HX641 14376 RC87.B93 A text-book of first RECAP ColumtJia WLni\)tv9iitf in tfje Citp of ^to Iforfe CoUcge of ^fjpsicianf; anb burgeons S^eference Hibrarp ^^mMmmm Digitized by tine Internet Arciiive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/textbookoffirstaOOburn A TEXT-BOOK FIRST AID AND EMEEGENCY TREATMENT BY A. C. BURNHAM, M.D. MEDICAL CORPS, U. S. R. INSTRUCTOR IN SURGERY IN THE POLYCLINIC HOSPITAL, NEW YORK CITY; ATTENDING SURGEON, DEPARTMENT OF SURGERY, VANDERBILT CLINIC, COLLEGE OF PHYSICIANS AND SURGEONS, NEW YORK CITY ILLUSTRATED WITH 160 ENGRAVINGS AND 2 PLATES LEA & FEBIGER PHILADELPHIA AND NEW YORK 1917 Copyright LEA & FEBIGER 1917 3 ^j5 PREFACE. In the preparation of this book the author has kept in mind the requirements of both the untrained first-aid worker and the advanced student who may be expected to practise the art under the conditions of modern warfare. In its essentials the practice of first aid is the same whether the worker is surrounded by the conveniences of a civihzed community or is in the wilderness or upon the battlefield. In any of these places emergencies may occur which in the absence of skilled medical aid require immediate volunteer treatment, the character of the services being determined by the skill of the volunteer and the available medical and surgical supplies. This book is intended to so train the volunteer assistant that when the emergency occurs he may be able to apply the principles of first aid to the case at hand. In addition the volume has been made complete in many small details, so that the advanced worker may find it a reliable reference book for both field and hospital work, and the camper and yachtsman, in the absence of a physician, may find in it sufficient information to enable him to assume temporary care of the sick and injured. In teaching first aid in the conventional course of six or eight lessons, it has not been the author's custom to attempt to cover the entire book. Such a plan being imprac- ticable, he has endeavored to fix the principles of treatment thoroughly in the minds of the students, so that the interest thus aroused will lead them to a further study of .the lesser details. IV PREFACE In coiidiictinij his courses tlio author has found it advan- tajxeous to c'onil)ine a part of the anatomy and jihysiolofjy with each lecture on treatment. Thus the anatomy of the hones and the joints is given in the lecture on fractures and dislocations, and the anatomy and ])hysiology of the circula- tion is 2 Fracture of the Ankle 1-53 Fracture of the Foot and Toes 135 Compound Fractures 135 Dislocations 135 Symptoms 130 Treatment ' 136 Habitual Dislocation 136 Persistent Dislocation 136 Special Dislocations 137 Dislocation of the Spine 137 Dislocation of the Clavicle 138 Dislocation of the Shoulder 138 Dislocation of the Elbow . 140 Dislocation of the Wrist 140 Dislocation of the Fingers 141 Dislocation of the Jaw 141 Dislocation of the Hip 143 Dislocation of the Patella 143 Dislocation of the Knee 143 Dislocated Meniscus 143 Dislocation of the Ankle and Foot 143 Dislocation of the Toes 143 Sprains 144 Sprained Ankle 145 Sprained Wrist 146 Sprained Fingers 146 Sprained Knee 146 Sprained Back 146 Wounds of Bones and Joints 147 Bullet Wounds of the Bones and Joints 147 CHAPTER VI. Miscellaneous Injuries. Burns 149 Severe Burns 152 Chemical Burns 153 Injuries Caused by Cold 154 Exposure to Cold 154 Frost-bite 155 COXTENTS Injurios Causod by Islcctririty Bite Wounds Di-K Bito . . llydropliohia Snake Bite . Insect Bites Tetanus 157 159 150 l(j() IGl 103 103 CHAPTER VII. General Injuries. Shock 1()G Fainting IGS Sunstroke 170 Heat Exhaustion 173 Exjjosure to Extreme Cold 174 Unconsciousness 174 Hysterical Unconsciousness 17G CHAPTER VHI. Suffocation. Artificial Respiration 179 Choking 184 Drowning 184 Suffocation by Smoke . , 187 Asphj'xiation bj^ Illuminating Gas 187 Asphyxiation by Irritant Gases 189 Asphyxiation bj' Gas in the European War 189 CHAPTER IX. Regional Injuries. Head 193 Wounds of the Scalp 193 Infection of the Scalp 194 Concussion of the Brain . . .... . 194 Intracranial Injury . . . 195 Eye 197 Contusion of the Eye 197 W^ounds About the Eye . . 198 Foreign Body in the Eye . 198 CONTENTS ' XI Ears 199 Boxer's Ear 199 Foreign Body in the Ear 200 Nose 200 Foreign Body in the Nose 200 Bleeding from the Nose 200 Mouth 201 Wounds of the Mouth 201 Hemorrhage from the Mouth 201 Hemorrhage from the Lungs 202 Hemorrhage from the Stomach 202 Internal Hemorrhage 202 Foreign Bodies in the Throat 203 Chest 204 Contusion of the Chest 204 Wounds of the Chest 204 Abdomen 205 Contusion of the Abdomen 205 Wounds of the Abdomen 207 Strangulated Hernia 207 Rectum, Bladder and Reproductive Organs 208 Injuries to the Extremities 208 Crushing Injuries 208 Division of the Tendons 210 Division of Nerves 210 Foreign Body 211 Muscle Strain 211 Rupture of a Muscle - 212 Bhsters and Abrasions of the Feet : 212 Ingrowing Toe-nails • 213 Splinter Beneath the Nail 213 Blood Bhsters 213 CHAPTER X. Poisoning. Symptoms 215 General Treatment 215 Antidotes 219 Special Poisonings 221 Caustic Acids 221 Caustic Alkahes 222 Carbolic Acid 222 Xll ^ COX'I'hWTS Siiecial Poisonings — Opium 223 Chloral 223 Strychnin 224 Belladonna 224. Bichloride of Mercury 224 Acute Alcoholism 225 Chloroform and I'^ther 227 IMushroom Poisoning 227 Ptomain Poisonins. Then, hearing the history in mind, make a careful (>xamination to locate wounds, fractures, etc. The examination should he thorough and should- he guided by the history and symptoms. IIowcwm-, a ])artial exami- nation Avill often indicate the extent of the injury. Thus when a patient has stejjped off the curh and turned his ankle, and is found sitting comfortably in a chair, it is hardly necessary to examine the arms for fractures, or the head for scalp wounds. It is to be supposed that in such a case the patient has enough intelligence to indicate the location of the injury. In other cases, where a man has fallen from a height and is only semiconscious, almost any conceivable injury may have occured, and the head, arms, legs, and back should be carefully examined. If the injury is apparently severe it is well to send at once for blankets, hot-water l^ottles, stimulants, etc. If these are later found to be unnecessary it has done no harm to luu'e them ready. Often the injury has been very slight, the patient having merely fainted from fear, recovery occurring in a few minutes without any treatment other than rest in the recumbent position. If the patient is in an uncomfort- able position it may be necessary to move him at once to a place where he can be more conveniently examined. To do this, make a hurried examination to detect any injury which might be made worse by transportation, and then move him the shortest ])ossible distance to a spot where a more thorough examination may be made. If there is a wound, rip or cut the clothing away so that the injury may be plainly seen. Do not attempt to apply a tournif{uet to stop hemorrhage before you have seen the bleeding-point. A case has recently occurred where a man bled to death from a ruptured varicose vein because no one GENERAL PRINCIPLES OF FIRST AID 21 had the intelligence to cut open the clothing and apply pressure with one finger against the bleeding-point. The man had been given a stimulant and had had a bandage wrapped about the bleeding leg, but no one had sufficient training in first aid to look for the bleeding-point and stop the hemorrhage by direct pressure. If you do not know what to do, do nothing at all. It is never necessary to act for the mere sake of doing something. In the case mentioned above, if one of the bystanders had not secured a sheet and wrapped it about the leg, thus hiding the extent of the hemorrhage it is possible that someone else might have examined the leg and noticed that the blood came from one small point, and could easily be stopped by pressure. Above all, remember that first aid is only common-sense combined with a little scien- tific knowledge. When you first see a patient, keep cool and do the obvious thing, such as putting out the fire in burn- ing clothing, pulling a person out from under the horses' hoofs, getting him away from falling timbers, rescuing a drowning person, and other simi- lar actions. Then proceed with the examination and do the thing which your knowledge of first aid teaches you is right and proper. But be sure to keep cool, and know what you are doing, and why. The United States Manual gives the following general first-aid rules for the sanitary troops: Fig. 1. — Varicose veins of leg. A small wound of these veins bleeds profusely. (Park.) 22 , GENERAL PRIXCIPLES OF FIRST AID 1. Act quickly and quietly. 2. Make the jjatient sit or lie down. 3. See the injury clearly before you treat it. 4. Do not remove more clothing than is necessary to examine the injury, and keep the patient warm with cover- ing if needed. Always rip, or if you cannot rip, cut the clothing from the injured part, and pull nothing off. "). (live alcoholic stinnilants slowly and cautiously, and only when necessary. Hot drinks, when obtainable, will often suffice. (). Keep from the ])atient all persons not actually needed to help him. EQUIPMENT AND SUPPLIES. The equipment and supplies needed by the first-aid worker vary within wide limits. The further the student progresses in first-aid experience, the better he is able, in an emergency, to secure satisfactory results with whatever supplies he may find at hand. In some cases he may be limited to those supplies which may be secured at an instant's notice; in others, he may have available all the surgical supplies of a well-equipped hospital. In general, it is better to use the specially prepared supplies when they are to be obtained, but the intelligent worker will often be able to improvise material and supplies with which he can attain most creditable results. Thus, it is possible to obtain a sterile dressing by boiling a piece of linen or gauze or by dipping a clean hanilkerchief in alcohol. Personally, I have had excellent results, when sterile supplies were not available, by applying a clean hand- kerchief wet with cologne (or whisky) directly against a bleeding surface, and bandaging it firmly against the wound. On one occasion a hospital orderly, while in bathing, accidentally cut a large vein in his leg, which bled profusely. He was near the shore, but a considerable distance from his party. There was literally nothing but sea and sand at hand. The man had had enough experience to know that he was in danger from the profuse hemorrhage, so he sat upon the beach and placed both thumbs in the wound, eft'ectually stopping the hemorrhage. Twenty minutes later EQUIPMENT AND SUPPLIES 23 his friends found him and apphed a permanent dressing. It may be added that although he did not receive medical treatment for several hours, the wound did not become infected. This was because the wound and hands had been well cleansed with sea water, which contains few pus-forming bacteria. Although it is sometimes necessary to work with impro- vised tools, better results will be obtained if the proper sup- plies are at hand. Numerous first-aid kits have been advised, but they must, necessarily, vary considerably, the contents depending largely upon the purpose to which the packet is to be put. In the choice of a first-aid kit the following points must be taken into consideration : 1. The size and weight. 2. Character of injuries likely to occur. 3. The experience of the operator. The size and weight are of the utmost importance. It is at once apparent that a complete equipment, such as might be ideal for a theater or factory, would prove much too large and heavy to carry on a canoe trip, while the kit car- ried in the canoe would be too large and heavy to carry on a tramp through the woods. If size or weight does not need to be considered, much more latitude may be given in the choice of supplies. The character of the prevalent injuries in a given locality must also be taken into consideration. In certain factories burns are very common, so that extra preparation should be made for this injury. In others, small particles are apt to get into the eyes and provision must be made for their removal. On fishing trips the fish-hooks are apt to be stuck in the hands. I have known fishermen who carried a sharp pair of wire cutters when they were on long trips. If the hook is stuck too deeply into the hand to be withdrawn the point is pushed inward until the curve causes it to emerge from the skin. The barbed point is then cut away and the hook is easily withdrawn. The skill of the operator should also be taken into consid- eration. If the first-aid worker has had no experience in the use of siu-gical instruments, it is unnecessary to include them in the outfit. In some cases, as on sea voyages and 24 GENERAL PRINCIPLES OF FIRST AID loiiij tri])s into tlie woods, it is advisable to carry suture materials and simple surs^ical instruments, so that they may be used when requiretl. Probably the simjilest form of first-aid packet is that used by the soldier. This must be small, lifj;ht, and easily a])i)lied. Each soldier in the T'nited States Army carries an indi- vidual sealed first-aid packet which is for his own personal use. Contents of United States Annij First-aid Packet. Printed slip of directions 1 Gauze bandages 4 X 84 inches 2 Gauze compresses, one sewed to each liandage . 2 Safety-pins 2 In the army packet the gauze is sewn to the bandage so that it may be applied to the wound without being handled. The gauze and bandages are both hnpregnated with a solu- tion of bicliloride of merciu-y. The Hospital Corps of the Army, that is, the enlisted ])er- sonnel of the sanitary troops, carry a first-aid ])ouch which is much more complete and which is for the use of the members of the Hospital Corps in applying first aid before the injured soldier is seen by the surgeon. United States Army Ilusintal Corps First-aid Pouch. Compressed gauze bandages G Gauze compresses (5 yard) 4 Iudi\'iduai first-aid packets, ns ub')vc 10 Iodine swabs 1 dozen Common pins } paper Safety-pins . 1 dozen Adhesive plaster, 5 yards by 1 inch 1 spool Aromatic spirits of ammonia 1 flask Cup 1 Tournicjuct, field 1 Dressing forceps 1 Scissors 1 Lead-pencil 1 Diagnosis tags 1 book The purpose of this packet is to supply the necessary efjuipment for first aid such as is commonly retpiired on the field and, at the same time, not to overload the attendant with seldom-needed sui)})lies. THE ORGANIZATION OF FIRST AID 25 For household use considerable latitude may be allowed in the selection of supplies. The following has been suggested as inexpensive, and at the same time fulfilling all ordinary requirements : HouseJiold First-aid Outfit. Bandages, assorted sizes 3 Sterile gauze 1 yard Cotton J pound Tincture of iodine (one-half strength) 1 ounce Carron oil, for burns 4 ounces Aromatic spirits of ammonia 1 ounce Adhesive plaster (1 inch by 5 yards) 1 roll Clinical thermometer 1 Safety-pins 1 dozen Vaseline 1 bottle Boric acid (powdered) 2 ounces In a household set of this sort almost any of the household remedies may be added, such as castor oil, Epsom salts, soda-mint tablets, alcohol, witch-hazel, hot-water bag, ice- cap, syringe, etc. It is advisable to prepare such an outfit as the above and keep it always complete and available for emergency use. Numerous first-aid kits have been prepared by the surgi- cal supply houses. Burrows, Wellcome & Co. prepare small cases which are made very compact by the use of com- pressed cotton and gauze, and medicine put up in collapsible tubes. A simple one called the "Boy Scout's First-aid Case" contains aromatic spirits of ammonia, boric acid ointment, carron oil, bandages, dressings, collodion, pins, and adhesive plaster. Larger and more complete sets may be secured from dealers. It is desirable that any outfit for general use should be made as simple as possible, so that it may be used, and used correctly, by M^hoever happens to be present when the emergency arises. When special training is given to attend- ants who are constantly present, as in factories, shipyards, and the like, the more complete outfits are to be preferred. THE ORGANIZATION OF FIRST AID. In the development of first aid in schools, colleges, and in industrial organizations the formation of first-aid squads 20 . CEXERAL PRIXCfPLES OF FIRST AID lias recently been advised and, in some locations, most care- fully carried out. The systematic study of emerfiency treatment, together with the feelin.u- wliic-h each member of the scpiad has that he is takiiiij an active i)art in first-aid work and not merelv stmhin"- the suhiect in the abstract, has given a decided stimulus to the entire subject. In addi- tion, the increasing interest in first aid has led to interest in sanitation and personal hygiene, with consequent improve- ment in health. In practice, four men usually constitute a "first-aid squad." One man is appointed captain and the other three assistant workers. They study the general problems of first aid, and at the same time the particular i)r<)blems of the school or factory in M'hich they work. They also study "team work," two of the assistants carrying the stretcher and the third carrying the first-aid packet. Each man knows his place and takes it without special instruction. In addi- tion, each man is trained to occupy the position of captain, or any other position which may become vacant. In order to stimulate interest and competition, certain companies have had first-aid meets, into which the first-aid squad enter with all the zest of a college student at an athletic meet. Problems in first aid are given and ])rizes given to the squad whose performance is nearest perfect, the mark- ing being done on the basis of speed, skill, and judgment. After a little practice, and with a groundwork of the prin- ciples of first aid, it is remarkable how skilfully uneducated workers will tackle original problems in first aid; for example, the removal of a patient with a fractured leg from a deep exca\-ation or the carrying of an unconscious man from the roof of a high building. This phase of the subject, which has been largely neg- lected except in the army and the navy, deserves a more prominent place in civil life. The institution of the study of first aifl and the development of the practice of first aid by the formation of first-aid squads is earnestly recom- mended for schools, stores, factories, and elsewhere, where large groups of indi\iduals are brought together. CHAPTER II. ANATOMY AND PHYSIOLOGY. For a proper understanding of the principles of first aid it is necessary to have some knowledge of the elements of normal anatomy and physiology. The better the normal workings of the body are understood, the easier it will be to apply the appropriate treatment for a given injury. THE BONES. In ordinary first-aid work only a general working knowl- edge of anatomy is required. For purposes of description it is necessary to designate the various bones by special names, but it is only required that the student have a general understanding of their size and location, without attempting to learn their anatomical names. The Skeleton. — The bony framework of the body, taken as a whole, is known as the skeleton. The bones serve to give attachment to the muscles and act as a support for the body and as an aid to locomotion. They also serve to protect the delicate organs from external injury. Thus, the brain is protected by the skull and the heart and lungs by the ribs. They also serve as an aid and support for most of the voluntary actions. For instance, if the hands and arms contained no bones all of the ordinary movements would be difficult or impossible. On the other hand, most of the invol- untary movements of the body, such as the heart action and the digestion, go on without the direct aid of the skeleton. The skeleton is divided, for purposes of description, into the head, the trunk and the extremities. The Head. — The head is made up of the cranium and the bones of the face. The craniimi is a firm bony case ■28 ANATOMY AND PllYSlOLOay Fig. 2. — Front view of the adult skeleton: 1, frontal bone; 2, parietal bone; 3, nasal bones; Jf, occipital bone; 5, orbit; 6, malar bone; 7, 7, upper and lower maxillm; 8, nasal cavity; 9, cervical vertebra;; 10, clavicle; 11, scapula; 12, sternum; 13, ribs; IJf, IJt, dorsal and lumbar vertebra;; 15, 15, innominate bones: 16, sacrum; 17, humerus; 18, radius; 19, ulna; 20, carpus; 21, meta- carpus; 22, phalanges of hand; 23, femur; S-|, patella; 25, fibula; 26, tibia; 27, OS calcis and astragalus; 28, cuneiform and ciiljoid bones; 29, metatarsus; 30, phalanges of toes. THE HONES 29 which protects the l)raiu. It consists oF several Hatteiicfl bones, forming' when nnited a strong i)rotective covering, completely enclosing the delicate tissues of the brain. The o walls of the skull are about one-eighth to one-fourth of an inch in thickness. In children they are ^'ery much thinner, indeed, in young infants, there are certain locations on top 30 AXATOMY A\n PiiYsmLnaY of the head wIutc tlie skull is very thin and nienil)ran()us in character, luning not yet inidergone bony change. In the anterior portion of the head is the face, formed by several small bones which together act as a b()n\' framework for the nose, cheeks, and jaws, while the forehead, on the other hand, is formed by a portion of the skull. It is impor- tant to remember this relation because, in injuries to the forehead, we may expect an associated fracture of the skull Fig. 4. — Side %'iew of the lower Jaw. (Gray.) and an injury to the brain, while in injuries to the portion of the face below the eyes, coincident brain injury is uncommon. The upper teeth are located in the maxilla, or upper jaw, and the lower teeth in the mandible, or lower jaw. The Mandible. — This bone, sometimes called the inferior maxilla, sometimes referred to simply as the jaw bone, is the only bone of the face which is movable. It moves freely on two joints which are situated in the skull just in front of THE BONES 31 the ears, and its motion is lim- ited chiefly to an up-and-down hinge-hke action. The Trunk.—The trunk con- sists of the spinal cohmin, the ribs, and the pelvis. The Spinal Column. — The spinal column extends from the skull to the pelvis, and serves as the bony framework of the neck and as the main support of the chest and abdomen. It is formed by twenty-four irregu- larly shaped disk-like bones (vertebrae), which are very strong-, and serve for the attach- ment of the strong muscles of the back and as a protection for the spinal cord, which runs through a canal formed by the openings in the center of the disk-like bones, the spinal canal. The bones of the spine may be felt in the middle of the back, run- ning from the skull to the pelvis. The Ribs. — These are flat ribbon-shaped bones, twelve on each side, curving from the spine to the breast bone in front. They enclose the heart and the lungs in the cavity of the chest. They are thin bones, and comparatively easily broken, moving slightly with respi- ration. The Pelvis. — At the lower end of the spine is a firm bony Fig. 5. — Lateral view of vertebral column. (Gray.) Jul cervical or Alius. 32 , AX ATOMY AM) PIIYSIOIAKIY case which contains the bhithler, the rectum, and the organs of generation. This is the pelvis, and is formed of large heavy bones, which, besides serving as a protection for the contained organs, must bear the weight of the body. The pelvis is larger above than belo^\', the flaring upper edge being felt at the sides just below the waist line. Two strong processes which project downward serve to support the body while sitting, while on the outer side of the pelvis are two large joint ca\itics which articulate with the large bones Fig. 6. — Bony pelvis from above. (Gray.) of the thighs. In the back the pelvis is formed by a thick wedge-shaped bone, the sacrum, which bears the direct weight of the body transmitted through the spine. The Upper Extremity. — The upper extremity consists of the cla\icle, the scapula, the humerus, the radius, the ulna, and the small bones of the wrist and hand. (Fig. 2.) The Clavicle. — The cLaA'icle, or collar bone, is the bone that can be felt, as a cylmdrical curved bone, at the front of the base of the neck. It extends from the upper part of the THE BONES 33 sternum, or breast bone, at its inner end, to the shoulder- blade, externally. This bone is frequently fractured. The Scapula. — This is commonly called the shouhler-blade, and is the thin flat triangularly shaped bone that can be felt just back of the shoulder. When the shoulders are drawn back the scapulae form wing-like projections, which are plainly evident in thin persons. At the outer angle is a hollow cavity which forms the shoulder-joint with the head of the large bone of the upper arm. The Humerus. — This is the largest bone in the upper extremity, and is sometimes spoken of as the arm bone. It joins above with the shoulder-blade and below with the bones of the forearm. In adults this bone is usually an inch or more in diameter. It is frequently fractured. The Forearm. — ^There are two bones in the forearm, the radius and the ulna. The radius is the heavier bone, and is located on the thumb side of the forearm. The ulna is a little longer than the radius and is the bone that forms the point of the elbow. It can be plainly felt just beneath the skin extending from the point of the elbow down to the inner side of the T^Tist. At the wrist the radius is on the thumb side, while the lower end of the ulna can be felt as a rounded prominence on the back of the ^^Tist on the same side as the little finger. Both of these bones are frequently fractured. The Carpus. — ^There are eight small bones in the hand which are crowded together in what is commonly called the wrist. Because they are so small and so crowded together it is very difficult to locate a fracture or dislocation of these bones with any degree of certainty. The Metacarpus. — There are five elongated bones, one for each digit, called metacarpal bones. In general, they occupy the location of what is commonly called the palm of the hand. The Phalanges. — ^Two shorter bones, similar in shape to the metacarpals, go to make up the thumb. They are called the phalanges. The one nearest the hand is designated as the proximal phalanx, and the one forming the tip of the thumb is called the terminal, or distal phalanx. In the fin- gers are found analogous bones, except that there are three 3 34 AX ATOMY AXD PIIYSTOLOaY phalanges in each fiiijjcr. The phalanges of the fingers are sonietinies ealled the first, the second, and thiixl phalanges of the respective fingers, the first being the one nearest the hand. The metacarpal liones and the i)halanges are fre- quently injured, both fracture and dislocation being very common. Scaphoid ■.,,^ Os magnum - . Trapfziu/n ..... Trapezoid -..._ Netacffrpal /)o>ies_ Semilunar -Cuneiform F/siform l/nciform fManxM- FiG. 7. — Showing detail of the bones of the hand. The Lower Extremity. — The lower extremity consists of the femur, the patella, the tibia, the fibula, and the small bones of the ankle and the foot. THE BONES 35 The Femur. — The large thigh hone is known as the femur. It is the largest and strongest hone in the hody, and extends from the pelvis to the knee. The thigh, like the arm, con- tains only one bone. P/iaia/ixJT. P/ialc/uxI... Netutfosai dones Jnt.c/juftfo/v/i. .. Nid. ciadeforui Ext. c/iniefor/u .... Kavlcalar l/oue. . Astragalus 7//berosit>j of fifth 7// eta tarsal Ao/ie. Culfoid dom Os Calcis Fig. 8. — Bones of the right foot. The Patella. — A small rounded bone, about the size of a silver dollar, forms the prominence of the knee. It is kno\\Ti 31) . ANATOMY AND PHYSIOLOGY as the patella, or knee-cap. It serves as an aid to the iimseiilar action of the knee-joint. It can be easily felt beneath the skin. It is freqnently fractured. The Leg. — The bones of the leg correspond to those of the forearm. There is a large strong bone, the tibia, and a long slender bone, the fibula. The tibia is called the shin bone, and can be felt beneath the skin along the shin and at the inner side of the ankle-joint. The fibula is deeply situated in the muscles of the calf, and can be felt only at the upper end, on the outer side of the leg, just below the knee-joint, and on the lower end where it lies on the outer side of the ankle-joint. The Tarsus. — There are seven small irregularly shaped bones of the foot which correspond roughly to the bones of the carpus. In the foot one of these bones, the os calcis, is especially well developed, forming the heel. The Metatarsus. — This corresponds to the metacarpus in the hand. The metacarpal bones occupy that portion of the foot between the midpoint of the foot and the base of the toes. They are five in number. The Phalanges. — ^The phalanges of the foot are analogous to those of the hand, but are smaller and less well developed. Fractures of the lower extremity are less common than those of the upper extremity but the}' are sufficiently com- mon to be of considerable interest to the first-aid worker. THE JOINTS. The bones are joined together by strong fibrous bands called ligaments. Where the bones move on each other there is formed a joint or articulation. In some cases the bones are joined so firmly that there is no motion, as in the bones of the skull and in the pelvis. In other cases there is only slight motion, as in the spine and the ribs, A\'hile in other joints the motion is very free, as in the shoulder and in the hip. Where motion is possible in all directions the joint is known as a ball-and-socket joint. In other cases motion is possible in only one plane, such as at the elbow and the knee-joint. Such a joint is known as a hinge-joint. THE JOINTS 37 Many of the joints are technically regarded as hinge-joints, although they have a small amount of lateral motion. Oblique 'popliteal ligament Medial menibcus Adipose tissue Bursa under Quadriceps feinoris Infja III ^patellar , ^ — Medial meniscus y *y ~L (jamenium paiellce Iiu)sa between tibia and ligamentu77i patellae Fig. 9. — Longitudinal section of the knee-joint showing ligaments, joint cavity and knee-cap, (Gray.) ?s ANA TOM Y A ND PH YSIOLOGY Each joint is lined with a thin membrane called synovial membrane, which secre es a scrons finid. The jinrpose of this Hnid is to act as a hibricant for the movement of the joint. When the synovial membrane l)t>c()mes inflamed the the condition is known as svnovitis. Ani. inf. iliac spine -. Intertrochanteric line Fig. 10. — Right hip-joint from the front with muscles entirely removed, showing the strong capsule thickened in front to form the iliofemoral ligament. (Gray.) The ligaments are strong, fibrous bands passing across the joint, and, being attached to the bones on either side of the joint, serve as restricting bands. In some joints they are THE JOINTS 39 fL£X lONC POl Fig. 11. — Sole of the foot with muscles removed, showing strong liga- ments which hold the bones together and support the arch of the foot. (Allen.) 