid 
 of iron. In all the cases mentioned except the last, the 
 antidote is administered when available, irrespective of the 
 
330 MANAGEMEN'T OF CASES OF POISOKING. 
 
 antecedent or subsequent use of emetics ; but in the excep- 
 tional case of arsenic, the stomach should be evacuated in 
 the first instance, and the antidote be permitted to remain 
 for the neutralization of any residuum of the poison. 
 
 568. Having prevented further injury from the ingest- 
 ed poison by neutralizing and evacuating its unabsorbed 
 remains, the attention of the attendant should be de- 
 voted to relieving suffering and obviating the tendency to 
 death. 
 
 569. The relief of suffering is called for mainly by the 
 irritant class. The burning pain in the stomach and bowels 
 indicates the inflamed or eroded condition of the mucous 
 membrane, and calls for the use of cooling, bland, and pro- 
 tective liquids, as olive oil, mucilage of acacia, linseed tea, 
 barley water, and gruels, with small quantities of ice or 
 ice water to allay thirst. Mustard to the pit of the stom- 
 ach or large emollient poultices over the abdomen afford 
 relief, but opium is the chief reliance in aggravated cases, 
 given by the mouth, by enema, or hypodermically. As 
 death in these cases is the result of increasing prostra- 
 tion and collapse, the tendency must be counteracted by 
 the use of beef essence, free stimulation, warmth, and fric- 
 tions. 
 
 670. The irritant effects of the few poisonous substances 
 in the second class are controlled as stated in the last para- 
 graph ; but oil should not be used as a protective in the case 
 of phosphorus or cantharides, as it dissolves the poisonous 
 principle in both instances, and would probably aggravate 
 the symptoms. The strangury of cantharides is controlled 
 by twenty or thirty drops of liquor potassse taken hourly 
 in water. Collapse is treated as in the purely irritant class ; 
 but in aconite poisoning digitalis may be tried to counteract 
 its directly depressant action on the heart; and if the dan- 
 
MANAGEMENT OF CASES OF POISONING. 331 
 
 ger from carbolic acid be rather from failure of the respira- 
 tion than from collapse, atropine, enemata of coffee, water 
 douches, and artificial respiration should be employed. 
 
 671. Of the poisons of the third class, opium, belladonna, 
 and hyoscyamus produce a stupor in which the respiratory 
 wants of the system are unheeded, and the patient dies 
 because he does not respire. Chloral.kills in the same way, 
 but there is in addition a paralyzing action on the heart 
 and muscular systgm that renders strychnine, .003 subcu- 
 taneously, of value as a remedy. Prussic acid, hemlock, 
 and tobacco also paralyze the muscular system, and require 
 stimulants, atropine, .001, digitalis, 1 c.c. of the tincture, 
 or strychnine hypodermically to counteract their influence, 
 and artificial respiration to prolong the hope of recovery. 
 Hellebore depresses the heart's action, an effect which is 
 counteracted by digitalis ; while the excitement of the heart 
 occasioned by digitalis is quieted by aconite. Strychnine 
 calls for bromid of potassium and chloral, and inhalations 
 of chloroform or nitrite of amyl to control the muscular 
 spasms and lessen the danger of exhaustion from their con- 
 tinuance, or of death from their intensity. 
 
 I. IRRITANTS. 
 
 572. Arsenic causes burning pain in the stomach, with 
 great thirst, nausea, vomiting of brownish matter and blood- 
 stained mucus, tenderness of the abdomen and purging with 
 much griping, straining, and suppression of urine; great 
 prostration with much anxiety, fainting, palpitations, and 
 cramps, ending in collapse with cold and clammy skin, 
 sighing respiration, and imperceptible pulse. The lavage- 
 tube or emetics ; after which a tablespoonful of recently pre- 
 pared ferric hydrate, given every five or ten minutes, until 
 
333 MANAGEMElfT OF CASES OF POISOKIKG. 
 
 the patient is relieved. The hydrate is prepared by pre- 
 cipitating a solution of tersulphate of iron by liquor of 
 ammonia, and straining and washing the precipitate to free 
 it from excess of ammonia. An antidote, ferri oxyduTn 
 hydratuTfi cum magnesia, the preparation of which involves 
 no loss of time in washing, has been provided by the Phar- 
 macopeia. The tersulphate solution is treated with an 
 excess of magnesia, instead of ammonia, and the precipitate 
 is immediately administered by the tablespoonful, for neither 
 the magnesia nor its sulpahte which is formed during the 
 precipitation interferes with the action of the hydrated 
 oxid. Suffering is then relieved and inflammation allayed 
 by mucilaginous drinks, cataplasTns, and morphine, and 
 threatening collapse averted by stiTHulants and the warmth 
 of hot-water bottles, flannels, and friction. 
 
 573. CoEROsivB SUBLIMATE is similar in its action to 
 arsenic, causing gastric and intestinal inflammation and col- 
 lapse. Egg-alhumen, milk or flour and water; the lavage- 
 tube or emetics ; subsequent treatment as in arsenical poi- 
 soning. 
 
 574. Sugar of lead induces the usual gastric symptoms, 
 but the vomited matters contain white chlorid of lead; 
 there is great abdominal tenderness with cramps and in- 
 creasing prostration, but the astringency of the lead salt 
 prevents the purging that generally characterizes irritant 
 poisoning. Sulphate of soda, sulphate of magnesia, or 
 aromatic sulphuric acid in water ; the lavage-tube or emetics ; 
 subsequent treatment as in arsenical cases. 
 
 575. ISTiTKATE OF SILVER produccs local symptoms with 
 much constitutional disturbance. Common salt in solution ; 
 the lavage-tube or emetics, and subsequent treatment as in 
 arsenic. 
 
 576. Zinc salts. — The sulphate, taken sometimes by 
 
MANAGEMENT OF CASES OF POISONING. 333 
 
 mistake for Epsom salt, is its own antidote by emetic 
 action ; subsequent collapse requires treatment as ia arsenic. 
 
 577. Copper salts. — The primary effects are those of 
 local irritants; the sulphate may be its own antidote. 
 White of egg, milk, or flour and water ; the lavage-tuhe or 
 emetics if required; subsequent treatment as in arsenical 
 poisoniag. 
 
 578. Taetar emetic. — Collapse is hastened by a direct 
 depressant action on the circulation. This poison acts as 
 its own antidote in evacuating the stomach. Tannin in 
 solution, or infusion of green tea, with morphine to allay 
 excessive vomiting and relieve suffering, and stimulants as 
 required. 
 
 579. Oxalic acid. — Chalk or whiting diffused Lu water; 
 the lavage-tube or emetics, and subsequently measures to 
 relieve suffering, and avert, or recover from, collapse. 
 
 580. Cboton oil, colocynth, and other drastic ca- 
 thartics tend to death by exhausting the patient. The lav- 
 age-tuhe or emetics ; opium and stimulants. 
 
 581. CoLCHicuM causes violent local irritation with in- 
 tense prostration. Tannin or green tea ; the stomach-tube or 
 emetics ; morphine and stimulants. 
 
 II. IRRITANTS with a SPECIFIC ACTION. 
 
 582. Cantharidbs produce the gastro- enteric symptoms 
 of irritant poisoning ; and also an irritant action on the kid- 
 neys, manifested by strangury and bloody urine; death is 
 preceded by delirium and convulsions. The stomach-tube 
 or emetics; mucilaginous, but not oily, preparations; 
 Tnorphine and stimulants: 
 
 583. Aconite causes a burning feeling in the throat and 
 stomach, with nausea, vomiting, purging, and intestinal 
 pains ; numbness and tingling of the muscles, merging into 
 
334 MANAGEMENT OF CASES OF POISONING. 
 
 paralysis ; great depression of the circulatioa and prostra- 
 tion, ending in general collapse, sometimes with convulsions 
 and stupor. The lavage-tiibe or emetics ; stimulants by 
 the rectum, or subcutaneously if rejected by the stomach; 
 warmth and frictions ; tincture of digitalis, 1 c.c, hypoder- 
 mically, and repeated, if need be, to strengthen the heart's 
 action. 
 
 584. Phosphorus manifests its irritant properties by 
 heat and swelling of the tongue and throat ; pain and dis- 
 tention of the abdomen, with mucous or bilious vomiting 
 and purging, sometimes bloody; anxiety, restlessness, 
 cramps, and convulsions, ending in stupor or general col- 
 lapse. Sulphate of copper, .2 in a tumbler of water every 
 five minutes until vomiting is induced; if free vomiting 
 have already occurred, the copper should be given once, 
 with opium to promote its retention ; sulphate of magnesia 
 to carry off the poison by its cathartic action ; mucilaginous, 
 but not oily, drinks ; cataplasms, opiates, and stimulants as 
 required. 
 
 585. Carbolic acid occasions a burning feeling, whiten- 
 ing the mucous membrane of the throat and stomach, and 
 speedily rendering it insensitive by coagulating its albu- 
 minoid principle; intense depression, cold and clammy 
 skin, feeble pulse, insensibility quickly deepening into stu- 
 por, with death from failure of the respiration or of the 
 heart. Sulphate of soda or sulphate of magnesia, white of 
 ^99i niilk or flour and water ; lavage-tube or apomorphine 
 subcutaneously, as emetics when introduced into the stomach 
 have little influence on its disorganized mucous membrane. 
 Stimulants by enema, or ammonia or hrandy by hypodermic 
 injection, ■with, warmth and frictions if syncope threaten; 
 atropine and artificial respiration if the breathing fail. 
 
MANAGEMENT OF CASES OF POISONING. 335 
 
 III. POISONS ACTING ON THE NERVOUS SYSTEM. 
 
 586. Opium narcotism. — -When a poisonous dose of 
 opium has been taken, the patient speedily passes from 
 drowsiness into a deepening stupor, in which his nervous 
 centres ultimately fail to recognize the necessity for respir- 
 ing, and he passes into death by ceasing to breathe. At 
 first the face is flushed and the breathing stertorous, the 
 pulse full and slow, and the stupor profound ; but this con- 
 dition differs in several points from apoplexy. There is no 
 paralysis other than the temporary relaxation and loss of 
 power involved in the loss of consciousness; the pulse, 
 although full, is soft and easily compressed, the pupils are 
 contracted, and the patient may be aroused to some degree 
 of confused consciousness by shaking, slapping, douching 
 with cold water, and speaking to him in loud, sharp tones. 
 After a time the pulse becomes weaker, small, scarcely per- 
 ceptible; the respiration diminishes in frequency by long 
 intervening pauses, and inspiration is slow and often inter- 
 rupted ; the face becomes pale, the skin clammy and cool, 
 the extremities cold. In the early stages the patient should 
 be douched with cold water, to rouse him from his stupor ; 
 the lavage-tube should be used or an emetic of mustard or 
 sulphate of zinc administered, after which strong coffee is 
 swallowed from time to time, or administered by enema, to 
 counteract the narcotic tendency. Every effort must be 
 made to keep the patient awake and conscious of the neces- 
 sity of breathing. If the stomach-tube is not at hand and 
 an emetic cannot be taken by the mouth, a hypodermic 
 injection [305] of .006 apomorphine may be used. The 
 respirations should be closely watched, and if they are 
 found to be steadily decreasing, and to have fallen below 
 ten per minute, sulphate of atropine .001 should be given 
 
336 MANAGEMENT OF CASES OF POISONING. 
 
 by subcutaneous injection, and repeated once or twice at 
 intervals of ten minutes if no favorable result be observed 
 in the mean time; but if the respiration becomes more fre- 
 quent, or even more regular, and particularly if the con- 
 tracted pupils undergo a slight relaxation, the patient may 
 be permitted to rest without further effort on Ms behalf, 
 unless called for by a subsequent impairment of the regu- 
 larity or frequency of the breathing. Permanganate of 
 potassium, .4, is recommended by some as a valuable anti- 
 dote; the water used in washing out the stomach might 
 have this quantity of the permanganate dissolved in it. 
 Artificial respiration may be used as a last resource. 
 
 587. Chloral. — The chloral sleep deepens into stupor, 
 during which respiration fails and the pulse becomes weak 
 and small. Treatment as in opium poisoning, with sul- 
 phate of strychnine, .003, by hypodermic injection, if death 
 from heart failure seems impending. 
 
 588. Belladonna and hyoscyamus. — Dryness and con- 
 striction of the throat, burning in the stomach, dimness of 
 vision, with, dilated pupils, hurried breathing, headache, 
 and delirium ending in stupor, with feeble pulse, cold ex- 
 tremities, and diminished respiration ; sometimes a scarlet 
 rash on the skin . Tannin ; the lavage-tube or emetics ; 
 coffee ; mustard and friction to the extremities. 
 
 589. Prussic acid, cyanide of potassium. — Death oc- 
 curs quickly from paralysis of the respiration and heart. 
 Cold douche and ammonia to the nostrils ; artificial respira- 
 tion and frictions ; enemata of hrandy. When oil qte bit- 
 ter ALMONDS is the poisonous agent, there will probably 
 be time for the use of emetics, with subsequent treatment 
 by stimulants. 
 
 590. Hemlock. — Extreme muscular prostration and death 
 from paralysis of the respiration; no delirium or coma. 
 
MANAGEMENT OP CASES OF POISONING. 337 
 
 Tannin or green tea; the lavage-tube or emetics; stimu- 
 lants ; frictions ; atropine and artificial respiration. 
 
 591. Tobacco induces dizziness, confusion of ideas, faint- 
 ness, nausea and vomiting, intense muscular prostration, 
 and fatal collapse with or without stupor. Tannin ; la nuge- 
 tube ; stimulants, warmth, frictions, and strychnine by sub- 
 cutaneous injection. 
 
 592. Hellebore. — Intense prostration, imperceptible 
 pulse, cold, clamm]4 skin, nausea and attempts at vomiting, 
 fainting, and fatal collapse. Tannin or green tea ; lavage- 
 tube or emetics ; morphine and stimulants by the mouth or 
 rectum ; ammonia, frictions, and digitalis. 
 
 593. Digitalis. — Nausea, vomiting, and great prostra- 
 tion, with cold sweats and feeble, almost imperceptible 
 pulse, stupor or delirium, and death from spasm of the 
 heart. Tannin or green tea ; the lavage-tube or emetics ; 
 stimulants and one or two minims of tincture of aconite by 
 hypodermic injection. 
 
 594. Stkychnine. — Violent Spasms of the muscular sys- 
 tem, lasting from one to five minutes, with intervals of 
 relaxation, prolonged sometimes for half an hour. During 
 a convulsion the features are contorted, the body bent rigidly 
 backward, and the breathing stopped or much impeded; 
 brain not affected. The patient dies of asphyxia during a 
 convulsion, or exhausted by the frequency and violence of 
 the fits. Tannin; lavage-tube or emetics; brom,id of po- 
 tassium, 7 gm., and chloral, .7, to control the paroxysms, 
 with chloroform or nitrite of amyl inhalations when the con- 
 vulsions are specially severe ; artificial respiration as a last 
 resource. 
 
 595. Poisoning by aeticles op food. — Meat, sausage, 
 cheese, shell-fish, certain species of mushrooms, fruits, etc., 
 sometimes occasion nausea, vomiting, violent cramps, pain, 
 
 22 
 
338 MANAGEMENT OF CASES OF POISONING. 
 
 diarrhea, and great depression of the vital powers. The 
 lavage-tuhe or emetics and cathartics to remove the noxious 
 material, with stimulants to relieve the subsequent depres- 
 sion. 
 
 596. Poisoning by Ehus toxicodendron. — A cutaneous 
 inflammation somewhat resembling erysipelas [426] is 
 often occasioned by contact with or even by exposure to 
 emanations from the leaves of the poison oak, poison ivy, 
 and other species of Ehus. The poison oak is a small 
 shrubby plant with a leaf which consists of three leaflets : 
 two lateral, each about four inches long and two-thirds as 
 broad, springing directly from the leaf-stalk, ovate and 
 pointed at the apex, and one terminal, stalked, ovate, with 
 a wedge-shaped base and pointed apex — all notched or 
 lobed on the margins and downy on the under surface. 
 The poison ivy climbs on trees and rocks to a considerable 
 height ; its leaflets are usually smooth above and below and 
 entire on the margins. The head and face become affected, 
 and sometimes the hands and upper extremities, or the hips, 
 scrotum, and adjoining parts of the thighs. The affected 
 surface is of a lurid-red color, 'covered, in aggravated cases, 
 with vesicles, the contents of which become incrusted on 
 drying, or ooze as a thin liquid from superficial fissures. 
 Pain, heat, irritation, and swelling are associated with the 
 redness; but although these often occasion considerable 
 suffering and loss of sleep, there is seldom much constitu- 
 tional disturbance. Generally the inflammation subsides in 
 about a week without leaving subcutaneous suppurations. 
 It is treated with aperient mediciues and cooling lotions. 
 
CHAPTER XIII. 
 
 PHARMACY. 
 
 597. All the members of the hospital corps are instructed 
 in the elements of pharmacy. Those who show a bent for 
 this kind of work are afterward assigned to duty in the 
 dispensary. The course of instruction teaches the care of 
 the dispensary, the names and uses of the utensils and 
 apparatus, and the methods of cleaning them ; the care of 
 the scales, and the use of the metric system of weights and 
 measures. The student is then required to familiarize 
 himself with the various articles on the shelves of the dis- 
 pensary and the pharmaceutical processes connected with 
 them, as solution, evaporation, precipitation, filtration, 
 fusion, sublimation, distillation, etc. ; the making of pills, 
 mixtures, tinctures, ointments, etc. ; and the use of the 
 thermometer, hydrometer, urinometer, etc. Poisons and 
 their antidotes [563-595], and disinfectants, with their 
 uses in limiting the spread of infectious diseases [32&- 
 337], also form part of this course. 
 
CHAPTER XIV. 
 
 ELEMENTS OP COOKERY. 
 
 598. Lectures are given to hospital corps companies of 
 instrnction on the articles of the ration, their money value 
 in connection with the accumulation of a hospital fund, the 
 principles involved in cooking them and in arranging for 
 variety in bills of fare ; but a knowledge of practical work 
 in the preparation of food can be obtained only by experi- 
 ence in the kitchen. The " Manual for Army Cooks," pub- 
 lished under the direction of the Commissary General of 
 Subsistence,' and Munson's "Emergency Diet for the 
 Sick," '' used in the course in dietetics of the hospital corps 
 company at Washington Barracks, D. C, give full instruc- 
 tions on the subject. 
 
 599. The diet of invalids is based on our knowledge of 
 the action of the stomach on food. As starchy and saccha- 
 rine articles, when properly prepared in a semi-liquid con- 
 dition, do not make any call on the powers of the stomach 
 for their digestion [221], they are largely used in the sick 
 chamber. Arrowroot, barley, corn-starch, farina, and tap- 
 ioca are invariably found in the list of hospital stores. 
 Nitrogenous substances, when used for the sick, are re- 
 duced to the liquid form, as beef tea, mutton, or chicken 
 broth, etc. The patient takes wine whey until he is able 
 to digest the casein of milk, and eggs beaten up with wine 
 
 ' Washington. Government Printing-office, 1896. 
 " Washington. Government Printing-office, 1900. 
 
ALIMENTATION. 341 
 
 or brandy until the stomach can digest more solid forms of 
 nutriment. Jellies lead on to custards, light puddings, and 
 various farinaceous dishes, and these to fish, chicken, and 
 carefully cooked meats. 
 
 600, All substances used as food are of an organic, and 
 hence putrescible, nature. If bacterial germs are kept 
 away the substance will not putrefy, but will dry up like 
 the preserved meat strips in use in Mexico and other hot 
 countries. The germs of putrefaction are so constantly 
 present in the atmosphere that it is difficult to preserve 
 food for any time when heat and moisture also are present ; 
 but when there are unclean spots in a kitchen or store-room 
 the speedy putrefaction of exposed articles becomes a cer- 
 tainty. Cleanliness is therefore the first requisite in a 
 cook ; no excuse should hold good against a want of clean- 
 liness. 
 
 601. The application of heat in the process of cooking 
 promotes the breaking up of the organic tissues and facili- 
 tates their digestion. Moreover, as heat destroys all germs, 
 the thorough cooking of food is preventive of intestinal 
 worms, trichiniasis, etc., and lessens the danger of seizure 
 in times of epidemic disease. The albuminoids, when 
 introduced into the stomach in their raw state, undergo 
 coagulation with subsequent solution of the coagulum in the 
 gastric juices. Heat applied in cooking coagulates the 
 albuminoids and prepares them for immediate solution. At 
 the same time it disintegrates or gelatinizes the fibres and 
 permits the dissolving process to penetrate more readily 
 into their substance. Starch, which forms so large a pro- 
 portion of all vegetable food, is indigestible in its raw 
 state, but under the influence of heat its granules are 
 broken up and its solubility increased by its transforma- 
 tion into dextrin and glucose. 
 