40 . ANATOMY AXD rilYSIOLOGY very firm, allowing little or no movement, while in other locations they must be \evy lax to allow the joint to move freely. If you attempt to bend the terminal phalanx of the finger to the side it is found to be firmly jield in place. That is because the lateral ligaments are com})arati\'ely short and strong. When the same phalanx is moved in the other direc- tion the movement is fairly free, being limited only by extreme flexion or extension. Consecpiently it is apparent that the ligaments on the front and back of the phalanges must be long and lax. In some joints, such as the small joints of the ankle, all the ligaments are short and strong, so as to gi\'e a firm sup- port and allow very little movement, while in other joints, for example the shoulder, free movement in all directions is permitted by the fact that all the ligaments are long and lax. In the shoulder most of the support is obtained by the strong muscles which pass across the joint rather than by the ligaments which offer almost no supi)ort to the ordinary joint movements. When the joint is bent so as to decrease the angle between the bones the movement is known as flexion, and the joint is said to be flexed. Movement in the opposite direction is extension of the joint. When the movement of the joint is such as to carry a portion of the body away from the midline the movement is known as abduction, while the opposite mo\'ement is adduction. THE MUSCLES. The bones are controlled by muscles which constitute the flesh of the body. Each muscle is made up of a fleshy por- tion, consisting of contractile muscle hirers, on either end of which is a fibrous tissue band known as the tendon. Tendons may be short and broad or may be long narrow bands several inches in length. The ends of the tendons are attached to the bones and are usually so arranged that they pass over a joint. As it is possible to contract the muscle at will, it can be seen that the contraction of the muscle will cause voluntary movement of the corresponding joint. THE MUSCLES 41 In the human body the processes are so complex that even the simplest movements are usually the result of the coordinated Fig. 12. — Muscles of the shoulders, neck and back. On the right side the outer layer of muscles has been removed. (Graj-.) 42 ANATOMY AND PHYSIOLOGY action of several muscles. A rough idea of the number and variety of the nniselos of the body may be obtained from the ilhistrations (l''ii2:s. 12 and lo), which show only a i>art of the nuiscles of the back and arm. Fig. 13. — Superficial muscles of left side of chest and upper arm. (Gray.) In some cases the long tendon attached to a muscle allows it to act on a bone some distance from the body of the THE BLOOD AND CIRCULATION 43 muscle. For example, the fingers are bent by a muscle of the forearm which acts by means of four long tendons, which extend from above the wrist to the distal phalanx of the fingers. The tendinous portion of the muscle has no contractile properties; it acts merely as a band which trans- mits the pull from the muscle to the bone. As muscles act only by contraction, it follows that they can do work only through their pulling action. Thus one group of muscles flexes a joint while another group extends it. These two groups are said to oppose each other. Where one group of muscles is in action, the opposing group is relaxed. The muscles surround the bones throughout the greater part of the body, and, in turn, are covered by the superficial fat and skin, giving form to the body. The tendons may be deeply located, surrounded by muscles and fat, or they may be close to the skin. On the back of the hand the tendons which extend the fingers are very superficial. They may be easily felt moving beneath the skin when the fingers are extended. The muscles described above are called voluntary muscles because they are under the control of the will. In addi- tion to these there is in the body another type, involun- tary muscles, which act independently, and are not subject to control. Involuntary muscles are found in the heart, the stomach, the intestines and in other internal organs. They are of the utmost importance in the vital functions of the body, but take no part in locomotion, or other volun- tary movements. They exist in a diffuse layer in the walls of the contractile organs but differ from voluntary muscles in not being grouped into bundles forming distinct muscles and in having no tendinous attachments. THE BLOOD AND CIRCULATION. The Blood. — The blood is a fluid tissue which circulates through the bloodvessels, permeating, by means of the smaller capillaries, all parts of the body. Its chief function is to carry oxygen and nourishment to the cells of the entire 44 ANATOMY AND PHYSIOLOGY body and to renioN^e the carbon dioxide and other waste products which result from ceUuUir acti\'ity. It is composed of a clear straw-colored fluid, the plasma, in which float numerous small red cells that gi\'e to the blood its red color. The red blootl corpuscles number ai)i)roximately r),()()0,0()0 to each cubic millimeter of blood and their chief function is the carrying of oxygen from the lungs to the body tissues. If, as a result of hemorrhage or other cause, their nimiber falls greatly below nt)rmal, the patient is said to be anemic. If the blood corpuscles become too few in number life ceases. Fig. 14. — Human rod blood corpuscles. Highly magnified. a, seen from the surface; 6, seen in profile and forming rouleaux; c, rendered spheri- cal by water; d, rendered crenate by salt solution. (Gray.) In addition to the red })lood corpuscles, there are other corpuscles found in the blood which are colorless and are called leukocytes, or white blood corpuscles. These are less numerous than the red, the average number being 5000 corpuscles per cubic millimeter. The leukocytes are chiefly concerned in the protection of the body against infection. They migrate tlirough the walls of the bloodvessels and attack bacteria which invade the body, for this reason being some- times called phagocytes. ^Yhen blood is allowed to stand outside the vessels of the body, it divides itself into two portions, a thick spongy part which is kn()\^n as the clot and a clear straw-colored fluid THE BLOOD AND CIRCULATION 45 which is called serum. This change is very important, as it is this process of coagulation, or clotting, whic:h takes place when small bloodvessels are cut, the clot forming a plug which stops the hemorrhage. Fig. 15. -Diagrammatic sketch showing heart and the beginning of the large vessels in their position in the chest. (Hare.) The Heart. — This is a large muscular organ which pumps the blood through the bloodvessels, thus forming the circu- lation. The heart is located in the left side of the chest, where its beat can usually be felt a few inches below the left nipple. It is about the size of a man's fist. It is divided longitudinally into a right and left side, each of which con- tains two cavities, one called the auricle and the other the ventricle. The auricle on the right side is connected with the ventricle on the right side by an opening, guarded by 46 AX ATOMY AXD I'lIYSinLOCY valves whicli i)ennit the blood to pass into the ventricle but do not allow it to be forced back again into the auricle. There is a similar opening between the left auricle and left ventricle, guarded by a similar valve. There is, however, no opening between the right and left sides of the heart. From the right \'entricle the blood is forced into the pul- monary artery, and from the left ventricle into the aorta. The mouths of both of these arteries are guarded by valves which allow the blood to pass from the ventricles into the arteries, but will not permit it to flow in the reverse direction. The adult heart contracts about seventy-two times per minute in the average person. In thin persons its beat may often be easily felt at the location of the apex of the heart, which is about two inches below and a little to the left of the left nipple. In stout persons, and in women who have large breasts, it can be felt just below and to the outer side of the left breast. However, in many persons it is impos- sible to detect the beat by means of touch, so that this sign is of limited aid in determining the action of the heart. If the ear is applied to the chest in this region the examiner can hear, with a little practice, the dull, muffled sounds made by the contraction of the heart, and can, if necessary, count the beats as they occur. However, for most practical purposes, the rate of the heart's action is taken from the pulsation of the radial artery at the wrist, to which the impulse of the action of the heart is transmitted through the bloodvessels. Conse- quently, we can count the beats at the wrist where the pulsa- tion is termed the pulse, and we speak of the pulse as being seventy-two beats to the minute in the average adult. In young children the pulse-rate may be much faster, a pulse-rate of 100 in a baby not being uncommon. In nervous individuals very slight causes may be sufficient to send the l)ulse to 100 or even considerably higher. The Arteries. — When the blood leaves the heart it passes into large musculofibrous tubes, which divide into smaller tubes; these in turn divide and subdivide into still smaller tubes, like the trimk and l)ranches of a tree. These tubes are called arteries and serve to carry the blood away from THE BLOOD AND CIRCULATION 47 the heart. The largest artery, the aorta, gives oft' branches soon after it leaves the heart, which pass up on each side of the neck to supply the corresponding sides of the neck and head. A little farther along a large artery is given oft' to Fig. 16. — Showing the deep arteries of the forearm. (Gerrish.) 48 . ANATOMY AND PHYSIOLOGY .siii)i)ly eacli ii])i)er cxtroniity. These large arteries pass down each arm, giving off smaller branches to supply the shoulder and arm, to the elbow, where they divide into two arteries, the radial and the ulna. It is the radial artery which can be felt pulsating at the wrist. After the aorta has gi\'en oft" the large branches to the head and arms it passes downward through the chest to the abdomen, where it divides into two large branches, which i^ass to the two lower extremities. In the chest and abdomen the aorta and its large su])(li\'isions gi^'e oft' large and small branches to supply the chest and the abdf)men. In the thigh the single large artery passes downward to about the region of the knee, where it divides into two smaller arteries. The arteries usually run deeply situated in the tissues, but in a few pl,aces they may be fairly close to the skin. When close to the skin or under observation in a wound they may be seen to pulsate, and if cut the blood spurts from them in bright red jets. While the k)cation of the arteries is fairly constant they are subject to some variation. In general it may be said that the smaller the artery the more apt it is to vary in its location. It is not uncommon for the radial artery to be situated a considerable distance from its normal location in the \^Tist. In such cases the examiner is sometimes led astray, believing the patient to be pulseless when the true condition is that the abnormal position of the artery makes it difficult or impossible to locate. The walls of the arteries are thick, strong, and elastic. They stand open when cut, in contradistinction to the veins, which are soft and ftaccid, and collapse unless filled witli blood. The Capillaries. — As the arteries di\'ide and subdivide they continually grow smaller, forming very small arteries, the arterioles, which in turn divide into minute thin-walled vessels, the capillaries. The walls of these minute vessels are so thin that the exchange of oxygen from the blood for the carbon dioxide and waste products of the tissue cells easily takes place. The minute network of the capillaries THE BLOOD AND CIRCULATION 49 passes to every portion of the body, so that even the sHght- est scratch injures many of these small vessels. The Veins. — ^The capillaries join together, forming larger vessels which are termed veins. These veins again join to form still larger veins, finally forming the large veins of the extremities and other portions of the body, which empty into the still larger veins of the trunk, finally emptying into the right auricle of the heart. The veins are less constant in their location and size than are the arteries, and do not pulsate. They are divided into two groups according to their location, the superficial, and deep, veins. The deep veins, as a rule, accompany the arteries, the blood flowing in the opposite direction. Usually two veins accom- pany each of the larger arteries. The superficial veins run in the subcutaneous tissue. In thin persons they can be easily made out just beneath the skin. Because they lie so close to the skin they are frequently injured by comparatively slight wounds. The blood in the veins flows in a steady stream, and is darker in color than that in the arteries. When either an artery or a vein is divided, bleeding usually occurs from both the proximal and distal portions of the injured vessel. The Circulation. — The flow of blood forms a complete circuit. Beginning at the right auricle, where the ^'enous blood enters the heart, it passes into the right ventricle, which contracts, forcing the blood through the pulmonary artery to the capillaries in the lungs, where it gives off carbon dioxide and takes up oxygen. The capillaries of the lungs join together to form the pulmonary veins, tlirough which the now oxygenated blood passes to the left aiu-icle. From the left auricle the blood passes to the left ventricle, which contracts and forces it into the aorta, and, tln-ough the aorta, to all the smaller arteries and finally to the capillaries, where the interchange between the blood and tissues takes place. The blood passes on tln-ough the capil- laries into the veins, which finally carry it back to the right auricle, and the circuit is completed. This process is repeated hundreds of times during the day. 4 50 AXATOM)' AM) I'llYSlOLOGY Median cephalic External /; cnUmeous uerie. ^/ :-|- FiG. 17.— Front view of the super- Fig. 18.— Superficial veins of the ficial veins of the arm, forearm, and front and inner surface of the lower hand. extremity. (Gray.) PLATE II I'li/iiKiiiii ri/ < 'ajji/lii I'ii's Diagram to Show the Course of the Circulation of the Blood. The pulmonary capillaries are the small vessels of the lungs. The systemic capillaries represent tViose of the skin, head and extremities. The third systeni shown represents the capillaries of the intestmes and liver. THE NERVOUS SYSTEM 51 THE NERVOUS SYSTEM. All voluntary movements and many of the involuntary functions of the body are under the control of the nervous system. It is tlu'ough the medium of the nerves that all the impulses arising outside of the body become sensory percep- CERE BRUM V Fig. 19. — Diagrammatic sketch of brain and spinal cord. (Gerrish.) tions. Even the simplest voluntary movement, such as picking up a book or drawing a straight line, is the result of a great number of coordinate nerve impulses. The sen- sation of taste, smell, sight, and hearing are all due to impres- sions made upon the brain through the mediimi of corre- sponding nerves. The nervous system is divided into the brain, the spinal cord, and the nerves. r.9 ANATOMY AND PHYSIOLOGY Fig. 20.-Nerves of the skin of the palm ..f the hand and arm. (Gray.) THE NERVOUS SYSTEM 53 The Brain, — ^This large solid organ, located in the skull, is the seat of the mind and the origin of voluntary impulses. It is made up of cells and nerve fibers. Any injiu-y to the brain is serious because it may interfere with the mind or "54 ANATOMY AND PHYSIOLOGY with tlie ability to perforin voluntary actions. Certain centers which control \ital functions, for example, respira- tion, are located in the brain. If such a center is injured death folloM's as an innnediate result. The brain is com- posed of the cerebrum, which is the larger portion, and is located ixhow and anteriorly, and the smaller portion, the cerebellum, which is posterior and below. Just below the cerebellum is a prolongation of the brain in the shape of a truncated cone, the base being continuous with the brain and the apex with the spinal cord. This is the medulla oblongata, and in it are found the vital centers hn- the control of respiration and the action of the heart. The Spinal Cord. — Passing from the lower end of the medulla and continuous with it is the si)inal cord, which is about the size of, or a little larger than, a lead-pencil. It is composed of nerve fibers and cells. It is located in the canal which is formed by the openings in the vertebriP, the spinal canal, and gives ofl fibers which go to make up the peripheral nerves, the fibers branching off the spinal cord and passing outward through the spaces between the vertebrae. The Nerves. — Arising both fi-om the brain and the spinal cord are ner\'e fibers which form the peripheral nerves. They are grouped together in bundles, which vary in size from the minutest microscopic fibers to bundles of fibers as large as the little finger. These nerve bundles are called the peripheral nerves, and the largest bundles are given special names. They divide and subdivide so that every portion of the body is supplied with nerve filaments. Nerves are of two general types, the sensory, which carry impulses from the periphery to the brain, and the motor nerves, which carry impulses from the brain to the muscles. Most large nerves contain both motor and sensor}' fibers. TJw Action of the Nerves. — This is usually very compli- cated even for the simplest voluntary action. For the pur- pose of description the nerves may be likened to electric wires and the brain to the battery. A nerve impulse originated in the peripheral ending of a sensory nerve is transmitted to the brain, where it is transformed to a motor rilE NERVOUS SYSTliM 55 impulse, and this motor impulse is transmitted to a muscle which contracts, resulting in motion. If, for example, the LUMBAR GANCLfA Fig. 22. — Spinal cord showing nerve roots. (Gerrish.) 56 ANATOMY AND PHYSIOLOGY hand is burned the sensation is transmitted at onee to the brain and the proper motor impulse started ^^■hich results Fig. 23. — Diagrammatic sketch showing the course of a nerve impulse. V, visual center; A, auditory center; W, writing center; Z', vocal center; a and v are sensory fibers conducting sound and visual perception; s, s' and s", are sensory nerve fibers from the skin of the mouth, hand and ej'e; m and 711' are motor fibers to the mouth and to the hand. The nerve impulse may Ije traced as follows: The object is seen and the impulse carried to the visual center and transmitted to the writing center which starts the impulse to the hand which, under the action of the impulse, writes the word. In the same way the name of the object seen may be spoken; or the impulse may start by a sense of touch or hearing and result in any form of volunlary action. in the hand beino; drawn away from the hot object. This is done so quickly that it ai)i)ears as though the action and the sensation occurred simultaneously, but, as a matter of THE NERVOUS SYSTEM 57 fact, there is an apprecial)le time elapsing between the moment the sensation originates and the movement of the hand. If the impulse is interrupted at any point the nerve reac- tion will be without result. Thus, if the sensory nerve going to the hand has been cut, the hand may be severely burned without any sensation being felt. If the sensory nerve is intact, but the motor nerve is cut, the burn is felt, but there is an inability to withdraw the hand. The sensory impulse may arise as a result of one of the special sensations. Thus we shut the eyes when a bright light is flashed in them, and we jump when a loud noise is heard. While the brain is the seat of all conscious action, con- sciousness is not essential to reflex action. The foot is withdrawn when pinched or pricked with a pin, and the eye is closed tightly when touched with a feather, even in people who are unconscious or asleep. This is known as a reflex act. The deeper the sleep or state of unconsciousness the less marked are these reflex acts. Thus, when a patient is anesthetized the fact that there is a reflex closure of the eye on lifting the lid and touching the eyeball is a sign that the patient is not deeply anesthetized. In the same way the closure of the lid and the reaction of the pupil to the action of light may be used to indicate the degree of uncon- sciousness following injury. In addition to the peripheral nerves just described there exists in the body a secondary system, nerves which arise in nerve centers located chiefly in the chest and abdomen, the sympathetic system. Centrally, these centers are con- nected with the nerves leaving the spinal cord and distally they send fibers to the organs of the abdomen and chest and to the bloodvessels of the entire body. While the action of the heart and the processes of diges- tion are to a certain degree automatic they are at the same time under the control of the s^nipathetic nervous system. Thus the mere sight of food is enough to cause salivation and the secretion of gastric juice, while an unpleasant sight may cause faintness and nausea. 