342 ALIMENTATION. 
 
 602. Heat is applied in cooking by various methods, as 
 boiling, stewing, frying, broiling, roasting, and baking. 
 
 603. The water used in boiling is merely the medium by 
 which the heat is communicated. None of the juices of the 
 meat or other article should be permitted to waste into it. 
 To this end the water should be slightly salted and boiling 
 vigorously when the meat to be boiled, is dropped into it. 
 After five minutes of active boiling the process is conducted 
 at a slow boiling or simmering temperature for a period 
 varying with the weight of the meat, usually estimated at 
 about fifteen minutes per pound. Salt meats, however, 
 should be put on the fire with cold water. Over-boiled 
 meat, like a hard-boiled egg, is tough from the density of 
 its coagulation. Fish is boiled in like manner until the 
 meat is found to separate readily from the back-bone, after 
 which it should be removed from the water and drained, 
 else it will become water-logged and insipid. Potatoes and 
 other root vegetables should be cut into pieces of equal size, 
 that the heat may penetrate to the centre of each at the 
 same time. If potatoes are peeled before boiling, the water 
 should be strongly salted to prevent the antiscorbutic salts 
 from being dissolved out. When a fork passes easily to 
 the centre, the water should be poured off and the vessel 
 replaced on the fire to get rid of superfluous moisture by 
 steaming. Beans, peas, rice, and other hard grains require 
 soaking in water before boiling. Milk, particularly if 
 thickened by the swelling starch cells of any of the meals 
 or flours, should be stirred constantly to prevent the scorch- 
 ing of the bottom layer; preferably, such preparations 
 should be made in a vessel having a water jacket. 
 
 604. In stewing meat, the small quantity of water used 
 is intended to be a part of the food. The meat is chopped 
 up to facilitate its disintegration, and the boiling is con- 
 ducted slowly and with care, to avoid scorching. 
 
ALIMElfTATIOK. 343 
 
 605. In making soup or beef stock, it is intended that the 
 whole of the soluble organic substances shall be transferred 
 to the water. Gelatin, dissolved from bones by seven or 
 eight hours' continued boiling, forms the basis of the soup; 
 but this is usually strengthened by the addition of meat 
 which, from its toughness, cannot be disposed of otherwise 
 to advantage. Gelatin is held by some physicians to be of 
 no value as a nutriment, but this seems inconsistent with 
 the results of every-day experience. Simmering, rather 
 than active boilingj is required in making soup; froth and 
 grease should be skimmed off as they gather on the surface. 
 The stock should be kept for use in tin or earthenware ves- 
 sels ; iron vessels give it an unpleasant taste. The soup is 
 completed by adding vegetables, cut into small dice, to 
 flavor and give substance. 
 
 606. In making beef tea, lean meat is chopped up finely 
 and simmered with water, a pint to a pound. Beef essence 
 consists of the juices collected by digesting the chopped 
 meat in a water bath. The meat is usually placed in a 
 wide-mouthed bottle, which is securely corked, and cooked 
 in a kettle of boiling water. 
 
 607. Hot fat or lard is used as the means of communicat- 
 ing heat in the process oi frying. The melted fat should be 
 hot enough to give out occasional puffs or jets of smoke be- 
 fore it is ready for the immersion of the articles to be fried. 
 The transmitted heat cooks the interior, and none of the fat 
 penetrates unless the temperature be too low. Meats should 
 be rolled in dry crumbs, cracker dust, flour, or corn-meal. 
 Food is also said to be fried when it is cooked in a pan 
 with merely enough of fat to prevent it from becoming 
 scorched and sticking to the hot metal. A fork should not 
 be used in turning meats, as the holes made by it permit 
 escape of the juices. 
 
344 ALIMENTATION-. 
 
 608. Broiling is generally conducted over a clear, smoke- 
 less fire by means of a supporting gridiron ; but if it be done 
 before instead of over the fire, the juices of the meat may be 
 collected in a dish and used for dressing. 
 
 609. Roasting is properly conducted in front of a clear, 
 hot fire, the roast swinging round by a mechanical contriv- 
 ance to present every part in sequence to the radiated heat. 
 A polished concave reflector on the off side concentrates the 
 rays on the meat, and a dish placed underneath collects the 
 liquid drips, which should be spooned up from time to time 
 and flushed over the roast. 
 
 610. Baked meats are now generally called roasts; The 
 oven is at a proper heat when the arm, bared to the elbow, 
 can be thrust in and held for about fifteen seconds without 
 discomfort. The meat, properly skewered and placed in a 
 roomy pan, requires frequent attention while in the oven. 
 If it be not basted or flushed with the melted fat from the 
 pan at short intervals, the juices from the interior will be 
 evaporated, and the roast will become dry and insipid. 
 Meats are baked about fifteen minutes to the pound. 
 
 611. If flour be mixed with a little water into a stiff, 
 plastic mass, and then kneaded and teased with the fingers, 
 dipping it into water from time to time to wash away the 
 starch that exudes from it, there will be found to remain a 
 tough, elastic, grayish substance which has been called 
 gluten. The presence of at least ten per cent, of this sub- 
 stance in flour is essential to the making of good bread. 
 Besides its gluten and starch, flour contains a small 
 quantity of glucose, which, when mixed with yeast, becomes 
 transformed into alcohol and carbon dioxid. In bread- 
 making the flour is converted into a stiff dough by knead- 
 ing with water and yeast; after which it is set aside over 
 night at about 75° Fahr. to ferment. If the temperature 
 
ALIMENTATION. 345 
 
 be too low, fermentation will not take place ; if too high 
 or too long continued the dough will become sour from the 
 transformation of a part of the alcohol into vinegar. Dur- 
 ing the fermentation the dough rises by the development 
 of carbon dioxid in minute bubbles throughout its substance, 
 each bubble held in position by a cell-wall of the sur- 
 rounding gluten and starch. The mass is then kneaded over 
 again to perfect the mixture and break up any large cavi- 
 ties which may have formed, and is cut off into loaves of 
 the size desired. These are permitted to stand for half an 
 hour for the continuance of fermentation in the forms, after 
 which they are placed in the oven. The heat expands the 
 minute bubbles of gas which permeate the dough, and the 
 loaf swells correspondingly; but this ceases as the moisture 
 becomes dissipated and the surface hard and brown. Dur- 
 ing the process the starch-cells swell and burst, and much 
 of their material becomes converted into glucose. Bread- 
 making transforms a stiff, solid mass of gluten and indi- 
 gestible starch into a substance so porous that the liquids 
 of the alimentary apparatus can easily penetrate it. It 
 must not be forgotten, however, that all the advantages of 
 good bread are lost if it be eaten while still warm from the 
 oven. It is then in an unfinished state ; there is so much 
 moisture 3,nd plasticity in it that chewing, instead of break- 
 ing it up into minute particles, consolidates it again into a 
 heavy, glutinous mass. By the time it is thoroughly cold 
 this undesirable plasticity is lost. One hundred pounds of 
 flour yield about 133 pounds of bread. 
 
 612. Dough may be made porous also by mixing with it 
 certain substances which will permeate its mass with bub- 
 bles of carbon dioxid. Carbonate of ammonia is sometimes 
 used for this purpose. The heat of the oven liberates and 
 expands the gas, and at the same time dissipates the volatile 
 
346 
 
 ALIMENTATIOK. 
 
 anunonia. But most of the baMng-powders, as these sub- 
 stances are called, consist of cream of tartar and bicarbon- 
 ate of soda mixed with a proportion of corn-starch to keep 
 them from acting on each other until they are wanted. 
 These add to the bread a certain quantity of Rochelle salt 
 ^tartrate of soda and potash — as the result of their com- 
 bination. Acid phosphate of lime and bicarbonate of soda, 
 with starch as a preservative, are sometimes used, the re- 
 sidual salts in this instance being phosphates of lime and 
 soda. Alum and bicarbonate are also used; part of the 
 sulphuric acid of the alum liberates the carbon dioxid, and 
 alumina remains as an insoluble and probably inert powder 
 along with the sulphates of potash and soda. Leavened or 
 fermented bread is more readily digested than that raised 
 with these powders, as during fermentation starch becomes 
 changed to a considerable extent into dextrin and glucose. 
 
 613. The following tables of full and light diets in use 
 in the General Hospital, Presidio of San Francisco, Cal., 
 Lieut. -Col. A. C. Girard, deputy surgeon-general, com- 
 manding, are submitted here as illustrations of the diet pre- 
 pared for sick and wounded soldiers of the United States : 
 
 FULL DIET. 
 
 Breakfast. 
 
 Dinner. 
 
 Supper. 
 
 Sunday. 
 
 
 
 Oatmeal and milk, 
 riam and egp:s. 
 Ilread and butter, 
 fruit, 
 i.'offee. 
 
 Vermicelli soup. 
 
 Roast veal, sage dressing, or 
 turkey or chicken and dress- 
 ing. 
 
 stewed peas. Mashed potatoes. 
 
 Farina pudding. Fruit. 
 
 Bread and butter. Coffee. 
 
 Veal stew or boiled ham. 
 
 Apple sauce. 
 
 Cake. 
 
 Bread and butter. 
 
 Tea. 
 
 Monday. 
 
 
 
 Gfcrmea and milk. 
 Beefsteak. 
 Fried potatoes. 
 Bread and butter. 
 Fruit. Ooflee. 
 
 Roast beef. 
 
 Masbed potatoes. String beans. 
 
 Tapioca pudding. 
 
 Bread and butter. Fruit. 
 
 Coffee. 
 
 Oodflsb balls or hash. 
 
 Bread and butter. 
 
 Pickles. 
 
 Jam. Sweet crackers. 
 
 Prunes. Tea. 
 
ALIMENTATION. 
 FULL DIET— ConMntted. 
 
 347 
 
 Breakfast. 
 
 Tuesday. 
 Oatmeal and milk. 
 Sausage. 
 Fried potatoes. 
 Bread, butter, coffee. 
 Fruit. 
 
 Wednesday. 
 Milk toast. 
 Beefsteak. 
 
 Bread, butter, coffee. 
 Fruit. 
 
 Thursday. 
 Germea and milk. 
 Hash. 
 
 Bread, butter, coffee. 
 Fruit. 
 
 Friday. 
 Oatmeal and milk. 
 Bacon and eggs. 
 Bread, butter, coffee. 
 Fruit. 
 
 Saturday. 
 Germea and milk. 
 Beefsteak. 
 Fried potatoes. 
 Bread, butter, coffee. 
 Fruit. 
 
 Dinner. 
 
 Vegetable soup. 
 Baked pork and beans. 
 Baked tomatoes. 
 Bread pudding. 
 Bread, butter, cocoa, fruit. 
 
 Roast mutton with dressing. 
 Mashed potatoes. 
 Com or fresh vegetables. 
 Chocolate pudding. Fruit. 
 Bread, butter, coffee. 
 
 Oyster soup. 
 
 Corned beef and cabbage. 
 Boiled potatoes. Radishes. 
 Rice pudding. Fruit. 
 Bread, butter, coffee. 
 
 Baked flsh with sauce. 
 Plain boiled potatoes. 
 Iresh salad. 
 
 Farina pudding. Fruit. 
 Bread, butter, cocoa. 
 
 Roast beef, veal, or pork. 
 Mashed potatoes. 
 Hot slaw. Cauliflower. 
 Bread pudding. 
 Bread, butter, coffee. 
 
 Fried liver and bacon. 
 
 Com bread and syrup, or 
 
 Biscuits. 
 
 Bread, butter, tea. 
 
 Fruit, 
 
 Mutton stew. 
 Pickles. Sweet crackers. 
 Bread, butter, tea. 
 Peacb cobbler. 
 
 Sliced roast beef. 
 Macaroni and cheese. 
 Preserves. 
 Bread and butter. 
 Tea. 
 
 Salmon salad. Potato 
 
 Apple sauce. 
 Ginger crackers. 
 Bread and butter. Tea. 
 
 Baked hash or stew. 
 Stewed prunes. 
 Assorted cakes. 
 Bread and butter. 
 Tea. 
 
 LIGHT DIET. 
 
 Sunday. 
 Oatmeal and milk. 
 Soft boiled eggs. 
 Milk toast. Coffee. 
 
 Monday. 
 Germea and milk. 
 Milk toast. 
 Boiled eggs. 
 Coffee. 
 
 Tuesday. 
 Oatmeal and milk. 
 Boiled eggs. 
 Coffee. 
 
 Wednesday. 
 Oatmeal and milk. 
 Soft boiled eggs. 
 Coffee. 
 
 Bice soup. 
 Farina pudding. 
 Coffee. 
 
 Plain tomato soup. 
 
 Bread pudding with lemon 
 
 sauce. 
 Coffee. 
 
 Barley soup. 
 Tapioca pudding. 
 Cocoa. 
 
 Consomm^ vermicelli. 
 Cornstarch pudding. 
 Vanilla sauce. Coffee. 
 
 Milk toast. 
 Cup custard. 
 Tea. 
 
 Farina mush and milk. 
 Sweet crackers. Jelly. 
 Toast. 
 Tea. 
 
 Biscuits or com bread. 
 Maple syrup. Boiled rice. 
 Milk toast and tea. 
 
 Sweet crackers. Jam. 
 
 Milk toast. 
 
 Tea. 
 
348 
 
 ALIMENTATION. 
 
 LIGHT DIET— Continued. 
 
 Breakfast. 
 
 Dinner. 
 
 SUPPEK. 
 
 Thursday. 
 
 
 
 Germea and milk. 
 Boiled eggs. 
 Coffee. 
 
 Oyster soup. 
 Elce pudding. 
 Coffee. 
 
 Macaroni and cheese. 
 Milk toast. Maple syrup. 
 Tea. 
 
 Friday. 
 
 
 
 Oatmeal and milk. 
 Boiled eggs. 
 Milk toast. 
 Coffee. 
 
 Fish chowder. 
 Farina pudding. 
 Cocoa. 
 
 Tapioca pudding. 
 
 Milk toast. Ginger 
 
 crackers. 
 Boiled eggs. Tea. 
 
 Saturday. 
 
 
 
 Oatmeal and milk. 
 Boiled eggs. 
 Coftee. 
 
 Vermicelli soup. 
 Sago pudding. 
 Coffee. 
 
 Germea mush. 
 Assorted cakes. Jelly. 
 Milk toast. 
 Tea. 
 
 In addition to the regular diet tables a special diet list is 
 provided for the use of v^ard surgeons for cases requiring 
 tMs kind of diet. 
 
 The remaining paragraph numbers of this Handbook 
 give the course in dietetics and the recipes for emergency 
 diet for the sick in the military service, prepared by Capt. 
 Edward L. Munson, assistant surgeon TJ. S. Army, virhile 
 in command of the Hospital Corps Company of Instruction 
 at Washington Barracks, D. C. 
 
OOUESE IIsT DIETETICS. 
 
 614. First Lesson. 
 
 Liquid Diet. 
 Milk: 
 
 Sterilized. 
 
 Milk punch. 
 
 With mineral water. 
 
 Albumenized. 
 Milk, peptonized: 
 
 Cold process. 
 
 Warm process. 
 Milk: 
 
 Whey. 
 
 Junket. 
 
 Second Lesson. 
 
 Liquid Diet. 
 Gruels : 
 
 Oatmeal. 
 
 Farina. 
 
 Rice. 
 
 Hard bread. 
 
 Arrowroot. 
 Drinks : 
 
 Koumyss. 
 
 Third Lesson. 
 
 Liquid Diet. 
 Drinks : 
 
 Lemonade. 
 
 Orangeade. 
 
 Eggnog. 
 
 Egg lemonade. 
 
 Sherry and egg. 
 
 Toast water. 
 
 Coffee. 
 
 Tea. 
 
 Fourth Lesson. 
 
 Liquid Diet. 
 Broths : 
 
 Beef juice. 
 Beef juice, bottled. 
 Beef tea, bottled. 
 Beef tea, with hydro- 
 chloric acid. 
 Beef broth. 
 Mutton broth. 
 Chicken broth. 
 
 Fifth Lesson. 
 Seview. 
 
350 
 
 COURSE IN DIETETICS. 
 
 Sixth Lesson. 
 Light Diet. 
 Canned soups : 
 
 Chicken. 
 
 Mutton. 
 
 Beef. 
 
 Clam broth. 
 Eggs: 
 
 Poached. 
 
 Cooked. 
 
 Boiled. 
 
 Omelet. 
 
 Custard. 
 
 Seventh Lesson. 
 
 Light Diet. 
 Toast: 
 
 Dry. 
 
 Milk. 
 Oatmeal : 
 
 Porridge. 
 
 Mush. 
 Parina : 
 
 Porridge. 
 
 Mush. 
 Eice: 
 
 Plaia boiled. 
 
 Steamed. 
 Milk porridge. 
 
 Eighth Lesson. 
 Light Diet. 
 Gelatine : 
 
 Lemon jelly. 
 
 Coffee jelly. 
 
 Wine jelly. 
 Dried fruit : 
 
 Stewed. 
 
 Baked. 
 Fresh fruit : 
 
 Stewed. 
 
 Baked. 
 Canned fruit, serving of. 
 
 Ninth Lesson. 
 Light Diet. 
 Potatoes : 
 
 Baked. 
 
 Koasted. 
 
 Boiled. 
 
 Mashed. 
 Beef: 
 
 Scraped. 
 
 Scraped, in sandwiches. 
 
 Broiled. 
 Chicken : 
 
 Stewed. 
 
 Minced, on toast. 
 
 Tenth Lesson. 
 Beview. 
 
 Eleventh Lesson. 
 The Hospital Stores. 
 Beef extract : 
 Bouillon. 
 As an addition to soups. 
 
COURSE IN DIETETICS. 
 
 351 
 
 Malted milk, preparation of. 
 Chocolate : 
 
 As a beverage. 
 
 As flavoring. 
 Arrowroot, blanc-mange. 
 Condensed milk, general uses 
 
 of. 
 Sugar, general uses of. 
 
 Twelfth Lesson. 
 The Ration. 
 Minimum field, travel, and 
 emergency ; general uses of. 
 Hard bread : 
 
 General uses of. 
 
 Toasted. 
 
 Toast water. 
 
 Hard-bread mush. 
 
 Hard bread as milk toast. 
 
 Brown betty. 
 Bacon : 
 
 General uses of. 
 
 Broiled. 
 
 Fried. 
 
 Boiled. 
 
 Thirteenth Lesson. 
 The Ration. 
 Canned roast beef : 
 
 Soup. 
 
 Stew. 
 
 Hash. 
 Canned salt beef : 
 
 Stew. 
 
 Hash. 
 
 FOUETEBNTH LeSSON. 
 
 The Ration. 
 Eice pudding. 
 Baked beans : 
 
 Soup. 
 Pea meal : 
 
 Soup. 
 
 Mush. 
 Tomatoes : 
 
 Soup. 
 
 Stewed. 
 
 Baked. 
 
 Fifteenth Lesson. 
 Review. 
 
 615. Approximate Measures. — Four teaspoonfuls of 
 liquid are equal to one tablespoonful. 
 
 Three teaspoonfuls of solid material, as sugar or arrow- 
 root, are equal to one tablespoonful. 
 
 One tablespoon contains one-half a fluid ounce. 
 
 One coffee cup, quartermaster's, contains ten fluid ounces. 
 
353 KECIPES. 
 
 One coffee cup, usual size, contains eight fluid ounces. 
 
 One glass tumbler, usual size, contains eight fluid ounces. 
 
 Two coffee cups, or glass tumblers, usual size, are equal 
 to one pint. 
 
 One tin cup, soldier's field mess outfit, contains one and 
 one-half pints. 
 
 EECIPES. 
 
 616. The following recipes are planned to include such 
 simple, digestible, appetizing, and readily prepared articles 
 of diet, especially adapted to the needs of the sick, as may be 
 made from the com.ponents of the several rations used in the 
 field or on detached service, the foods included in the hospital 
 stores, and a few special articles selected for their nutritive 
 value, ease of preparation, palatability, and probable avail- 
 ability under ordinary circumstances. While the number 
 of articles of diet which can be made from these food stuffs 
 might be considerably augmented, it is believed that the 
 selection made herein is suflBeiently ample to meet the re- 
 quirements of any emergency. Many food materials havmg 
 a known value in the nourishment of the sick are not in- 
 cluded in this list ; not becajise their utility is unrecognized 
 or underestimated, but through the fact that their special 
 characteristics and the conditions of campaign or field 
 service are such that they would probably be unattainable 
 at the time when most to be desired. The Hospital Corps 
 man should, therefore, in his care of the sick, understand 
 how to make the best use of such articles of food as may 
 be confidently expected to be available, either wholly or in 
 large part, under any of the probable conditions of militiary 
 service. 
 
LIQUID DIET. 353 
 
 LIQUID DIET. 
 
 617. Sterilized Milk. — Pour the milk into a granite 
 saucepan (or a double boiler) and raise temperature of milk 
 to about 190° F. Keep it at this point for one hour. Do 
 not boil the milk. Any utensil used for this purpose must 
 be absolutely clean. 
 
 618. Milk Punch.— Three-fourths of a coffee cup of 
 milk (six ounces). * 
 
 Two tablespoonfuls of brandy or whiskey. 
 
 One teaspoonful of sugar. 
 
 Grated nutmeg, to taste. 
 
 Sweeten the milk (preferably sterilized) with the sugar. 
 Stir into it the brandy. Shake it up well by pouring from 
 one cup into another, or by the use of a milk shaker, until 
 a froth is formed. Grate a little nutmeg on top and 
 serve. 
 
 The term "cup " in this recipe, as in all others, means 
 the ordinary coffee cup, holding eight ounces. 
 
 619. Milk with Mineral ok Aerated Waters.— Mix 
 equal quantities of sterilized milk with seltzer, soda water, 
 or lime water, and serve immediately. 
 
 620. Albumenized Milk. — Beat up the white of an egg 
 till light. Add a good-sized pinch of salt, and four ounces 
 of fresh, cool milk which has been sterilized. A little 
 sugar may be added if desired. 
 
 621. Peptonized Milk (Cold Process). — Into a clean 
 quart bottle put the contents of one peptonizing tube, mix- 
 ing it with four ounces of cold water. Add one pint of 
 fresh cold milk, shake thoroughly, and place the bottle on 
 ice. Use clean cotton to plug the bottle. 
 
 Jn place of the peptonizing powder, five grains of pepsin 
 23 
 
354 RECIPES. 
 
 and fifteen grains of sodium bicarbonate, to be obtained 
 from tbe dispensary, may be employed. 
 
 622. Peptonized Milk (Warm Pkocess). — Into a clean 
 quart jar or bottle put the powder contained in one of the 
 tubes above mentioned, together with four ounces of cold 
 water. Add one pint of fresh milk and shake the whole 
 well. Place the bottle in a pan or kettle of hot water 
 maintained at such a temperature that the hand can just be 
 held in it without discomfort. Keep the bottle in the 
 water for ten minutes. Put on the ice immediately after 
 removing from the hot bath, to check further digestion. 
 If ice is not available, pour the milk into, a saucepan and 
 heat quickly to boiling. 
 
 623. Whey. — Warm one pint of milk to about blood 
 heat, or about 100° F. Dissolve half a rennet tablet in 
 one tablespoonful of cold water. Stir it into the milk 
 and let stand until the latter is curdled, which will be in a 
 few minutes. Break up the curd with a fork and strain off 
 the liquid (whey). This may be sweetened with sugar, 
 and when cooled makes a refreshing drink for fever patients. 
 
 624. Junket. — Heat one pint of fresh unboiled milk to 
 about blood heat, or about 100° F. Dissolve a full table- 
 spoonful of sugar in it. Add half a rennet tablet which 
 has been dissolved in one tablespoonful of cold water. It 
 will set the milk in about fifteen minutes. Put in a cool 
 place till ready to be used. It can be served plain, or with 
 cream, sugar, and a little nutmeg. 
 
 625. Oatmeal Geuel.— Two tablespoonfuls of oatmeal. 
 (Rolled oats. ) 
 
 One pint of water. 
 
 One-half teaspoonful of salt. 
 
 One teaspoonful of sugar. ' 
 
 Heat the water to boiling. Add the salt and then the 
 
LIQUID DIET. 355 
 
 oatmeal. Cook it in a saucepan for thirty minutes on the 
 fire, or in a double boiler for two hours, then strain through 
 a fine wire strainer or piece of clean gauze. If fresh milk. 
 is to be had, use it to flavor ; if not, use condensed milk, 
 one teaspoonful to the half pint of gruel. 
 
 626. Farina Gruel. — One tablespoouful of farina. 
 One pint of water. 
 
 One teaspoonful of sugar. 
 
 One-half teaspoonful of salt. 
 
 Into one pint of wSter, raised to boiling, put a half tea- 
 spoonful of salt ; then add the farina and cook for twenty- 
 minutes. Flavor with sugar and condensed milk, if fresh 
 milk is not available. Strain and serve hot. 
 
 In this recipe, as in others, condensed milk is used in a 
 strength of one teaspoonful to the half pint of gruel. 
 
 627. Rice Gruel. — Two tablespoonfuls of rice. 
 Or one tablespoonful of rice flour. 
 
 One pint of boiling water. 
 
 One-half teaspoonful of salt. 
 
 One teaspoonful of sugar. 
 
 Wash the rice thoroughly in two waters, after removing 
 any specks that may be mixed in the grain. Have the 
 cooking water boiling. Add the salt and then the rice. 
 Boil for two hours, when the rice should be almost entirely 
 dissolved. Strain. Add condensed milk and sugar, if de- 
 sired. Some persons prefer the use of salt alone. 
 
 If ground rice or rice flour is used, it should be mixed 
 with cold water before mixing with boiling water and re- 
 quires but thirty minutes boiling. Flavor with sugar or 
 condensed milk. 
 
 628. Hakd-Bkead Gkuel. — Toast hard bread thoroughly 
 and grind it into a powder. To one pint of boiling water, 
 to which one-half teaspoonful of salt has been added, add 
 
356 KBCIPES. 
 
 two tablespoonfuls of hard-bread powder. Boil ten min- 
 utes and then strain. Flavor with one teaspoonful of sugar 
 and one teaspoonful of condensed milk to each cupful of 
 the gruel. 
 
 629. Areowkoot Geuel.— One tablespoonful of arrow- 
 root. 
 
 One pint of hot water. 
 
 One teaspoonful of sugar. 
 
 One-third teaspoonful of salt. 
 
 Wet the arrowroot with two tablespoonfuls of cold 
 water, mixing the salt and sugar with it. Pour on the hot 
 water and boil for ten minutes, stirring constantly. Arrow- 
 root gruel may be flavored with cinnamon by boiling a small 
 piece in the water with which the gruel is made. Nutmeg, 
 lemon peel, lemon juice, or sherry wine may be used for 
 flavoring; but the sherry should be avoided unless the 
 gruel is to be served cold. 
 
 630. KouMYSs. — Dissolve one-fourth cake of compressed 
 yeast (Fleischmann's) in a little warm water. If Fleisch- 
 mann's yeast is not obtainable, use one-fourth cake of ordi- 
 nary compressed yeast or half a fluid ounce of bakers' yeast. 
 Warm one quart of fresh milk to about 90° F., add one 
 tablespoonful of sugar and the dissolved yeast ; bhoroughly 
 mix and put into a stout bottle, tying a small piece of cloth 
 firmly over the cork to hold it in place. Shake well, and 
 allow to stand for six hours at a temperature of about 70° 
 F. Then put the bottle on ice upside down, and allow to 
 stand for three days before using. Condensed milk may 
 be used with as good a result as fresh milk. Use five parts 
 of water to one part of condensed milk, and omit the 
 sugar. 
 
 631. Lemonade. — One small lemon or lime. 
 One tablespoonful of sugar. 
 
LIQUID DIET. 357 
 
 Three-fourths of a coffee cup of water (six ounces). 
 
 Wash and wipe the lemon or lime. Squeeze the juice 
 into a glass or bowl. Then add the sugar, pour on the 
 water, and strain. Serve at once. Boiled or sterilized 
 water should be used. 
 
 632. Orangeade. — One orange. 
 One teaspoonful of sugar. 
 
 Three-fourths of a coffee cup of water (six ounces). 
 
 Wash and wipe the orange. Squeeze the juice into the 
 sugar. Add the cold water, previously boiled. Strain 
 and serve. 
 
 633. Eggnog. — One egg. 
 Two teaspoonfuls of sugar. 
 
 Three-fourths of a coffee cup of milk (six ounces). 
 
 Salt, to taste. 
 
 Beat the egg up till light. Add sugar and salt and then 
 the milk, which is better when not too cold. With the 
 addition of one or two tablespoonfuls of brandy this makes 
 a very strengthening drink for convalescents. 
 
 634. Egg Lemonade. — One egg. 
 One small lemon. 
 
 Two teaspoonfuls of sugar. 
 
 Beat up the white and yolk of the egg separately ; add 
 sugar to yolk. When both are light, mix them together 
 and add the strained juice of the lemon. Pour into a glass 
 and serve with a spoon. 
 
 A little cold water may be added if the beaten egg is too 
 foamy. 
 
 635. Sherry and Egg. — One egg. 
 One teaspoonful of sugar. 
 
 Two tablespoonfuls of sherry wine. 
 Break the egg into a bowl and add the sugar. Beat the 
 two together until they are thoroughly mixed. Add two 
 
358 AECIPES. 
 
 tablespoonf uls of sherry wine and an equal quantity of cold 
 water. Mix thoroughly, strain, and serve immediately. 
 
 636. Toast Water.— Toast three slices of soft bread till 
 very brown and dry throughout. Break up fine, add one 
 pint of boiling water, and set aside for fifteen minutes. 
 Turn into a strainer or piece of gauze and strain. The 
 water thus obtained may be used plain, or a little sugar or 
 condensed milk may be added. It may be served either 
 hot or cold. 
 
 637. Coffee. — To each cup of water allow one table- 
 spoonful of coffee, freshly roasted and ground. Have the 
 water boiling. Mix the coffee with a little cold water and 
 pour it into the boiling water. Let the whole come to a 
 boil, and then set aside for five or ten minutes to steep 
 and settle before using. If muddy, it may be cleared by 
 boiling with egg shells, or, in their absence, by a dash of 
 cold water. Add sugar and fresh or condensed milk to 
 flavor as desired. 
 
 638. Tea. — To each half pint of boiling water add one 
 teaspoonful of tea. ' Let it steep or infuse for five minutes. 
 Never let tea boil. Add sugar and fresh or condensed 
 milk to flavor as desired. 
 
 639. Beef Juice. — Cut a lean piece of steak, from the 
 round or other good portion, about one-half pound in weight. 
 Remove all fat and fibrous tissue. Broil over a clear, hot 
 fire so that the meat becomes pink and full of juice. It 
 should not be merely done on the outside and raw mside. 
 Cut into small pieces and squeeze out the juice. Add a 
 little salt and it is ready to serve. 
 
 If it is needed warm place the cup holding the juice in a 
 bowl of warm water. Do not let the temperature of this 
 water exceed 160° F. 
 
 640. Beef Juice (Bottled). — Choose a good, well- 
 
LIQUID DIET. 359 
 
 flavored piece of beef, half a pound in weight. Cut away 
 the fat, leaving only the lean. Cut this up into small 
 pieces. Put these into a clean glass jar and cover the lat- 
 ter. Set the jar in a deep saucepan of cold water and heat 
 gradually for one hour. Then strain out the juice and 
 press the meat. Add a little salt and serve. 
 
 If the temperature of the water exceeds 160° F. the beef 
 juice becomes brown and flaky. A half pound of beef 
 should give from three to four tablespoonfuls of juice. 
 
 641. Beef Tea (Bottled). — Select and prepare the beef 
 as for bottled beef juice, except that to each half pound of 
 meat a cup of cold water should be added, pouring the 
 water over the beef after it has been put in the jar. The 
 liquid thus obtained will resemble the beef juice in every 
 respect except strength. Add a little salt and serve. 
 
 642. Beep Tea with Hydbochloeic Acid. — Select and 
 prepare the beef as above. Put into a bowl and pour over 
 it one cupful of cold water, to which five drops of dilute 
 hydrochloric acid have been added. Let the whole stand 
 for two hours in a cool place. Strain, add salt to flavor, 
 and serve cold. This tea may be heated ; but the albumen 
 which coagulates and appears as brown flakes should not 
 be strained out, for it is the nutritious portion of the tea. 
 
 643. Beef (oe Mutton) Beoth. — One pound of lean 
 beef (or mutton). 
 
 One quart of water. 
 
 One teaspoonful of salt. 
 
 Soak the meat, previously chopped fine, in the cold salted 
 water for at least two hours, in the vessel in which it is to 
 be cooked, keeping it on ice or in a cool place during this 
 time. Then expose to moderate heat. Keep the vessel 
 covered and allow the broth to simmer, keeping up the 
 original quantity of water, for three hours at least. Let it 
 
360 EEOIPES. 
 
 cool over night, skim off the fat in the morning, and keep cov- 
 ered in a cool place until needed. Heat and serve as required! 
 
 644. Chicken Broth. — Fowls are better to use for broth 
 than young chickens. Pluck and prepare by singeing with 
 a blazing newspaper, straw, or dry grass. Remove all 
 refuse — entrails, oil bag, crop, lungs, etc. Wash well in 
 cold water, then cut up and disjoint. To each pound of 
 chicken add a quart of cold salted water and simmer for 
 two hours ; then boil for two hours. Add rice or powdered 
 hard bread or soft bread crumbs in the proportion of one 
 tablespoonful to each quart of water. Vegetables, such as 
 onions, garlic, carrots, celery, and parsley, may also be 
 used, a tablespoonful to the quart, and should be put in 
 when the broth is first put on to cook. Strain, remove the 
 fat, and serve hot. 
 
 645. Canned Soups. — To render canned soups ready for 
 eating, simply raise them to the boiling point by immersing 
 the cans in boiling water for half an hour to thoroughly 
 heat the contents ; or empty and heat the contents iu a 
 granite saucepan. After diluting with the proper amount 
 of water, following directions on the cans, they are ready 
 to serve. Before heating any canned article a hole should 
 be punctured in the upper end of the can. 
 
 646. Clam Beoth (Canned). — This may be served hot 
 or cold. If the broth is desired plain, add an equal quan- 
 tity of water to the clam juice and heat to the temperature 
 required. Do not boil. Clam broth can also be given 
 iced. If fresh milk is available, equal parts of milk and 
 clam juice may be heated up together. 
 
 SEMI-SOLID OR LIGHT DIET. 
 
 647. Poached Eggs. — Pour sufl&cient boiling water into 
 a clean cooking utensil and add salt in the proportion of 
 
SEMI-SOLID OR LIGHT DIET. 361 
 
 one teaspoonful to the quart of water. Place it on the 
 stove to boil. Break a fresh egg into a small dish, and 
 when the water boils slide the egg gently into it. When 
 the albumen or white is firm, or at the end of two minutes, 
 lift the egg out of the water with a skimmer and place it 
 on a piece of hot, nicely-browned toast or hard-tack. 
 Sprinkle with a little salt and pepper and serve hot. 
 
 648. SoPT-CooKED Eggs. — Put into a saucepan as many 
 eggs as are to be cooked. Pour over them water enough to 
 cover. The water should have been brought up not quite 
 to the boiling point. Let the eggs stay in the water from 
 seven to ten minutes, and the result is an evenly cooked 
 egg throughout. When the water is poured on the eggs 
 do not set the pan on the fire. No further heating is re- 
 quired, but the water should not be allowed to cool down 
 too rapidly. 
 
 649. Boiled Eggs. — Carefully put into boiling water as 
 many eggs as are to be cooked. Eor soft-boiled eggs, leave 
 in three minutes and then at once remove. For hard-boiled 
 eggs, boil from seven to ten minutes. 
 
 650. Omelet. — Two eggs. 
 
 Two tablespoonfuls of milk, cream, or water. 
 
 One-fourth teaspoonful of salt. 
 
 Pepper, to taste. 
 
 Beat up the yolks and whites of the eggs separately. 
 Add the salt to the yolks. Mix the whites and yolks to- 
 gether with the milk, cream, or water. Place a small piece 
 of butter or bacon fat in a pan or plate hot enough to melt 
 it. Pour in the omelet, and with a sharp knife loosen the 
 edges as they solidify and fold over the omelet into a half 
 circle. When done, turn out on a plate and serve hot. 
 When milk cannot be had, water may be used. 
 
 Spanish omelet has minced onion added to the above. 
 
362 RECIPES. 
 
 An excellent addition to the plain omelet is a dressing 
 made of canned tomatoes and boiled crumbled hard bread, 
 strained, seasoned, and heated together. Never use flour 
 in an omelet, as it cannot be cooked sufficiently in the short 
 time that should be given to eggs. 
 
 651. Baked Custard. — One pint of fresh milk. 
 Two eggs. 
 
 One-third teaspoonful of salt. 
 
 Two tablespoonfuls of sugar. 
 
 Small piece of cinnamon. 
 
 Put the cinnamon in the milk and pour into a saucepan 
 to heat. Break the eggs into a bowl with the sugar and 
 salt, and beat until well mixed but not light. When the 
 milk comes to a boil pour it over the eggs. Stir slowly to 
 dissolve the sugar. Strain the mixture into cups, set them 
 in a deep pan of boiling water, and bake for twenty min- 
 utes in a moderately hot oven. 
 
 652. Dky Toast. — Cut the bread in slices one-third of 
 an inch in thickness. Toast may be made either by dry- 
 ing bread in an oven and then placing on a toaster over the 
 fire, or the bread may be allowed to dry and brown in the 
 oven. Toast that is moist and soft in the middle should 
 never be given to an invalid. Have it dry, crisp through- 
 out, and of a golden-brown color. Serve hot, either dry 
 or buttered. 
 
 653. Milk Toast. — Put a cup of milk into a saucepan 
 and let it heat to the boiling point. Have ready three 
 slices of nicely-browned toast. Put a little salt in the milk 
 and pour it over the toast. A little butter may be spread 
 on the latter, but it is a more delicate dish without it. 
 Serve hot. 
 
 654. Oatmeal Poeeidge. — Three tablespoonfuls of oat- 
 meal or rolled oats. 
 
SEMI-SOLID OR LIGHT DIET. 363 
 
 One pint of boiling water. 
 
 One-fourth teaspoonful of salt. 
 
 Dissolve the salt in the water, then add the oatmeal. 
 Cook for two hours in a double boiler. Eolled oats require 
 cooking only half an hour. Oatmeal is very appetizing 
 when served cold in mold shapes, and it will frequently be 
 eaten in this way when it would be refused if served in 
 any other form. Variations may be made by using farina, 
 browned rice (bro'^ned in the oven before steaming and 
 molding), arrowroot, etc., giving further change by serving 
 occasionally with sweetened fruit juices, fresh, dried, or 
 canned, instead of cream or milk. 
 
 655. Oatmeal Mush. — One cup of oatmeal or rolled oats. 
 Three cups of boiling water. 
 
 One teaspoonful of salt. 
 
 Pick over the oatmeal before using. Boil for half an 
 hour if rolled oats are used. Coarse oatmeal requires from 
 two to three hours cooking. Salt should be added to the 
 water before the oatmeal is put in. 
 
 656. Farina Mush or Porridge. — Three tablespoonfuls 
 of farina. 
 
 One pint of boiling water. 
 
 One-half teaspoonful of salt. 
 
 The water must be boiling before putting in the farina. 
 Boil for half an hour. It may be served with fresh milk, 
 or condensed milk diluted one to four parts of boiliug water, 
 or with stewed dried fruit, such as prunes, peaches, or 
 apples. Cold farina mush may be sliced and fried for the 
 use of convalescents. 
 
 657. Plain Boiled Eice. — One-haK cup of rice. 
 Two cups of boiling water. 
 
 One-half teaspoonful of salt. 
 
 Pick the rice clean. Wash thoroughly in two waters, 
 
364 RECIPES. 
 
 pouring off the last when ready to put the rice into the 
 boiling water. Add the salt to the water. Pour in the 
 rice and boil steadily for half an hour. In order to see if 
 the rice is done, take out some of the grains and crush be- 
 tween the fingers. If done, they will mash easily and feel 
 perfectly soft. Do not stir the rice, as this will cause it 
 to fall to the bottom and burn. Serve with sugar and fresh 
 or condensed milk, or with stewed fruits. 
 
 658. Steamed Eicb.— Wash the rice thoroughly in two 
 waters. Use in same proportions as are given for boiled 
 rice. Use a double boiler. Have the water boiling in lower 
 boiler. Place the above mixture of rice, boiling water, and 
 salt in the upper chamber, and let cook for one hour. Do 
 not stir. Keep the rice covered while steaming, and keep 
 the lower boiler well supplied with boiling water. Serve 
 as with boiled rice. 
 
 659. Milk Porridge. — The flour for milk porridge should 
 be prepared in the following manner : Tie up in a muslin 
 bag or a towel as much flour as desired and boil for four or 
 five hours, then bake in an oven until dry. To make the 
 porridge, grate two tablespoonfuls of the dried flour, mix 
 it with cold water into a paste, and add to it one pint of 
 boiling milk or boiling water. Boil for ten minutes. If 
 water alone is used to make the porridge, condensed or fresh 
 milk may be used in addition, in equal parts or diluted one- 
 half with water. 
 
 Condensed milk used in this recipe is made in the strength 
 of one part of condensed milk to four of water. Salt is 
 added in the proportion of one teaspoonful to the quart of 
 boiling milk or water. 
 
 660. Lemon Jellt. — One-fourth box of gelatine (one- 
 half ounce). 
 
 One-fourth cup of cold water. 
 
SEMI-SOLID OB LIGHT DIET. 365 
 
 One-fourth cup of fresh lemon juice (about the amount 
 yielded by two lemons) . 
 
 Three tablespoonfuls of sugar. 
 
 One and one-fourth cups of boiling water. 
 
 Put the gelatine to soak in the cold water, about twenty 
 minutes being required for this process. When dissolved 
 pour on the boiling water. Add the lemon juice and sugar. 
 Stir thoroughly and strain through a fine-meshed cloth into 
 a china or granite-ware mold, cooling in a refrigerator or 
 by placing in a pan of cold water. Never use tin molds for 
 lemon jelly. 
 
 661. Coffee Jelly. — One-fourth box of gelatine (one- 
 half ounce). 
 
 One-fourth cup of cold water. 
 
 One cup of boiling water. 
 
 One-half cup of strong coffee. 
 
 Two tablespoonfuls of sugar. 
 
 Soak the gelatine in the cold water for half an hour. 
 Pour on the boiling water, then put in the sugar and coffee. 
 Strain it through a cloth into a mold or dish in which it 
 may be cooled, either in a pan of iced water or in a 
 refrigerator. Coffee jelly may be served with cream and 
 sugar. 
 
 Have the coffee strong, two tablespoonfuls of coffee to 
 each cup of water. Where vanilla extract is available, one- 
 half teaspoonful will be advantageously added to the above 
 recipe. 
 
 662. Wine Jelly. — One-fourth box of gelatine (one-half 
 ounce). 
 
 One-fourth cup of cold water. 
 
 One-half cup of sugar. 
 