58 ANATOMY AXD PHYSIOLOGY The relation of the nervous system to the general physieal eonclition will receive further consideration in reference to syncope and shock. VESTIBULC Fig. 24. — Section through the head and neck showing cavities of the throat and nose, beginning of the trachea, and the larynx. (Gerrish.) THE RESPIRATORY SYSTEM. The respiratory system consists of the nasal passages, the larynx, the trachea, the bronchi, and the lungs. The Nose. — Air is admitted to the body through the nose, which consists of the external nose and the nasal passages. The nasal passages are two in number, separated by a thin partition, the nasal septum. In its passage through the nose the air is warmed and a certain amount of dust and other extraneous material is removed. If the air is dry it receives sufficient moisture in the nose to render it less irritating to the lungs. THE RESPIRATORY SYSTEM 59 The Larynx. — The air passes from the nasal passages through the throat into the larynx, which is situated at the beginning of the trachea. The larynx is located just behind the base of the tongue, and during the act of swallowing it is covered with a thin fibrous flap, the epiglottis, which prevents the entrance of food into the trachea. The larynx contains the vocal cords, which are instrumental in producing the voice. Vallecula Median glosso c2ngloUic fold E'piglottis fTuhercle of epiglottis Vocal fold Ventricular fold A ry epiglottic fold Cuneifonn cartilage Corniculate cartilage Trachea Fig. 25. — Showing larynx and vocal cords from above. (Gray.) The Trachea. — Below the laryixx is a firm tube-like struc- ture, the trachea, which passes downward in the midline and can be felt in the lower anterior portion of the neck. The trachea acts as a passageway for the air between the larynx and the bronchi, and is about one-half inch in diameter and several inches long. The Bronchi. — ^The trachea divides, in the upper part of the chest, into two similar though smaller tubes, one to each lung. These are the two main bronchi. These divide and subdivide into smaller bronchi, the smallest of which are termed bronchioles. In this manner the air is distributed to all parts of the lungs. The Lungs. — The bronchi gradually become smaller, end- ing in minute air cells where the interchange of oxvgen takes GO ANATOMY AND PHYSIOLOGY place between the insi)ired air and the blood. The minnte air cell has a very thin wall which is in direct contact with the small capillaries of the lungs. The blood and air do not mix but the oxygen and carbon dioxide pass freely through the thin layer of membrane separating the two. Respiration. — The air is drawn into the chest by suction. The ribs are raised and the flat fibromuscular diaphragm, which separates the chest from the abdomen, is drawn down- ward so that the cavity of the chest is enlarged and the air rushes in to fill the space, in the same manner as air rushes into the chamber of a pump when the piston is withdrawn. The lungs themselves act simply as inert sacs which expand as the air rushes in. This is called inspiration. The ribs now descend and the diaphragm mo\'es upward and the air is forced out. This is called expiration. The combination of the two methods constitute the act of breathing or respiration. Both inspiration and expiration are controlled to a slight degree by the will. When respiration ceases for a period of more than two or three minutes, changes take place in the body cells that soon result in death. It is impossible to say how long respiration may cease before death occiu-s. Apparently reliable reports have appeared from time to time in which recovery has taken place after respiration has been absolutely absent for five minutes or longer. In most cases, however, cessation of respiration for more than a very short time, three to five minutes, results in death. In health the rate of respiration varies from 14 to 24 per minute. In disease the rate may be as low as 8 and as high as 60. Both of these extremes indicate serious dis- turbances. In children the respiration-rate is more rapid, the normal being considerably higher than in adults. In cases of pneumonia it is not uncommon to see a child with a respiration of (iO or higher make a complete recovery. Physiologically, the respiration is increased by exertion and the breathing of rarefied air, such as occurs in high altitudes. THE ABDOMEN 61 THE ABDOMEN. The lower half of the trunk is known as the abdomen. In it are found the organs of digestion, the liver, the spleen, and the kidneys. The Alimentary Canal. — Digestion of food takes place almost entirely within the alimentary canal. It begins in the mouth and is continued in the stomach and the small and large intestines. The food is taken into the mouth, where it is broken up and mixed with the secretions of the salivary glands before it is swallowed. It then passes through a long tube, the esophagus, or gullet, to the stomach, where it is mixed with the gastric juice. The process of digestion is continued in the small intestine, and the nutri- tive products of digestion are absorbed through the walls of the small and the large intestines. The Stomach. — The stomach is a musculomembranous sac holding about two or three pints and located in the upper part of the abdomen. The food remains in the stomach for a period varying from a few minutes to two or three hours before passing into the intestines. This fact is impor- tant, because in case of poisoning the poison may be almost entirely removed if the stomach is emptied during the half- hour immediately following the ingestion of the poisonous substance. The food passes out of the stomach into the small intes- tine, which is a flaccid musculomembranous tube about twenty feet in length. This tube connects with a similar one about six or seven feet in length, the large intestine. The latter in turn ends in the rectum. During its passage through the small and large intestines the food undergoes further digestion and the digested material is absorbed, the food fibers and other indigestible portions of food remaining in the intestinal canal to be excreted in the process of defecation. The Liver. — In the right upper portion of the abdomen is a large reddish-brown organ, weighing about tlu-ee or four pounds, the liver. It is a solid organ made up almost entirely of liver cells, which secrete, bile. Most of the blood carrv- 62 AXATOMY AXD PHYSIOLOGY ing the absorbed pri)duets of digestion passes through the liver before it enters the general cireuhition. During its Fig. 26. — The front view of the abdominal contents. The liver has been lifted upward to show the stomach and gall-bladder. The large intestine (colon) may be seen running upward on the right side, (hen across the abdo- men and downward on the left. (Gerrish.) THE ABDOMEN 63 passage through the hver the blood undergoes certain chemical changes which are not very clearly understood but Avhich are essential to life. In crushing accidents the HEPATIC VEINS INFERIOR PHRENIC ARTERIES CESOPHAGUS SUPER MESENTE ARTE INFERI MESENTEF ARTEF COMMC ILIAC ARTEF AND VEI INTERNAL SPERMATIC ^^ ARTERY ^^ AND VEIN i^^ INTERNAL " — ILIAC ARTERY M AND URETER Fig. 27. — Showing the kidneys and great vessels of the abdomen in their normal position. The stomach, liver, and intestines have been removed. (Gray.) 64 ANATOMY AND PHYSIOLOGY liver is sometimes ruptm'ed, hemorrhage from tlic torn tissue being very jirofuse. The Kidneys. — Located in the back part of the abdominal caxity, one on each side of the spine, are two bean-shaped' glandular organs, the kidneys. Each weighs about five ounces. They excrete the urine, that is, they remove the excess of water and the waste products from the blood by a process which is partly filtration and ])artly selected cellular secretion. The urine passes from each kidney through a narrow tube about twelve inches in length, the ureter, to the l)ladder. The Bladder. — The urine passes through the two ureters into a musculomembranous sac, the bladder, which serves simply as a temporary storehouse for the urine. It will hold ordinarily a pint or more and is partially under volun- tary control. When full it may be ruptured by crushing injuries or by falls, allowing the urine to escape into the abdominal cavity. The Peritoneum. — Most of the organs of the abdomen are covered by a thin, serous membrane, the peritoneum, which is kept constantly moist by a serous secretion of jx'ritoneal fluid. The organs are thus allowed to move upon each other without friction. When the intestines, the bladder, or any other hollow organ is ruptured the contents escape into the general abdominal cavity and come into contact with the peritoneal covering of these organs, resulting in peritonitis. Owing to the fact that communication with all parts of the peritoneal cavity is free, the spread of infectious material is apt to be \'ery rapid. The Reproductive Organs. — The organs of reproduction, in both male and female, are located partially within the pelvis and partially external to the pelvis on the lower part of the trunk. Owing to the abundant nerve supply of these organs injury is apt to result in pain and evidences of shock, out of all proportion to the apparent severity of the injury received. CHAPTER HI. WOUNDS AND WOUND INFECTION. CONTUSIONS. When an injury has been caused by a blow with a bhnit object without laceration of the overlying skin it is called a contusion or bruise. The result is a crushing injury to the tissues, associated with hemorrhage beneath the skin, which later becomes apparent in the familiar "black-and-blue" spot. This area of hemorrhage beneath the skin is known as ecchymosis, or snhcutaneous hemorrhage. Depending upon the depth of the hemorrhage, the ecchy- mosis appears at a variable time after the injury, and is most pronounced where the skin and tissues are very loose. Thus, about the eye, where the bleeding is immediately beneath the skin and the tissues are very loose, a compara- tively slight injury may result in a large area of discolora- tion, which appears within a few hours. In the arms and legs it may take the blood a long time to reach the skin; that is, the black-and-blue spot does not appear at once but only after two or three days. Treatment. — Contusions are usually painful for several days and tender to pressure for a few days longer. The black-and-blue spot gradually becomes less distinct and disappears after about two weeks. In examining a patient a contusion is felt as a tender spot. It is the familiar bruise, which is so commonly seen, and requires little or no first- aid treatment. If you are sure that there is no fracture or deeper injury the bruise itself may usually be disregarded. If the pain is very severe, bathing in cold water or the application of cloths dipped in cold water will give relief. The absorption of the blood in the tissues may be hastened after the second day by the use of hot baths and hot com- 5 66 WOUNDS AND WOUND INFECTION presses in place of cold. If the contusion has been very extensive, rest in bed or rest of the part by use of a sling will afi'ord considerable relief. If a bruise appears to be unusually painful a ])hysician should be called to examine for fracture or other injury to the deeper parts. In accidents the injured i)erson rarely complains of an ordinary contusion. They only become aware of the bruise after several hours when they notice stiffness and pain. If, after an injury, a patient applies for treatment immediately, the surgeon suspects an injury to the deeper parts; but if he does not com])lain of pain imtil the next day, and then the disability is ^■ery slight, there is probably only a contusion and little possibility of serious injury. Contusions of the head, chest, or abdomen have a special significance, and will be referred to later. WOUNDS. A wound is a separation of the soft parts of the body, associated with incision or laceration of the skin or mucous membrane. They are divided into four general types: 1. Contused icounds, made with blunt instruments; there is a contusion associated with a wound of the skin, usually bursting or tearing in character. 2: Inched wounds, those made with a knife or other sharp- cutting instrument. 3. Lacerated wounds, torn or jagged wounds made with rough, irregularly shaped instruments. 4. Punctured woiinds, made by sharp-pointed instruments. The characteristics of all wounds are pain, tenderness, and hemorrhage. The type of wound is at once apparent on inspection. Treatment. — Wounds are the most common injuries that the first-aid worker is required to treat, and the imj^ortance of proper emergency treatment cannot be too strongly emphasized. It is here that first aid accomplishes its great- est work. Every single injury of the skin and tissues which causes bleeding externally, from the smallest pin-prick or HEMORRHAGE 67 abrasion (a superficial wound of the skin) to the terrible lacerations of the extremities, is a wound; and each and every one should receive the most painstaking care. Cases are not rare where lack of care following an insignifi- cant injury, such as an abrasion or a small punctured wound, has resulted in blood-poisoning and death; and there have been many cases in which intelligent emergency treatment has not only prevented fatal hemorrhage but has kept the wound clean and sterile, so that secondary infection did not occur. There are three specific requirements for the successful treatment of wounds: 1. The arrest of hemorrhage. 2. The prevention of infection. 3. The restoration of function. For the first-aid worker the arrest of hemorrhage and the prevention of infection are the most important. The restora- tion of function is largely in the hands of the surgeon, HEMORRHAGE. Hemorrhage means bleeding. The term is not confined to serious and prolonged bleeding, but it is applied to bleed- ing of every sort. It may be due to the division of a number of capillaries, when it is usually mild, or to the division of larger vessels, either arteries or veins, in which case it is more difficult to control. Capillary Hemorrhage. — Capillary hemorrhage is the slow oozing which comes from the exposed surface of a wound. If this surface is swabbed free of blood there can be found no special bleeding-point, but the entire surface seems to exude blood. The total amount may be considerable but never enough to endanger the life of the patient. Hemor- rhage which is purely capillary in character stops after a few minutes. When it is desired to stop it sooner a pad of sterile gauze is pressed against the bleeding surface and held in place for a minute or two, or bound in place with a ban- dage. Hemorrhage of this type may be almost disregarded because it is stopped by the application of the dressing. 68 WOUNDS AXD WOrXD IXFECTION Venous Hemorrhage. — Tliis form of liemorrliagc is apt to be \"cry i)rofusc. If a large vein is cut a patient may bleed to death, but, as a rule, the thin wall of the vein collapses and the hemorrhage eeas(>s automatically. The blood from a vein is darker than that from an artery, and it flows slowly and steadily. Both ends of the di^'ided vessels bleed freely, but the distal^ end is apt to bleed more than the proximal. Direct pressure applied to the bleeding-point will sto]) venous hemorrhage. Arterial Hemorrhage. — AYhen an artery is cut the bright red blood spurts in jets from the wound. This is charac- teristic of arterial hemorrhage but in some cases the end of the vessel may be deep in the wound so that the spurting is not evident. As in acuous hemorrhage, both ends of the divided vessel bleed freely but in this case the hemorrhage is most marked from the end nearest the heart. Bleeding from small arteries will stop after slight pressure. Only in the larger arteries is a special method required to control the hemorrhage. METHODS OF CONTROLLING HEMORRHAGE. Remembering that a little blood makes a great show, the first step is to determine how se^'ere the bleeding is. In some cases the face and hand ma}' be entirely covered with blood when the bleeding itself has entirely stopped. Locate definitely the bleedmg-point before attemptmg to stop the hemorrhage. I have seen a patient at death's door as a result of hemorrhage from a ruptured varicose vein, simply because no one had the intelligence to look for the bleeding- point. In this case the foot was almost covered with blood and the first-aid enthusiast had carefully AM-apped a sheet about the foot AA'ithout noticing that the blood came from a point higher up the leg. In addition to the sheet wrapped about the foot, a tourniquet had been applied about the thigh in such a manner that the venous return from the leg 1 The distal end is the end farthest away from the heart. The proximal end is the end nearest the heart. METHODS OF CONTROLLING IIEMORRHAGE 09 was stopped but the arterial flow was not interfered with. When this patient was seen all that was required was to remove the tourniquet and make the patient lie down with the leg slightly elevated. The bleeding then stopped spontaneously. The direct methods of controlling hemorrhage are: 1. Direct pressure. 2. Elevation. 3. Application of heat or cold. 4. The tourniquet. 5. Styptics. 1. Direct Pressure. — This is the most important method. In any case where pressure may be applied directly to the bleeding-point, hemorrhage will stop as long as the pressure is continued. In operating the surgeon often divides fairly large vessels. When this occurs the operator quickly puts his finger on the bleeding-point, thus immediately stopping the hemorrhage. The vessel is then clamped with a specially devised clamp, or ligated at once. Even in the arteries the pressure of the blood is comparatively slight, so that if the finger can be placed over the bleeding-point the hemorrhage can be stopped at once. However, in ordinary cases pressure with the finger is unnecessary. When most wounds are examined the hemorrhage is found to be slight or at most only moderate. If the blood is flowing in a steady stream, it requires prompt attention; if it is dropping rapidly, the patient is in no danger, but measures should be taken to stop the bleeding at once; if it is dropping slowly from the wound, say five or six drops a minute, there is no great hurry and it is permissible to take sufiicient time to secure the best available material for a dressing. Direct pressure on any bleeding wound can be secured by the use of a gauze compress, or, if one is not at hand a folded handkerchief can be used, care being taken to use sterile compresses when they are available. A compress is placed directly in the wound and held firmly w4th the fingers. This will show at once whether the bleed- ing is under control. If not, another compress should be applied and this repeated until the wound is firmly packed 70 WOUNDS AND WOUND INFECTION with gauzo. 1 have rarely seen an emergency liemorrhage whifli could not he stopped by this method. After the eoni])resses are in place a siuiti" l)andaii;e is api)lied directly over the Avound. Where the bleeding is j)rot'use, a bandage may be placed on \ cry tightly and left on for a few hours and then re})laced by a looser bandage. Care should be taken not to leave the tight bandage on too long, for this may result in constriction of the i)art with secondary gangrene. Fig. 28. — Flexion of the knee to control hemorrhage from the foot. The knee i.s held in acute flexion by a rubber bandage. This method is applic- able only to the elbow or the knee in hemorrhage from the hand or foot. (Park.) Siu-geons apply direct pressure by the use of artery clamps and ligatures. The artery clamp is a specially designed instru- ment which is clamped over the end of the bleeding vessel, holding it tightly closed. A ligature is a piece of catgut string or a silk thread which is tied about the end of the bleeding vessel, just as a string might lie tied about a rubber tube. Both the ligature and artery clamp are available only for advanced students in first aid and are usually unnecessary in emergenc}' w(irk. METHODS OF CONTROLLING HEMORRHAGE 71 2. Elevation. — This is a valuable adjunct to any method. If a bandaged hand continues to bleed it will often stop when the hand is held over the head. When there is bleed- ing from the foot, the patient is told to lie down and the foot is raised well above the body. In bleeding from the nose the head is kept erect, not bent forward over a basin. 3. Heat and Cold. — Water as hot as it can be borne, or ice- water, will tend to stop hemorrhage. Before the present technic was perfected surgeons sometimes cauterized wourtds with a hot iron to stop hemorrhage. Both heat and cold are seldom used except where a bandage cannot be applied, as in the nose or mouth. In such cases they may be very valuable. •='*-*«:auii Fig. 29. — Piece of rubber tubing used as a tourniquet. The attached clamp holds the knot firm. The tubing would be more effective if applied above the knee. 4. The Tourniquet. — This is the most widely known and most abused instrument of first aid. It is widely known because it is easily understood and appeals to the popular fancy. It is abused because it is almost always wrongly appUed. It is only applicable to hemorrhage from the extremities and to be correctly applied it must be fastened tightly enough to stop the arterial flow. If applied less firmly, it only acts to increase the hemorrhage. I have seen many cases where a tourniquet has been applied in an emer- gency case and I have never seen a single case where it accomplished its purpose. In most cases where I have seen ll'Of'.VD^' .1A7) WOIWD IXFECTIOX it ap])lic(l all that was irciuiivd to stoj) the hlcedint;' was the iviiioxal ol' the tourniquet. The ordinary directions for its use are as follows: A hand- kerchief or strip of strong cloth is placed loosely about the limb between the wound and the heart and the ends tied together. A cloth jjad or hard object is ])laced over the location of the main artery and a stick, i)assed under the l)and at the opposite side of the limb, is used to twist the bandage so as to make the wad press firmly against the artery. If the location of the artery cannot be remembered the tourniquet is applied without the pad against the artery. From the above description it is apparent that to corr^^'ctly apply a toiu'niquet a certain knowledge of anatomy is necessary. As" it must be applied tightly enough to com- press the artery it is only possible to use it in the upper arm and thigh. In the forearm and leg, the two bones give sufficient protection to the arteries so that they cannot be conipressed by the ordinary tourni- quet. For a wound of the hand or arm where other methods fail to control the bleeding the tourniquet should be applied with the pad on the inner side of the arm over the brachial artery. For a wound of the leg, where direct pressure w^ith bandaging and elevation are not sufficient, the tourniquet is applied with a pad about one in(;h })elow the midpoint of the crease in the groin over the femoral artery. In addition to its other disadvantages the tourniquet is apt to lead to gangrene if left on too long. After half an hour it should be removed and left off if possible. Fig. 30.— Tourniquet for control of bleeding from the arm. The pad is placed directly over the artery. METHODS OF CONTROLLING HEMORRJIAGE 73 Do not be in too much of a hurry to use the tourniquet; use it only as a method of last resort. Fig. 31. — Location of the principal arteries. 1, temporal artery; 2, occipi- tal artery; 3, facial artery; Jf., lingual artery; 5 and 6, common carotid artery; 7, subclavian artery; 8 and 9, axillary artery; 10, brachial artery; 11, radial artery; 12, ulnar artery; 13, external iliac artery; llf, femoral artery in Scarpa's triangle; 15, femoral artery in Hunter's canal; 16, ante- rior tibial artery ; 1 7, posterior tibial artery ; 1 8, posterior tibial artery behind the internal malleolus; 19, dorsalis pedis artery. Pressure to stop hemor- rhage from the leg should be made at IJf or 15; from the arm at 9 or 10. Pressure at the other points is apt to be unsatisfactory. 74 WOUNDS AND WOUND INFECTION o. Styptics. — riiemicals used to sto]) lioinorrhage are called styptics. Hydrogen peroxide, adrenalin, tincture of ferric chloride, alum and silver nitrate have all been used. They are rarely of service except in small hemorrhages about the nose and mouth. Fig. 32. — Pressure with the thumbs on the femoral artery to stop hemorrhage from the thigh or leg. (Wharton.) INFECTION AND SUPPURATION. When living pathogenic^ bacteria are introduced into a wound, it is said to be infected. These bacteria may or may not cause inflammation with the formation of pus. If few in number they may be killed by the antiseptic forces of the body or by antiseptics used in the treatment of the wound. If they grow and develop the wound becomes inflamed, and there is a discharge of pus. This is called suppuration. Ordinarily, we do not speak of a wound as infected unless the wound shows suppuration. Bacteria. — Bacteria, or germs, are microscopic organisms, so small that many millions might be lodged upon the head of a pin. There are hundreds of different varieties, only a comparatively few of which cause disease. They grow very rapidly, a single bacterium increasing to many millions in a few days. 1 Pathogenic bacteria are th(jsc which give rise to disease in the human body. INFECTION AND SUI'FU RATION 75 Bacteria are found almost everywhere; in the air we breathe, in the water we drink, on the surface of the skin, and on the outside of all the objects we handle. Any object which is exposed to the air soon becomes covered with many thousands of bacteria. Even things which appear very clean and well polished give lodgment to many bac- teria, while things which appear dirty and dusty are usually literally swarming with germs. Fortunately only a few are pathogenic, or disease breeding. These pathogenic bac- teria are most common where many people are congregated. Thus, in theaters, schools and generally about populous centers there are many disease bacteria, while in the forests, on uninhabited sea islands and in the cold regions of the north they are very rare. Fig. 33. — Microscopic appearance of staphylococci. Magnified 1100 diameters. (Park and Williams.) In the European War the battles were fought in the fields of northern France. The highly cultivated earth was simply loaded with bacteria, many of which were of the pathogenic variety. The result was that almost every wound became infected. In the Boer War the fighting was largely confined to the virgin territory in South Africa containing very few pathogenic bacteria. Consequently infected wounds were less common in the Boer War. Bacteria are divided into two main groups; the bacilli, or rod-shaped bacteria; and the cocci, or round bacteria. The cocci are further divided into: (1) Streptococci, which grow 76 WOUNDS AXD WOUM) INFECTION in strings or cliains; (2) staphylococci, which grow in bunches; (o) tliplococci, which grt)W in i)airs. There arc other general forms l)ut the above are the varieties most frequently seen. Fig. 34. — Showing how streptococci grow in chains. Magnified 1000 diameters. (Hcrzog.) INIany of the so-called infectious diseases are caused by bacilli, for example: tuberculosis, typhoid fever, and diph- « ■Qt, ^^ *• „ / ,'/ 'T Fig. 35. — Showing diplococci Ijeiiig taken ui) and destroyed by phagocytes. (Abbott.) theria. Suppuration and woinid infection are usually caused by streptococci or staphylococci, although they may be INFECTION AND SUPPURATION 77 caused by bacilli or diplococci. Pneumonia and meninf^itis are caused by diplococci. Each variety of bacteria is again divided into diflerent subdivisions. Thus we have tubercle bacilli, the bacillus of typhoid fever, the diphtheria bacillus, the tetanus bacil- lus, the streptococcus of erysipelas, the pneumococcus, and the meningococcus. Some of these bacteria are specific, that is, they always cause the same disease. The tubercle bacillus, when it causes disease, always causes tuberculosis, and the tetanus bacillus always causes tetanus. Abscess formation and wound infection is usually caused by one of the various forms of cocci, rarely by the bacilli. In general, infection with streptococci is apt to be more severe than staphylococci infection. Asepsis and Antisepsis.^ — When a wound or object is free from living bacteria it is said to be aseptic or sterile. Septic is the opposite term and indicates the presence of infection. Objects may be rendered aseptic by heat or by chemicals (disitifectants) strong enough to kill all living organisms. When a thing is aseptic it is said to be "surgically clean," which is somewhat different from clean in the ordinary sense. Thus you may take a rusty needle or soiled handkerchief and boil it for twenty minutes and it will be rendered surgically clean, although apparently little changed, while the white handkerchief and the highly polished needle that has been lying on the table for several days, although apparently clean, may be covered with germs. An antiseptic is a substance which tends to prevent infec- tion without injuring the tissues. Thus, alcohol can be poured on the hands, killing many of the germs without causing serious injury to the hands. In surgery, articles are rendered aseptic or sterile by one of three methods : 1. The application of heat. 2. The use of disinfectants. 3. The use of antiseptics. Aseysis by Heat. — Heat may be applied by the open flame, by boiling, or by superheated steam. The open flame is 78 WOUNDS AXD WnrXD IXFECriON rarely used in surgery, l)ut it is of some use iu first-aid work. A needle or knife-blade held in a fiame until it is too hot to touch is completely sterilized, or aseptic. This process soon destroys the steel and is consequently seldom used. In surgical ])ractice, boiling is the method connnonly used to disinfect instruments. Instruments, rubber goods, and glassware may be boiled without injury. In emergencies gauze and cotton may be sterilized by boiling. The boiling should be contiiuied for at least fi^'e minutes, or, better still, twenty to thirty minutes. In hospitals and surgical sup- ply houses, gauze, cotton, and bandages are sterilized by the use of superheated steam. This has the advantage of leaving the material dry so that it is easily handled. Small packages of sterilized material may be A\Tapped in muslin or in paper coverings for transportation. These coverings when dry are not penetrated by bacteria. Disinfectants.