 One-haK cup of sherry wine. 
 
 One and one-fourth cups of boiling water. 
 
366 KECIPES. 
 
 One small piece of cinnamon. 
 
 Put the gelatine and cold water together in a dish large 
 enough to hold the whole mixture. Let it soak for halt 
 an hour, then pour the boiling water (in which the piece of 
 cinnamon has been simmering) over the softened gelatine. 
 Add the sugar and wine, strain through a clean cloth into 
 a china or granite-ware mold, and cool in a refrigerator or 
 a pan of cold water. 
 
 663. Stewed Pkunbs. — One pint of prunes. 
 One and one-half pints of water. 
 One-fourth cup of sugar. 
 
 Juice of one lemon. 
 
 Soak the prunes for fifteen minutes in warm water to 
 soften the dirt. Wash carefully, rejecting those that feel 
 granular or are worm-eaten. Stew them in the sugar and 
 water in a covered saucepan from one to two hours, or until 
 tender. The fruit should be plump, soft, and tender to the 
 stone. As the water evaporates, restore the amount so that 
 there will be as much at the end as at the beginning of the 
 cooking. Add the lemon juice before taking off the fire. 
 Cool, and serve. 
 
 664. Stewed Dkied Apples, Apricots, oe Peaches. — 
 Wash the fruit thoroughly. Soak for four or five hours in 
 the cold water it is to be cooked in, using only a sufficient 
 quantity of water to cover. Heat in a covered granite-ware 
 saucepan, simmering slowly for two hours. Do not boil. 
 If the fruit is allowed to simmer it will not burn or need 
 stirring, which breaks it up and makes it look unsightly. 
 Apricots need plenty of sugar, but this should not be 
 added until five minutes before taking oft' the fire. Lemon 
 juice or lemon peel may be added to poorly flavored 
 apples, a tablespoonful of the juice or the peel of half a 
 lemon to the pound of fruit, or spices may be used for 
 
SEMI-SOLID OR LIGHT DIET. 36? 
 
 flavoring. The use of brown sugar in stewing dried frait 
 is to be preferred, because of the better flavor which it 
 gives. 
 
 665. Stewed Raw Apples. — Wash, pare, and core three 
 apples (tart are best) ; put them into a saucepan with a cup 
 of water and two tablespoonfuls of sugar, and stew gently 
 till they are soft, but not broken. A tablespoonful of lemon 
 juice may be added before they are taken from the fire if 
 the apples are poor in flavor. A bit of lemon peel, cinna- 
 mon, or cloves is alse a good addition. 
 
 Any wholesome acid fruit can be prepared in about the 
 same manner. 
 
 666. Baked Apples. — Select fair, sound, and preferably 
 tart apples. Wash and wipe them and cut out the cores, 
 removing all the seeds and husks. Cut ofE any dark spots 
 on the outside. Put the prepared apples into a granite or 
 earthenware dish. Put into each apple from one-half to 
 one teaspoonful of sugar, according to the acidity of the 
 fruit, and a bit of lemon peel. Pour boiling water into the 
 dish about one-fourth inch deej), and bake in a moderately 
 hot oven. When perfectly soft all through the fruit is 
 done. The time for baking varies, according to the species 
 of apple, from half an hour to two hours. 
 
 667. Canned Fruit, Serving of.- — Remove from cans 
 several hours before using and put in porcelain or granite- 
 ware dish to cool. Canned fruit is much improved by cool- 
 ing, being more palatable and refreshing than if served direct 
 from the can. Never allow fruit to remain in cans when 
 once opened. This applies particularly to very acid fruit, 
 and also to meats, fish, or vegetables. 
 
 668. Baked Potatoes. — Have the potatoes of a uniform 
 size, so that all may be done at the same time. Wash them 
 thoroughly and bake in a hot oven from forty-five to fifty 
 
 24 
 
368 KECIPES. 
 
 minutes. They are recognized as being done by tlie soft, 
 yielding sensation given on pinching. 
 
 669. Roasted Potatoes. — Bury under the hot ashes of 
 an open fire (camp) for half an hour or more. The thor- 
 oughness of cooking is recognized as with baked potatoes. 
 Break open by squeezing. Brush the ashes off first. 
 
 670. Boiled Potatoes. — Wash the potatoes well. Pare 
 carefully so as not to waste. Put them on to cook in boil- 
 ing salted water, enough to cover, and let boil for thirty 
 minutes. It requires more time for large size potatoes. 
 When easily pierced by a fork they are done. Drain off 
 the water, and dry them on top of the stove by moving the 
 boiler back and forth for a minute or two. Serve as quickly 
 as possible after they are cooked. 
 
 671. Mashed Potatoes. — Prepare as for boiled potatoes. 
 When cooked, drain off the water and mash in the dish in 
 which they were boiled. Add butter, pepper, and salt, to 
 taste, and lastly put in a little milk or cream. Whip up 
 lightly and serve immediately. Keep the dish covered 
 until served. 
 
 672. ScKAPED Beef. — Cut a piece of steak from the 
 round, about half a pound in weight and about an inch 
 thick. Lay it on a clean meat board and with a dull knife 
 scrape out the pulp until there is nothing left but stringy 
 fibre. Season the scraped pulp with salt and make it into 
 small cakes. Broil for two minutes either by direct heat 
 over a clear fire, or by heating a clean pan or plate and, 
 when hot, placing the meat on it. Have both sides cooked 
 sufllciently. This is a safe food for a patient beginning to 
 take solid nourishment. Scraped beef may be prepared 
 very easily over an alcohol lamp. 
 
 673 . Scraped-Beef Sandwiches . — Place a piece of round 
 steak on a meat board and scrape out all of the pulp with a 
 
SEMI-SOLID OR LIGHT DIET. 369 
 
 dull knife ; add to the pulp a little salt and pepper and 
 enough raw beef -juice to make it into a firm jelly. Have 
 stale bread cut into very thin slices and spread the beef pulp 
 on them ; cut the sandwiches quite small. Never use butter 
 in making beef sandwiches. 
 
 674. Broiled Beef (Steak). — Have a clear, hot fire, 
 either coal or charcoal. Put the steak on a broiler, place 
 directly over the fire for about a minute, then turn and do 
 the same with other side. By applying greater heat at the 
 outset the juices are kept in the meat. It requires from 
 five to seven minutes over a clear fire to broil a steak an 
 inch thick. Season both sides with salt and a little pepper, 
 but no butter. Serve "hot. A baked potato is a good 
 vegetable to serve with the above, as is also boiled rice. 
 
 Another good way to broil steak is to heat a granite-ware 
 plate on a stove till it is quite hot. Place the steak on it 
 till one side is done, then turn it and do the same with 
 other side. 
 
 675. Stewed Chicken. — Boil a chicken, prepared as for 
 broth, until tender. Set it away till it is cool. Skim off 
 the fat ; take the meat and cut it up in cubes or small pieces, 
 rejecting all skin, gristle, tendons, and bones. To one cup- 
 ful of the meat add one pint of the broth, seasoning with 
 salt and pepper. Mix one teaspoonful of flour with a little 
 cold water, blend it thoroughly, and add it to the chicken. 
 Let the whole stew for ten minutes, and serve with toast 
 or boiled rice. 
 
 676. Minced Chicken on Toast. — Prepare the chicken 
 as for broth. When cool, skim off the fat and mince up 
 the meat fine, rejecting all skin, tendons, gristle, and bone. 
 Season with salt and a little pepper. Add enough broth, 
 or, better yet, cream, if available, to make it of the proper 
 consistency, or about that of cream. Have ready some 
 
370 RECIPES. 
 
 nicely browned dry toast, pour the minced chicken over it, 
 and serve hot. 
 
 THE HOSPITAL STORES. 
 
 677. Beef Extract (Liquid). — To four ounces of cold, 
 sterilized water add half a teaspoonful to one teaspoonful 
 of the liquid extract. Mix thoroughly ; season with salt 
 and pepper to taste, and, if obtainable, with celery salt. 
 
 Where a hot beef tea is required the above preparation 
 may be heated, care being taken not to remove the nutritious 
 curdy flakes produced by boiling. 
 
 678. Malted Milk. — Mix one or two tablespoonfuls of 
 malted milk with a like quantity of warm, boiled water. 
 Add more water to make up half a pint. Season with salt 
 to taste. 
 
 Boiling water cannot be used to advantage in making up 
 this preparation. 
 
 679. Chocolate. — Grate one ounce of chocolate. Have 
 ready one pint of boiling milk. Mix the grated chocolate 
 with some hot milk iuto a paste, add to it the boiling milk, 
 and boil five or six minutes. Flavor with sugar, one tea- 
 spoonful to the piat. The chocolate issued in the hospital 
 stores is partly sweetened. If unsweetened chocolate is 
 used, a tablespoonful of sugar is required. If fresh milk 
 is not available, make the chocolate with boiling water and 
 add one teaspoonful of condensed milk to each half pint of 
 chocolate. 
 
 680. Aeeowroot Blanc-Mangb. — Two tablespoonfuls 
 of arrowroot. 
 
 Two-thirds pint of hot water. 
 
 Two tablespoonfuls of sherry or brandy. 
 
 Two teaspoonfuls of sugar. 
 
THE BATIOKS. 371 
 
 Mix the arrowroot into a smooth paste with three table- 
 spoonfuls of cold water. Add this to the hot water. Bring 
 to a boil, stirring constantly till well blended and free from 
 lumps. Let boil for ten minutes. Add the sugar and 
 sherry or brandy. Beat up quickly and pour into a bowl 
 or mould to cool. Arrowroot blanc-mange may be made 
 with fresh hot milk or condensed milk diluted. If boiling 
 water is used it causes the starch of the arrowroot, when 
 first poured in, to form into lumps. Hence it is best to 
 have the water not (Juite at boiling point. 
 
 THE RATIONS. 
 
 681. Hard-Beead Toast Water. — Two tablespoonfuls 
 of powdered hard bread. 
 
 One pint of boiling water. 
 
 One-half teaspoonful of salt. 
 
 Add the powdered hard bread, after toasting or parching 
 in an oven, to the salted boiling water. Boil for ten min- 
 utes. Strain through gauze and serve hot or cold. The 
 toast water may be flavored with sugar, condensed milk, 
 or whiskey. 
 
 682. Hard-Bread Mush or Porridge. — One cup of 
 powdered hard bread. 
 
 Four cups of boiling water. 
 
 One teaspoonful of salt. 
 
 Mix and boil for ten minutes. The resulting mush may 
 be eaten with condensed milk or stewed dried fruit. 
 
 Care should be taien to prevent scorching by frequent 
 stirring, and the water should be boiling in all cases before 
 adding the powdered bread. 
 
 683. Hard Bread as Milk Toast. — Toast two or three 
 pieces of hard bread to a good brown color by placing in an 
 
372 KECIPES. 
 
 oven or over a clear fire on a toaster. When done, pour 
 enough boiling water over them to soften thoroughly. Di- 
 lute two tablespoonfuls of condensed milk in four times as 
 much boiling water. Drain off the water from the toasted 
 bread and pour on the milk. Serve hot. 
 
 684. Hard Beead and Dkied Apples (Bkown Betty). 
 — Soak the dried apples for at least four hours. Grease a 
 baking pan or dish and place in it first a layer of sliced 
 apples, then a layer of hard-bread crumbs, or whole hard 
 bread softened in boiling water for ten minutes, with small 
 quantities of butter or fat pork and sugar, and a little 
 ground cinnamon sprinkled over each layer. Continue till 
 the dish is full, having bread crumbs for the top layer. 
 Moisten with a cup of water, or fresh or diluted condensed 
 milk, and bake for three-quarters of an hour in a moder- 
 ately heated oven. When a fork easily pierces the apples 
 the pudding is cooked. It can be eaten hot or cold with 
 butter and sugar worked up together and flavored with 
 cinnamon or nutmeg ; with a simple syrup of sugar and 
 water, or with the following sauce : 
 
 685. Sauce foe Haed-Bkead Pudding. — One pint of 
 boiling water. 
 
 One tablespoonful of flour. 
 
 One-half cup of sugar. 
 
 One lemon. 
 
 To the water add the flour, mixed into a paste with 
 three tablespoonfuls of cold water. Boil for ten minutes. 
 Add the sugar and lemon juice, strained ; or other flavor- 
 ing to taste. 
 
 686. Bacon, Beoiled. — Wash in cold water. Cut into 
 thin slices and broil over clear coals, either on a broiler or 
 with a fork. Serve immediately. 
 
 687. Bacon, Feied. — Cut into thin slices after washing, 
 
THE EATIOKS. 373 
 
 roll in haxd-bread crumbs, and fry in a very hot pan which 
 has been greased. Season with pepper and serve immedi- 
 ately. The bacon may be fried without the bread crumbs 
 if preferred. 
 
 688. Bacon, Boiled. — Wash the bacon in cold water. 
 Scrape and trim off any rusty or brownish spots, and if 
 very hard or dry, soak for a few hours in cold water. Put 
 it on to cook in enough cold water to cover it well, let it 
 come slowly to a boil, and then boil steadily until done. As 
 the water evaporates or boils away replenish it with more 
 boiling water. When the bacon can be easily pierced with 
 a fork in the thickest part it is sufficiently cooked. Save 
 the fat, it will be usefvil in frying ; and if greens are to be 
 cooked, leave enough in the water to season them. 
 
 689. Canned Eoast Beef, Soup. — One pound (one-half 
 can) of roast beef. 
 
 One pint of cold water. 
 
 Salt and pepper to taste. 
 
 Cut the beef into small pieces and add it to the cold 
 water. Let the whole come to a boil and then simmer 
 gently for half an hour. Skim ofE the fat and strain, tak- 
 ing care to express all the meat juice and gelatine from the 
 meat. Season with salt and pepper to taste. A little beef 
 extract, when added to the above, improves the value and 
 palatability of this soup. A tablespoonful of hard bread, 
 powdered, may be added if rice or other grains are not 
 available. 
 
 690. Canned Eoast Beef, Stew. — Two pounds of 
 canned roast beef. 
 
 Six small potatoes. 
 
 One onion. 
 
 Salt and pepper to taste. 
 
 Wash, peel, and slice the vegetables. Cover them with 
 
374 RECIPES. 
 
 sufficient boiling salted water. Put them on to boil, and 
 when nearly done add the roast beef, well cut up. Season 
 to taste with pepper aud salt, and let the whole simmer 
 ten or fifteen minutes before serving. If potatoes are not 
 to be had, hard bread, crumbled and softened in boiling 
 water, may be used with the meat. Canned tomatoes, in 
 varying proportions, make a good addition to the stew as 
 already described. In the absence of any other vegetables, 
 they may be added to the meat in the proportion of pound 
 for pound.' 
 
 691. Canned Roast Beef, Hash. — Two pounds of 
 canned roast beef. 
 
 Six boiled potatoes, small. 
 
 One onion. 
 
 Pepper and salt to taste. 
 
 Chop up the meat and vegetables thoroughly. Mix well. 
 Season with pepper and salt and brown in a hot dish or 
 frying pan, previously greased with pork or bacon, in an 
 oven or over the fire. When potatoes cannot be obtained, 
 a very good hash may be made by the use of softened hard 
 bread or boiled rice in their place. 
 
 692. Canned Salt Beef, Stew. — Cut up the contents 
 of a two-pound can. Cover with cold water and bring to 
 the boiling point. Then add vegetables as directed for 
 roast beef stew. Season with pepper, but add no salt. 
 Stew for three-quarters of an hour. 
 
 693. Canned Salt Beef, Hash. — Two pounds (one can) 
 of salt beef. 
 
 One cup of hard-bread qrumbs. 
 
 One onion. 
 
 Bacon fat or beef fat (about the size of an egg). 
 
 Water, or soup stock. 
 
 Pepper and salt. 
 
THE RATIONS. 375 
 
 Chop up the beef. Add the bacon fat or beef fat, and 
 add sufficient water or soup stock to moisten the whole. 
 Season with pepper and a very little salt. Parboil the 
 onion, chop it up, and add it to the mixture. Put into a 
 frying pan or mess plate and brown on both sides. If de- 
 sired, the onion may be fried before adding it to the hash. 
 
 694. Rice Pudding. — Two tablespoonfuls of rice. 
 One tablespoonful of sugar. 
 
 One pint of fresh milk. 
 
 Nutmeg or cinnamon as flavoring. 
 
 Wash the rice and cover with the milk, previously sweet- 
 ened and flavored. Set in a moderately hot oven. Stir 
 every fifteen minutes during the first hour and then once at 
 the expiration of the next half hour. Let bake two hours 
 and until the brown top forms. This gives a creamy, 
 slightly brown pudding. 
 
 695. Baked-Bbast Soup. — Take cold baked beans, add 
 twice as much water as beans, and let them simmer till soft. 
 When done, add half as much canned tomatoes and strain. 
 If too thick add more water. Season to taste with salt 
 and pepper. 
 
 696. Pea-Meal Soup. — One-half pound of salt pork or 
 
 bacon. 
 
 One and one-half pints of water. 
 
 Two tablespoonfuls of pea-meal. 
 
 Boil the bacon or pork in the water. When the meat is 
 nearly cooked, add the pea-meal and let simmer until the 
 meat is thoroughly done. Skim off the fat, season with 
 pepper, and serve. Canned salt meat can also be used to 
 make pea soup, but does not require so long to prepare, as 
 the meat is already cooked. Season with pepper and very 
 little salt. Serve hot. 
 
 697. Fried Pea-Meal Mush.— One pint of water. 
 
376 RECIPES. 
 
 One teaspoonful of salt. 
 
 Four tablespooafuls of pea meal. 
 
 Add the pea meal to tlie salted water. Boil for twenty 
 minutes. Cool by pouring out into a plate or mess tin. 
 Slice and fry quickly in hot bacon fat (for convalescents). 
 
 698. Tomato Soup. — To one can of tomatoes add an 
 equal quantity of water and let simmer for half an hour. 
 Mix one tablespoonful of flour with an equal quantity of 
 beef dripping or bacon fat. Add it to the tomatoes. Season 
 with pepper and salt. If very acid, a teaspoonful of sugar 
 may be added to disguise the acidity. Boiled rice or hard- 
 bread crumbs make a very good addition to tomato soup. 
 Serve hot. 
 
 699. Stewed Tomatoes with Hard Bread. — To each 
 can of tomatoes add half an onion chopped fine, salt and 
 pepper to taste, and, if tomatoes are very acid, enough 
 sugar to counteract the acidity. Cover, and stew for three- 
 quarters of an hour. Hard-bread crumbs are added to 
 thicken to the consistency desired. 
 
 700. Baked Tomatoes with Haed Bread. — Mix enough 
 hard-bread crumbs with the canned tomatoes to absorb the 
 greater portion of the juice ; season with salt, pepper, and 
 thin slices of bacon laid on top, and bake from three-quar- 
 ters of an hour to an hour. Onion, either raw or fried, may 
 be chopped up and added to the seasoning. 
 
INDEX TO PARAGRAPHS. 
 
 Abdomen, compression of, as a 
 mode of artificial respira- 
 tion, 474 
 contusions of, 389 
 wounds of, 454 
 Abscess, 359, 392 
 Abscesses, pya;mic, 417 
 Absorbent cotton in burns, 883 
 
 system, 380 
 Absorption from the stomach, 
 321 
 from the small intestine, 328 
 from the large intestine, 239 
 by the skin, 245 
 of putrefactive products of 
 
 wounds, 414-416 
 of catgut ligatures, 448, 444 
 induced by counter-irrita- 
 tion, 380 
 .Acarus scabiei, 73 
 Accessory foods, 308 
 Accidents, etc., management of , 
 371-374 
 etc., which call for artificial 
 respiration, 475-481 
 Accommodation of the eye, 357 
 Acid phosphate of lime in bak- 
 ing, 613 
 Acids, corrosive eflfects of, on 
 the skin, 385 
 
 Acids, poisoning by, 563 
 Aconite as a poison, 570, 583 
 as a remedy in poisoning, 
 571, 593 
 Acromion process, 163 
 
 fracture of, 517 
 Acting Hospital Stewards, duties 
 
 of, 9 
 Actual cautery, in dog bites, 431 
 Adam's apple, 161 
 Administration building of gen- 
 eral hospitals, 133, 135 
 Administrative system of the 
 
 human body, 249 
 Aeration of the blood in the 
 
 lungs, 284 
 Affusion, cold, in asphyxia from 
 
 noxious gases, 480 
 Air, carbon dioxide in, 385, 337 
 effects of deprivation of, 
 
 298 
 exposure to, for the arrest of 
 
 bleeding, 441 
 respired; effects of breath- 
 ing it, 236 
 respired, upward tendency 
 
 of, 339 
 sanitary analysis of, 337 
 volume of, required to ven- 
 tilate, 338 
 Air cells of lungs, 333 
 
378 
 
 INDEX TO PARAGRAPHS. 
 
 Air cells of lungs, movement, 
 during ordinary breathing, 
 234 
 Airing of bedding on transports, 
 120 
 of interior of huts, 105, 110 
 of ward or barrack-rooms, 
 necessity for, 91 
 Air space in log huts for winter 
 use, 104^107 
 in hospital wards, 123 
 Albumen of the blood, 181 
 as a food, 208 
 test for, in urine, 322 
 Albumenized milk, 620 
 Albuminoids decomposed into 
 urea, 315 
 digestion of, in the small in- 
 testine, 227 
 of food, solution of, in stom- 
 ach, 221, 222 
 in fresh meat, 209 
 in pork, 209 
 
 Influence of cooking on, 601 
 Albuminuria in yellow fever, 331 
 Alcohol in serpent bites, 433 
 
 insensibility from, 465 
 Alcoholic stimulants, harmful- 
 
 ness of, In camp, 70 
 Alimentation, 208-230 
 Alkalies, poisoning by, 563 
 Alum in baking, 613 
 as a styptic, 438 
 Alveolar abscess, 397 
 Ambulance boxes for emergency 
 supplies, 30 
 companies, 27 
 
 officers, duties and responsi- 
 bilities of, 27, 31, 61 
 
 Ambulance stations during bat- 
 tle, 39, 42 
 train on the march, 81, 32 
 Ambulances, cases that require 
 
 transportation in, 27 
 American National Red Cross, 55 
 Ammonia as a counter-irritant, 
 366, 369, 382 
 to the nostrils to promote 
 
 respiration, 474 
 poisoning by, 563 
 in bites and stings, 432-434 
 Amoeboid movements, 183 
 Amputation, triangular bandage 
 
 on stump after, 424 
 Amputations, assistance re- 
 quired during, 283-286 
 Anaesthesia, local, 294, 395 
 Anaesthetics, 387 
 Anastomosis, 197 
 
 venous, 303, 305 
 Animal heat, 248 
 Ankle, sprains of, 390 
 dislocation of, 561 
 Anopheles, 75 
 
 Anterior temporal arteries. 190 
 tibial artery controlled by 
 pressure, 193, 421 
 Antidotes, chemical, in poison- 
 ing, 566, 567 
 Antimony as a poison, 566, 578 
 Antisepsis during operations, 
 
 279-383 
 Antiseptics, 336 
 Aorta, 189, 192 
 
 Apomorphine as an emetic in 
 poisoning, 502, 522, 523, 565, 
 585, 586 
 Apoplexy, 313, 456-458 
 
INDEX TO PARAGRAPHS. 
 
 379 
 
 Appendix vermiformis, 339 
 Arachnoid membrane, 353 
 Areolar tissue, 154 
 Arm, fracture of, 165, 518-533 
 to arm vaccination, 81 
 sling for, 434 
 Army itch, 73 
 Arnica in contusions and sprains, 
 
 389, 390 
 Arrowroot blanc-mange, 680 
 
 gruel, 639 , 
 
 Arrow wounds, 437 
 Arsenic as a poison, 567, 513 
 
 administration of, 304 
 Arsenical soap in toothache, 898 
 Arterial blood, 187, 198, 307 
 coats, retraction of, when 
 
 cut, 440 
 hemorrhage, 440 
 Arteries which can be com- 
 pressed, 481 
 enlargement and contraction 
 of, 196 
 Artery forceps, 384, 444 
 Articles of Geneva Convention, 
 
 54, 55 
 Artificial respiration, 471-481 
 respiration, conditions which 
 
 call for, 475-481 
 respiration in chloroform in- 
 sensibility, 389 
 respiration in cases of poi- 
 soning, 570, 571, 585, 586, 
 589, 590, 594 
 Ashes for sinks, 115 
 Asphyxia, 398 
 
 from coal gas, charcoal 
 fumes, etc., 480 
 Astigmatism, 363 
 
 Astragalus, 179 
 
 Astringents for capillary hemor- 
 rhage, 438 
 A-lent, 95 
 Atropln as a poison, 088 
 
 as a remedy in poisoning, 
 570, 571, 585, 586, 590 
 Attending surgeons at field divi- 
 sion hospitals, 30 
 Auditory canal, 364 
 Auricles of heart, 187 
 Autumnal fevers, causation of, 
 
 75 
 Axilla, 191 
 Axillary artery, 191 
 
 artery controlled by press- 
 ure, 431 
 vein, 300 
 
 B. 
 
 Bacilli, 388 
 
 Back-bone, 157 
 
 Bacon, cooking of, 686-688 
 
 Bacteria of nitrification, 137 
 
 of putrefaction, 386 
 
 of putrefaction in wounds, 
 414-416 
 
 in food, 599 
 Bags, hot water, 363 
 
 ice, 363 
 Baked apples, 666 
 
 custard, 651 
 
 meats, 610 
 
 potatoes, 668 
 Baked- bean soup, 695 
 Baking of bread, 611 
 
 powders, 613 
 Bandage, triangular, 434, 45C 
 Bandages, roller, 503 
 
380 
 
 INDEX TO PAKAGEAPHS. 
 
 Bandages, starch, etc., 504 
 Base hospitals, 121 
 Basilic vein, 304 
 Baths, 278 
 
 hot air, 278 
 mercurial vapor, 380 
 in typhoid fever, 347 
 Bath-tub connections with soil- 
 pipe, 135 
 Battle, the field hospital during, 
 35-53 
 injuries and losses in, 37 
 Bayonet wounds, 407 
 Beans, digestion of, 323 
 Bed, changing patient from one 
 to another, 277 
 moving patient to, after an- 
 
 sesthesia, 291 
 preparation of, for patient, 
 275 
 Bedding of the field hospital, 80, 
 
 43 
 Bed-sores, 315 
 
 in typhoid fever, 341, 394, 
 350 
 Bedsteads in temporary camps, 
 
 103 
 Beef broth, 643 
 essence, 606 
 extract, 677 
 juice, 639, 640 
 steak, broiled, 674 
 stock. 605 
 tea, 606, 641, 643 
 Bees, stings of, 434 
 Beet root, action of, on urine, 
 
 330 
 Belladonna as a poison, 571, 
 588 
 
 Bell-traps, 144 
 
 Bicarbonate of soda in baking, 
 
 613 
 Biceps muscle of the arm, 167, 
 
 191, 304 
 Bichloride of mercury as a disin- 
 fectant, 338 
 as a poison, 566, 578 
 Bicuspids, 316 
 Bile, 226 
 
 Bismuth, effects of, 804 
 Bite of rabid dogs, 431 
 Bladder, urinary, 172, 247 
 hemorrhage from, 320 
 Blank forms for reports, etc., 
 
 14-17 
 Blankets, airing of, 110 
 
 in the field hospital, 30 
 Bleeding from wounds, 437-447 
 from wounds, first aid in, 
 431, 423 
 Blisters, 370 
 
 on burned or scalded sur- 
 faces, 383 
 on the feet, 405 
 introduction of medicine by 
 means of, 345 
 Blood, the, 180-188 
 
 alteration of, in sunstroke, 
 
 459 
 apoplectic extravasation of, 
 
 458 
 expectorated, in chest 
 
 wounds, 453 
 fiow of, accelerated by mus- 
 cular action, 305 
 in the pleural cavity, 454 
 quantity transmitted to an 
 organ, 196, 225 
 
INDEX TO PARAGRAPHS. 
 
 381 
 
 Blood, samples for Widal's test, 
 354 
 in urine, 320, 391 
 vomiting of, in poisoning, 
 572, 584 
 Blood -colored urine in malarial 
 
 fevers, 320 
 Bloodless operations, 384 
 Blood-letting, vein selected for, 
 
 204 
 Boiled eggs, 649 
 potatoes, 670 
 rice, 657 
 Boiling as a cooking process, 603 
 influence of, on hard waters, 
 
 130 
 as a mode of purifying wa- 
 ter, 118 
 in water as a disinfecting 
 measure, 72, 84-86, 89, 331 
 Boils, 393 
 
 blind, 394 
 Bone, 153 
 
 forceps, 284 
 Books of record kept at hospi- 
 tals, 18, 145 
 Bovine lymph, 81 
 Bowels, condition of, related to 
 varicose veins, 206 
 movements of, 310 
 Bower's trap, 141 
 Brachial artery, 191 
 
 artery controlled by press- 
 ure, 421 
 plexus, 253 
 Brain, the, 249-252 
 
 compression of, 456 
 concussion of, 456 
 congestion of, 457 
 
 Brain, influence of venous blood 
 on, 298 
 exposure of, in wounds, 510 
 Brassard of hospital corps, 54 
 Bread-baking, 611 
 Breast-bone, 162 
 Brigade hospitals, during war, 
 
 24, 25 
 Bright's disease, 321 
 Broiling as a cooking process, 
 
 608 
 Bromid of potassium in poison- 
 ing, 571, 594 
 occasional effects of, 304 
 Bronchial breathing, 234 
 
 tubes, 332, 298 
 Brown Betty, 684 
 Bruises, 389 
 Bubo, treatment by pressure, 
 
 380 
 BufEy coat of blood, 181 
 Bugs in the ear, 490 
 Bunions, 404 
 Burns, 382-384 
 
 C. 
 
 Calcaneum or heel-bone, 179 
 Camp of field hospital, estab- 
 lishment of, 33, 34 
 
 diseases, 67-91 
 
 grounds, old, objectionable, 
 65 
 
 guard of field hospital, 34 
 
 importance of, 62 
 
 improvement of, 109 
 
 itch, 73 
 
 selection of, 63-65 
 
 site, change of, 113 
 Camps, cleanliness of, 112 
 
383 
 
 INDEX TO PAEAGRAPHS. 
 
 Camps infected with typhoid 
 
 fever, 76 
 Canine teeth, 215, 216 
 Canned fruit, 667 
 
 roast beef, 689, 691 
 salt heef , 693, 693 
 soups, 645 
 Cantharides as a counter-irritant, 
 370 
 as a poison, 570, 582 
 Capelline bandage, 449 
 Capillaries, 186, 198 
 Capillary hemorrhage, 195, 437, 
 
 438 
 Carbolic acid in infectious dis- 
 eases, 333, 334 
 eifects of, on urine, 304 
 as a disinfectant, 333 
 a poison, 567, 570, 585 
 acid in burns, 383 
 acid in toothache, 398 
 Carbolized catgut, 443 
 Carbonate of ammonia in bread- 
 making, 612 
 of soda in burns, 382 
 Carbon dioxid exhaled from the 
 lungs, 207, 237 
 insensibility from, 480 
 a measure of the vitiation of 
 
 respired air, 237 
 in bread-making, 611, 612 
 in air before and after breath- 
 ing, 335, 237 
 Carbonic oxid, insensibility 
 
 from, 480 
 Carbuncles, 395 
 Carcasses, disposal of, 114 
 Cardiac region, 188 
 Caries, 398 
 
 Carotid arteries, 190 
 
 artery controlled by press- 
 ure, 421 
 Carpus, 169 
 Carron oil in burns, 383 
 Cartilages of the air tubes, 332 
 
 of the joints, 164 
 
 of the ribs, 163 
 Casein as a food, 208 
 
 of milk, 310 
 Cases to be reported, 15 
 Castor oil, administration of, 304 
 
 in injuries of the eye, 885 
 Catgut ligatures, absorption of, 
 443 
 
 sterilization of, 281 
 Cathartics, drastic, as poisons, 
 
 580 
 Catheter, introduction of, 319 
 
 in brain injxiries, 456, 458 
 
 in fracture of the pelvis, 529 
 
 in fractures of the spine, 513 
 
 in typhoid fever, 350 
 Catlin, 385 
 Cauterization ' of poisoned 
 
 wounds, 429-433 
 Cellular tissue, 154 
 Centigrade temperature scale, 
 
 301 
 Centipedes, stings of, 433 
 Cephalic vein, 204 
 Cerebral nerves, 249, 353 
 
 symptoms of typhoid fever, 
 339, 343, 343, 850 
 Cerebrospinal meningitis in over- 
 crowded quarters, 91 
 Cervical nerves, 353 
 
 vertebrce, 157, 161 
 Cesspools, disinfection of, 334 
 
INDEX TO PARAGRAPHS. 
 
 383 
 
 Cesspools of general hospitals, 
 
 132 
 Chafing in the groins, 406 
 Chair for dental operations, 
 
 399 
 Chalk in cases of poisoning, 563, 
 
 567, 579 
 Chaplain of hospitals, duties of, 
 
 148 
 Charcoal in frost-bite, 387 
 
 fumes, asphyxia from, 480 
 Cheese, poisoning by, 995 
 Chemical analysis of drinking- 
 water, 139 
 Chest, triangular bandage for, 
 424 
 wounds of, 452 
 wounds, effects of, on respi- 
 ration, 298 
 Chicken broth, 644 
 Chicken-pox, 85 
 Chief Surgeon, duties of, 35, 39, 
 
 42, 46 
 Chilblains, 388 
 Chill, increased heat of body 
 
 during, 374 
 Chin, bandage for, 450 
 Chloral as a poison, 571, 587 
 as a remedy in strychnia 
 poisoning, 594 
 Chlorids in the urine, 317 
 Chlorinated solutions as disin- 
 fectants, 333 
 Chloroform by inhalation, 287- 
 389 
 in cases of poisoning, 571, 
 
 594 
 in dislocations, 536, 554 
 Chocolate, 679 
 
 Choking, artificial respiration 
 for, 478 
 by fragments of meat, 495 
 Cholera, 78 
 
 Chronic inflammation, 379 
 Chyle, 228 
 
 Chyme, 331, 224, 228 
 Cicatrix of burns, 383 
 Cicatrization of wounds, 413 
 Cineritious matter of the brain, 
 
 251 
 Circulation of the blood, 185 
 systemic, 186-206 
 pulmonary, 207 
 portal, 202 
 collateral, 197 
 Cisterns, 127 
 Clam broth, 646 
 Clavicle, 163 
 
 dislocation of, 540 
 fracture of, 515, 516 
 Cleanliness in the kitchen, 600 
 in the treatment of wounds, 
 
 open sores, etc., 293 
 personal, in winter quarters, 
 
 111 
 of troops in quarters, 116 
 of troops on transports, 130 
 of wards, nurses, and pa- 
 tients, 370 
 Clerical work, 14, 18, 58, 59, 145 
 Climatic influences, a cause of 
 
 camp diseases, 67 
 Clothing Account Book, 14, 18 
 fragments of, in wounds, 
 
 408 
 inadequate, a cause of camp 
 diseases, 67, 68 
 Clotting of blood, 181, 183 
 
384 
 
 INDEX TO PARAGRAPHS. 
 
 Clove hitch, 543, 546, 554 
 Coagulability of flbrin, 181 
 
 of lymph, 330, 359 
 Coagulated blood, arrest of hem- 
 orrhage by, 440 
 Coagulation of blood, 181, 183 
 
 of chyle, 228 
 Coal gas, asphyxia from, 480 
 Coaptation of fractures, 499 
 Cocaine as an anaesthetic, 295 
 Coccyx, 158 
 Cod-liver oil, administration of, 
 
 304 
 Coffee, 687 
 
 as a remedy in poisoning, 
 
 570, 586, 588 
 jelly, 661 
 Colchicum as a poison, 581 
 Cold in the treatment of inflam- 
 mation, 362 
 insensibility from, 468 
 baths, 278 
 climates, food required for, 
 
 210 
 sponging, 347 
 Colic from lead in drinking- 
 water, 131 
 Collapse, 358 
 
 from loss of blood, 422 
 in cases of poisoning, 563, 
 570, 572, 573, 576, 578, 
 579-581, 583, 585, 591-595 
 in typhoid fever, 351 
 in wounds of chest, 452 
 Collar bone, 163 
 
 dislocation of, 540 
 fracture of, 425, 515, 516 
 Collateral circulation, 197 
 Colles' fracture, 523 
 
 Colocynth as a poison, 580 
 
 Color-blindness, 263 
 
 Colorless corpuscles of blood, 
 
 183 
 Combustion, 248 
 Comminuted fractures, 497 
 Common iliac arteries, 192 
 
 tent, 95, 96 
 Complicated fractures, 497 
 Complications of wounds of 
 
 chest, 452 
 Compound fractures, 497 
 Compresses, 410 
 
 graduated, 439 
 Compression of brain, 313, 456, 
 
 508, 509 
 
 Concave glasses to aid sight, 260 
 
 Concentration of troops, effects 
 
 of, on hospital department, 22 
 
 Concussion of brain, 318, 456, 
 
 508 
 Condemnation of medical prop- 
 erty, 17 
 Condiments, 208 
 Condyles of the femur, 176 
 of the humerus, 166 
 of the humerus, fracture of, 
 518, 519 
 Cone for inhalation of ether, 290 
 Congestion, 196, 359 
 chronic, 370 
 of the brain, 457 
 Congestive fevers, in over- 
 crowded quarters, 91 
 Conjunctiva, 256 
 Conjunctivitis, 485, 486 
 
 caused by gonorrhoea! mat- 
 ter, 293, 486 
 Connective tissue, 154 
 
INDEX TO PAEAGKAPHS. 
 
 385 
 
 Contagious diseases should be 
 
 recognized early, 71 
 Contractility of arteries, 196 
 
 of muscles, 154^156 
 Contraction of cicatrix in burns, 
 
 382 
 Contused wounds, 407, 417 
 Contusions, 389 
 
 exudations in, 416 
 Convalescence in typhoid fever, 
 
 344 
 Convex glasses to aid sight, 359, 
 
 261 
 Convolutions of the brain, 251 
 Convulsions from disordered di- 
 gestion, 464 
 of epilepsy, 462 
 of sunstroke, 459 
 in teething children, 315, 464 
 Cooking, elements of, 598-612 
 Cooks of field hospitals, .duties 
 
 of, 31, 34, 37 
 Copper, salts of, as poisons, 
 577 
 sulphate, as a disinfectant, 
 337 
 Corium, 241 
 Cornea, 256, 263 
 
 sloughing of, 486 
 Corns, 403 
 Corpuscles of the blood, 182, 188 
 
 of lymph, 230 
 Corrosive sublimate as a disin- 
 fectant, 333 
 as a poison, 566, 573 
 acids, effects of, on the skin, 
 
 385 
 action of strong acids and 
 alkalies, 563 
 25 
 
 Cotton, wadding or batting as a 
 
 padding for splints, 501 
 Cotton-wool in bums, 383, 383 
 Cotyloid cavity, 175 
 Cough, bronchial, in typhoid 
 
 fever, 339 
 Council on the effects of deceased 
 
 soldiers, 14 
 Counter-extension in dislocation, 
 536 
 in fracture, 530 
 Counter-irritation in inflamma- 
 tion, 366-373 
 in chronic inflammations. 
 380 
 Cowhom forceps, 399 
 Cradles, 409 
 Cranium, bones of, 158 
 
 fractures of, 508 
 Cream of tartar in baking, 612 
 Crepitus in fractures, 498 
 Cricoid cartilage, 161 
 Croton oil as a counter-irritant, 
 372 
 as a poison, 580 
 Croup, suffocative paroxysms 
 
 of, 366 
 Crusta petrosa, 218 
 Crystalline lens, 256 
 Culex distinguished from ano 
 pheles, 75 
 yellow fever propagated by, 
 79 
 Cupping-glasses, 365 
 Custard, baked, 651 
 Cuticle, 241, 342 
 
 development of, in vesicated 
 burns, 383 
 Cut throat, 451 
 
386 
 
 INDEX TO PARAGEAPHS. 
 
 Cyanid of potassium as a poison, 
 589 
 
 D. 
 
 Dead, disinfection of the bodies 
 
 of the, 333 
 Dead house of General Hospi- 
 tals, 135 
 Deafness attending sore throat, 
 
 364 
 Death from chloroform inhala- 
 tion, 389 
 signs of, 483 
 
 In fractures of the spine, 513 
 Deaths and interments, Register 
 of, 18 
 sudden, in camp, due to 
 
 overcrowding, 91 
 en route to base hospitals, 
 how recorded, 47 
 Decomposition as a sign of death, 
 
 483 
 Deep wells, 138 
 Deficiency of food, effects of, 
 
 313 
 Deformities caused by the con- 
 traction of burns, 383 
 Deformity in fractures and dislo- 
 cations, 498, 536 
 Deglutition, 314 
 Delirium attending hemorrhage, 
 433 
 tremens, 467 
 in typhoid fever, 343 
 Deltoid muscle, 164, 165 
 Dental case, 403 
 
 pulp, 318, 319, 398 
 Dentine, 318 
 Deodorants, 336 
 
 Derma, 341 
 
 Descriptive Lists and Books, 17, 
 
 18 
 Desquamation after inflamma- 
 tion, 359 
 in bums, 383 
 in scarlet fever, 86 
 Destruction by Are as a disin- 
 fecting agency, 339 
 Detached troops, hospital provi- 
 sion for, 53 
 Dextrin, 338, 601 
 
 produced by action of saliva, 
 330 
 Dhobie itch, 73 
 Diabetes, 331, 323 
 Diaphoretics in inflanmiation, 
 
 373, 375 
 Diaphragm, 173, 233 
 Diarrhoea, association of, with 
 scurvy, 69 
 causation of, 68, 93, 313 
 caused by hard waters, 130 
 in teething children, 315 
 in typhoid fever, 339, 341 
 Diazo reaction, 353 
 Diet, deficient, effects of, 69, 313 
 errors of, a cause of boils, 
 
 393, 394 
 errors of, a cause of camp 
 
 diseases, 69, 93 
 full, when required, 311 
 of invalids, 599 
 low, as a remedial measure, 
 
 378 
 of patients in hospital, 311 
 of typhoid fever patients, 
 
 346 
 variety of, necessity for, 310 
 
INDEX TO PARAGRAPHS. 
 