^ — Strong acids and alkalies, carbolic acid (phenol), solution of formalin, and many other substances in strong solutions kill all bacteria, serving to sterilize effectually all articles wliich are introduced therein. Instruments, glassware and rubber goods may be sterilized by this method; but, owing to the fact that disinfectants are injurious to the tissues, the excess must be washed off with sterile water before use. For this reason the disinfectants have a limited use in surgical practice. Their use is largely confined to the disinfection of infectious excreta and for the disinfection of waste materials, such as pus-soaked gauze, blood-stained cotton and the like. Antiseptics. — These are substances which may be used in milder solutions to prevent the growth and destroy bacteria, without injury to the body tissues. As may be sujjposed they are less eft'ective than disinfectants but they are suscep- tible to broad usage and in many places where disinfectants cannot be used. The most frequently used antiseptics are tincture of iodin (one-half strength) , alcohol (one-half to full strength), boric acid (saturated solution), hydrogen perox- ide, weak solution of carbolic acid, bichloride of mercury (1 to 1000) and many others. These solutions are of consid- erable value in surgery because of their convenience and THE REPAIR OF WOUNDS 79 because they are not very injurious to the tissues. Some antiseptics, such as tincture of iodin, may be used freely in some parts of the body, but are not suitable for application on the more delicate parts, as for example, about the eye. Instruments and glassware may be soaked for several hours in carbolic acid solution (5 per cent.) and rendered completely sterile. If the skin is painted with tincture of iodin, an incision may be made and if care is taken not to allow infection to enter the wound subsequently it will heal without suppura- tion. In the same manner, if the skin is cut and immediately painted with tincture of iodin and covered with a dressing infection will not take place. If the same treatment is given with alcohol or peroxide of hydrogen, the antiseptic action is also obtained, but less powerfully than with tincture of iodin. Surgical Preparation of the Hands. — Due to the fact that bacteria are always present on the surface and in the pores of the skin, it is an impossibility to render the hands surgically clean. For this reason^ surgeons when operating use rubber gloves which may be sterilized by boiling or by long immersion in antiseptics. If the hands are well scrubbed with soap and water for five minutes or longer and tests are made, very few bac- teria will be found. If in addition they are immersed from three to five minutes in an antiseptic (bichloride of mercury, 1 to 1000) tests will show almost no bacteria. They are almost "surgically clean" and should be so prepared before doing a surgical operation or dressing a wound. It is important to remember that many more germs are ^emo^'ed by the use of soap and water than by disinfectants alone. So that in an emergency treatment it is far better to wash the hands well than to dip them in antiseptic solutions. THE REPAIR OF WOUNDS. The healing of wounds and the necessary measures to produce the normal return of function are more in the province of the surgeon than in that of the first-aid worker, SI) WOiXDiS AXD WOL.MJ J\FL:cTU)X but the c'ni(.'riren(.'y tiratiiicnt is hottt'r uiulorstood if the first-aid workt-r lias a clear c'()iicoi)tioii of tiic i)rocoss of lu'aliut;-. ^MleIl tho wouiul heals without iutVi'tiou or sujjpuratiou, it is said to heal by first iutention. The surj^eon briugs the cut cuds of the tcudous aud skiu iuto ai)i)ositiou by sutures or other suitable uiethods, aud the suiall crevice betweeu the incised surfaces fills with blood clots which remain asep- tic. \\'ithin a few days small bloo(h-essels grow through these thin clots and enter the oi)posit.e surface of the wound. Fig. 36. — Swelling and inflanmiation of the forearm antl hand from an infected wound of the hand. (Ashhurst.) In time proliferation of the cellular elements holds the wound edges firmly together, and healing is complete. There is little or no discharge from such a wound. ^Yhen there is suppuration or M^hen the edges of the woimd are not approximated, the \\'ound heals by granulation. In such cases the wound fills from the bottom and the edges, which become covered with a soft bright red cellular tissue called granulation tissue. The slow proliferation of this tissue gradually fills the wound until it reaches the level of the skin. The skin slowly grows inward from the margin THE REPAIR OF WOUNDS 81 of the denuded area, finally covering the surface of the wound. Primary union, or healing by first intention, usually takes place in about a week and the union is firm at the end of the second week. Compared with this, healing by granulation is very slow. Even a comparatively small wound may require several weeks, and large wounds may not be entirely healed after four or five months. Fig. 37. — Infection of the finger from a neglected wound. This should have been incised several days before. (Park.) Clinical Course of Infected Wounds. — When a wound is infected there is a period varying from a, few hom:'s to a few days during which it is to all appearances aseptic. This is the incubation period during which the bacteria, though present and active, do not make themselves evident. Following this is the stage of reaction when the wound becomes painful and tender. The edges are reddened and indurated (hard). The presence of bacteria causes a con- gestion in the region of the wound. The white cells are thrown out as a protective agency to destroy the bacteria, 6 82 WOUNDS AND WOUND INFECTION and in cortain sta,u:es of tlio i)r()(rss tlio Avliitc (vlls may he sorn, niion)sc()])ically, in the ])rcH'ess of clo\"ourin,u tlio bac- teria. The mixture of sermn, bacteria, Avhite blood cells, and partially destroyed tissue cells is called pus. If the pus can be freely discharged, and the bac^teria are not powerful enou<:;h to overcome the body resistance, heal- ing Avill take jilace. But if the discharge is confined so that it cannot escape or if the bacteria are especially poisonous, the area increases in size, and cellulitis, or blood poisoning, may result. This is shown by pain, redness, and swelling of the part. (Figs. o() and 37.) In cases in which the discharge is free and the infection is subsiding, healing takes place from the bottom and the wound gradually fills with granulation tissue while the sup- puration still continues. After a week or ten days the suppuration has usually to a huge extent subsided and healing by granulation proceeds in a normal manner. SUMMARY OF THE TREATMENT OF WOUNDS. A. Clean Wounds. 1. Inspection of the wound to determine the degree of injury and the amount of bleeding. 2. The cleansing of the hands with soap and water. If there is time, before handling the wound, the hands should be rendered surgically clean by the method previously described. 3. The sterilization of the icoiind. (a) If the wound is apparently clean it should be painted with tincture of iodin (one-half strength) or rinsed with alcohol (50 per cent.). The iodin should be swabbed on the cut surface as well as upon the surrounding skin. (b) Wounds showing gross contamination with dirt and grime. These wounds are best treated })y preliminary washing with soaj) and water followed by thorough rinsing with clean water. Iodin or alcohol may then be applied. 4. The Dressing. — Sterile gauze is placed over the wound so as to stop the bleeding. If sterile gauze is not obtainable, a clean handkerchief or piece of linen may be soaked in 50 SUMMARY OF TREATMENT OF WOUNDS 83 Figs. 38 and 39. — Showing the appearance of a badly infected hand before treatment and the same hand after it had been incised by the surgeon. (Kanavel.) 84 WOrXDS AM) WOUND IXFECTION per cent, alcohol, whisky, or other antiseptic sohition and applied wet to the wound. 5. Bandaging. — A bandage is applied to hold the dressing in place. If hemorrhage is profuse, several compresses and a very firm bandage may be necessary. A tournicpiet is rarely required and should never be applied until other measures fail.' Fig. 40. — Felon of the thumb which has opened spontaneously. Incision would have prevented this large area of ulceration. (Park.) B. Infected Wounds. — When a wound shows evidence of infection (increased pain of a throbbing character, swelling and redness) it requires treatment at once. If professional advice is not available, the treatment should always be directed toward securing free discharge. The dressing should be removed at once. This, in itself, often allows the discharge which has been retained by the adherent dressing to escape. A continuous 1 Owing to the excessive bleediuR it may be necessary to apply a dressing without the preliminary care of the hands and the wound. It may be necessary to pack the wound cjuickly with the available material at hand. If this is so, secure the cleanest material possible. A clean handkerchief or towel is a substitute for sterile gauze under these circumstances, care being taken to unfold the towel or handkerchief so that an absolutely clean spot is brought next the bleeding surface. After such a dressing has been applied the wound recjuires expert care as soon as possible. SUMMARY OF TREATMENT OF WOUNDS 85 wet dressing? is then applied, usinfi; preferably a saturated solution of borie acid to keep the dressing constantly wet. If boric acid is not available, 10 per cent, alcohol or witch- hazel may be used. The essential point is to keep the dress- ing wet so that drainage may be free, and this may be done Fig. 41. — Inflammation about the finger-nail as the result of an infected "hang-nail." (Kanavei.) with ordinary tap water if no antiseptics are at hand. Car- bolic acid is nemr used as a wet dressing, because it may cause gangrene. Clean wounds if not deep or extensive may not require the services of a physician; infected wounds always need professional care. Whenever pus is present beneath the skin, or elsewhere in the body, an incision is required at the earliest opportunity. Figs. 37 and 38 represent an advanced stage of suppuration which should have been treated by incision before becoming so pronounced. CHAPTER IV. BANDAGING. A BANDACK is a Strip of cloth, usually muslin or ji;auze, which is ai)i)lie(l to the body to hold a dressing in place, to secure splints, or to protect and support any part of the body. In physicians' offices and in hospitals the roller ban- dage is used almost exclusively, but, in emergency work, the triangular bandage is often more easily secured and applied. If neither form is obtainable a handkerchief or torn strips of clean cotton or linen cloth may be used. As the bandage material does not come in contact with the wound it is not necessary that it be sterilized. However, a sterile bandage is an additional precaution against infection, and most of the bandages prepared by the surgical supply houses are sold in sterile packages ready for use. THE TRIANGULAR BANDAGE. This bandage, often called Esmarch's triangidar bandage, is made from any suitable material, preferably unbleached muslin, by cutting a piece about a yard square diagonally from corner to corner, forming two triangular bandages. The result is a triangular piece of cloth with one long margin, the base, and two shorter margins, the sides. The corner opposite the lower border, or base, is called the apex or point of the bandage. The two other corners are termed the ends. The bandage may be made from any suitable material, and may vary in size, but for satisfactory work the base should be at least 40 inches in length. To fold the bandage, when not in use, the two ends are brought together, thus folding it perpendicularly down the center,' then the ends and point are folded over to the base ' When folded in this manner, the bandage forms a triangle, half the size of the original. It may be conveniently used in this smaller size in some locations. THE TRIANGULAR BANDAGE 87 of the perpendicular, thus forming a square, which is again folded through the center. The rectangle thus formed is folded, forming a square, and again folded, forming a rectan- gular packet about six inches in length, which easily fits into the pocket. For use, the bandage may be used open or folded, either broad or narrow. In folding for use, the bandage is spread out with the base toward you and the point is brought down to the middle of the lower border. Then fold it toward you, once for the broad bandage, two or three times for the nar- row bandage. The bandage is never placed directly in con- tact with the wound, but only after the sterile dressing has been applied. The method of application of this bandage for the various regions of the body is as follows:^ Fig. 42. — The triangular bandage. (Wharton.) Wounds of the Scalp. — Lay the middle of the bandage on the head so that the lower side lies crosswise over the fore- head, the point hanging down over the nape of the neck. Carry the two ends backward over the ears, cross them at the back of the head, bring them forward and tie them on the forehead. Then stretch the point forward, turn it over the back of the head and fasten it with a pin. Wounds of the Forehead. — Fold the bandage narrow, lay its center over the wound, and, carrying the ends backward tie them at the opposite side of the head, or, if the bandage be long enough, the ends may be crossed at the back of the head, carried forward and tied in front. ' Instructions for Using the Triangular Bandage. Published by the Society for Instruction in First Aid to the Injured, New York City. ss BANDAGING Wounds of the Chest. — I'hice the middle of tlie bandage on the chest with the ])oint over one shonlder, carry the two ends around the chest and tie at the hack; next (h-aw the point o^•er the shoulder downward and tie or pin it to one of the ends. Wounds of the Hip. — Fold a bandage narrow and tie it around the body for a waist belt. Lay the center of a second bandage on the wound, with the ])oint upward, pass the ends around the upper part of the thigh, cross and carry to the front, and knot them together. Next pass the point imder the waist belt and fasten it with a i)in. Wounds of the Upper Arm. — Place the center of a l)road-folded bandage on the front of the limb, carry the ends around to the opposite side, cross them, bring them back, and knot them together. Next take a broad-folded bandage, throw one end over the shoulder on the woimded side, carry it round the neck so as to be visible at the opposite side; then bend the arm carefully and carry the wrist across the middle of the bandage hanging down in front of the chest. This done take the lower end over the shoulder on the sound side and tie the two ends together at the nape of the neck. This second bandage forms a sling for the arm. Wounds of the Forearm, with Broad Sling for Arm. — Bandage the wound as above. Then take a second bandage, throw one end over the shoulder on the sound side, and carry it round the back of the neck so as to be visible at the opposite side, where it is to be held fast; place the point behind the elbow of the injured arm and draw down the end in front of the patient. Next, bend the arm carefully and place it Fig. 43. — Diagram illustrating var i o u s ways of applying the triangular bandage. THE FOUR-TAILED liANDAflE 89 across the chest in the middle of the cloth. Then take the lower end upward over the shoulder on the wounded side and knot to the other end at the nape of the neck. This done, draw the point forward round the elbow and fasten it with a pin. Wounds of the Hand. — Take a bandaji;e, spread it out, and lay the wrist on the lower border with the fingers toward the point. Next turn the point over the fingers and carry it up on the wrist. This done, carry the ends round the wrist, fixing the point, carry them back again and knot together. Wounds of the Thigh, Knee or Leg. — Bandage in the same manner as was directed for wounds of the upper extremity. Usually a single bandage is all that is required. Wounds of the Foot. — ^Take a bandage, spread it out and place the sole of the foot in its center, with the toes in the direction of the point. Draw the point upward over the toes and the instep of the foot; then take the ends forward round the ankle, across the instep, carry them downward and knot them together on the sole of the foot, or, if the bandage be long enough, cross them, bring them forward again, and knot on instep. To Secure Splints. — Ordinary or improvised splints may be applied to the broken limb, and held in position by taking two triangular bandages, folded broad or narrow according to circumstances, and tieing them securely, one above and the other below the fracture. To Improvise a Tourniquet. — Fold the triangular bandage narrow and tie it about the limb over a firm pad above the course of the main artery; then insert a stick under the ban- dage and twist it until such pressure is brought to bear upon the artery that the circulation of the blood through it is stopped. THE FOUR-TAILED BANDAGE. This is made from a strong piece of cloth about a yard long and five or six inches in width. The ends are split down the middle to a point three or four inches from the center. It is particularly applicable to wounds about the head and face. 90 BANDAGING Wounds of the Scalp.- — The conter of the l^iuidage is placed ()\('r x\\v (Iri-ssiiig and the end allowed to hang down on both sides. The two front ends are then drawn back and pinned at the back of the neck and the two back ends are drawn forward and fastened beneath the chin. If the dressing is on the back of the head the ends are crosst^i and fastened under the chin and over the forehead. Hp 3 Fig. 44. — Four-tailed bandage of the chin. (Wharton.) Wounds of the Chin. (Applicable also to fracture of the lower jaw.) — The bandage should be narrower than that described above, about three inches in width, and the slits should be extended nearer to the center of the bandage. After the dressing has lieen applied (or without a dressing in the case of fracture) the center of the bandage is placed over the point of the chin and the lower tails are carried upward and fastened over the top of the head. The upper tails are then fastened back of the neck. THE ROLLER BANDAGE. The roller bandage is made by tearing strips of muslin or gauze about fi^•e yards long, and three or four inches in width. These are rolled either with the fingers, or by THE ROLLER BANDAGE 91 machine, into a closely wound roll. When narrower ban- dages are required the roll may be cut, transversely, with a sharp knife into the desired width. To Roll a Bandage.— In rolling a bandage it is necessary to make the first turns very tight, or a loose bandage, which is very diflncult to apply, will result. The roll is started by folding the end of the bandage tightly upon itself until a small firm roll is formed. This is held by the ends between the thumb and index finger of the left hand. The loose end of the bandage passes between the thumb and index finger of the right hand. The roll is grasped in the palm of the Fig. 45. — Method of rolling a bandage by hand. (Wharton.) right hand and by a rotary movement of the right -^-rist combined with the alternate holding and loosening of the left hand, the roll can be completed. With a little practice a tightly wound roll may be obtained. Machine-rolled bandages are more satisfactory for use. They may be rolled with a hand machine, or may be pur- chased ready for use. Application of a Bandage. — A few inches of the bandage is unrolled and the loose end taken in the left hand while the roll is held in the right. The outer side of the bandage is then placed next to the dressing and the bandage carried V 02 BANDAGING around the part to ho drosscxl, making a single turn, wliich anchors the hanclage. The simplest form of bandage, the circular handngc, is a])])lical)lc to ])(trti()ns of the body and Fig. 46. — BandaKO wimlcr. (Wharton.) -extremities where the size remains the same. In this case the bandage is carried around and around the part in a spiral until the dressing is entirely covered. ^Vhc^ this is done the end is cut and secured either by a pin or by tearing %^ m Fig. 47. — Roller bandage. (Wharton.) the bandage into two tails, one of which is passed backward about the limb and tied to the other end on the opposite side. THE ROLLER BANDAGE 93 Figure-of-eight Bandage. — In haiidagiiif^ an arm or leg it is found that a- simple eircular bandage does not fit snugly. There is a fulness of one edge at some point. In order to overcome this the direction of the bandage is altered until both edges fit snugly. This means that the bandage must be turned sharply upward and carried around the limb several inches above the previous turn. It is now brought downward and forward over the upward turn, crossing it and forming a figure-of-eight. This process is repeated, over- lapping each turn slightly, so as to cover in the entire part. Fig. 48. — Figure-of-eight bandage of the leg. (Wharton.) The slack or fulness is located at the back of the upper turn, where it will be covered with subsec^uent turns. Care should be taken in any bandage to have it applied firmly, but never tight enough to act as a hindrance to the circulation. Spiral Reverse Bandage of the Forearm. — Another method of taking in the slack which occurs along one side of a ban- dage applied to a part of the body which shows variation in size and shape is the spiral reverse. On the arms and legs, which are roughly cone-shaped, the lower edge of the circu- lar bandage is always loose, especially in stout persons. Unless the spiral reverse or the figm-e-of-eight is applied, 94 BAXDAdlXa t\\v bandatic will \)v uik'ncmi in appearance and easily disar- ranged. In making a spiral re\erse of the forearm the bandage is first fixed by two eirenlar turns about the wrist. Tlu> third turn is made to run up the forearm so that both edges of the strip lie smoothly on the forearm. The right hand holds the bandage taut and the left thumb is placed ui)on the lower margin of the bandage at a ])oiut corresponding to the median line of the forearm. The right hand is now allowed to relax and the bandage, turned toward the operator through an angle of ISO degrees, is passed around the limb and again drawn taut. There is now a rcA'erse of the ban- r iG. 49. — Spiral reversed bandage of the upper cxtreiuit>'. (Wharton.) dage at one point, and the next turn may be made smoothly about the forearm overlai)ping the preceding turn about one-half. Each time the bandage reaches the front of the arm a reverse is made. Near the elbow where the forearm grows smaller the reverse may be discontinued and the bandaging continued by the use of circular turns. If this bandage is correctly applied the forearm will be smoothly coverefl and the reverses lie in a straight row down the front of the forearm. The spiral reverse may be applied in the same manner to the arm, leg, or thigh. Spica of the Shoulder.- T he term si)ica is generally used to denote a bandage which includes a part of the extremity rflE ROLLER BAND AGE 95 and a part of the trunk. The spica of the shoulder begins by two or three circular turns about the upper part of the arm on the affected side. The l)andage is then carried a little upward and across the shoulder, obliquely downward across the back, under the armpit of the opposite side, and upward across the chest to the afiected shoulder, and finally around the arm. The next turn follows the first, overlapping about one-half at the shoulder, but exactly coinciding beneath the opposite armpit. When completed the shoulder will be covered. Fig. 50. — Spica of the shoulder. (Wharton.) Spica of the Groin. — Two circular turns are taken about the upper part of the thigh and the bandage is then carried obliquely upward to the waist line, crossing the thigh from within outward. It is then carried once and a half about the waist to the front of the abdomen, from whence it is directed obliquely downward, crossing the first oblique turn on the front of the affected thigh and finally covering the first turn made around the thigh. The turns are repeated until the groin is entirely covered. Spica of the Buttock. — The operator stands behind the patient and begins the bandage by two turns about the upper part of the thigh, the turns being made from within 90 BANDAGING outward, as in thr pircoding ])aii{la<2:o. For the left buttock the l)an(laj;e is carried ol)li(juely upward across the left thij:;h to the waist line on the left side, then around the abdomen to the right side, making a full circular tm'u about the waist to the back. From this ])oint the bandage inclines downward to the left thigh, crossing the first ob]i(]ue turno\er the left })uttock and tlu'n making a single turn around the thigh. This process is continued by overlapping the ()})lique turns until the buttock is (>ntirely covered. For the right buttock the turns are the same, but run in the reverse direction. The Spica of Both Groins. — Ihis bandage is begun by a circular turn about the waist and carried on to the left thigh in an oblique direction. After a circular turn about the thigh the bandage is carried obliquely back to the waist and a circular turn made. It is next passed obli(|uely to the right thigh. These turns are alternated until both groins are covered. The buttocks may be covered in the same manner by making the points of crossing behind. Figure-of-eight of the Elbow. — ^This should always be applied when the elbow is partially l)ent. Otherwise it will prove too tight and most uncomfortable. The bandage begins by a circular turn about the upper part of the fore- arm and is carried obliquely across the bend of- the elbow to the lower part of the arm, where a complete turn is made. The next turn brings the bandage obliquely down across the bend of the elbow to the forearm, where it encircles the forearm a little higher than the previous turn. The figure- of-eight is then continued, overlapping the turns until the point of the elbow is covered. The bandage may be applied in the reverse direction, that Fig. 51. — Spica of the buttocks. (Wharton.) THE ROLLER BANDAGE 97 is, beginning at the point of the elbow. Two circular turns pass around to the elbow at this point; the third turn is now carried a little above the first two turns at the outer side and the fourth turn a little below them; all the turns coinciding at the bend of the elbow. In this manner a figure- of-eight is developed which soon covers the entire region of the elbow. The bandage is fixed by a circular turn about the forearm. Fig. 52. — Figure-of-eight bandage of the elbow. (Wharton.) Figure-of-eight of the Knee.^ — ^This corresponds exactly to the figure-of-eight of the elbow. Finger-tip Bandage. — This is begun by two turns of a nar- row bandage about the wrist. The third turn is brought down obliquely across the back of the hand to the affected finger, where it is passed once or twice around the finger to fix it firmly in place. It is turned on itself at a right angle and held by the finger of the left hand while the right hand draws the bandage downward over the tip of the 7 98 BAXDAGING finger to tlie front of this finyor. The direction is elinnijed, the fold l)eiiiu- held hv the thnnih of the left hand and the Fig. 53. — Figurc-of-cight bandage of the knee. (Wharton.) Fig. 54.— Spiral bandage of the finger. (Wharton.) bandage brought back to the back of the finger where it is held with the left forefinger. This is repeated until there THE ROLLER BANDAGE 99 are several turns over the tip of the finger. Holding these folds in place, the direction of the bandage is again changed and a circular turn made about the end of the finger over the loose folds which cover the tip. The bandage is then carried up the finger, either by circular turns or by a spiral reverse, to the base of the finger, from whence it is carried across the back of the hand to the wrist, where it is fixed. If more than one finger requires bandaging, the same bandage may be used by passing obliquely to the second finger after completing the first bandage at the wrist. Fig. 55. — Gauntlet bandage. (Wharton.) Fig. 56.