 387 
 
 Dietetics, course in, 614 
 Digestion in the large intestine, 
 
 in the small intestine, 237 
 in the stomach, 221-333 
 Digitalis as a poison, 571, 593 
 as a remedy in cases of 
 poisoning, 570, 571, 583, 
 593 
 Dining-room of General Hospi- 
 tals, 125 
 Diphtheria, 88, 298, 494* 
 Discharge papers of enlisted 
 
 men, 14 
 Discipline of General Hospitals, 
 
 147 
 Disinfectants, 336-387 
 in chiclien-pox, 85 
 in cholera, 78 
 in diphtheria, 88 
 of excreta, 338 
 in glanders, 436 
 in itch, 73 
 in measles, 89 
 of privy-vaults or cesspools, 
 
 334 
 in scarlet fever, 86 
 in small-pox, 84 
 in typhoid fever, 849, 855 
 in yellow fever, 79 
 Dislocations, 535-563 
 Dislocation, prevention of recur- 
 rence, 538-540, 543, 544, 
 558 
 complicated, 537 
 symptoms of, 536 
 treatment of, 536 
 Displacement of bone in frac- 
 tures, 498 
 
 Displacement of bone, danger of, 
 in fractured pelvis, 539 
 danger of, in fractures of 
 the spine, 513, 513 
 Dissection wounds, 439 
 Diuretics in inflammation, 373 
 Division hospital, capacity of, 
 30 
 hospital, personnel of, 30 
 hospital, on the march, 31 
 hospital in battle, 35-53 
 Dog bites, 431 
 
 Dorsal artery of the foot, con- 
 trolled by pressure, 193, 
 431 
 nerves, 253 
 vertebrfe, 157, 163 
 
 Douche, cold, in poisoning, 586, 
 589 
 
 Douching for the arrest of bleed- 
 ing, 441 
 Drainage, 138 
 
 natural, 63 
 
 surface, of camp, 105, 109 
 
 tubes, sterilization of, 281 
 Drains of general hospitals, 132 
 
 for sewage and waste water, 
 133, 138-140 
 
 from wounds, 411 
 Draughts in ventilation, 238 
 Draw sheets, 375, 314 
 Dressings, sterilization of, 281 
 
 field, or first aid, 423, 435 
 
 immovable, 503 
 Drill, manual, 19, 30 
 
 dental, 897 
 Drops of a liquid, 304 . 
 Drowning, resuscitation of the 
 479 
 
388 
 
 INDEX TO PARAGRAPHS. 
 
 Drum corps, duties of, during 
 
 battle, 38, 43 
 Drum of the ear, 364 
 Dry cupping, 365 
 toast, 653 
 earth closets, 116 
 Dryness of camp site essential 
 
 to health, 63 
 Dugouts as winter quarters, 91 
 Dulness on percussion, 172 
 Dura mater, 353 
 Dust, influence of, in camps, 
 
 65 
 Dysentery, 77 
 
 E. 
 
 Ear, 364 
 
 foreign bodies in, 490, 491 
 
 method of syringing, 491 
 Ears, bleeding from, in frac- 
 tured skull, 508 
 Earth-closets, 116, 133 
 Earthy salts in water, 130 
 llcraseur, 440 
 
 Education of members of Hospi- 
 tal Corps, 12 
 Effusion of serum, 184 
 Egg albumen in cases of poison- 
 ing, 563, 566, 573, 577, 585 
 
 lemonade, 634 
 Egg-nog, 633 
 
 Ehrhch's diazo reaction, 353 
 Elbow-joint, dislocation of, 544 
 
 fractures near, 519, 530 
 Elevators, dental, 401 
 Emergencies, medical and surgi- 
 cal, first aid in, 371-274 
 Emetics, in alcoholic coma, 465 
 
 in opium poisoning, 586 
 
 Emetics, In poisoning, 565, 567- 
 
 573, 583, 585-595 
 Emmetropia, 858 
 Emphysema, 451, 453 
 Enamel of teeth, 318, 319 
 Enemata, 310 
 Engorgement of blood-vessels, 
 
 relief of, 360-373 
 Epidemic disease, specially re- 
 ported, 15 
 disease prevented by cook- 
 ing, 601 
 Epidemics of measles in newly 
 raised regiments, 89 
 of typhoid fever in newly 
 raised regiments, 76 
 Epigastrium, 162, 173 
 Epilepsy, 462, 463 
 Epistaxis, 488 
 
 in typhoid fever, 339 
 Epsom salt in inflammation, 373 
 in poisoning, 567, 574, 584, 
 585 
 Equipment of hospital corps, 31 
 Eruption of chicken-pox, 85 
 of measles, 89 
 of roseola, 87 
 of scarlet fever, 86 
 of small-pox, 80 
 of the teeth, 215, 216 
 Erysipelas, 124, 426 
 Escharotics in poisoned wounds, 
 
 439 
 Esmarch's bandage, 386 
 Estimates for repairs, etc., to 
 
 post hospitals, 16 
 Ether, inhalation of, 287, 388, 
 290 
 spray, a local ansesthetic, 394 
 
INDEX TO PARAGRAPHS. 
 
 389 
 
 Eustachian tube, 264 
 Evaporating lotions In inflamma- 
 tion, 363 
 Evaporation of water, coolness 
 
 produced by, 348 
 Eversion of the foot in disloca- 
 tion of the hip-joint, 553 
 of the foot in fractured 
 femur, 530 
 Excreta, disinfection of, 333 
 Executive officer of a Jjospital, 
 
 39, 145 
 Exercise, food required for, 210, 
 311 
 influence of, on the flow of 
 blood through the veins, 
 305 
 passive, 380 
 Exhalations, cutaneous, quan- 
 tity of, 344 
 Exhaustion on marches, 83, 470 
 Experience, importance of prof- 
 iting by, 33 
 Expiration, mechanism of, 333 
 Extemporized general hospitals, 
 
 133 
 Extension in reducing disloca- 
 tions, 536 
 by weights in cases of frac- 
 tured thigh-bone, 531 
 Extensor muscles of the upper 
 extremity, 167, 170 
 tendon of the thigh, 177 
 Extensors of the toes, 178 
 External iliac arteries, 192 
 jugular vein, 303 
 saphenous vein, 304 
 Extraction of teeth, 899-401 
 Extravasation of blood, 184 
 
 Exudation, 184 
 
 absorption of, by massage, 
 380 
 
 Eye, 356-263 
 
 drops, mode of using, 484 
 foreign bodies in, 483-486 
 injury to, by acids, 385 
 teeth, 215, 316 
 
 Eyes, glazing of, as a sign of 
 death, 483 
 
 F. 
 
 Face, bones of, 160 
 Facial nerve, 354 
 
 artery, controlled by press- 
 ure, 431 
 Faeces, 329 
 
 involuntary passage of, 313, 
 463, 513 
 Fahrenheit's temperature scale, 
 
 301 
 Fainting, 378, 357 
 
 on forced marches, etc., 470 
 Faintness from loss of blood, 
 
 373, 433 
 Fangs of the teeth, 217 
 Farcy, 485, 436 
 Farina gruel, 626 
 
 mush or porridge, 656 
 Fat, emulsification of, in the 
 small intestine, 226, 338 
 as a food, 208, 209 
 Fauces, 214 
 Felon, 396 
 Felt, perforated, as a material 
 
 for splints, 500 
 Female nurses in hospitals, 3, 
 
 125 
 Femoral artery, 192, 193 
 
390 
 
 INDEX TO PARA6EAPHS. 
 
 Femoral artery, controlled by 
 pressure, 421 
 hernia, 174 
 vein, 201 
 Femur, 176 
 
 fractures of, 530-533 
 dislocation of head of, 548- 
 558 
 Festering of wounds, 414 
 Fever, inflammatory, 374 
 hectic, 881 
 septic, 415 
 traumatic, 374^378 
 Fibrin of the blood, 181 
 Fibrinous principles of food, 208 
 Fibrous tissue, 155 
 Fibula, 178 
 
 fracture of, 533, 534 
 Field dressing of gunshot 
 wounds, 423 
 hospitals, 23-24 
 hospital during battle, 35-53 
 hospital on the march, 31-84 
 hospital work, object of, 45 
 hospitals during winter 
 
 camps, etc., 57 
 Return of killed, wounded, 
 
 and missing, 59 
 service, organization for, 
 
 22-30 
 tourniquet, 443 
 Final statements of enlisted men, 
 
 14 
 Finger, bones of, 169 
 dislocation of, 547 
 fracture of bones of, 538 
 ligature on, as evidence of 
 
 death, 483 
 nails, growth of, 185 
 
 Finger pressure for arrest of 
 hemorrhage, 441 
 tips, sensitiveness of, 343 
 Fire, destruction by, as a disin- 
 fectant, 329 
 precautions against, in hos- 
 pitals, 136, 151 
 First aid in accidents, 373 
 
 aid in gunshot wounds, 419 
 aid packet, 423 
 dressing-stations during bat- 
 tle, 39, 41, 43 
 Fish, boiling of, 603 
 bones in gullet, 495 
 digestion of, 223 
 Fission of bacteria, 338 
 Flies, infections carried by, 76- 
 
 78 
 Floating ribs, 162 
 Flour, use of, in burns, 882, 383 
 and water in poisoning, 566, 
 
 573, 577, 585 
 wheat, composition of, 308, 
 
 309 
 baking of, 611, 613 
 Fluctuation, 392 
 Fly-blisters, 370 
 Follicles of small intestine, 324 
 
 of stomach, 221 
 Food, effects of deficiency of, 
 218 
 digestibility of different arti- 
 cles of, 323 
 effects of excess of, 313 
 improper, 68 
 of invalids, 599 
 poisoning by articles of, 595 
 propagation of typhoid fe- 
 ver by, 355 
 
INDEX TO PABAQRAPHS. 
 
 391 
 
 Foot, dislocations of, 563 
 
 triangular bandage for, 434 
 Forced respiration, 333 
 Forceps, dental, 399, 400 
 Forearm, fractures of, 533-536 
 
 first aid in, 435 
 Foreign bodies, intrusion of, into 
 the system, 483-496 
 matter in wounds, 408, 410, 
 433, 453, 454 
 Formaldehyde generatjprs, 333 
 Formalin as a disinfectant, 333 
 for sterilizing the hands, 380, 
 393 
 Foiir tailed bandage, 449, 450, 
 
 511 
 Fracture-box for the leg, 534 
 Fractures, 497-534 
 first aid in, 435 
 progress of union in, 507 
 removal of patient to hospi- 
 tal, 374 
 symptoms of, 498 
 Fresh-air inlet into main drain 
 
 of buildings, 140 
 Friction in chronic inflamma- 
 tions, 380 
 Frost-bites, 387 
 Fruits, spoiled, bad effects of, 
 
 595 
 Frying as a cooking process, 607 
 Full diet, 311 
 
 P'umigation by sulphur, 336 
 Fund, hospital, 14, 150, 311 
 
 G. 
 
 Gall-bladder, 336 
 Galvanized iron, action of drink- 
 ing water on, 131 
 
 Ganglia, sympathetic, 349, 267 
 Gangrene, in frost-bite, 387 
 
 less common in hand than 
 foot, 197 
 Gargling the throat, 308 
 Garters a cause of varicose veins, 
 
 206 
 Gases, asphyxia from noxious, 
 
 480 
 Gastric juice, 331 
 Gelatin as a nutrient, 605 
 
 in bone, 153 
 General Hospitals, plans of, 123 
 Geneva Convention, Articles of, 
 
 54, 55 
 German measles, 90 
 Germicides, 336 
 
 Germs, destruction of, by cook- 
 ing, 601 
 Glanders, 435, 436 
 Glands, lymphatic, 330 
 
 of the mesentery, 328 
 
 sebaceous, 343 
 
 sudoriparous, 344 
 Glauber's salt as an antidote in 
 poisoning, 467, 574, 585 
 
 in inflammation, 373 
 Glenoid cavity, 163, 166 
 Glottis, 161 
 Glucose, 601, 611 
 
 produced by action of saliva, 
 etc., 320, 327, 328 
 Gluteal muscles, 176 
 Gluten as a food, 208 
 
 of wheat flour, 309, 361 
 Glycerine suppositories, 811 
 Gonorrheal ophthalmia, 486 
 Graduated compresses, 439 
 Granulation, 411, 413 
 
392 
 
 IITDEX TO PAKAGKAPHS. 
 
 Granulations, indolent, 413 
 
 Gravel, 324 
 
 Gravitation, influence of, on the 
 
 circulation, 361 
 Gray matter of the brain, 251, 
 268 
 matter of the spinal cord, 
 253 
 Grease in kitchen and pantry 
 
 sink-traps, 135 
 Green blindness, 263 
 Gristle, 162 
 Gullet, 161 
 Gumboils, 397 
 Gums, lancing of, in teething 
 
 children, 215 
 Gunshot wounds, 418-435 
 
 in the campaigns of 1898-99, 
 27 
 Gurgling in typhoid fever, 339 
 Gutta-percha filling for teeth, 
 398, 402 
 splints, 500 
 
 Haemoglobin, 182 
 Hsemorrhoids, 206 
 Hoemothorax, 452 
 Hair follicles, 243 
 Hall's method of artificial res- 
 piration, 473 
 Hamstring muscles, 177 
 Hand, dislocation of, 545 
 
 pronation and supination of, 
 
 168, 169 
 triangular bandage for, 424 
 Handkerchief as a bandage, 
 
 450 
 Hands, sterilization of the, 280 
 
 Hard bread, cooking of, 681-684 
 
 corns, 403 
 
 gruel, 628 
 
 pudding, sauce for, 685 
 Hardness of waters, 130 
 Head, bandages for, 424, 449, 450 
 
 wounds of, 448 
 Heart, 186-188 
 
 cessation of movements, a 
 sign of death, 482 
 
 increased action during ex- 
 ercise, 205 
 
 nerves of, 267 
 Heat as an aid to ventilation, 239 
 
 in the preparation of food, 
 601, 602 
 
 in the treatment of inflam- 
 mation, 363 
 
 animal, 248 
 
 dry, as a disinfectant, 335 
 
 exhaustion, 470 
 
 febrile, 374 
 
 and ventilation of pavilion 
 wards, 123 
 Heat-stroke, 459-461 
 Hectic fever, 381 
 Hellebore as a poison, 571, 592 
 Hemiplegia, 313 
 Hemispheres of the brain, 251 
 Hemlock as a poison, 571, 590 
 Hemorrhage, 273, 357, 437-447 
 
 arterial, 440 
 
 capillary, 198, 437, 438 
 
 venous, 439 
 
 danger of recurrence during 
 reaction, 446 
 
 first aid in, 431, 422 
 
 from collateral circulation, 
 197, 443, 447 
 
INBEX TO PAEAGRAPH8. 
 
 393 
 
 Hemorrhage, intermediate, 446 
 intestinal, in typhoid fever, 
 
 341, 351 
 nature's modes of arresting, 
 
 440 
 primary, 445 
 secondary, 447 
 Hemorrhoids, 206 
 Hepatic vein, 203 
 Hernia, 173, 174 
 Hip, triangular bandage for, 
 
 434 
 Hip-bones, 175 
 Hip-joint, dislocations of, 548- 
 
 558 
 Hopper water-closet, 134 
 Horses, glandered, 435, 436 
 Hospital boats and cars, 131 
 Corps, enlistments for, 8 
 Corps, instruction of, 4, 13 
 Corps, organization for field 
 
 service, 27-30 
 Corps, private, qualifications 
 and responsibilities of, 370 
 Corps, purposes for which 
 
 organized, 369 
 Corps, reports of, 14 
 Corps, uniform, etc., of, 31 
 fever, 91 
 
 fund, 14, 150, 213 
 gangrene, 134, 436 
 provision for detached 
 
 troops, 53 
 Stewards, appointment and 
 
 duties of, 7-10 
 Stewards, duties of, 29, 30, 
 
 37, 41, 47, 146, 150 
 Stewards, number of, at di- 
 vision hospitals, 28 
 
 Hospital stewards, number of, 
 
 allowed to posts, 8 
 
 Stewards, number of, with 
 
 ambulances in time of 
 
 war, 37 
 
 Stewards, qualifications of, 
 
 10 
 Stewards' quarters, esti- 
 mates for, 16 
 Stewards, re-examination of, 
 
 prior to re-enlistment, 7 
 tents, 98, 121 
 Hospitals, Base, 121 
 Field, 35-52 
 General, 121-151 
 Post, 1-21 
 
 Regimental, inefficiency of, 
 34 
 Hot baths, 278 
 air baths, 378 
 
 water as a counter-irritant, 
 373 
 House drains, for sewage, 188 
 Houses near field hospitals, 36, 
 
 44, 51 
 Humanized vaccine, 81 
 Humerus, 166 
 
 dislocation downward, of 
 
 head of 541-543 
 fracture of, 165, 425, 518- 
 522 
 Huts for troops during winter, 
 
 105, 108 
 Hydrochloric acid, burns by, 385 
 Hydrophobia, 431 
 Hyoscyamus as a poison, 571, 
 
 588 
 Hypermetropia, 361 
 Hypodermatic injection, 305 
 
394 
 
 INDEX TO PAEAGEAPHS. 
 
 Hypodermic syringe, steriliza- 
 tion of, 381 
 
 Ice, use of, in irritant poisoning, 
 569 
 
 and water in frost-bite, 387 
 
 bags, 363 
 Iced water, objections to use of, 
 
 in heat-stroke, 461 
 Ileo-csecai valve, 239 
 Ilium, 175 
 
 Immovable dressings for frac- 
 tures, 503-506 
 
 dressings for sprains, 390 
 Impacted fractures, 497 
 Incised wounds, '107-409 
 Incisors, 315, 210 
 Incubation, period of, 76, 79 
 Indolent sores, treatment of, 380 
 Infected wounds, 436, 436 
 Inferior vena cava, 301, 303 
 Inflammation, 356-378 
 
 chronic, 379, 380 
 
 local characteristics of, 359 
 
 treatment of, 360-378 
 Inflammations, special ; their 
 symptoms and treatment, 382- 
 406 
 Inflammatory fever, 374-378 
 Information slips, 18 
 Inguinal hernia, 174 
 Inorganic foods, 208 
 Insects in the ear, 490 
 Insensibility, causes of, 455-470 
 
 by anaesthetics, 287-290 
 
 from alcohol, 465 
 
 from apoplexy, 458 
 
 from cold, 468 
 
 Insensibility from concussion of 
 the brain, 456 
 from compression of the 
 
 brain, 456 
 from congestion of the brain, 
 
 457 
 from epilepsy, 462 
 from fainting, 470 
 from interference with the 
 
 respiration, 469 
 from narcotic poisoning, 586 
 from sunstroke, 459 
 Insensible perspiration, 344 
 Inspection of troops on trans- 
 ports, 130 
 monthly sanitary, 16 
 of camps, 119 
 Inspiration, mechanism of, 333 
 Instillation of eye-drops, 484 
 Instruction of Hospital Corps, 
 
 13 
 Instruments, surgical, steriliza- 
 tion of, 381 
 Intelligence, seat of the, 180, 351, 
 
 367, 368 
 Intermediary hemorrhage, 446 
 Internal iliac arteries, 193 
 
 saphenous veins, 204, 206 
 Intestinal hemorrhage in typhoid 
 fever, 341, 351 
 perforation in typhoid fever, 
 341, 353 
 Intestines, position of, in abdo- 
 men, 173 
 Intoxicants, 70 
 Inventory of effects, 14 
 
 and Inspection Reports, 17 
 Inversion of the foot in disloca- 
 tions of the hip-joint, 550, 551 
 
INDEX TO PARAGRAPHS. 
 
 395 
 
 Involuntary muscles, 154 
 lodid of potassium in chronic in- 
 flammations, 380 
 Iodine as a counter-irritant, 373, 
 380, 390 
 occasional effects of, 304 
 Ipecacuanha in poisoning, 565 
 Iris, 256 
 
 Iron, administration of, 304 
 hydrated oxid of, as an anti- 
 dote in poisonittg, 567, 573 
 Irreducible hernia, 174 
 Irrigation of wounds, 414 
 Irritant poisons, 573-581 
 
 poisons having a specific 
 action, 583-585 
 Ischium, 175 
 Isolation in infectious diseases, 
 
 338 
 Issues, counter-in-itation by, 371 
 Itch, 73 
 
 Jactitation in typhoid fever, 338 
 Joints, 164 
 
 Jugular veins, 300, 203 
 Junket, 634 
 
 K. 
 
 Kerosene oil, for the destruction 
 
 of mosquitoes, 75, 79 
 Kidneys, position of, 173, 246 
 hemorrhage from, 320 
 regulators of the animal 
 heat, 248 
 Killed, proportion of, to 
 
 wounded in battle, 27 
 Kitchen refuse of regimental 
 camps, 114 
 
 Kitchen sinks, connection of, 
 
 with soil pipes, 135 
 Kitchens of General Hospitals, 
 
 135, 126 
 Knapsack-room of hospitals, 125, 
 
 136 
 Knee-cap, 177 
 
 dislocation of, 559 
 Knee-joint, 177 
 
 dislocation of, 560 
 sprains of, 390 
 Koumyss, 630 
 
 L. 
 