- -Demigauntlet bandage. (Wharton.) Gauntlet Bandage. — This is similar to the preceding except that the tips of the fingers are not necessarily covered. The bandage passes from the wrist to the finger and spirally around the finger to the tip. No attempt is made with these first turns to cover the entire finger. A circular turn is then made about the end of the finger and the bandage continued to the base either by a figure-of-eight or a spiral reverse. From the base of the finger the bandage goes back to the wrist and then to a second finger until all the fingers are 100 BANDAGING covered. It will now be found that the entire back of the hand is covered, but the palm is left free. In the demigauntht the bandage is the same, except that the fingers are not bandaged. The turn around the wrist is made a nil brought down to the base of the finger, a single turn being made, and the bandage then brought back to the wrist. The bandage is carried to the other fingers in the same manner, the result being that the back of the hand is covered but the palm and fingers are left free. A reverse gauniJei is a similar bandage so applied as to cover the palm ^^'hile the back of the hand is left free. Fig. 57. — Bandage of the foot, not covering the heel. (Wharton.) Figure-of-eight of Ankle and Foot. — It begins by a circular turn about the ankle and then passes obliquely downward to the base of the toes where a single turn passes around the foot. It then runs oblicjuely across the ui)per surface of the foot to the side of the foot where it parallels the sole to the back of the heel, then, running around the heel it passes forward parallel to the outer edge of the sole to about the midi)art of the foot. From this point it passes obliquely over the foot, crossing the previous oblique turn. In this bandage the lower margin is made firm while the upper margin is left slack to be covered by the second turn of the figure-of- eight. As the bandage is continued the third or fourth turn falls naturally around the ankle where the bandage is fixed. This bandage does not cover the point of the heel. THE ROLLER BANDAGE 101 Figure-of-eight of the Heel. 1 his bandage begins with a circular turn directly around the heel and instep. The next turn coincides with the first at the instep but overlaps slightly below the heel. This is followed by another turn whicrh over- laps slightly above the heel, thus forming a figure-of-eight. These turns are repeated until the entire heel is covered. The bandage may be completed by circular turns about the foot or ankle, as required, or it may be continued up the leg. Fig. 58. — Recurrent bandage. (Wharton.) Recurrent Bandage of the Toes. — The toes are seldom ban- daged separately as are the fingers. After the dressing is applied, the bandage is started on the upper surface of the foot and held in place by the fingers of the left hand. It passes directly downward over the toes and onto the sole of the foot. About two inches from the toes it is held by the left thumb and turned directly backward over the toes to the upper surface of the foot, This process is repeated until the toes are all covered and the ends of the recurrent strips are held in place by a few circular turns about the foot. Recurrent Bandage of the Slump. — An amputation stump may require bandaging. This is accomplished in exactly the same manner as the recurrent bandage of the toes. Figure-of-eight of the Leg. — A circular turn is made about the ankle and the bandage carried upward by spiral turns 102 BAXDAGING until the increasing? si^e of the leji causes tlie lower niar{j;in of the bandajie to become slack. This usually occurs after about three turns. The bandage is then inclined oblicjuely upward to above the calf and a circular turn is made about the leg at this point. Tlie next turn is inclined obliciuely downward, crossing the upward turn obli(|uely, and another circular turn is made about the ankle just above the previous circular turns. The bandage is then carried upward, over- lapping the upward turn and again passed around the leg just above the calf. These turns are all repeated until the leg is covered. After the first few figures-of-eight the cir- cular turns may be omitted. If there is much tendency to swelling of the foot, this bandage should be combined with the figure-of-eight of the foot and ankle. Fig. 59. — Recurrent bandage of an amputated stump covered with a spira reverse extending up the hmb. (Wharton.) Eye Bandage. — For the right eye. A one and a half-inch bandage is fixed by two circular turns about the head abo\'e the ears, running from right to left in front. The third turn is carried downward at the back of the head below the right ear, and then upward, covering the right eye. The left eye is bandaged in the same manner, excepting that the bandage is reversed, beginning from left to right. For both eyes the first three turns are put on as above and the fourth turn is continued around the head. When this turn reaches the front of the head the bandage is carried downward from THE ROLLER BANDAGE 103 right to left over the left eye, below the left ear aiifl finally upward to join the circular turns. A single turn is com- pleted bringing the bandage to the back of the head from whence it is carried downward below the right ear, over the right eye and back to the forehead. The turns continue alternately until both eyes are covered. Fig. 60. — Bandage of the right eye. (Wharton.) Fig. 61. — Bandage of both eyes. (Wharton.) Ear Bandage. — The ears may be covered in exactly the same manner as the eyes except that the turns are made to overlap at the region of the ear instead of at the eye. Head Bandage. — The back of the head may be bandaged with a two-inch bandage fixed by two circular turns around the head above the ears. The third turn covers the first turns in front, but behind, it is carried about one-half inch below the previous turns. The fourth turn again covers the previous turns in front, but is carried upward about one- half inch behind. By continuing these turns, keeping the bandage a single width in front and alternating the turns, first below and then above at the back of the head, a large area may be successfully bandaged. If this process is reversed and the circular turns made to overlap behind, the forehead may be covered by making each turn a little higher in front than the previous turn. 104 BANDAGING The top of the head cannot be covered by either of these banchiges. This portion of the scalp may be covered by a bandage which starts at the top of the head and is carried chrecth' downward, behind the left ear, under the chin and upward in front of the right ear to the starting-point. The second turn is carried downward, coN'ering the first turn behind the left ear, then under the chin and upward, this time behind the right ear. The third turn passes around the head in the same manner, this time in front of both ears. There are thus three distinct turns; one passes behind the Fig. 62. — Bandage adapted to wounds of the back of the head, or of tlie forehead. (Wharton.) left ear and in front of the right; the next passes behind both ears; and a third passes in front of both ears. The alter- nating turns in front of, and behind the ears hold the bandage firmly fixed. This bandage may also be adapted to the treatment of wounds of the face. Recurrent Bandage of the Head. — For this bandage a two- inch roller is used. The bandage is started on the forehead and carried in the midline over the top of the head to the nape of the neck. It is turned upon itself and brought back to the starting-point, the second strip l)cing carried slightly to one side. On reaching the starting-point the bandage is THE ROLLER BANDAGE 105 again reversed and carried backward, ()\'crlai>piiig about one inch to the other side. When this tliird fold of the bandage reaches the nape of the neck it is again folded upon itself and brought back to the forehead overlapi)ing the second fold. If this process is repeated the entire scalp will be covered with overlapping folds running backward and forward. With the last fold the bandage is turned on itself so as to make a circular fold about the head above the ears, which holds the end of the recurrent folds firmly in place. As will be noticed the bandage over the scalp is very loose and incapable of exerting the slightest pressure. Fig. 63. — Recurrent bandage of the head. (Wharton.) Circular Bandage of the Neck. — A dressing of the neck may be held in place by a simple circular bandage. It is very important not to exert pressure in bandaging the neck. The bandage should be simply laid on. Any attempt to draw the bandage taut will result in constriction of the neck, with great discomfort to the patient. Barton's Bandage. — ^This bandage is of especial use in frac- ture of the lower jaw, but it may be used to hold a dressing in place in any region covered by it. A two-inch bandage is started at the top of the head and carried downward behind the left ear, around the back of 106 BANDAGING tlu> neck and forward alonj;- the ri<,dit side of the jaw to the chin. Curvinf;- in front of the chin the bancUige runs along the left side of the jaw below the left ear, to the back of the neck, and from here is carried upward beliind the rijjht ear to the startin.u--])oint. From tiiis point the bandajfe con- tinues in tlie same direction over the top of the head and downward just behind the left eye to the chin, which it passes directly under, and is carried upward across the right cheek, behind the right e>e to the starting-point. This completes the bandage, but the turns may be repeated several times for security. Fig. 64. — Barton's bandage f"i- fracture of the jaw. (Wharton.) Bandage of the Neck and Axilla. — A dressing of the axilla or armpit may be held in place by a figure-of-eight bandage of the neck and axilla. The bandage is fixed by two circu- lar turns around the upper part of the arm, the third pass- ing upward behind the shoulder to the front of the neck, around the neck, in front of the shoulder, under the arm- pit, behind the shoulder, and again to the front of the neck; thus forming a figure-of-eight. This figure-of-eight turn may be repeated, and if desired, circular turns about the neck or arm may be added. Bandage of the Chest and Axilla. — This bandage is adapted to hold a dressing in one axilla. THE ROLLER BANDAGE 107 The bandage starts in the midhrie and is carried over the shoulder and around beneath the injured armpit, across in front of the chest, under the armpit of the opposite side and across the back to the shoulder of the injured side. From here the bandage passes downward under the axilla, across the back to the opposite axilla and around to the front of the chest at the starting-point. Figure-of-eight Bandage of the Chest. — This bandage starts over the breast-bone and passes to the right shoulder, curv- ing behind it to the axilla and forward on the chest to the starting-point. From here it passes obliquely across the chest in the same direction to the left shoulder, around Fig. 65. — Antericir figure (Wharton.) which it passes to the left axilla, running forward and across the chest to the starting-point. This completes the anterior iigure-of -eight of the chest. The posterior figure-of-eight of the chest is made in a similar manner, starting from the midline of the back. Breast Bandage. — This may be made to retain dressings or to make pressure on one or both breasts. To bandage the right breast the roller is started beneath the breast and carried horizontally across the chest from right to left, entirely around the chest to the starting-point. It then passes obliquely upward over the lower margin of the right breast to the left shoulder, passing over it and then down- ward across the back and around the chest one inch above 108 BANDAGING tlu* first horizontal turn. When tliis is completed a second oblique turn is made about an inch above the first. These Fig. 66. — Bandage to support right breast. (Wharton.) Fig. 67. — Bandage of l)oth breasts. (Wharton.) THE ROLLER BANDAGE 109 turns are continued alternately until the breast is entirely covered. If it is desirable to cover both breasts the first two turns are made as above. The third turn passes around the chest to the back, from whence it passes upward to the right shoulder and obliquely downward across the chest below the lower margin of the left breast, passing around to the back to overlap the circular turns. Fig. 68. — Velpeau bandage. (Wharton.) These three turns are alternated: first the circular turn, then the oblique turn to the right breast, passing from below upward, followed by another circular turn, and finally an oblique turn passing from above downward, supporting the left breast. In the double bandage the best support is given to the breast on the side where the oblique bandage passes from below upward. In the above case the bandage applied to the right breast gives the best support. If the left breast requires a greater support, this bandage should be reversed. Circular Bandage of the Chest and Abdomen. — ^In the male the breasts may be bandaged by a circular spiral running either upward or downward. The abdomen may be ban- daged in the same manner. no BANDAGING The Velpeau Bandage. — This })anda<;'o is used to fix the arm and i'urearin ati;aiiist the ehest. The forearm of the extrem- ity to be bandaged is placed obliquely across the chest with the fingers near the opposite collar-bone. For the right arm the bandage is fixed by a circular turn about the chest, passing from right to left. It is then carried across the back to the injured shoulder and downward, over the point of the shoulder, across the outer side of the upper arm, turning on itself to be carried across the front of the chest just above the first circular tiu-n, passing entirely around the chest. When the elbow is reached this turn passes in front of the elbow, holding it firmly against the chest and passing to the left side of the chest; from this point the bandage passes obliquely upward across the back to the left shoulder and is continued as described above, each turn overlapping the preceding until the arm is covered. This bandi'ge is espe- cially applicable to fractures of the collar-bone. CHAPTER V. FRACTURES AND DISLOCATIONS. When an injui\y results in a wound of the skin it is usually fairly easy to determiiue the nature of the injury from inspec- tion of the injured part. But when the body is injured by a blow with a blunt instrument, or by a fall, it is much more difficult for the first-aid worker to determine the extent of the injury to the deeper parts. There may be a sprain or dislocation, a bone may be broken, one of the vital organs may be torn or ruptured, or there may be only a simple bruise or contusion of the tissues. Some idea of the extent of the injury may be gained from the appearance of the patient. After a severe injury there is usually considerable shock, the face is pale, the pulse is weak, and there is evidence of great pain. The converse of this is not always true. Very rarely we see patients who are suffering from fractures or other severe injuries, who have apparently very little pain. In the excitement of an accident a patient with a severe injury may temporarily forget his own pain and be of aid in helping others. On the other hand, some persons are so constituted that even the sight of blood causes a nervous shock which makes them turn pale and grow weak and faint. As a result they may appear to be severely injured. In practice give every case the benefit of the doubt and treat as severely injured every patient who shows evidence of shock until you are reasonably certain that no serious injury is present. FRACTURES. When a bone is broken it is said to be fractured and the break is called a fractiu*e. It is commonly believed that a fractured bone is different from a broken bone. This is an error; they are one and the same thing. 112 FRACTURES AXD DISLOCATIONS Bones may be broken just as a stick of wood is broken, directly across, the two ends beinj; separated; they may be spht longitucHnally or obHqnely; or a chip or hirfj;er piece may be broken horn the end or side of the bone without permanently interferinji; with the function or usefulness of the bone. In young bones there is considerable elasticity, so that they bend a little before breaking; but in the aged the bones are brittle, breaking ^•ery easily. 1 have seen a child fall two stories without receivng a fracture, and I have treated a man of eighty who fractured his thigh-bone by stepping down oil' the curb. In some cases the force of the blow will drive one fractured end of the bone directly into the other frag- Fiii. 69. — Compound fnicturc of the tirru. Note the end of the h)\ver fragment protruding from the wound. (Ashhurst.) ment. This is called an impacted fracture, which, when the impaction is firm, may allow the patient a reasonably satisfactory use of the injured arm or leg. If you will cut a branch from a tree and bend it you will notice that the branch will l)end a long way and finally break on one side without separating entirely. A similar fracture of the bones occurs in children and is known as " green-stick" fracture. In general, fractures are of two kinds, .ninylc and rompoinul. If the bone is fractured without an associated woinid of the skin, the fracture is said to be simple. A compound fracture is one in which the injury is complicated by a woimd of the overlying soft parts, FRACTURES 113 It is very important to understand the diflerence })e- tween these two classes of fractures. Compound fracture is exposed to infection through the wound, and has, therefore, more serious and dangerous consequences. In compound" fracture the wound may result from an external force, such as a blow or a bullet wound; or the jagged end of the bone may be forced through the skin from within. When bacteria causes infection of a wound connected with a broken bone, the bone itself is apt to become infected and the result is much more serious than that following infection of an ordinary wound. In gunshot fractures the fractures are always compound. In some cases the bullet causes a shattering of the bone in many pieces (Fig. 70) . A fracture of this type, whether the result of a bullet wound or other injury, is termed a com- minuted fracture. Symptoms of Fracture. — The examiner recognizes the presence of fracture by symptoms and physical signs. They are : 1. Pain and tenderness. 2. Disability. 3. Deformity. 4. False point of motion. 5. Crepitus. 6. Special surgical signs. Pain and Tenderness. — These are the most important of all the signs, and are sometimes the only signs present. When, after an injury, the patient suf- fers severe pain, especially when any at- tempt is made to move him, a fracture should always be suspected. If the pain is excruciating in character, causing the patient to cry out on any attempt at motion, there is almost certainly a fracture present. Fig. 70. — Injury to bone inflicted by steel- mantled ball at 1300 yards. (Park.) 114 FRACTURES AND DISLOCATIONS Temlenioss, or pain on })ressnre, is a constant symptom. In examining for a fracture it is customary to aj)ply lirm Fig. 71. — Longitudinal splitting fracture of the tibia, and oblique fracture of the fibula. This fracture would be very difficult to diagnose. (Ashhurst.) pressure over the bone to determine where tenderness exists. When the tender spot is found a special examin- ation is made at this point. If firm pressure does not ehcit FRACTURES 115 tenderness at any point there is, almost certainly, no fracture present. The exception to the above is seen during loss of con- sciousness, when the detection of fracture rests chiefly on false point of motion, deformity, and crepitus. Disability. — Partial disability is the rule in fracture. Usually the disability is immediate and marked, increas- ing during the first twenty-four hours. In impacted and green-stick fractures, as well as in incom- plete and chipping fractures, the disability may be very slight. A chauffeur drove his car for several days while suffering from a fractured wrist, and a child was recently seen who played about the house for over a week with only slight evidence of disability from green-stick fractures of both bones of the forearm. In a recent drama the plot rested upon the fact that it was impossible for a man who had just broken his wrist to hand a card to another man with the injured hand. To the surgeon who has seen many fractures, this statement is as absurd as the common belief that because the fingers can be moved there cannot possibly be a fracture. Remember that the disability depends largely on the sever- ity of the fracture. Severe fractures with complete separa- tion of the bones cause the most disability. I believe that the inability to walk is an important sign in fracture of the lower extremity. While the foot and leg may sometimes be moved freely without pain, the patient is rarely able to bear his weight on the fractured leg. Deformity. — The shape of the limb is altered, partially due to the swelling and partly to the break m the bone. When the bone is near the skin the broken ends may be felt. In other cases, the shortening and the crooked appear- ance of the limb must be depended upon in order to make a diagnosis. False Point of Motion. — This is an important sign when present. If the limb moves at a point where there is ordi- narily no joint, the bone must be broken. There is no other alternative. Crepi'us.—li you rub the two ends of the broken bone together there results a dull grating sensation which is no FRACTURES AXD DISLOCATIONS transniittod to tlio cxiunlnin.u hands and can sonu'tinics even be lieard. This is called crepitus and is an almost certain sign of fracture. It is not wise for the first-aid worker to elicit either false point of motion or crepitus as he may therehy increase the disi)lacement of the fractured ends. These symi)toms should, however, be borne in mind, us they are frequently noted in Fk;. 72. — E(cliyiiio.si.s tweiUy-four hours after fracture of the upper end <;f of the liunicrus. Note that there is almost no visible deformity. (Ashhurst.) the routine examination of those severely injured. "^1 hey are both absent in imjjacted fractures and are seldom obtained in fractures without displacement. Ecchymosis, or hemorrhage beneath the skin, is a common symptom of fracture. It becomes evident after a day or two and appears externally as the common "Idack-and-blue" spot. Because it appears so late it is of little value in the early diag- FRACTURES 117 nosis of fractures. It also occurs after simple bruises of the soft tissues, Sjwcial Surgical Signs.— In addition to the above signs the surgeon determines the variety and extent of the fracture Fig. 73. — X-ray showing callus several weeks after fracture of the radius. After a few months the lump in the region of the fracture will have entirely disappeared. (Ashhurst.) Fig. 74. — Fracture of the femur with healing in a deformed position. Vicious union. (Park.) by other methods, chiefly the measurement of the affected parts and the use of the rr-rays. The latter method is not US FRACTURES AXD DISLOCATIONS available for emergency work but, because it. o-ives us a pic- ture of the fractured bone, it will be used in the discussion of certain fractures. Union of Fractures. — Healing takes place by the growth, about the thickened ends of the bone, of a tough, fibrous material called callus. This begins within a few days, and at the end of a week or ten days results in a fairly firm imion. It gradually changes to true bone, so that after two or three months the bone is as firm at the point of the fracture as elsewhere. An .r-ray taken several months after a fractiu-e may show absolutely no evidences of the injury. Treatment of Fracture. — When the broken ends are dis- placed the process of putting them together is called reduc- tion. Splints are used to hold the fractured ends in place (fixation). The special forms of treatment will ])e indicated imder the different forms of fracture. First Examine the Patient. — To determine if a fracture is present let the patient lie do^Mi in as comfortable a position as possible and examine the limb through the clothing for pain or deformity. If a fracture is suspected, remove enough clothing by cutting or ripping to examine the injured part. j\Iove the limb as little as possible, thus avoiding pain and the danger of mcreasing the extent of the injury. When the limb is exposed examine it slowly and carefully in order to determine the extent of the fracture. There is no necessity for hurry in such a case. If the limb shows only slight deformity it should be supported on a soft cushion and pro- tected until the arrival of the physician. Cold compresses, that is, cloths wet in cold water and a]:)plied to the injured part — will relieve the pain. If there is a marked deformity the attempt may be made to correct it by grasping the limb below the fracture and pulling it in a straight line. If a mod- erately strong pull does not reduce the deformity the attempt should be abandoned. ^Yhile it is desirable to secure the aid of a physician to reduce the fracture, there is not the same urgency as in the case of wounds. The fracture may be "set," or reduced, even after several days have elapsed. There is no harm in allowing the patient to wait several hours, or longer, if the FRACTURES 119 fractured bone can be kept at rest. For those cases which must be moved before seeing a physician, a splint of scjme sort must be apphed. SpHnts are made of thin strips of wood or card-board which may be bandaged to the limb so as to prevent the separa- tion of the fractured bones. The sphnt shoukl be cut long enough to include the joint above and below the fracture, and should be a little wider than the thickness of the limb. In emergencies any form of a straight stick, such as a cane, an umbrella, or a branch cut from a tree, will serve as a temporary splint. Paste-board, folded newspapers, sole leather, and strips of tin have been successfully used. Ordi- FiG. 75. — Improvised pillow splint for fracture of the leg. (Brewer.) narily a most satisfactory splint may be cut from the thin wood used in making egg cases, or other similar boxes used in the grocery trade. Every splint must be padded. This serves two purposes: It makes the splint fit the irregularities of the limb, conse- quently making it more comfortable for the patient, and the padding allows for the swelling almost certain to follow, which, if prevented by tight bandages, might cause added injury to the limb. Cotton is the best material to use for padding, but if this is not available, other material may be used, such as a folded blanket, strips of cloth, grass, hay, or any other elastic material. 120 FRACTURES AND DISLOCATIOKS In order to apply the splints the limb is held by an assis- tant and the si)lints ])la(cd one on each side of the injured limb, each s])lint well ])n)lected by ])addiu|^from the hand. If this is successful the bones will come together with a click. In order to prevent recurrence the arm is bound to the chest with the elbow bent to a little less than a right angle. After the third or fourth day the arm may be removed daily from the bandage and the joint moved a little, but, except for this, it should be firmly bandaged to the chest for at least two weeks. It should be carried in a sling for two or three weeks longer. Dislocation of the Wrist. — This is an extremely rare dislo- cation. Most cases which appear to be dislocations are Fig. 100. — Di.sloration of the elhow backward. Outline draw- ing of bones. (Speed.) DISLOCA TfONS 141 fractures of the lower end f)f tlie radius. (See Colles's frac- ture.) The treatment is the same as for fracture. Dislocation of the Fingers. — The finger should be pulled in the long direction of the fingers until the hone slips into Fig. 101. — Diagrammatic sketch showing dislocation of the thumb. This can usually be reduced by pulling the thumb toward the ends of the fingers. (Park.) place. Pressure may be made on the projecting end of the bone. A cold compress held in place by a bandage relieves the pain and gives all the support required. Dislocation of the Jaw. — This is a not uncommon disloca- tion, and usually occurs when yawning or laughing. The jaw Fig. 102. — Method of reducing dislocation of the lower jaw, (Park.) is held wide open and cannot be closed. To reduce the dislocation the patient is placed upright in a chair, and the operator, standing in front of him, places the thumbs on either side upon the lower back teeth and presses do-un- 142 FRACTURES AND DISLOCATIONS ward aiul thou a little backward. The jaw will siiaj) into place. Ill ortler to protect the thumbs, they should be well ^^Tapped with a strip of gauze or a handkerchief, otherwise they may be injured when the jaws snap together. Fig. 10.3. — Deformity due to dislocation of the upper end of the femur backward. This is a common form of hip dislocation. (Stimson.) D/SLOdA TIONH 143 Dislocation of the Hip. — The patient lies helpless and is unable to move the injured thigh. This is a very difficult dislocation to reduce. The attempt may be made as follows: With the patient lying on his back and held })y an assistant, the leg is steadily and firmly pulled directly downward. It is then slowly moved outward until it forms an angle of about 60 degrees with the other leg. At this point it is slowly rotated, until the toes on the injured side are directed a little outward and finally, the pull being constantly kept up, the leg is brought back to the midline again. If this is not successful it is better to wait-for the arrival of the surgeon. If the patient must be transported he should be carried on a cot or stretcher. A splint is not required. Dislocation of the Patella. — This is a rare form of disloca- tion. The patella is usuall}"^ dislocated outward or simply turned on edge. Direct pressure will often cause it to snap back into place. The knee should be kept stiff with a posterior splint for several weeks. Dislocation of the Knee. — Almost always a fracture dislo- cation. Should be treated as a fracture. Dislocated Meniscus. — In the knee there is a small piece of cartilage, triangular in shape, called the meniscus. This may be caught between the two bones, causing the knee to "lock." The patient has a sharp pain and falls to the ground and is unable to bend the knee. If the patient is placed upon his back so that the muscles are relaxed and attempts made to move the knee the carti- lage will usually slip out from between the bones. Follow- ing this the patient is able to walk with only slight pain but in a few hours the knee begins to swell and is very painful. For this reason the patient should be put to bed at once and cold compresses applied to the knee. As this condition is apt to recur, patients soon learn to unlock the joint without aid. Dislocation of the Ankle and Foot. — Any dislocation in this region is apt to be associated with fracture, and should be treated as such. Dislocation of the Toes. — Dislocation of the toes is treated in the same manner as dislocation of the fingers. 144 FRACTURES AXD DISLOCATIONS SPRAINS. When a joint is subjected to sufficient strain to tear the H.uanicnts a sprain results. In dislocation the liijjaments tear and the bone slips out of the socket, but in s])rain the injury stops Avhen the lipuneuts are torn, so that a sprain may be considered as a beginning dislocation. Among first-aid workers a common error is to mistake a fracture for a sprain. More than half of the "sprains" which come to the surgeon for treatment prove to be frac- tures. Always hesitate to diagnose a case as sprain unless there is very slight disability. For example, if a patient can walk without difficulty, but has a painful and swollen ankle, the case is probably a sprain. If the injury is severe enough to prevent walking it is almost certainly a fracture. There is an old saying that "a bad sprain is worse than a break." This is an error which arose because many injuries were diagnosed as sprains and treated as sprains when they really were fractures. As a consequence the constant irri- tation of the fractured bone which was not put in a splint caused more pain and disability than a fracture which was recognized and treated as such. Until you have considerable experience suspect a fracture in every case of "sprain" of even moderate severity. Treatment. — In general, sprains may be treated by one of two methods. The first method consists of rest combined with the appli- cation of cold for one or two days followed by firm ban- dages and massage with gradually increasing use of the joint. The second method consists of massage and a firm bandage from the first, allowing the patient moderate use of the injured limb from the time of the injury. The bandage must be applied very firmly and removed daily for massage which must always be in the direction of the flow of venous blood, that is, toward the heart. Care must be taken in this method not to cause constriction of the limb by the use of a bandage which is too tight. Adhesi^'e straps serve admir- ably as a support. They should be applied so as to nearly HPIiAINH 145 surround the liml), a narrow space \)ii\n\i, left to allow for swelling. The method chosen depends somewhat upon the severity of the injury. The first method should be chosen if there is the slightest possibility of fracture. In any case where pain and disability persist for more than a few days a physician should be consulted. As most sprains must be treated on general principles^ only a few will be given in detail. Fig. 104. — Sprained riffht ankle. Note the swelling especially on the outer side. (Ashhurst.) Sprained Ankle. — This is the most common and typical sprain and will consequenth' be discussed first. Usually the ligaments on the outer side of the ankle are torn and the ankle is especially tender at this point. The usual history of a sprained ankle is that the patient "turns" the ankle. After a moment of severe pain he is able to walk with very little pain. Several hours later when the swelling becomes more extensive the pain grows very severe again. In fracture of the ankle this period of comparative comfort is usually absent. 10 146 FRACTURES AND DISLOCATIONS Either luclliDcl uf treatiucut may hv used. If the sprahi is not too severe the ankle may be strapped or l)aiidaf!;ed firmly and the patient allowed to walk from the first day. The bandage should be worn for about three weeks. To prexent recm'rence laced shoes should be worn for sex'eral months. Sprained Wrist. — Tliis is rart-ly se\ere. A tij;ht bandage or a leather wrist sui)])ort keeps tlie w rist sufliciently at rest until healing can take place. Sprained Fingers. — The fingers and thumb are frecjuently sprained. Usually a bandage for a few days is all that is required. If the pain persists, adhesive straps may be used for support. Sprained Knee. — Sprained knee is usually caused by a twisting injury. The joint may become greatly swollen, owing to exudation of serum into the knee-joint (water on the knee). In such cases the patient should be i)ut to bed with an ice-cap a])])lied to the afl'ected knee. After three days, when the swelling and pain have decreased, the knee should be well wrapped in cotton, a firm bandage applied and the patient allowed to \\alk about. During the subsid- ing stage massage and hot application Mill serve to aid recovery. Sprained Back. — The term "s})rained back" usually includes several different conditions. True sprain consists of injuries to the ligaments between the pehis and the spine or between the various \'ertebnc, caused by sudden twist- ing or bending of the back. The same injury may cause a tearing or rujiture of the thick muscles of the back, this latter condition being termed a strain in contradistinction to the tearing of the ligaments, which is a sprain. A closely allied condition known as luml)ago may follow exposure to cold, especially when combined with unusual muscular exertion. Clinically, these three conditions are hard to differentiate and they are consequently all treated in the same manner. Treaiment. — In severe cases the patient is confined to bed but ordinarily he merely avoids active muscular exercise. A combination of three forms of treatment is advised: Massage, support and the application of heat. WOUNDS OF BON EH AND JOINTS 147 Massage tends to increase the })1()()(] supi)ly and to carry off the extravasated blood which is always present in the tissues after a sprain or strain. Support may be secured by a heavy bandage applied around the back and abdomen, or by a wide canvas belt. Overlap- ping strips of adhesive plaster, extending across the back and well onto the abdomen, is one of the most satisfactory forms of support. For the chronic cases canvas elastic belts and other mechanical supports have been devised. The application of heat may be made with the ordinary hot-water bottle or bag, or with hot cloths or sand-bags. Usually dry heat acts best. A satisfactory form of treatment, combining heat and massage, consists in placing the patient face downward in bed, covering the back with a piece of flannel and ironing the back with a hot iron. The movement of the iron up and down the back serves as massage. WOUNDS OF BONES AND JOINTS. Closely allied to fractures and dislocations are wounds of bones and joints. When bones are wounded the injury is practically a compound fracture even if only a small cut has been made in the bone. The treatment is the same as for compound fracture. In wounds of the joints there are the same dangers of infection and blood-poisoning as in the case of compound fracture. The preliminary treatment of the wound is the same and the necessity of adequate professional care is even more urgent than it is in compound fractures. Bullet Wounds of the Bones and Joints. — The introduction of a bullet or other foreign body into a bone or joint increases the probability of infection. While the bullet itself is apt to be sterile it carries into the wound pieces of clothing and dirt from the surface of the body so that the wound is almost certainly infected. The first-aid treatment consists in the application of tincture of iodin to the wound and surrounding skin together with the transportation of the patient to a hospital or other point where skilled sm'gical 14S FUAcrrUKS AM) DISLOCATIOXS attention may ])v secuird. Do not, on any account, probe the wound or attenii)t to remove the bullet. Such attempts onh' succeed in introduciui;- more infection into the woimd. Fius. 10.", :iiHl nil,. — Expciiniciital Kuii.shot fractures with .oO and .38 calibre IjuUela at high velocity. (U. S. Army Med. Museum.) During transportation the part should be kept at rest by the use of an appropriate splint. CHAPTER VI. MISCELLANEOUS INJURIES. BURNS. Burns may be caused by contact with fire or hot sub- stances or by contact with certain chemicals. All burns are the result of destruction of tissue either by the action of heat or chemicals. For convenience of description burns are divided into three classes or degrees. A first-degree burn is one in which there is simple red- dening of the skin, such as is seen as a result of sunburn. In this only the most superficial layer of the skin is injured and there is no blister formation. Healing is not accom- panied by scar formation. Fig. 107. — Scald of back of hand twenty-four hours after injury, showing blister formation. (Ashhurst.) A second-degree burn is the most common type, the destruction of tissue extending deeper, with the formation of blebs or blisters. In cases which do not become infected scar formation is comparatively slight. Third-degree burns are associated with destruction of the entire thickness of the skin, occasionally with charring of the tissues. Extensive scar formation follows healinsf. 150 ^[ISCELL^xEO^s ix.r fries As the ^e^^•e supply of the skin is very abundant, burns are extremely painful and are apt to be accompanied by considerable shock. The sex'erity of a burn depends upon two factors: the degree anil the extent of the burn. First-degree burns, if extensive, are apt to be followed by serious results. An extensive burn caused by steam or hot water, although entirely of first or second degree may result in death. Symptoms. — The symptoms var>' with the extent of the buiMi. In small superficial burns i)ain and redness of the skin are tb.e only symptoms. In deeper burns blister forma- Fio. 108. — Scald of l)ack of hand, showing blister formation. (Brewer.) tion occurs shortly after the injury. In extensive ])urns and in those of the third degree there is a ]ieriod of shock with weak pulse action and subnormal temperature. This lasts from a few minutes to several hours and is then fol- lowed by a period of reaction with fever. This fever may subside or it may be continued because of aljsorption from the })urned area or from infection of the denuded surfaces. ]3urns in children are apt to be more severe and are more often fatal than in adults. First Pvt Ovt the Fire. — If the clothes are burning, wrap the patient in a rug, blanket, or other woolen wraj). If nothing of the sort is at hand, make the patient lie down and BURNS 151 roll over on the ground and beat the fire with your coat or other similar object. If water is available it should be thrown on the burin'ng clothing, but it is not advisable to leave the patient in order to secure water. On no account should the patient be allowed to walk or run in search of help. Treatment. — For first-degree burns, such as sunburn or superficial burns with hot steam, an application of bland oil, such as vaselin or cold cream, will relieve the pain, and is usually all that is required. For small second-degree burns, such as frequently occur and are commonly treated at home, the application of a bland oil, such as vaselin or olive oil, covered with a dressing of absorbent cotton, will relieve the pain and aid healing. In order to prevent subsequent infection, an oint- ment composed of 10 per cent, boric acid in vaselin is pref- erable to a non-antiseptic dressing. If the facilities are available the skin should be well cleansed with soap and water before applying the ointment. In the care of these small burns it is usually unnecessary to consult a phy- sician. The burn is dressed daily, the blebs not being punctured unless they are large and troublesome, in which case they may be nicked on one side with a pair of sharp scissors, previously sterilized. If infection becomes evident (increased pain and redness with the presence of pus) a physician should be consulted. A moderately severe local burn should be entirely well at the end of the second week. Carron oil^ was previously widely used in the treatment of burns. During recent years boric acid ointment has been given the preference because of its antiseptic qualities, but in very painful burns carron oil may be preferred because of its cool, soothing character. Other substances which may be used in an emergency are olive oil, fresh lard, cotton- seed oil, or any other bland oil. Butter is not suitable because its high percentage of salt increases the pain. Wet dress- 1 Carron oil is a mixture of equal parts of linseed oil and lime-water, well shaken to form an emulsion. It is freely applied to the injured surfaces and covered with cotton or gauze. 152 M ISC ELL A XEO US J A ./ 1 ' R/LS ings of l)it'arb()nate of so'la (ordiuan' Uakinu' soda) in 1 or 2 l)or cent, solutions' may l)e used. In small burns which become infected, the contents of the blister taking on the characteristics of pus (becoming thick and turbid), it is best to cut the bleb entirely away and to a])])ly a w(>t dressing of 2 per cent, boric acid solution. Severe Bums. — These cases recjuire the ser\ices of a physician as soon as possible. The patient should be put to bed at once and treatment started for the accomjianying shock. Uemember that in severely burned patients the temi)erature is apt to be subnormal and that the body heat should !)(> ])reserved. Fig. 109. — Showing mcthij(t nl ticatiiiK a severe bui'ii by the use of skin grafts. (Ashhurst.) Treatment. — The clothing should })e carefully cut away and renio\'ed except such portions as may be stuck to the skin, which should not be disturbed. One of the oils men- tioned above should be thickly applied and covered with gauze or cotton held in place by a loose bandage. For the ])ain, some form of anodyne must be gi\-en, pref- erably under the instructions of a physician; but if medical care is not available, morphin, | grain repeated after half an hour if necessary, should be given at once. Opium, | grain, or paregoric, 1 teaspoonful, may be given in the same manner. While the use of medications of this sort is very dangerous in unskilled hands it is preeminently proper in ' A rounded teaspoonful of hicurhouatc of soda or boric acid to a pint of water makes approximately a 1 per cent, solution. BURNS 153 such a case to give some sort of aiuxlyiie to deaden tlie i);iin when medical advice is unobtainable. If the pulse is ra])id and weak and the patient is evidently in collapse, stimulation should be given as outlined under the treatment of shock. The careful cleansing of the burned area should be omitted until the patient has recovered from the primary shock. Afterward the burns can be exposed, cleansed and care- fully dressed. There is always absorption from the burned areas causing fever for several days or longer. During this period (which may last for weeks) the patient should be kept in bed on a full, nourishing diet, careful attention being given to general nutrition, digestion, bowels, skin, etc. Burns which become infected should be dressed with gauze kept wet with 2 per cent, boric acid solution. The healing of extensive burns is apt to be very long drawn out, lasting for weeks or months. Chemical Burns. — Burns may be caused by strong acids, such as sulphuric or nitric acids; by strong alkalies, such as caustic soda, potash and quicklime; or by chemical irritants, such as iodin, capsicum, mustard, etc. The injury caused by a strong acid or a strong alkali is different from the ordinary burn. The lesion is destructive from the beginning, there being no blister formation. On the other hand, the chemical irritants cause marked blister formation with little or no tissue destruction. Treatment. — The first step consists in the removal of the excess of the chemical present, either by wiping it away or by washing it oft' with water. Wipe the excess off with a handkerchief or whatever else you have at hand and then look for water. Certain substances may be used to neutralize the caustic. Acids should be neutralized with weak alkalies. Bicarbonate of soda is usually available in an emergency, but any other weak alkali, such as milk of magnesia or lime-water, may be used. x\lkalies should be neutralized b}^ weak acid solutions, such as vinegar or lemon juice.^ 1 Vinegar is a dilute solution of acetic acid; lemon juice contains citric acid. 154 ^fISCELLANEOUS INJURIES Carbolic acid is unlike other acids in that it is not neu- tralized by alkalies. Carbolic acid burns should be immedi- ately washed with alcohol or solutions containiui;- alcohol, such as whisky or brandy. In burns due to irritants the excess of irritant should be removed. Runnin<2; water will remove a certain percentage of most irritants, but in some cases the substance is more easily and quickly removed by other solutions. INIustard can be removed by the use of oil or soap and water; alcohol will remove capsicum or iodin. After the chemical has been removed as completely as possible a bland ointment is ai>])lied and the l)iu-n dressed daily in the same manner as a burn caused by heat. INJURIES CAUSED BY COLD. Cold may cause local injury or a general chilling of the entire body. Exposure to Cold. — In healthy persons exposed to extremely low temperatures for long periods, and in others (especially when weakened by cNbaustion or starvation) exposed to tem- peratiu-es comi)aratively considerably higher, the entire body may be chilled, the result being depression of the vital jn-o- cesses which, if continued, may finally lead to insensibility and death. In soldiers weakened by exhaustion, sickness, and insuffi- cient food the bad effects of exposure to cold are freciucntly seen. The patient is weak, depressed, and hardly able to move about, complaining of a sensation of numbness and fatigue. The pulse is wt>ak and the temperature is subnormal. The skin of the hands and feet is bluish or i)urplish in color. Treatment. — If the condition is not marked it is sufficient to get the patient to a warm place and give hot drinks, such as hot coffee, broth or hot water. If unable to reach shelter at once a fire should be built and hot drinks pre])ared. Alcoholic drinks may be given in small doses when the patient is in warm quarters. Never give alcohol to such a patient until thv jicriod of exposure is over. The action of INJURIES CAUSED BY COLD 155 alcohol is simply to dilate the surface bloodvessels, giving ail artificial sense of warmth, while at the same time allowing a further dissipation of body heat if the surrounding air is much below body temperature. In severe cases the patient is put to bed between warm blankets, the body is rubbed with the hands or warm rough towels, and hot drinks given as directed above. If the patient is unconscious, an enema of eight ounces of coffee solution is injected into the rectum and, if necessary, artificial respiration is begun. \ ^1 Wa ^^/k ^ \ • ,98 W . .IHjH ■jjjj^^^l^H^Ml V \. 'm-Tl ul ^^^^^^1 U J ^^^^^1 ^^^^^^^^^L #31 r f fl^^H i^^mH 1/ / ^^j^^^^H Fig. 110. — Frost-bite of hands four days after injury. Notice resemblance to burns with blister formation. (Ashhurst.) Frost-bite. — With or without the general eflfects of cold, the fingers, toes, ears, or even an arm or leg may be frozen, resulting in what is known as frost-bite. The part first becomes numb and blue and later, white and stiff. In the mildest degree of frost-bite the hands and feet, after exposure to cold, become red and swollen (chilblains), and there is a sensation of burning and itching. In more severe cases, as the circulation returns, there is an exuda- tion of serum beneath the outer layer of the skin and blisters result. In still more severe cases the circulation does not return to the fingers and toes affected, and the part remains 156 Ml^CELLAXEO US IXJ URIES pale and bloodless. Later gangrene results and tlie^gan- grenous area tiu-ns blaek. Treatment. — For chilblains the feet should be bathed dail\- \vith applications of alternating hot and cold water. \Mien exjjosetl to cold, warm stockings, which are removed when indoors, should be worn. Stimulation of the skin with alcohol or si)iritsof cami)h()r tends to relieve the i)ain and to i)rcvent recurrence. When actual frost-bite has occurred, the fingers, hands, or other ])arts affected, should be rubl)e(l with water which is gradualh- warmed. The old belief that a frost-bite should m Jg^M 1 1^ *■" •';>«, jj ^^^^ HI Fig. 111. — Result of frost-bite after two days and nights of exposure. (Park.) be rubbed with snow or ice-water has been proved an error. However, it is not desirable to secure too rapid a reaction, so that it is better to start with water about room tempera- ture. x\fter the circulation returns the parts are loosely wrapped in cotton and a bandage ai)plied. If blisters or gangrene occurs the lesion should be treated in exactly the same manner as a burn. A special form of frost-bite is caused by applying an ice- cap directly to the skin. A superficial ulceration results Avhich is called an "ice-cap burn." If care is taken never to apply an ice-cap without a towel or piece of gauze between the bag and the skin, this injury will not occur. INJURIES CAUSED HY Kl.liCTKK'ITY \:n INJURIES CAUSED BY ELECTRICITY. Electricity causes injury tiu-ou^h its local action, rcsultinji; in a burn; or through its general action, resulting in i)rostra- tion and unconsciousness, a condition analagous to that of surgical shock. ^ Fig. 112. — Electric burns of right forearm and neck due to current from "live wire" carrying 1200 volts. (Park.) It is most important that the person be removed at once from the influence of the current. A dry stick of wood or piece of rope may be used to break the contact, or the patient may be dragged away from the contact by catching ' The tsrm shock, used surgically, has not the same meaning as when used in reference to electricity. However, severe electric shocks may cause surgical shock in the same manner as any other injury. 158 MISCELLANEOUS INJURIES hold of a portion of his clothing. Do not hesitate because 'the i^atient is apparentlN' lifeless. UecoNcries have occurred after many minutes of apparent death. Fig. 113. — X-ray Ijiirii, the result of too long exposure to the .r-rays. (Park.) After the electrical contact has been broken the patient should be examined immediately to determine the extent of the injury. If he has stopped breathing, artificial respira- tion should be begun at once. In this case every instant is of \alue, consecpiently the patient should not be moved from the immediate vicinity of the accident. Continue artificial BITE WOUNDS 159 respiration until the patient breathes normally or until a physieian arrives. If no physician can be (jbtained artificial respiration should be kept up for at least an hour. When the breathing is normal the patient should be put to bed and the general treatment for surgical shock insti- tuted. The local burns caused by the action of electricity should be treated in the same manner as any other burn. X-ray burns are a particular kind of electric burns. They result from exposure to the direct rays, and may follow exposure for only a few minutes. The burn does not make its appearance for several days after the exposure. Great care should be exercised by those who work about .r-ray machines not to expose themselves to the direct rays from the light. BITE WOUNDS. Dog Bite.— The wound caused by the bite of a dog, cat or other animal is usually a lacerated one, and, to a large extent, the treatment is the same as for any other wound. But bites have certain general and special characteristics which differentiate them from other wounds. In the first place they are very apt to be infected with the ordinary pus organisms. If you stop to consider the dirt and filth that is eaten by animals with their food, it is easy to understand that their mouths must contain large numbers of bacteria. In addition, hydrophobia is spread by the bite of the "mad dog," so that this disease must always be considered. While most cases of hydrophobia are caused by dog bites, the disease may be transmitted by any animal. Wounds m^ade through the clothing are less dangerous than wounds of the hands and face, because the virus is wiped from the animal's teeth as they pass through the clothes. Treatment. — Because any animal may be suffering from hydrophobia, and because of the possibility of infection with ordinary pus germs from any bite, every bite wound should be cauterized. Cauterization should be performed with pure carbolic acid as follows : A swab is made by wrapping a small wad of cotton about IGO MISCELLANEOUS INJURIES the* 011(1 of a t()otli-j)k-k or match and (li|)])c(l in stroiii;- car- bohf acid (])lienol). Tiic wound is then sponged (h'v and tlic carl)ohc acid carefully a])j)licd to c\"cry uook and cranny in the wound area. The excess carbolic acid is immediately washed away by pouring alcohol into the wnuiid. A sterile dressing is then applied. If carbolic- acid is not a\ailal)lc, full strciiuth tincture of iodin may be used to swab out the wound. Cauterization with an iron heated to a reel heat has been advised, but it has recently been abandoned because of the extreme pain. Tt is justifiable only in cases where the animal is known to be suffering from hydroi)hobia. Hydrophobia. — Hydrophobia, or rabies, is an acute infec- tious disease of man and animals, caused by a specific virus which must be transmitted through an abrasion or other wound of the skin. Symptoms. — The symptoms are depression and weakness, followed by convulsions and death. The old idea that ani- mals suffering from rabies feared water is unfounded. It arose from the fact that animals, during the convulsive stage, are imable to drink water because attempts at drinking bring on cramps of the throat. These same con\'ulsive cramp- like seizures in man are accompanied by a gutteral sound which has given rise to the belief that men suffering from this disease "bark like dogs." If a dog is suspected of having ral)ies it should ne\'er be killed until it has been shut up and kept under obser\'ation for at least a week or ten days. If the dog does not become sick and die during this time it is not suffering from hydro- phobia. An animal with disease will soon liegin to show symptoms. At first the animal is simi)ly sullen, refusing food, and crawling away into dark corners. When callefl it either refuses to come or comes after several commands and soon shrinks out of sight. During this i)eri()d the animal will drink water, but will eat little or nothing. As the dis- ease progresses there are . spasms of the throat, usually brought on by attempts to drink, and later the animal becomes excited, running about and snapi)ing wildly at friend and for. In this stage the animal will rarely turn out BJTI'J WOUNDS 161 of its path to l)ite anyone. Still later, general convulsions and death occur. , If the animal has already been killed and you are unde- cided whether it was rabid or not, the entire head should be removed and sent to the health authorities for examina- tion. The diagnosis can be made from examination of the brain. When a man has been bitten by a mad dog there are never any symptoms for several weeks or months after the injury. This allows the patient time to wait for the labor- atory report on the condition of the animal before taking the treatment. Fig. 114. — Tooth marks made by snake bites: on the left a harmless snake; fang-marks in the center and on the right indicate a poisonous snake. (Ashhurst.) The Pasteur Treatment. — If a human being has been bitten by a dog or other animal known to have hydrophobia, development of the disease may almost certainly be pre- vented by the Pasteur treatment, started within two weeks after the injury. The treatment consists of the injection of gradually increasing doses of the virus after it has been made much less powerful by prolonged exposure to the air. The important point for the first-aid worker to remember is that the patient must be sent to a competent physician for treatment not later than ten days after the injury. Snake Bite. — Whereas hydrophobia acts through an infectious virus, snake bite