 Lacerated wounds, 407, 410-414 
 wounds, relative infre- 
 quency of bleeding from, 
 440 
 Lacteals, 238, 330 
 Lactose, 310 
 Lamb, digestion of, 332 
 Large intestine, 172, 239 
 Larvae of mosquitoes, 75, 79 
 Laryngotomy, 493 
 Larynx, 161 
 
 foreign bodies in, 493, 493 
 in scalds of throat, 386 
 suffocation in diseases of 
 the, 298 
 Latrines, 142 
 
 of general hospitals, 132 
 Laughing-gas, inhalation of, 387 
 Laundry, connections with soil- 
 pipes, 135 
 of general hospitals, 125, 126 
 Lavage tube, 565, 572-575, 579, 
 
 580, 583, 585-588, 590, 592 
 Lavatories, company, in winter 
 camps, 111 
 
396 
 
 INDEX TO PARAGRAPHS. 
 
 Laxative enemata, 310 
 Lead in drinking-water, 131 
 lotions in rubefacience, 363, 
 382, 390 
 Leaks in plumbing work, 137 
 Leather splints, 500 
 Leavened bread, 611 
 Leeches, 364 
 Leg, fractures of, 533, 534 
 
 first aid in, 425 
 Lemonade, 631 
 Lemon jelly, 660 
 
 juice in cases of poisoning, 
 563 
 Lens, crystalline, 256 
 Lice, 73, 74 
 Ligaments, 164 
 Ligation of arteries, 443, 444 
 Ligatures for arrest of hemor- 
 rhage, 441, 443 
 in poisoned wounds, 429, 
 
 432 
 methods of sterilizing, 381 
 Light, protection of fevered pa- 
 tients from, 270 
 Limbs, triangular bandage for, 
 
 424 
 Lime-water test for air, 337 
 Lime salts in water, 130 
 Line of battle, first aid given on, 
 
 39,40 
 Liniments, use of, 380 
 Lint as padding for splints, 501 
 Liquids, administration of, to 
 
 weak patients, 307 
 Liquor ferri subsulphatis as a 
 styptic, 438 
 potassse in poisoned wounds, 
 433 
 
 Liquor potassse in poisoning by 
 cantharides, 570 
 
 sanguinis, 181 
 Liver, actions of, 236 
 
 blood-vessels of, 202 
 
 position of, 173 
 Location of field hospitals dur- 
 ing battle, 35, 36 
 Lockjaw, 430 
 
 Log huts as quarters, 104, 107 
 Logwood, action of, on the urine, 
 
 320 
 Loins, sprains of, 391 
 Long-sightedness, 361 
 Looking-glass, evidence of life 
 
 by means of a, 483 
 Loop bandage, 501 
 Loss, percentage of, in battle, 37 
 Low diet, 878 
 Lower jaw, dislocation of, 539 
 
 jaw, fracture of, 511 
 Lumbar nerves, 358 
 
 vertebrae, 157 
 Lung, penetration of, 453 
 Lungs, 307-232 
 
 hemorrhage from, 438 
 
 to remove water from, in 
 cases of drowning, 479 
 Lymph, 230 
 Lymphatics, inflammation of, 
 
 429 
 Lymphatic system, 230 
 
 M. 
 
 Maggots in the nose, 487 
 Magnesia in cases of poisoning, 
 563 
 salts in water, 130 
 Malarial diseases, 75 
 
INDEX TO PAKAQEAPIIS. 
 
 397 
 
 Malleoli, internal and external, 
 
 178 
 Malted milk, 678 
 Manipulation in reducing dislo- 
 cations, 536 
 Many-tailed bandage, 504 
 March, field liospital on the, 31- 
 
 34 
 Marshall Hall's method of artifi- 
 cial respiration, 473 
 Mashed potatoes, 671 
 Massage, 380 * 
 
 Mastication, 214 
 Mattresses, disinfection of, 329 
 Measles, 89 
 
 malignant, in overcrowded 
 
 quarters, 91 
 susceptibility of young sol- 
 diers to, 89 
 Measures, approximate, in cook- 
 ing, 615 
 Meat, cooking of, 603 
 fresh, analysis of, 209 
 spoiled, bad effects from, 
 326, 595 
 Median basilic vein, 204 
 
 cephalic vein, 204 
 Medical History of Post, 16, 18 
 oflBcer the sanitary oflScer of 
 
 military camps, 119 
 officer, visits of, to the post 
 
 hospital, 11 
 officers, duties of, on the 
 
 line of battle, 41 
 officers, duties of, at ambu- 
 lance stations, 43 
 officers at field division hos- 
 pitals during battle, 43, 
 44 
 
 Medical officers in charge of 
 wounded en route to base, 
 46, 47 
 officers supervise the in- 
 struction of the members 
 of the Hospital Corps, 13 
 Medicines, administration of, 304 
 Medullary matter of the brain, 
 
 251 
 Mercurial vapor-bath, 380 
 Mercuric chlorid as a disinfect- 
 ant, 333 
 as a poison, 566, 573 
 Mercury absorbed by the sldn, 
 
 345 
 Mesenteric glands, 228 
 Mesentery, 224 
 Metacarpal bones, 169 
 
 bones, fracture of, 537 
 Metatarsal bones, 179 
 Meteorological report, 16, 18 
 Miasms from the human body, 
 91 
 generated in huts, 106 
 Middle ear, 264 
 
 Milk, a perfect food for the child, 
 210 
 in cases of poisoning, 563, 
 
 566, 573, 577, 585 
 malted, 678 
 porridge, 659 
 punch, 618 
 sterilized, 617 
 toast, 653 
 
 of lime as a disinfectant, 333 
 Milk-teeth, 315 
 Minced chicken on toast, 676 
 Mineral salts in water supplies, 
 130 
 
398 
 
 INDEX TO PARAGRAPHS. 
 
 Molar teeth. 215, 316, 319 
 Monsel's solution, 438 
 Monthly Personal Reports, 14 
 Reports of Personnel and 
 
 Transportation, 14 
 Reports of Physical Exam- 
 ination of Recruits, 15 
 Reports of Sick and 
 
 Wounded, 15, 59 
 Sanitary Reports, 16 
 Morning Report Book, 18 
 
 Report of the Hospital 
 
 Corps, 14, 18 
 Report of Sick and 
 Wounded, 15, 18 
 Morphia in cases of poisoning, 
 563, 569, 573, 578, 581, 583, 
 593 
 Mosquito bites, 434 
 Mosquitoes as propagators of 
 malarial fevers, 75 
 as propagators of yellow 
 fever, 79 
 Motor nerves. 354 
 Mucilaginous drinks in poison- 
 ing, 563, 569, 573, 583, 584 
 Mucous membrane of air pas- 
 sages, 333 
 membrane of alimentary 
 
 canal, 314 
 membrane of small intestine, 
 
 334, 338 
 membrane of stomach, 331 
 membrane of the urinary 
 
 bladder, 347 
 membrane, stimulant treat- 
 ment of, 380 
 Mucus, 314 
 Mud in camps, 65 
 
 Multicuspids, 316 
 Munson's ventilated tent, 99 
 Muscles, 154r-156 
 
 disintegration of, by use, 316 
 spasmodic quivering of, as 
 evidence of life, 477 
 Muscular coat of arteries, 195, 
 196, 440 
 contraction in cases of frac- 
 ture, 351 
 Mushrooms, poisoning by, 595 
 Musicians during battle, 88 
 Mustard, counter-irritant action 
 of, 883 
 as an emetic in poisoning, 
 
 565 
 plasters, 866, 868 
 Muster and Pay Rolls, 14 
 Mutton broth, 643 
 Myopia, 360 
 
 N. 
 
 Nails, 185, 341 
 
 Narcotic poisoning, 571, 586-588 
 Nasal cavity, maggots in, 489 
 Nauseants as febrifuge remedies, 
 
 378, 375 
 Navel, 173, 173 
 Nerves, 349, 354, 355 
 Nitrate of silver as a poison, 567, 
 575 
 of silver in poisoned wounds, 
 
 439-431 
 of silver to proud flesh, 43 
 of silver eye-drops, 484-486 
 Nitric acid, burns by, 385 
 Nitrification, bacteria of, 137 
 Nitrite of amyl in poisoning, 571, 
 594 
 
INDEX TO PAKAGKAPHS. 
 
 399 
 
 Nitrogenous food, 208 
 
 Nitrous oxid gas, inhalation of, 
 
 287 
 Non-nitrogenous food, 308 
 Noi-mal saline solution, 339, 341, 
 
 351, 353 
 Nose, bleeding from the, 488 
 foreign bodies in, 488 
 maggots in, 489 
 Nurse, ward duties of, 269, 370 
 special instructions to be 
 given to, 338 • 
 Nurses of Held hospitals, duties 
 
 of, 31, 34, 37 
 Nursing of typhoid fever cases, 
 
 346-355 
 Nutrient enemata, 300 
 
 O. 
 
 Oakum as padding for splints, 
 
 501 
 Oatmeal gruel, 635 
 mush, 655 
 porridge, 654 
 Obstruction of veins, 305, 206 
 Odors, foul, bad effects of, in 
 
 camps, 68 
 (Esophagus, 161, 214 
 Ofilcer of the Day of general 
 hospitals, 147 
 of the Day in military 
 camps, 112 
 Officers' quarters at general hos- 
 pitals, 125 
 Oil of bitter almonds as a poison, 
 589 
 cloves in toothache, 398 
 olive, in injuries of the eye, 
 383 
 
 Oil in cases of poisoning, 563, 
 569, 570, 583, 584 
 of vitriol, burns by, 385 
 Olecranon process, 167 
 Olfactory nerve, 365 
 Omelet, 650 
 
 Operating room in general hos- 
 pitals, 125 
 staff of field hospitals. 43-45 
 table, preparation of, 383 
 Operation, preparation of patient 
 
 for, 383 
 Operations, duty of nurse dur 
 
 ing, 383 
 Ophthalmia, purulent, 293, 486 
 Opiate enema, 310 
 Opium as a poison, 571, 586 
 as a remedy in cases of poi- 
 soning, 569, 580, 584 
 Optic nerve, 256 
 Orangeade, 632 
 Order and Letter Book, 18 
 Organic matter in drinking- 
 vFater, 118, 129 
 matter in the perspiration, 
 
 344 
 matter in respired air, 336 
 Organization for -wax service, 33 
 Organs of the body, 152 
 
 of the senses, 355-366 
 Outline figure cards, 15 
 Overcrowding, progressive ef- 
 fects of, 91-93 
 in huts, 108 
 Overflow-pipes to plumbing fix- 
 tures, 135 
 Oxalic acid as a poison, 567, 
 
 579 
 Oxidation, 248 
 
400 
 
 INDEX TO PARAGRAPHS. 
 
 Oxygen carried by red corpus- 
 cles of blood, 183, 198, 207 
 Oxyphosphate cement, 398 
 Oysters, digestion of, 333 
 
 Pain, cause of, in inflammation, 
 
 359 
 Palmar arterial arch, 191 
 
 arches controlled by press- 
 ure, 421 
 Pan, water-closet, 134 
 Pancreas, 337 
 Pantry sinks, connection of, 
 
 with soil-pipes, 135 
 Papillae of the skin, 343 
 
 of the tongue, 366 
 Paralysis in apoplexy, 458 
 of face, 254 
 in fracture of the spine, 513, 
 
 513 
 in sprains of loins, 891 
 from sunstroke, 459 
 Paraplegia, 313 
 Passive motion in fractures of 
 
 the leg, 534 
 Pasteboard splints, 500 
 Patella, 177 
 
 dislocation of, 559 
 Pathways in camps, 109, 114 
 Patient, examination of, in acci- 
 dents, 372 
 preparation of, for bed, 275, 
 
 278 
 preparation of, for opera- 
 tion, 282 
 Pavilion wards of general hos- 
 pitals, 123 
 Pay accounts of enlisted men, 14 
 
 Pea meal mush fried, 697 
 
 soup, 696 
 Peas, digestion of, 323 
 Pectoral muscles, 164, 165 
 Pediculi, 73, 74 
 Pelvis, 171 
 
 fracture, 529 
 
 triangular bandage for, 434 
 Penetrating wounds of the chest, 
 453, 453 
 wounds of the abdomen, 454 
 Pensions based upon medical 
 
 records of war service, 58 
 Peppermint test for leaky soil- 
 pipes, etc., 137 
 Peptone, 331, 337 
 Peptonized milk, 631, 633 
 Percussion, 173 
 Pericardium, 188 
 Perineal band in fractured 
 
 femur, 580, 581 
 Periosteum, 158 
 
 Peristaltic movements of the in- 
 testines, 226 
 Peritoneum, 173 
 Personal reports of medical ofli- 
 
 cers, 13 
 Perspiration, 344 
 Persulphate of iron as a styptic, 
 
 438 
 Peyer's patches, 324 
 
 in typhoid fever, 340, 841 
 Phalanges of the fingers, 169 
 
 of the toes, 179 
 Pharmacy, knowledge of, re- 
 quired, 597 
 Pharynx, foreign bodies in, 495 
 Phosphates of the urine, 317, 
 833, 834 
 
INDEX TO PAEAGKAPH8. 
 
 401 
 
 Phosphorus, a constituent of 
 nervous tissues, 317 
 as a poison, 567, 570, 584 
 Phrenic nerve, 253, 313, 513 
 Pia mater, 253 
 Piles, 206 
 Pioneers of field hospital, 34, 37, 
 
 43 
 Pit of stomach, 162, 172 
 Plans of general hospitals, 122 
 Plantar arch, 193 
 Plasma, 181 
 
 Plasmodium malarise, 75 
 Plaster, application of, to close 
 wounds, 408, 409 
 of Paris in fractures, 506, 
 
 534 
 strapping of sprained joints, 
 
 390 
 strips in contused wounds, 
 416 
 Pleura, 281 
 
 Pleurisy, character of respira- 
 tion in, 298 
 Plumbing, 133-141 
 Plunger water-closets, 134 
 Pneumonia, condition of air cells 
 
 in, 298 
 Pneumothorax, 452 
 Poached eggs, 647 
 Poisoned wounds, 428-434 
 Poisoning by articles of food, 595 
 by Rhus toxicodendron, 596 
 Poisons, chemical antidotes for, 
 567 
 classification of, 564 
 Police, company, 110 
 
 general, of regimental 
 camps, 112-114 
 
 26 
 
 Police of general hospitals, 147 
 Popliteal artery, 193 
 
 artery controlled by press- 
 ure, 421 
 Pork, food principles of, 209 
 Portal circulation, 202 
 Post Hospital, service of, 3-21 
 Posterior tibial artery, 193 
 
 tibial artery controlled by 
 pressure, 421 
 Potassa as an escharotic, 371 
 as a poison, 563 
 cum calce, 371 
 Potassae, liquor, in poisoning by 
 
 cantharides, 570 
 Potatoes, cooking of, 608, 668- 
 
 671 
 Pott's fracture, 561 
 Poultices, 368 
 
 in abscesses, boils, etc., 390, 
 
 395 
 after application of a fly- 
 blister, 370 
 in corns and bunions, 403, 
 
 404 
 in frost-bites and chilblains, 
 
 387, 388 
 in sloughing burns, 383 
 in whitlow, 896 
 in the treatment of wounds, 
 413, 429 
 Poultry, digestion of, 222 
 Presbyopia, 259 
 
 Pressure, arteries which may be 
 controlled by, 421 
 a cause of inflammation, 
 
 404 
 as promotive of absorption, 
 380 
 
402 
 
 INDEX TO PAEAGtEAPHS. 
 
 Prevenlability of camp diseases, 
 
 66 
 Prickly heat, 73 
 
 Primary dressing of gunshot 
 wounds, 433 
 hemorrhage, 445 
 union of wounds, 409 
 Prison fever, 91 
 Privy vaults, disinfection of, 
 
 334 
 Processes, spinous, 157 
 Pronation, 168 
 
 danger of impairment of, in 
 fractures, 526 
 Property purchased with the 
 hospital fund, 14 
 of field division hospital, 
 
 cared for by, 29 
 destroyed, 17, 339 
 Prostration from loss of blood, 
 422 
 with excitement, 358 
 Proud flesh, 413 
 Prussic acid as a poison, 571, 589 
 Ptomaines, 326, 414 
 Ptyalin, 230 
 Pubes, 175 
 
 Pulleys, use of, in reducing dis- 
 locations, 536, 554 
 Pulmonary arteries, 207, 333 
 circulation, 186, 307 
 valves, 307 
 veins, 232 
 Pulp of tooth, 318. 219 
 Pulse, 191, 397 
 
 influence of muscular action 
 
 on, 376 
 reduction of, by medication, 
 378 
 
 Pulse and respiration, relative 
 frequency of, 333 
 
 Punctured wounds, 407, 454 
 
 Pupil of the eye, 256 
 
 Pupils in conditions of insensi- 
 bility, 458, 586 
 
 Purgatives in inflammation, 373, 
 375 
 
 Purulent conjunctivitis, 486 
 
 Pus, 359 
 
 Putrefaction, germs of, 336, 414r- 
 416, 599 
 
 Pyaemia, 416 
 
 Pyloric end of stomach, 231, 223 
 
 Quarantine restrictions in chol- 
 era, 78 
 
 Quarterly report of property, 17 
 
 Quicklime, as a disinfectant, 116, 
 333 
 
 Quiet as a remedial measure, 377 
 
 Quinine, effects of, 304 
 
 R. 
 
 Eadial artery, 191 
 
 artery controlled by press- 
 ure, 431 
 Radius, 167 
 
 fractures of, 533 
 Rain conductors, connection of, 
 with main drain, 139, 143 
 water, 137 
 Ration returns, 14 
 Rations, 211 
 
 for the wounded during and 
 after an engagement, 30 
 Reaction, general, 358 
 Recipes for articles of diet, 616 
 
INDEX TO PABAGKAPHS. 
 
 403 
 
 Record books of a post, 18 
 Records of field hospitals, 58-60 
 
 medical, Importance of, 58 
 Recruits, report of examination 
 
 of, 15 
 Rectum, absorption from, 229 
 Recurrent bandage for the head, 
 
 449 
 Red-blindness, 263 
 Red corpuscles of blood, 181, 
 182. 184 
 Cross Society, 56 
 Redness, cause of, in inflamma- 
 tion, 359 
 Reducible hernia, 174 
 Reduction of dislocations, 586 
 Reef-knot, 444 
 Reflex action, 267, 268 
 Refuse matters of camp, dis- 
 posal of, 114 
 Regimental hospitals, defects of, 
 in war service, 24 
 medical officers, availability 
 
 of, for special duties, 59 
 medical officers, duties of, 
 after a battle, 58 
 Registers of Patients, 15, 18 
 of Examination of recruits, 
 
 18 
 of Hospital fund, 18 
 Remissions in fever, 303, 839 
 Remittents simulating typhoid 
 
 fever, 91 
 Reports and papers from the 
 post hospital, 13-18 
 and papers during field 
 
 operations, 58, 59 
 and papers from general 
 hospitals, 145 
 
 Requisitions for supplies, 17, 46, 
 
 50 
 Resonance on percussion, 172 
 Respiration, 231-236,298 
 
 artificial, 471-481 
 Respiratory murmur, 234 
 
 movements to be counted in 
 certain diseases, 299 
 Rest in the treatment of inflam- 
 mation, 361, 376 
 Rests during marches, 470 
 Retching, dry, treatment of, 309 
 Retina, 256 
 Retractor, 284 
 
 Returns of Medical Property, 17 
 Re vaccination, 83 
 Reverses in bandaging, 502 
 Rheumatic inflammations, 379 
 Rheumatism simulated by 
 
 scurvy, 69 
 Rhubarb, action of, on urine, 320 
 Rhus, poisonous species of, 596 
 Ribs, 162 
 
 fracture of, 514 
 Rice gruel, 627 
 
 pudding, 694 
 Ridge ventilation, 123 
 Rigor, 374 
 
 mortis, 482 
 River water, 118, 128 
 Roasted potatoes, 669 
 Roasting as a cooking process, 
 
 609 
 Rochelle salt in bread, 612 
 
 in inflammation, 373 
 Roller bandage, 449, 502 
 Roseola, 87 
 
 Rose-colored spots in typhoid 
 fever, 339 
 
404 
 
 INDEX TO PAKAGKAPHS. 
 
 RStheln, 90 
 Rubber gloves, 280 
 Rubefacients, 366, 382 
 Rupture, 173, 174 
 
 S. 
 
 Sacral nerves, 253 
 
 Sacrum, 158, 171 
 
 Saline purgatives, action of, 378 
 
 substances in fresh meat, 209 
 Saliva, 214 
 
 action of, on starch, 320 
 Salt, Epsom, 567, 574, 584, 585 
 
 Glauber, 567, 574 
 
 table, as an article of food, 
 208 
 
 table, in poisoning, 567, 575 
 Salt nieat, digestion of, 222 
 Salts of the urine, 317, 324 
 Sand-bags as a support in frac- 
 ture, 531 
 Sanitary Report, Monthly, 16, 
 
 119 
 Saphenous veins, 304 
 Sausage, poisoning by, 595 
 Saw, use of, in amputations, 286 
 Scabies, 73 
 Scalds, 383 
 
 of the throat, 386 
 Scalp wounds, 448 
 Scalpels, 384 
 Scapula, 163 
 
 fracture of, 517 
 Scapular muscles, 164, 165 
 Scarf-skin, 241 
 Scarification of the conjunctiva, 
 
 486 
 Scarificator, spring, 365 
 Scarlatina, 86 
 
 Scarlet fever, 86 
 Sciatic nerve, 258 
 Sclerotic, 256 
 Scorpion stings, 483 
 Scraped beef, 672 
 
 sandwiches, 673 
 Screw tourniquet, 442 
 Scurvy, 69 
 
 Sebaceous glands, 248 
 Secondary hemorrhage, 447 
 
 union of wounds, 411 
 Sediments in urine, 324 
 
 in water cisterns, 137 
 Sensations, 249 
 Sensory nerves, 254 
 Septic fever, 415 
 
 intoxication, 414 
 Septicaemia, 415 
 Serpent bites, 433 
 Serum, 181 
 Sewage, 183, 138 
 
 in drinking-water, 118, 139 
 Sewerage, 138 
 Sewers, 143 
 Shallow wells, 128 
 Shampooing in chronic inflam- 
 mations, 380 . 
 Sheets, renewal of, under help- 
 less patients, 314 
 Shell-flsh, poisoning by, 595 
 Shelter, inadequate, a cause of 
 
 camp diseases, 67, 68 
 Shelter-tents, 93, 94, 107 
 
 in field hospitals, 43 
 Sherry and egg, 635 
 Ship fever, 91 
 Ships, fumigation of, 836 
 Shirt, to take off and put on, 276 
 Shock, 357, 358 
 
IKDEX TO PARAGRAPHS. 
 