acts by the direct injection of an extremely poisonous fluid. The bite of a snake is really a U 102 MISCELLANEOUS INJURIES hypodoriiiic injection, t\\v i)c)is()n entering tlie blood streiun throngh tlie small i)nnetures made by the snake's fangs. As the ])oisou is injected through a groove in the snake's fang, rather than sim])l>' l)y the saliva covering the teeth, as in rabies, the clothing gi\'es nnich less protec-tion than in the latter case. Symptoms. -The poison acts \cr\' rapidly, tlu- foot or hand beginning to swell at once; general symi)toms develop within a few minutes. Collapse and unconsciousness may quickly residt. Treatment. — Most of the treatment must be given by the first-aid worker. There is rarely o])portunity to secure a physician in time to give the preliminary treatment. In the first place an improvised tourniciuet must be at once applied a few inches above the wound. This stops the circu- lation and prevents the rapid spread of the poison. Next, the wound should be cut widely open so that it will bleed freel\' and the poison sucked from the wound. This is not a dangerous procedure, for, if not swallowed, only a small amount of poison could possibly enter the system from the mouth. Then, if materials are at hand, the wound should be cauterized with pure carbolic acid or with a red hot iron and left open so that bleeding may be free.' It has been shown in animals that the dose of snake \'cnoni which caused instant death could be borne if injected beneath the skin in small fractional doses, given ()^'er a i^eriod of several hours. This fact is taken advantage of in the treat- ment of snake bite. After the tourniciuet has been in jilace for about half an hour it is loosened for a few minutes and then reapi)lied. This allows a little poison to enter the sys- tem but not enotigh entirely to overwhelm the })ody. This is repeated at intervals. I )uring this time the treatment of shock should be started and stimulation begun. Small doses of whisky may be given to sustain the system, but there is no advantage in intoxica- tion, as is commonly supposed. ' Mason's Handbook for the Hospital Corps, U. S. Army, advises the injection of permanganate of potash in 2 per cent, solution, hypodermically, in the vicinity of the wound. This causes decomposition of the venom. BITE WOUNDS 163 Coffee and other drinks should he <^iven in larj^e (|uanti- ties to increase ehmination, and the patient kei)t warm hy the use of blankets and hot-water bags. As soon as the pri- mary period of shock has passed, a dose of salts should be given as an additional aid to elimination. If the patient lives more than three or four hours, there is little danger of a fatal ending. After recovery begins, the injury should be dressed with a wet boric acid dressing and treated as an infected wound. Insect Bites. — ^Insect bites or stings result in small poi- soned wounds which may be very painful. The bites of the tarantula and the centipede and the sting of the scorpion are especially painful,, but are rarely dangerous to life. Surrounding the injury there is an area of swelling, and, in severe cases, there is considerable shock. Treatment. — In mild cases weak ammonia water or solu- tions of bicarbonate of soda should be applied to neutralize the poison, which is acid in reaction. Following this, cold compresses, mentholated vaselin, or spirits of camphor may be applied to relieve the pain. In severe cases the wound should be incised with a sharp knife, the poison squeezed or sucked from the wound, and the wound washed with weak ammonia or other alkaline solution. Whisky may be given and other measures taken to prevent shock. After the first symptoms have passed a wet dressing may be applied and the wound treated as any other infected wound. Tetanus. — Tetanus or lockjaw is a general disease, the result of wound infection with the tetanus bacillus. It is especially apt to occur after punctured wounds or any other wounds where dirt is carried deeply into the tissues. The tetanus bacillus is normally found in the intestinal canal of horses, so that the disease is prone to follow wounds con- taminated with dirt containing horse manure, such as stable refuse, cultivated field soil, and dirt from the streets. As the bacillus does not thrive in the open air, tetanus is more apt to follow deep, punctured wounds where the air is not in contact with the deeper parts of the wound. A rusty nail is apt to cause tetanus because the rough iron is likely to 104 M ISC ELL A XEO I '.S' / XJ CRI ES earn' iutVctod niatorial (k>c])lN' iiitc) the tissues. The synip- tDins tlo not occur until about cirinkliug with ice-water. If a clinical thermometer is a\ailable, the cold pack (or cold bath) should be continued until the temperature is below 103° ¥. Otherwise it is con- tinued initil the jxatient becomes conscious and the skin feels cool. Fig. 117. — Showing the applicatinn of a cold-waUr roil in the treatment of sunstroke or other forms of congestion of the Ijraiii. (Hare.) An ice-cap to the head, cool drinks, and massajiie of the body during the cooling process, are all valuable adjuncts to treatment. The cold pack must not be too long continued or the tem- perature may be reduced considerably below normal. After it is stopped, watch the i)atient carefully. Jf the Hushing of the face retin-ns and the temperature rises, the cold i)ack should again be started, but if the patient remains })ale with a normal or subnormal tcmi:)(M-ature and a weak and rapid pulse, he is evidently sull'cring from the secondary effects of the injury to the nerves and rccpiircs treatment HEAT EX JI A U.ST J ON 173 to prevent seeondary shock. I)urin<^ this staj^e it may be necessary to apply external heat. After the immediate effects of the sunstroke have passed off the patient shoukl be kept at rest for several days until recovery is complete and sliould avoid prolonged exposure in the sun for several months. Fig. lis. — Giving a patient a cold bath for sunstroke with special square bath tub and stretcher. (Hare.) HEAT EXHAUSTION. This condition occurs as a result of working in a heated atmosphere,^ especially when the physical or mental powers are exhausted or depressed. Symptoms. — The symptoms differ from those of sunstroke and are more those of exhaustion. The face, instead of being greatly flushed, is pale or only slightly flushed, and the skin is moist and may be cool. The temperature is not increased 1 This condition is very common in the heated boiler pits of ocean steamers, in factory firemen and in soldiers marching in hea^-y clothes or accouter- ments. It often occurs in the hot dry climate of Mexico and Arizona where, owing to the rapid evaporation of perspiration, sunstroke is uncommon. 174 GENERAL I XJ CRIES and the pulse is rapid and weak. l\Miipnrary uiiconscious- noss may occur. Treatment. — As this couihtioii is more in the nature of syncope, or fainting;, the ai>i)Hcation of cold is unnecessary. The patient should be laid horizontally in a cool i)lace and given cool drinks and mild stinudation. Stokers who are brought to deck unconscious are usually able to return to work within a few hours. EXPOSURE TO EXTREME COLD. The treatment of the depression due to exposure to extreme cold has already been given in the discussion of frost-bite. It may be notetl that the general treatment is practically the same as the treatment of shock. UNCONSCIOUSNESS. I'liconsciousness, or coma, is a state in which the patient is entirely oblivious of his surroundings. lie is imable to answer when spoken to and cannot be aroused. In some cases the condition is only partial, that is, he may be aroused, but soon becomes unconscious when let alone. This latter condition is called incomi)lete unconsciousness or semi- unconsciousness. A person asleep is not, properly speaking, unc(Miscious, because he may be awakened by ordinary means. There is no other condition which causes the first-aid worker so much trouble as unconsciousness. It may result from so many different diseases that it is often difficult even for a physician to decide upon the cause. We have already seen that the state may be induced by shock, fainting, sunstroke, heat prostration, snake bite, hydrophobia, tetanus, and exposure to cold. In addition it may be due to alcoholism, to head injuries, to apoplexy, to epilepsy, asphj'xiation (drowning or gas poisoning), to nephritis,^ to hysteria, and to many poisons and acute diseases. • Unconsciousness due to nephritis (kidney disease) occurs in the hite stages and is known as uremia or uremic coma. ilNCONSCIO USNE>S>S 175 In emergency eases tlie following' conditions, in the order of their frequency, are the most often seen: fainting, alcohol- ism, epilepsy, head injuries, nephritis, and as})hyxiation. As it is so difficult to determine the cause, it is well to ado])t a plan of treatment which will be suitable for all cases until the cause can be determined. First lay the patient upon his back and loosen the clothing about the neck. hAamine first to determine the presence of asphyxiation, hemorrhage, sunstroke or poisoning, for these conditions demand immediate treatment. If there is no evidence of any of these, note the pulse and the appearance of the face. If the face is pale and cold the head should be placed lower than the body and stimulation given. If the face is flushed the head should be raised slightly and cold cloths applied to the forehead. Give the patient plenty of fresh air and loosen the clothing over the chest so as to allow free breathing. While you are doing this send for a physician and learn from the bystanders or from friends as much as you can regarding the onset of the condition. The symptoms of the patient and the surroundings will enable you to exclude some of the conditions mentioned; thus sunstroke and freezing belong only to the extremes of temperature. The history of a fall or blow would point to a brain injury which could be confirmed by examination of the head for bumps or wounds. Asphyxiation is at once evident if the respiratory action is watched. If unconsciousness is not the result of an accident, find out if the patient has been drinking or has complained of being sick. Whether the period of unconsciousness started with a convulsion (epilepsy, uremia, tetanus, strychnin poisoning), or after a more or less prolonged period of illness (sunstroke, acute disease, etc.). If you are unable to determine the probable cause of coma, you must treat the symptoms rather than the disease. If the body is cold and the face pale, give stimulants, apply external heat, and cover with blankets; but if the face is flushed and feels warm, stimulation and external heat is unnecessary. 170 aEXKh'Al. J.WJi'h'IES P>xamino for injury, notice tlie odor of tho ])reatli, and search for sijjns of heniorrliaije. If tlie l)reatlun<^ stoi)s, bef:;in artificial resijiration and keep it up until the jjliysician arrives. Hysterical Unconsciousness. This condition is the result of a functit)nal disorder of the ner\"ous system. The i)atient, usually a woman, falls to the jjround apparently' uncon- scious, but the fall is not so heedless or sudden as to result in injury. Often there is no ascertainable cause for the attack. ^^ometimes it is brought on by a friyht or emotional shock. The face appears normal in appearance, the eyes are closed but the lids are trenudous and attempts to oj)en the eyes are resisted. The eyeballs are rolled upward and the pupils are normal. The ])ulse is normal but the res})iration is greatly disturbed, possibly slow and dee]) or very shallow and rai)id. The Ixxly may be limp or held rigid. If the hand is pinched or pain caused in any other manner the part is with- drawn but the patient can seldom be made to speak or cry out. In short, the entire appearance is that of a person who is "faking" for some unknown cause. "When the physician arrives, patients of this tyi)e are sur- rounded by a crowd of sympathizers who are rubbing the wrists and dashing cold water in the face and otherwise causing a great commotion. In some cases there are con- vulsive movements of the arms and legs (hysterical convulsions) . Treatment. — While the unconsciousness is nt)t a true coma, yet it is due to a loss of nerve control and should not be treated as ordinary malingering. The patient should be left with one unexcitable attendant, who should not give any treatment, but should speak quietly and firmly and attempt to help the patient gain control of herself. The usual result is that after a few minutes recovery is complete. In cases which persist for some time, the o])inion of' a physi- cian should be secured. Even among ])hysicians cases are occasionally AATongly diagnosed as hysteria, later a more or less serious complaint being foimd which was previously entirelv overlooked. CHAPTER VOL SUFFOCATION. Suffocation, or asphyxiation, is that form of unconscious- ness which is due to the shutting off of the supply of oxygen to the hnigs. In some cases the obstruction to the entrance of air into the lungs is mechanical. This occurs in constric- tion of the neck by hanging or choking, in obstruction of the windpipe by a foreign body, and the obstruction of the mouth and nose with sand or dirt or other similar material. In other cases asphyxiation occurs as the result of the attempts to breathe air too poor in oxygen. This is seen most frequently in high altitudes and in deep mines. In mines the air is usually tested with the miner's lamp. When the lamp ceases to burn it is recognized that the air is not fit to breathe. A similar result is seen in attempts to breathe air mixed with other gases. The gas may cause asphyxiation because it displaces the air from the room or it may be itself poi- sonous. For example, illuminating gas illustrates both of these principles; it is poisonous of itself and at the same time displaces the ordinary air. In drowning, or suffocation in falling sand or dirt, there is practically no available air, so that breathing stops immediately. A rather unusual accident has been described which illus- trates a rare method of asphyxiation: A man nearly buried in a tunnel cave-in was buried in dirt and gravel up to his neck, but his head was above ground. Here, although sur- rounded by an abundance of air, he was unable to breathe because the weight of the dirt and sand prevented the inspiratory movement of the chest. 12 178 SUFFOCATION Treatment, lu the tivatuuMit of asphyxiation there are three steps whieh must be carrii'd out: 1. The cause of sufl'oeatlou nuist he removech 2. Artificial respiration must l)e ))ei:;uu. 3. Accompany iuij; injuries and shock nnist recei\e ai)pro- priate treatment. Prcliniinari/ Trcdfmcnf.- The first thinu' to do is to remo\e the obstruction to l>reathing. Patients should be taken from the water when drowning"; carried from the smoky atmosi)here in suffocation by smoke; foreifin bodies should be remoNed from the mouth; and air-tight clothing and constricting bands removed from the neck. Fig. 111*. — .Vrtificial respiration \)\ Scluicfcr's inctluul. ]5.v tliis iiieaii.s fluids and mucus are more readily expelled fruni the upper respiratory tract than in the older methods. (Hare.) When this is done, if breathing has ceased, artificial respiration should be begun at once. Suffocation is one of the few emergencies in which a great deal depends upon the speed in which the remedial measin-es are carried out. While artificial respiration is being ])crformed, an assistant can be sent for dry clothing, blankets, stimulants, or for other remedies which may be required, depending on the nature of the injury. A RT I Fir I A L liKHI'I II A TION 179 ArfificiaJ Rcsjjiration. — Artificial respiration consists in movement of the chest by a second person in imitation of the normal respiratory movement. Of the different methods of artificial respiration, the following three methods are the most widely known. The first is one of the best because it can be performed by one person and can be carried out over a long period with the minimum amount of fatigue. The details of the methods of artificial respiration are as follows : Schaefer Method. — 1 . The patient is placed face downward upon the floor or ground, with the arms stretched out above the head^ and the face turned to one side, so that there is no hindrance to the entrance of air into the nose or mouth. As the tongue is apt to drop backward it should be drawn outward by inserting one finger in the mouth and hooking the tongue forward. 2. Kneel astride the subject's thighs; rest the palms of your hands over the muscles of the small of the back, the fingers spread over the lower ribs on each side. 3. With the arms held stiff, swing forward slowly so that the weight of your body is gradually but not violently brought to bear upon the patient's back. If you try this on a friend you will notice that this movement forces the air from the chest. Immediately swing backward, releasing the weight from the chest, which expands because its natural elasticity allows the air to rush into the lungs. 4. Repeat this complete movement about fifteen times a minute; that is, repeat the forward-and-backward movement, which represents a complete respiration, every four or five seconds. 5. Continue these movements until the patient breathes naturally or until a physician arrives. If no physician can be obtained keep up the artificial respiration without interruption for at least an hour. When natural breathing returns try to time the move- ments to the natural breathing. It is permissible to stop occasionally for a few seconds to see if the natural respira- tory movements are returning. ^ Id some cases the arms may be bent and placed at the sides (Fig. 119). 180 SUFFOCATION The Siilirfftcr Method. — In this the i)ationt is ])liiced iii)on his hack with a pad beneath his shoulders and the operator ,^ &■ / ^^ 1.' > #^^ ^ Fig. 120. — Sylvester's method of artificial respiration. ]'"irst inovcmeiit: the patient's arms are placed at right angles to the trunk, the elbows resting on tlic flour, to expand or inflate the chest. (Hare.) Fig. 121. — Sylvester's method of artificial respiration. Second movement: the patient's arms are drawn toward the physician, in order to expand the chest still further. (Hare.) kneels above his head. After seeinj,^ that the mouth is free and that the tongue has not fallen back, the movements are as follows: ARTIFICIAL RESPI RATION 181 1. The arms are grasped near the el})ows and drawn well up above the head (inspiration). 1'hey are held here for about two seconds (Figs. 120 and 121). Fig. 122. — Sylvester's method of artificial respiration. Third movement: the patient's arms are raised and the elbows approximated to contract the chest. Fig. 123. — Sylvester's method of artificial respiration. Fourth movement: the patient's elbows and forearms are pressed forcibly upon the floating ribs to expel the air from the chest. 2. The arms are brought do\Miward so that the elbows are against the chest and firm, steady pressure is made. This 1S2 SUFFOCATION nioveiiUMit forces the air out of the chest (ex])iratlon) (Fisjjs. 122 ami 123). These movements should he contimu-d ahout fifteen times a minute; that is, a complete inspiration and exi)iration every four seconds. Time yourself if i)ossil)le while doinji; this, for, in the excitement the mo\ement is apt to he hui'ricd and much too fast. The chief disadvantajie of this movement is that the tongue may dro]) hack and act as an imjx'dimcnt to resi)ira- tion. An assistant should watch constantly to he sure that this does not occur. In addition, this method involves much harder work for the operator than the Schaefer method. If the movements are to be kept up for a long time, the oi)erator must he "spelled" by a third person or the easier method must be chosen. Man'hall IlalFs Method. — In this method the patient is placed on the floor or ground with the face downward, his forehead 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 increased by making pressure on the lower ribs. Then the operator, with one hand on the j)atient's free arm near the shoulder and the other imder or in front of the corresponding hip-bone, rolls the body to the side and a little beyond. An assistant aids in this move- ment by handling the head and the underlying arm. When the body has been thus rolled somewhat more than half- way round, the chest becomes relie\ed from superincumbent weight and a certain volume of air enters. After resting a second or two in this attitude of inspiration, the patient is returned to the prone position and pressure made along the ribs to imitate the expiratory act. Merhaniral Rr.H].iruti()n. — During recent years two mechan- ical respirators ha\'e been put on the market (the lung motor and the pulmotor). Both of these work on the prin- ciple of a pump, to which is attached a tube, on the end of which is a mouth-piece so made as to fit closely over the j)atient's mouth. When the pumj) has been adjusted to the patient's lung cai)acity the mouth-piece is placed over the A HTIFIC/A L HESri RA TION 183 patient's mouth and air f()rcil)ly pumped in and drawn out of the lungs. These maclvines are much better than the man- ual methods, but are seldom availal>le when required. The choice of a. method of artificial respiration depends on the condition of the patient, the number of assistants, and the strength of the operators. The first is the easiest Fig. 124. — The lungmotor. One of the machines used for mechanical artifi- cial respii'ation : A, volume gauge slide pin; P, pointer for gauge slide pin; E, inspiration cylinder; C, oxygen inlet; Z>, air inlet; B, air and oxygen mixing valve; H, expiration cylinder; T, tubing; M, mouth-piece. to apply. The two latter are a little more efficacious when sufficient assistants are at hand. There is no objection to changing from one method to another, when the movements must be continued for a long time. If natural breathing returns and then ceases, begin artificial respiration again. When consciousness returns, give the patient hot coffee or hot beef tea, and massage the arms and legs toward the heart IS-t SUFFOCATION as an aid to tlie circulation. Tlicn carry him to slielter where he can rest (inieti>' in a warm hed for several hours. Use other methods for the i)revention of shock. CHOKING. Chokini; may result from constriction about the neck or from foreign bodies in the windpi])e. The first rc(iuirement is the removal of any obstruction. In adults a foreiji;n body can often be remo\'ed from the windpipe by a sharp blow u])on the back, wliich causes a sudden ex])ulsive movement, ("hildren can be i)ickcd up by the heels and lield head down- ward to dislodge a small particle which has been drawn into the windpipe or throat. If this is not successful, and the for- eign body is in the back part of the throat, it may sometimes l)e dislodged by means of the finger introduced into the mouth. In patients who are suffering from alcoholism or other form of poisoning, as well as those unconscious from drown- ing or electric shock, the tongue may fall })ack so as to shut off the windpipe. Always examine for this condition in any unconscious patient who is having difficulty in ])reathing, and, if present, draw the tongue do\Miward with the finger inserted in the mouth. When the throat is clear and there are no constricting bands about the neck, respiration should be resumed at once. If the patient does not begin to breathe immediately, artificial respiration should be begun without delay. DROWNING. The first step necessitates the removal of the drowning person from the water. This requires an expert knowledge of swimming and the various methods of supporting a drown- ing person in the water. It is, of course, useless to jump into deep water unless you are able to swim. When a person falls overboard, immediately throw a life- preserver, or chair, or some other object that will float into the water and immediatel\' summon help. Do not jump DROWNING 185 into the water yourself unless you .arc an expert swimmer. There have been cases where valuable time has been lost because' the rescuing party has had to go to the assistance of the would-be rescuer, himself badly in need of help. The only instance in which an indifferent swimmer is justi- fied in jumping into the water is in case a child or other helpless person has fallen in. In such case be sure to grasp some object which will float so that the additional support will be at hand. On reaching the drowning person, be careful not to allow him to draw you under. Swimming instructors advise hit- ting a panic-stricken person with the fist and partially stun- ning him. Support the drowning person by grasping him by the hair or clothing and holding him with the mouth and nose just above water until help arrives. Only an expert swimmer can tow a drowning person, even a small child, to the shore. Remove the body from the water at once and begin treat- ment on the spot except in very cold weather when it is permissible to move the patient to shelter if it is near. It is difficult to say how long the patient may be submerged without death resulting. Apparently authentic cases have been reported in which the rescued person was revived after several hours under water. However, this is so improbable that the accuracy of the observation may be questioned. It is certain that submersion for more than five minutes is very apt to be fatal. On the other hand, recovery has resulted in innumerable cases where the patient was apparently dead. Consequently artificial respiration should always be resorted to, except in persons known to have been under water for an hour or longer. The steps to be taken in the resuscitation of a drowned person are as follows: 1. Removal of wet seaweed and debris from the mouth. This is accomplished by the introduction of the finger into the back of the throat. 2. Removal of water from the lungs. The patient is placed face downward on the ground and then lifted by plac- ing the hand beneath the abdomen so that the head hangs 180 SUFFOCATION (lowinvanl. This allows \vluite\or water is ])r('stMit to run out of the mouth. 3. Artificial respiration hy oi\e of the methods already described. Fig. 125 Figs. 125 and 120. — Method of raisiujj; the Ijody of a i^aticnt just removed from the water to allow the water to run out of the luii^.s. (Burnham.) 