 405 
 
 Shock in burns, 384, 385 
 in wounds, 420 
 death from, in burns, 563 
 Shoes, narrow-toed, bad effects 
 
 of wearing, 404 
 Shortening of limb in fracture, 
 
 156 
 Short-sightedness, 360 
 Shoulder, triangular bandage 
 
 for, 424 
 Shoulder-blade, 163 
 fracture of, 517 
 fracture of, first aid in, 425 
 Shoulder-joint, 164 
 
 dislocations, 541 
 Sibley tent, 100 
 
 Sick and Wounded, Reports of, 
 11, 15 
 and wounded, transporta- 
 tion of, 31, 33, 46 
 Sieges, field hospitals during, 57 
 Signs of death, 483 
 Silicate of soda bandage, 505 
 Silk ligatures for arteries, 443, 
 444 
 thread for sutures, 408 
 thread, sterilization of, 281 
 Silkworm gut for ligatures, 443 
 
 sterilization of, 381 
 Silver wire, sterilization of, 381 
 Silvester's method of artificial 
 
 respiration, 473 
 Simmering as a cooking process, 
 
 603, 605, 606 
 Sinks in military camps, 114-116 
 
 infected, 76 
 Siphonage of traps, 141 
 Six-tailed bandage for the head, 
 450 
 
 Skin, 340-245 
 
 action of, in regulating heat 
 
 of body, 248 
 desquamation of, in scarlet 
 
 fever, 86. 359, 383 
 inflammation of, in teething 
 children, 315 
 Skull, bones of, 159 
 
 fracture of, 508-510 
 Slaughter-house offal in camps, 
 
 disposal of, 114 
 Sleep, necessity for, 185, 368 
 Sleeplessness, caused by hunger, 
 
 313 
 Sling for the upper extremity, 
 
 434 
 Sloughing, in burns, 383 
 
 in frost-bite and chilblains, 
 
 387, 388 
 in contused wounds, 416, 477 
 Sloughs in boils, 393 
 Small intestine, 173, 334 
 Small-pox, 80 
 
 Smell, the best method of detect- 
 ing impurity in air, 237 
 Smith's anterior splint, 533 
 Smothering, artificial respiration 
 
 for, 477 
 Snow-blindness, 486 
 Snow and water as remedial in 
 
 frost-bite, 387 
 Soap, action of hard water on, 
 130 
 suppositories, 311 
 and water in poisoning, 563 
 Soda, caustic, as a poison, 563 
 Sod-cloth of tents, 95 
 Soft cooked eggs, 648 
 corns, 403 
 
406 
 
 INDEX TO PARAGEAPHS. 
 
 Softness of waters, 130 
 Soil-pipes, 133, 186 
 
 ventilation of, 140 
 Soils, as relating to the site of 
 
 camps, 63-65 
 Sordes, 306, 342 
 Sore throat in scarlet fever, 86 
 Sounds of the heart, 188 
 Soup, 605 
 
 Specific gravity of urine, 331, 333 
 Spinal cord, 157, 349, 353 
 
 cord, reflex action of, 367, 
 368 
 
 nerves, 349 
 Spine, fracture of, 313, 512, 513 
 
 bed-sores in fractures of, 315 
 Spinous processes of the verte- 
 bra, 157, 512 
 Spirit of camphor in chilblains, 
 
 388 
 Spleen, 173, 335 
 Splinters in wounds, 408 
 
 a cause of abscess, 392 
 Splints, 500 
 
 extemporized in field ser- 
 vice, 425 
 
 fixed by triangular bandage, 
 434 
 
 use of, in sprains, 390 
 
 use of, in wounds, 409, 410 
 Spores of bacteria, 328 
 Spotted fever in overcrowded 
 
 quarters, 91 
 Sprains, 380, 390 
 
 of the loins, 391 
 Spring forceps, 384, 444 
 
 scarificator, 365 
 Stable manure, disposal of, 114 
 Starch as food, 208 
 
 Starch, influence of cooking on, 
 601, 611 
 use of, in burns, 382, 383 
 bandage, 503, 504, 534 
 Steam, as a disinfectant, 281, 
 
 330 
 Steamed rice, 658 
 Sterilization in surgical proceed- 
 ings, 280-282 
 Sterilized milk, 617 
 Sterno-mastoid muscle, 161, 303 
 Sternum, 162 
 
 Stewards, duties of, in the field, 
 29, 30, 37, 41, 47 
 at general hospitals, 146, 
 150 
 Stewed apples, 665 
 chicken, 675 
 dried fruit, 664 
 prunes, 663 
 Stewing as a mode of cooking, 
 
 604 
 Stimulant applications in chronic 
 inflammations, 380 
 applications in frost-bite and 
 chilblains, 387, 388 
 Stimulants in shock and syncope, 
 357, 470 
 in prostration from bleeding, 
 
 273, 423 
 in internal injuries, 389 
 in wounds of the chest and 
 
 abdomen, 453 
 in poisoned wounds, 432 
 in exposure to extreme cold, 
 
 468 
 in concussion of the brain, 
 
 456 
 in alcoholic stupor, 466 
 
INDEX TO PAKAGRAPHS. 
 
 407 
 
 Stimulants in cases of poison- 
 ing, 563, 569, 571, 573, 
 578, 580-585, 589-593, 595 
 in artificial respiration, 474 
 Stomach, 173, 231 
 
 foreign bodies in, 496 
 hemorrhage from the, 438 
 pump in poisoning, 565, 573- 
 575, 577, 579, 580, 583, 
 585-588, 590-593 
 nourishment administered 
 by, 451 
 Stone in bladder, 335 
 Store-rooms of general hospitals, 
 
 135 
 Strangulated hernia, 174 
 Strangulation, artificial respira- 
 tion for, 476 
 Strangury in poisoning, 583 
 Strap-and-buckle fastenings for 
 
 splints, 501 
 Strapping with plaster to pro- 
 mote absorption, 380 
 Straw as a material for splints, 
 
 500 
 Streets, company, proper condi- 
 tion of, 109 
 Striae of voluntary muscles, 153 
 Strychnine as a poison, 571, 594 
 as a remedy in cases of poi- 
 soning, 571, 587, 591 
 Styptics, 437, 438, 441 
 Subclavian arteries, 191 
 
 artery controlled by press- 
 ure, 421 
 vein, 300 
 Subsistence officer of field hospi- 
 tal, 39 
 Subsoil water, 118, 138 
 
 Subsultus tendinum, 343 
 Sudoriparous glands, 244 
 Suffocation, 477-481, 563 
 Sugar as food, 208 
 in urine, 331, 323 
 of lead as a poison, 567, 574 
 Sulci of the brain, 351 
 Sulphate of copper as an emetic 
 in poisoning, 565, 577 
 of copper as an antidote in 
 
 poisoning, 567, 577, 531 
 of copper as a poison, 566, 
 
 577 
 of copper to proud flesh, 413 
 of iron as a deodorant, 337 
 of magnesia as a remedy in 
 poisoning, 567, 574, 584. 
 585 
 of soda as an antidote in 
 
 poisoning, 567, 574, 585 
 of zinc as an emetic in poi- 
 soning, 565 
 of zinc as a poison, 576 
 Sulphates in urine, 317 
 Sulphur, a constituent of albu- 
 minous tissues, 317 
 as a disinfectant, 336 
 Sulphuric acid, aromatic, as an 
 antidote in poisoning, 563, 
 574 
 Sunstroke, 459-461 
 Superior vena cava, 200 
 Supination, 168 
 
 in fractures of forearm, 633, 
 536 
 Suppositories, 311 
 Suppression of urine, 325 
 Suppuration in burns, 383 
 in lymphatic glands, 330 
 
408 
 
 INDEX TO PAKAGEAPHS. 
 
 Surgeon in charge of a field hos- 
 pital, duties and responsi- 
 bilities of, 29-60 
 in charge of a general hos- 
 pital, duties and responsi- 
 bilities of, 145 
 Surgeon's call at post hospitals, 
 11 
 knot, 444 
 Surgical operations, preparation 
 for the performance of, 379- 
 290 
 Susceptibility of young soldiers 
 
 to typhoid fever, 76 
 Suspensory bandage for rupture, 
 
 174 
 Suture for closing wounds, 408 
 Sutures in contused wounds, 416 
 not used in wounds of scalp, 
 448 
 Swabbing the throat, 308 
 Sweat, 244 
 
 Swelling, cause of, in inflamma- 
 tion, 359 
 Sympathetic nerves, 249 
 
 nervous system, 267, 268 
 fever, 374-378 
 Symptoms, changes in, noted, 
 
 270, 273 
 Syncope, 273, 357, 470 
 
 influence of, on hemorrhage, 
 440 
 Synovia, 164 
 Syphilis, danger of infection 
 
 from sores, 293 
 Syphilitic inflammation, 379, 
 
 380 
 Syringing ear, method of, 491 
 Systemic circulation, 186 
 
 T. 
 
 Tablespoonful, 304 
 Tannin as a styptic, 438 
 
 in cases of poisoning, 566, 
 578, 581, 588, 590, 594 
 Tarantula bites, 433 
 Tarsal bones, 179 
 Tartar on the teeth, 219 
 Tartar emetic as a counter-irri- 
 tant, 373 
 emetic as an emetic in poi- 
 soning, 565 
 emetic as a poison, 578 
 Tea, 638 
 
 green, in cases of poisoning, 
 566, 578, 581, 588, 590, 594 
 Teaspoonful, 304 
 Teeth, 315-219 
 
 extraction of, 399-401 
 filling cavities in, 402 
 Teething, constitutional disturb- 
 ances attending, 215 
 Temperature charts, 303 
 
 charts in typhoid fever, 339 
 rise of, after surgical opera- 
 tions, 393 
 lowering of, as a sign of 
 
 death, 482 
 normal, 300 
 
 of patients, how taken, 302 
 scales; to change Fahren- 
 heit to Centigrade, and 
 vice versa, 301 
 of wards, 270 
 Temporal arteries, 190 
 Temporary hardness of waters, 
 130 
 teeth, 215 
 Tenaculum, 284 
 
INDEX TO PAEAGBA.PH8. 
 
 409 
 
 Tendo-Achillis, 178 
 Tendons, 155 
 
 of forearm, 170 
 Tenesmus, 310 
 Tent-flies for extending hospital 
 
 shelter, 44 
 Tents, common, 95, 96 
 
 conical, wall, 101 
 
 hospital, 98 
 
 large, dangerous, 93 
 
 Munson's, 99 
 
 shelter, 94, 102 
 
 Sibley, 100 
 Tepid baths, 278 
 Test for sugar, etc., in urine, 
 
 330-824 
 Tests for organic matter in 
 
 drinking-water, 139 
 Testicle, contusions of, 389 
 Tetanus, 430 
 Thermic fever, 248 
 Thermometer, clinical, 302 
 Thigh, triangular bandage for, 
 
 434 
 Thigh-bone, 176 
 
 fractures of, 435, 530-533 
 Thoracic aorta, 181 
 
 duct, 228 
 Throat, scalds of, 386 
 Thumb, bones of, 169 
 
 dislocations of, 546 
 Thyroid cartilage, 161 
 Tibia, 177, 178 
 
 fractures of, 533, 534 
 Tibial arteries, 193 
 
 arteries controlled by press- 
 ure, 421 
 Tin, sheet, as a material for 
 splints, 500 
 
 Tincture of iodine in chronic in- 
 flammations, 372, 380, 382, 
 388, 404 
 of iodine in serpent bites, 432 
 Toast, 652, 653 
 water, 636 
 Tobacco as a poison, 571, 591 
 Toes, tendons of, 178 
 Toilet of patient, 270, 348 
 Tomatoes, cooking of, 698-700 
 Tongue, 266 
 
 appearance of, in disease, 
 
 306 
 in typhoid fever, 339, 343, 
 
 348 
 position of, in artificial res- 
 piration, 471 
 Tooth, extraction of, 397, 399- 
 401 
 socket, hemorrhage from, 
 438 
 Toothache, 398 
 Tormina, 310 
 Torsion, 441 
 
 Touch, special organ of, 842 
 Tourniquet, 442 
 Trachea, 161, 233 
 
 foreign bodies in, 492 
 Tracheotomy, 494 
 Transfer slips, 15 
 Transports, sanitary care of, 180 
 Traps on fixtures, soil-pipes, and 
 
 drains, 133-135, 139-141, 144 
 Traumatic fever, 374^378 
 Trenching of camps, 105, 109, 
 
 114 
 Triangular bandage, 434, 450 
 Trichiniasis prevented by cook- 
 ing, 601 
 
410 
 
 INDEX TO PARAGRAPHS. 
 
 Trikresol as a disinfectant, 333 
 
 Trochanter, 176 
 
 Truss, measurement of patient 
 
 for, 174 
 Trypsin, 227 
 
 Tuberosities of the humerus, 166 
 Turpentine stupes, 366, 867 
 
 in chilblains, 388 
 Tympanites, 339, 341 
 Tympanum, 264 
 Typhoid fever a camp disease, 
 76, 92 
 fever, germs of, in drinking- 
 water, 118 
 fever in overcrovfded quar- 
 ters, 91 
 fever, symptoms of, 339-344 
 pneumonia due to over- 
 crowding, 91 
 Typhus fever in overcrowded 
 quarters, 91, 92 
 developments in dugouts 
 and badly constructed 
 huts, 106 
 prevented by a free allow- 
 ance of air space, 124 
 
 U. 
 
 Ulceration of a blood-vessel, 447 
 
 of bunions, 404 
 
 of chilblains, 388 
 
 in burns, 383 
 Ulna, 167 
 
 fractures of, 524 
 Ulnar artery, 191 
 
 artery controlled by press- 
 ure, 421 
 Umbilical hernia, 173 
 Umbilicated vesicles, 82 
 
 Umbilicus, 172, 173 
 Unguents, use of, in burns, 382, 
 
 383 
 Uniform of Hospital Corps, 21 
 Union by the first intention, 409 
 by the second intention, 411 
 in fractures, 507 
 Units of hospital organization 
 
 for war service, 22 
 Urasmic convulsions, 325 
 Urates in urine, 318, 324 
 Urea, 318 
 Ureter, 246 
 
 Ureters, hemorrhage from, 320 
 Urethra, 247 
 
 hemorrhage from, 320 
 Uric acid, 316, 318, 324 
 Urinals for winter camps, 117 
 Urinary sediments, 324 
 Urine, 316-318, 320-325 
 albumin in, 322 
 blood-colored, by medicines, 
 
 320 
 blood-colored in malarial 
 
 fevers, 320 
 bloody, in cases of poison- 
 ing, 582 
 bloody, in sprains of loins, 
 
 391 
 disposal of, in camps, 117 
 involuntary discharge of, in 
 
 epilepsy, 462 
 retention of, 325 
 retention of, in apoplexy, 
 
 458 
 retention of, in fractures of 
 
 the spine, 513 
 sugar in, 321, 323 
 suppression of, 325 
 
INDEX TO PARAGEAPES. 
 
 411 
 
 Urine, suppression of, in poison- 
 ing, 572 
 in typhoid fever, 850 
 Uiinometer, 331 
 
 Vaccination, 81 
 Valve water-closet, 134 
 Valves of aorta, 187, 195 
 
 of heart, 187 
 
 of veins, 205 
 Vapor-bath, merciirial, 380 
 Varicose veins, 206 
 Varioloid, 83 
 Veal, digestion of, 223 
 Veins, 199-207 
 Vense cavse, 200-302 
 Venous blood, 187, 198, 307 
 
 hemorrhage, 439 
 Ventilation, 338, 339 
 
 of log huts, 104-107 
 
 of pavilion wards by the 
 ridge, 123 
 
 as a preventive of erysipelas, 
 436 
 
 of soil-pipes, 140 
 
 of surgical wards, 293 
 Vent-pipe in trap to prevent 
 
 siphonage, 141 
 Ventricles of the brain, 351 
 
 of the heart, 187 
 Vermicular movements of the in- 
 testine, 226 
 Vertebrae, fracture of, 312 
 Vertebral column, 157 
 Vesicants, 366 
 Vesication in burns, 383 
 Vesicular breathing, 234 
 
 matter of the brain, 351 
 
 Villi of small intestine, 328 
 Vinegar in cases of poisoning, 
 
 563 
 Vision, acuteness of, 258 
 Vocal chords, 161 
 Voluntary muscles, 154 
 Vomiting, 309 
 
 in alcoholic coma, 466 
 
 in concussion of the brain, 
 
 456 
 in contusions of the abdo- 
 men, 389 
 during inhalation of ances- 
 
 thetics, 289 
 after operations on the ab- 
 dominal cavity, 291 
 
 W. 
 
 Wagons, army, for transporta- 
 tion of wounded, 46 
 field hospital, 30, 31 
 
 Walking supervised by reflex 
 action, 267 
 
 Wall -tent for officers, 97 
 
 Wards, cleanliness of, 270 
 
 fumigation of, by burning 
 sulphur, 336 
 
 Wardmasters in general hospi- 
 tals, 149 
 
 Ward Surgeons of general hos- 
 pitals, duties of, 147 
 
 Warm baths, 378 
 
 Warm-water dressings, 363 
 
 Warming of general hospitals, 
 135 
 
 Warmth obtained at expense of 
 ventilation, 102 
 
 Wash-basin, connection with 
 soil-pipe, 135 
 
412 
 
 INDEX TO PABAGEAPHS. 
 
 Washing of clothes in camps, 
 
 118 
 Wasps, stings of, 434 
 Waste matters of camp, disposal 
 
 of, 114 
 Water, boiled or filtered, to be 
 used, 118 
 called for in cases of hemor- 
 rhage, 423 
 chemical analysis of, 129 
 cistern, 137 
 dissipation of, in lungs, 307, 
 
 235 
 douches in narcotic poison- 
 ing, 586 
 importance of, as a food, 308 
 lead in, 131 
 
 natural purification of, 137 
 rain, 137 
 
 soft and hard, 180 
 sterilization of, 118 
 subsoil, 138 
 surface, 138 
 tests of purity, 139 
 use of, in sunstroke, 460, 461 
 use of, in syncope, 470 
 well, 138 
 Water-carriage for sewage, 133 
 Water-closets, 134 
 Water-gas, accidents from, 481 
 Waterhouse-Forbes sterilizers, 
 
 118 
 Water-seals, 133-141 
 Water-supply of general hospi- 
 tals, 136 
 of camps, 118 
 necessity for, as a cooling 
 
 agency, 459 
 a cause of camp diseases, 68 
 
 Water-supply, in cholera, 78 
 propagation of typhoid fever 
 by, 76, 93 
 Wedge-tent, 95 
 Weekly Report of Sick and 
 
 Wounded, 59 
 Wells, 138 
 
 in camps, 118 
 Wet cupping, 365 
 packing, 347 
 Wheat flour, analysis of, 309 
 Whey, 633 
 Whiskey, harmfulness of, in 
 
 camp, 70 
 White corpuscles of blood, 183, 
 380 
 matter of the brain, 351 
 matter of the spinal cord, 
 358 
 Whiting in cases of poisoning, 
 
 568, 567, 579 
 Whitlow, 396 
 Widal's test, 354 
 Windows, ventilation by, 339 
 Windpipe, 161 
 Winds, protection from, in 
 
 camps, 65 
 Wine jelly, 663 
 Winter huts for troops, 103- 
 
 108 
 Wire mattress as a surgical bed, 
 
 580 
 Wisdom teeth, eruption of, 
 
 316 
 Wooden splints, 500 
 Worms, intestinal, prevented by 
 cooking, 601 
 convulsions from presence 
 of, in intestine, 464 
 
INDEX TO PABAGBAPH8. 
 
 413 
 
 Wounded, lists of, required after 
 an engagement, 59 
 transportation of, to base of 
 
 supplies, 46 
 left to the care of the enemy, 
 50 
 Wounds, 407-454 
 
 treatment of, at field dress- 
 ing - stations, 41, 419- 
 425 
 Wrist, fracture of, 523 
 Wrist - joint, diHocation of, 
 545 
 
 Yellow fever propagated by mos- 
 quitoes, 79 
 
 Zinc, action of drinking-water 
 
 on, 131 
 chloride as a disinfectant,337 
 salts of, as poisons, 576 
 sheet, as a material for 
 
 splints, 500 
 sulphate of, as an emetic in 
 
 poisoning, 665