4. The restoration of the body heat. This can be done by the use of warm blankets and other forms of external heat. After breathinfi retm-ns the patient should be ])ut to bed, and given warm drinks and stiimilants. Pneumonia or ASPIIYXIAriON BY ILLUMINATfNO GAS 187 bronchitis may follow from the irritation of the inspired water so that it is advisable to keep the patient in bed for several days after the accident. SUFFOCATION BY SMOKE. In rescuing a person from a room filled with smoke a moist cloth placed over the mouth will make the smoke much less irritating. It should also be remembered that near the floor the smoke is less dense than at a higher level, so that one may be able to crawl where it is impossible to walk. Fill the lungs with fresh air before entering the room and work as quickly as possible while in the smoky atmosphere. When the rescued person is not unconscious it usually requires only a few minutes in the fresh air to revive him. When unconsciousness is complete begin artificial respira- tion as soon as possible after reaching the open air. In addition, sprinkle cold water in the patient's face and give stimulants as soon as consciousness returns. The irritation of the smoke is apt to cause bronchitis and pneumonia. Consequently, it is advisable to keep tbe patient quiet, preferably in bed, for several days after the accident. ASPHYXIATION BY ILLUMINATING GAS. The ordinary form of gas asphyxiation is carbon mon- oxide poisoning, which is most frequently seen in poisoning with the ordinary illuminating gas. The condition comes on slowly, unconsciousness often occurring without warning. There are apt to be preliminary headache, dizziness, and throbbing of the head in the presence of the escaping gas. Ringing in the ears and spots before the eyes may occiu-, but usually all the symptoms are so mild that they pass unnoticed. In illuminating gas poisoning unconsciousness occurs early. During this stage the lips, skin, and nails take on a bluish tinge, the heart becomes rapid and weak and the respiration shallow and irregular, finally ceasmg entirely. While the above refers to illuminating gas poisoning the 188 SUFFOCATION symptoms and treatment are very similar in ])ois()ninc; witli gas from eoal fires, sewer gas, mine gas, and poisoning from so-called "back draught" at fires where the air is laden with carbon monoxide as a result of incomplete combustion. Treatment. — Never take an open light of any sort into a room filled with gas, as the gas may become ignited, resulting in a dangerous explosion. Before entering a room filled with gas take two or three deep breaths of fresh air and then hold the breath until the \\indow is reached. Open the window widely or break the glass if it does not oi)en I'asily. Take another deep breath of fresh air at the open window and then search the room for persons overcome by the gas. (^irry the first person found to the open air and return yoiu'self, or send someone, to open the remaining ^\in(lo^^■s, if there are any, and to make a carefid search for other \'ictims. On one occasion I was called to attend a mother and child, overcome with gas, and on arri\'ing I found a second child unconscu)US in an adjoining room, who had been completely overlooked. \Yhen open air is reached, the respiration of the patient should be carefully observed, and, if weak or absent, artificial respiration should be started. If the patient is able t(^ swallow, hot coffee or other stimulant should be given at once. The unconsciousness of gas poisoning is dilf erent from other forms of suffocation. When the open air is reached the patient may revive rapidly, or unconsciousness may continue or even grow deeper. This is because in carbon monoxide (illuminat- ing gas) poisoning the blood undergoes a permanent change which diminishes its power to absorb oxygen. Patients are sometimes seen who remain unconscious for days as a result of illuminating gas poisoning. Recovery after these long periods of unconsciousness is very rare. After respiration has begun, means should be taken to remove the patient to the nearest hospital, where expert medical attention may be secured.^ If this is not to be 1 The modern treatment of carbon monoxide poisoning depends mainly upon the transfusion of blood, a surgical procedure which consists in the introduction of healthy blood into the bloodvessels of the patient. ASPHYXIATION BY IlililTANT (JASES 189 obtained tlie treatment must ])o confined to rest in })ed in a well-aired room, combined witli the administrati(^n of nour- ishment and stimulants when the patient is able to swallow. ASPHYXIATION BY IRRITANT GASES. In asphyxiation by irritating gases, such as bromin, chlorin, or formalin, the chief efi'ect is an intense inflamma- tion of the eyes, nose, throat, and lungs. At first this makes breathing difficult. Later the inflammation may cause bron- chitis and pneumonia severe enough to result in death. In America these cases are seen only in workers in chemi- cal factories, but in the European war such gases have been used extensively in oft'ensive and defensive operations. For this reason the following official report is published in full. While the report contains many technicalities, it is thought better to publish it as it stands rather than to attempt to modify it in any way. Asphyxiation by Gas in the European War.^ — Chlorin or bromin gas, compressed into liquid form and liberated from large metal tanks when the wind is blowing toward an opposing trench, has caused very distressing deaths when inhaled in concentrated form. Being heavy gases they hug the ground, moving to leeward, and sink into the trenches. The first effect is to cause the eyes to water, and this is quickly followed by a violent irritation of the bronchial tract. If troops are unprotected and remain in the trenches they rap- idly develop a capillary bronchitis, with a hypersecretion of thin watery mucus, which fills up the air spaces of the lungs and practically causes death from drowning. Those receiv- ing concentrated doses died in from one to tliree hours, sometimes from edema of the glottis, but principally from exhaustion of the heart in trying to pump the blood thi-ough the engorged capillaries surrounding the bronchioles and ultimate air spaces of the lungs. This suffocating process sometimes lasts from one to three days, the younger men with stronger hearts holding out longer than the older. 1 Surgn. A. M. Fauntleroy, U. S. Navy: Report on the Medico-Military Aspects of the European War. 190 SrFFOCATlOX Tlu> mortality from this t'orm of sull'ocation depends on tlu' degree of eoiieentration of the j^as inhaled antl the age of the patient. Man\' eases have been mild on account of the capricious action of tlie wind in distrihuting the gas along the trenches, some parts of tlu' Hne receiving it in more concentrated form than others. This results in all stages of an asphyxiating bronchitis, from the grave cases which are cyanosed and gasping for breath to those suffering from a mild form of irritation of the bronchioles. On this account some recover (piickly and others, lingering for a longer ])eri()d, slowly regain the normal, not infrecpiently exhibiting more or less marked evidence of bronchiectasis. The postmortem examinations of the lungs show them to be about four times their normal weight, with an enormous dilatation of the air spaces, which latter arc filled with a thin, watery, and sometimes blood-streaked nnicus. Treatment. — As regards treatment, those in the open air seem to sutler less. Oxygen gas, administered slowly, unques- tionably gives relief. Atropin, hypodermically, is used for the overdistended right heart, while the lateral prone position of the patient favors drainage of the lung fluid. By far the most important is, of course, the prophylactic use of some form of combined helmet and respirator, which is intended not only to render the gas innocuous but also to protect the eyes. When the gas was first used it came as a surprise and there were many more victims than at present. There are a number of different types of protecting masks in use, all having for their object the neutralization of the gas when inhaled through the mask or helmet. Ex])erience has taught that to be effective the protecting apparatus must either be in the form of a helmet entirely covering the head and tucked in at the neck, or in the form of a mask fitted siuigly around the face under the chin and over the front part of the cap above the \'is()r, by means of strong elastic tape. The mask or helmet should be made of some impermeable material, such as mackintosh, with a piece of transi)arent celluloid, about r with adhesi\e ])laster. Infection of the Scalp. — Occasionally after insignificant injuries w hich have been neglected, and even after wounds sntnred by skilled surgeons, infection may develo]) and s])read ra])i(lly beneath the scalp. This is shown by increased throbbing pain and swelling of the scalp. The swelling is not marked but is evident only through a slight thickening of the snrroimding scalp which, very characteristically, "pits" on pressin-e — that is, when the finger is remo\'ed after firm pressure a pit is left \\hich does not disappear for some minutes. Treatment. — This condition is very serious and recjuires attention ■\\'ithin a few hours. When no surgeon is avail- al)le the woimd should be opened widely by cutting the sutures and o])ening the cavity of the wound, so that any retained pus may escape. If the wound is small the crust should be removed with a sterile pair of scissors or a sharp tooth-pick, previously dipped in iodin. In any case a large wet boric acid dressing should be applied. Concussion of the Brain. — This condition results from se\'ere blows and falls upon the head. It is supposed to be due to a jarring or shaking of the brain, and the patient is said to be stunned or knocked senseless. Temporarily the brain ceases to functionate. The ])atient is dizz\', confused, nauseated, pale, and sometimes unconscious. The pulse is rapid and weak and the respiration is irregular. If the condition is limited to simple concussion the period of insensibility lasts for only a few minutes. However, such after-efi'ects as headache, weakness, and nausea may last for some time. Treatment. — ]Most cases recover consciousness after a few minutes' rest, but they should be kept at rest for several hours in a quiet darkened room, the head and shoulders slightly elevated. If they show symptoms of shock, heat should be applied to the body and an ice-cap placed upon the HEAD 195 head. Stimulants should be given cautiously in cases of head injuries. Intracranial Injury. In iDany cases after a blow on the head the symptoms are more severe, indicating a more serious injury to the brain. If the brain is pressed upon })y a fragment of a bone, as occasionally happens in fracture of the skull, or if a small vessel inside the skull bleeds and the escaped blood, confined within the bony cavity, causes pressure on the brain, the result is known as compression of Fig. 127.- -Perforating bullet wound of the head with wound of exit showing brain protrusion. (Park.) the brain. In more severe cases the brain substance may be torn and severely injured, this condition being known as laceration of the brain. These conditions, together with concussion, are sometimes spoken of as intracranial injury, a rather loose diagnosis which indicates simply that the brain has been injured, without designating the particular type of injury present. After a blow on the head the first-aid worker is" interested chiefly in deciding whether there have been any serious conse- 196 REGION A L I .\J URI ES qiicnces or wliether the condition is sini])U' concussion which will (juickly i)ass away. In most hospitals it is made a standini;' I'ulc to keep every head injury under observation for several hours, to lie cer- tain that no serious injury is present. Symptoms. — ^^''he mildest cases show only concussion with symptoms which clear up within a few minutes. INIore severe cases show the symptoms of ordinary concussion which, instead of clearinu; up, persist for several hours. These cases should be watched very closely for evidences of compression of the brain. Fig. 128. — Cross-section of the head showing hemorrhaKe between the skull and brain, a result of a blow on the skull without fracture. (Ashhurst.) If the injury to the skull results in the rupture of a blood- vessel in the brain the patient at first shows symptoms of concussion which may entirely disappear within a few min- utes. As the torn vessel slowly bleeds, the escaped blood, held within the firm bony cavity of the skull, causes gradu- ally increased pressure which makes itself evident in uncon- sciousness, deep stertorous respiration, irregular heart action, and possibly death. This is known as "compression of the brain," and is very similar to apoplexy. If the hemorrhage in the brain is from a very small vessel the secondary symp- EYE 197 toms of compression may not occur for several hours after the injury. In laceration of the brain, unconsciousness occurs at once and lasts for a long. time. The intermediate stage of complete consciousness is practically never present. If a patient has received a head injury he should be kept at rest as outlined under Concussion and watched for symp- toms which might indicate serious injury to the brain. If the patient grows slowly more and more stupid and unresponsive, or if semiconsciousness or unconsciousness occur after a preliminary stage of clearness, there is almost cer- tainly hemorrhage within the skull. If there is vomiting, a slow pulse, or persistent headache, the condition is less cer- tainly, but possibly, present. Unequal pupils, convulsions, or paralysis of an arm or leg are bad symptoms when they occur. If any of these symptoms occur after a blow on the head, even if the injury is apparently insignificant, it is best to secure the services of a physician. Treatment. — ^The treatment consists of rest in bed, with the head and shoulders slightly elevated,^ an ice-cap being applied to the top of the head. The body should be kept warm and hot drinks may be given. Stimulants should rarely be given to a patient suffering from head injuries. EYE. Contusion of the Eye. — A blow in the eye results in the ordinary "black eye," the discoloration being caused by bleeding beneath the skin. Because the skin about the eye- lids is very loose there may be considerable hemorrhage from a very slight blow. The dark color of the blood in the tis- sues (ecchymosis) persists for about two weeks, that is, until the ecchymosis is entirely absorbed. Treatment. — ^The treatment consists in the application of cold compresses or cold water immediately after the blow is 1 A convenient method of securing elevation is that of placing blocks under the head of the bed so that it is elevated about 8 to 10 inches. 198 RECIOXAL IXJI'IUES received. After the seeoiul day hot ai)])hcati()ns wliich tend to hasten ahsorptioii. are preferable. Wounds about the Eye. — These are apt to be associated with profuse heinorrhaue. Stronp; antiseptics should be avoided because of the danger of injury to the eye. Boric acid in saturateil solution is a non-irritatiuii; antisei)tic which may be applied freely. Foreign Body in the Eye. — Small specks of dirt and sand may be blown into the eye. ITuless they rest directly on the cornea' there is ^•ery little pain. After a foreign body has been in the eye for a few hours the entire eye api)ears congested antl inflamed. Fig. 129. — Method of lioldinn the upiter lid tvinipd back in scarcliiu^ for a foreign body. (Vcasey.) Treatment. — Never rub the eye, because this only serves to increase the irritation. Blo\nng the nose or winking rapidly is the simplest method of removing a foreign body. If this is not successful, grasj) the eyelashes on the upper lid, draw the upper lid downward, so that the lashes of the lower lid sweep the inner surface of the upper lid. Or get the patient in a good light and draw the lower lid downward, looking carefully for the speck, especially at the inner end of the eye. If it is not found, turn the u])i)er lid backward ' The front ijart of the eyeball tlirough wliich the light passes. EARS 199 over a match or a small stick and look on the inner surface of the upper lid. If you are. still unable to see the foreign body, it is better to send the patient to a physician. If the body is found it may be lightly brushed away with a swab made by wrapping a little cotton aroimd the end of a match, or with the corner of a handkerchief. The inflammation which remains after the particle is removed requires fre- quent irrigation^ with boric acid solution. If very severe, compresses wet with boric acid should be applied. EARS. Boxer's Ear. — After a blow on the ear there is sometimes a hemorrhage beneath the skin which may make the ear Fig. 130. — Boxer's ear. (Posey and Wright.) several times its normal thickness. The swelling is apt to remain permanently, and, as it is common among prize ^ To irrigate the eye the head is tipped back and the solution dropped into the eye with a medicine dropper. If an eye cup is available the solu- tion may be poured into the cup which is applied to the eye, the head being then tipped backward and the eye winked rapidly in the solution. 200 . nECIOXAL IX JURIES fighters, it has been termed "boxer's ear." When it first t)ecurs a firm bandage should be a})])hed o\er a n)tt()ii com- press so as to hmit the amount of swelUng. Foreign Body in the Ear.--(1iil(hvn frequently ])ush matcl'.cs, beans, beads, and other small bodies into the ears. Flies and other insects may crawl into the ear during sleep. If an insect gets into the ear it causes a loud buzzing, which is most uncomfortable. If a lighted candle is held just outside the ear while the j^atient is in a room otherwise dark the insect will freciiiently crawl out towartl the light. Or warm water may be dropped into the ear, drowning the insect and stopping the buzzing. After the buzzing has st()i)})ed the ear may be gently syringed with warm water, which may finally remove the insect. Other o})jects, such as l)eads which do not swell, may be removed in the same way, but be careful not to wet pieces of wood, or beans, or similar objects, as they will swell and cause severe pain. Never try to pick a foreign body out of the ear with a yi'in ov other instrument. Such attempts only ])ush the body farther in and may cause permanent injury to the ear drum. NOSE. Foreign Body in the Nose. — A foreign body in the nose may sometimes be remo^■cd by blowing the nose ^'iolentl3' or by sneezing. A sneeze may be caused by tickling the nose with a feather or by the use of snuff. The i)atient should be instructed to keep the mouth closed during the act of sneezing. Bleeding from the Nose. — This may follow a blow upon the nose or may occur sponstaneously. Usually the hemor- rhage stops after a few minutes, but in some cases the bleeding may be se\'ere enough to cause alarming symptoms. Treatment. — The head should be held backward so that the nose is elevated. A little blood swallowed will do no harm. The collar should be loosened and a cold cloth or piece of ice applied to the back of the neck. This will relieve most cases. Other methods which may be tried are the placing of a piece of folded card-board beneath the iii)per lij); the MOUTH 201 holding of the soft part of the nose firmly together; cloths dipped in ice-water and appHed to the face; and ice-water sniffed up the nose. When the clot forms, allow it to remain in place. Never allow the patient to blow the nose. This only dislodges the clots and starts the bleeding anew. In obstinate cases a plug of cotton can be placed in the bleeding nostril to check the hemorrhage. A long strip of loose cotton should be used, not bigger than the finger, and packed back into the bleeding nostril with a blunt instru- ment, such as a dull lead-pencil. An additional measure, which has never failed me even in severe cases, is the introduction of a plug of snow into the bleeding nostril. When snow cannot be secured, a piece of ice is pounded in the corner of a towel until it is of the con- sistency of coarse snow and then molded with the fingers roughly into the shape of a narrow cone and pressed into the nostril. If the patient becomes faint he should lie down with the head turned to one side. If these simple measures do not stop the hemorrhage within a few minutes a physician should be called. MOUTH. Wounds of the Mouth. — The blood supply of the mouth and lips is very free, consequently there is apt to be profuse hemorrhage even from slight wounds. In wounds of the mouth or tongue it is impossible to apply a dressing. If large they should be referred to a physician for suture; if small the patient is given a mouth wash (peroxide of hydrogen) to use frequently and the wounds are let alone. Hemorrhage from the Mouth. — Bleeding from the mouth may come from a wound of the mouth or throat, or it may be coughed or vomited up. Always examine the mouth carefully to see whether the blood which is spit up comes from a local injury or from some of the internal cavities, such as the lungs or stomach. Treatment. — When the blood comes from a cut on the tongue or lip it may be stopped by direct pressm-e- with a compress held in place with your finger. When there is per- 202 REGIOXAL l.WJURIES sisttMit blocdiuu; after the extraction of a tooth the cavity may he j^aeked with a small pluu; of cotton. In most cases the hleecling stops spontaneously, hnt if it i)ersists the patient may he given ice to snck and a mouth wash of ])eroxide of hydrogen (one-half strength). Hemorrhage from the Lungs. — This condition is known as hemoptysis, and is connnonly caused by pulmonary tuber- culosis. The blood is bright red and frothy and is coughed up. The condition is rarely followed by fatal consequences, but the patient is usually greatly alarmed. If the bleeding has been profuse or prolonged the i)atient is ])alc and restless, and there are the other symptoms of internal hemorrhage. Treatment. — l\it the patient to bed with the head low and try to keep him as quiet as possible. Give him a cup in which to exi)ectorate, so that he may spit out the blood without raising his head. An ice-cap is placed over the chest and the patient is given ice to suck. ^Medical atten- tion should be secured as soon as possible. The diet should be limited to fluids, always given cold. Hemorrhage from the Stomach. — Hemorrhage from the stomach, or hematemesis, is caused by the rupture of a vein in the stomach, or as the result of bleeding from an ulcer. The blood is vomited instead of being coughed uj), as in hemoi)tysis, and is darker in color. In some cases it may be changed to a very dark brown, having the appearance of coffee grounds. It may be mixed with partially digested food. The general symptoms are those of internal hemor- rhage. Treatment. — The patient should be i)laced in bed with an ice-cap placed over the stomach. Al)solutely nothing is given by mouth, not even cold water, but the patient may be given ice to suck if the fluid is not swallowed. Otherwise the treatment is the same as for internal hemorrhage. Internal Hemorrhage. — The symptoms of internal hemor- rhage are exactly the same as those of external hemorrhage, except that the blood is not seen or only part of it may appear at the surface. In hemoptysis and hematemesis, or after a stab wound of the abdomen or chest, the diagnosis is comparatively easy; MOUTH 203 but after injuries to the abdomen, in which there is no vom- iting of blood, the diagnosis is much more difficult. There is always paleness associated with a rapid pulse and shortness of breath (air-hunger). The hands and feet are cold, and the patient is restless and complains of intense thirst. Treatment. — The patient is placed flat in bed and kept absolutely quiet, not even being allowed to get up to go to the toilet. If the location of the bleeding is known, an ice- cap or a cold compress is placed over this point. The patient is covered well with blankets and hot- water bags are placed against the legs and feet. If the hemorrhage comes from the stomach, nothing should be given by mouth; otherwise cold drinks may be given. Stimulants are never given unless the condition becomes serious, in which case coffee or aromatic spirits of ammonia may be given by mouth, or coffee solution may be injected into the rectum. The patient should be kept absolutely quiet until the physician arrives. This is one of the cases where it is dan- gerous to attempt to transport the patient even if a physi- cian is not obtainable for several days. Patients receiving such injuries on the battlefield are not able to stand transportation to the base hospitals. Foreign Bodies in the Throat. — A pin, a coin, or other small object may be accidentally swallowed. When it is drawn into the air passages it causes choking, which has been described elsewhere. If it passes down into the throat it may remain lodged there, or it may pass down into the stomach. If it remains in the upper part of the throat it can some- times be seen and removed. ]\Iore often it is out of sight, but the patient feels it as a hard lump in the lower part of the neck. Often if the throat is tickled the patient will vomit, the force of the vomiting removing the foreign body. If this does not occur the patient may swallow" the object by tak- ing a large drink of water or a mouthful of food. ^Mien the object is sharp, such as a pin, there is daiiger that the sharp 204 RECIOXAL IXJFRIES ])oint may injure the stoinach or the intestines. Conse- quently it is advisable to {;ive at once a large amount of some food, which is digested with difficult^', the theory being that the sharp object will pass through the intestines firmly embedded in the mass. Uncooked rolled oats or bran are excellent substances for this ])urpose. CHEST. Contusion of the Chest. — Hard blows upon the chest or sudden pressure upon the chest, such as is seen in " buffer accidents," result in a momentary cessation of respiration. The patient is unable to "catch" his breath and the face and neck become blue and congested. Such cases usually recover after a short rest. If there is difficulty in breathing, artificial respiration should be begun. After the first effects of the injury have passed away, examine carefully for fracture of the ribs. Wounds of the Chest. — These are important because they may penetrate the chest cavity and injure the heart or lungs. If the heart has been injured the pulse is rapid and weak and the patient shows a marked degree of shock. He should be kept strictly at rest until the arri^■al of the physician, and the treatment given as outlined under Internal Hemorrhage. The surface of tlie wounds should be painted with tincture of iodin and a dry dressing applied. ^Yhen the chest cavity is entered the air rushes in through the opening during inspiration and is expelled during ex])i- ration. If the wound is carefully examined the entrance and exit of air can often be detected. In addition, if the lung is injured, the patient complains of cough and brings up blood-stained expectoration. If the air escapes beneath the skin a condition known as subcutaneous emphysema results, in which there is swelling in tlie region of the wound. This swelling is due to air in the tissues, and when i)ressed upon gives a characteristic sensation of crepitus. Treatment. — The woimd should be dressed with a small sterile dressing, after preliminary })ainting with iodin, and the entire dressing covered with adhesive i)laster or other ABDOMEN 205 material which \\'ill not [)ermit the passaS 211 Treatment. — The wound is treated on general princii)les, and if a motor nerve is eut a surgeon is secured to suture the ends. If a sensory nerve is cut no attempt is made to suture it. The sensation returns after about three months, the adjacent nerves growing inward to supply the anesthetic area. ' Foreign Body. — Occasionally a foreign body, such as a splinter or a sliver of steel, is introduced beneath the skin. If it can be seen, grasp it with a pair of fine forceps and withdraw it. If it is deeper, slightly enlarge the wound with a sharp knife and look for the end of the splinter. If it can now be easily seen, withdraw it. If it cannot be easily seen, dress the wound but never probe deeply into the tissues. If the splinter is large it is almost sure to cause suppuration, consequently it should be removed by a surgeon as soon as possible. A piece of needle is sometimes driven into the hand. If it is entirely out of sight it is useless to incise to try to find it. Either allow it to remain or apply for surgical aid. Needles and other pieces of metal are located by the .r-rays. Hypodermic needles often break oft' where the blade of the needle joins the screw cap. Consequently, those who have to give hypodermic injections should be careful not to insert the needle its entire length. A fish-hook may catch in the hands or other parts of the body. If the barb is beneath the skin the point should be pushed forward so as to come out at another point. The barbed end is now cut away with a pair of wire-cutters and the hook drawn back. It is now easily drawn out of the skin. Bullet wounds of the arms and legs should be sterilized with tincture of iodin and a dry dressing applied. Never probe for the bullet. The bullet may divide a tendon or nerve in the same manner as occurs in an incised womid. Muscle Strain. — ^In lifting a heavy weight or in sudden twisting mo\Tments the muscles may be slightly over- stretched and torn. This is known as muscle strain. It is painful but otherwise has no significance. Treatment. — Massage with a strong liniment, such as chloroform liniment, and the application of heat is usually •212 REGIONAL IXJUIilES all that is required. A firm baiulajiie may be worn for a few days if the ]>ain is severe and if support is desired. Rupture of a Muscle. — Tn some eases a nuiscle or tendon is torn entirely aert>ss. This hapjxMis most fretjuently in the biceps of the arm, the tendo-Aehillis behind the heel, and the tendon attached to the knee-caj). There is severe pain and loss of strength in the aii'ected jjart. As the symptoms resemble fracture it is advisable to appl>' a splint and ,keep the part at rest until the ser\ices of a ])hysician can be secured. Blisters and Abrasions of the Feet.— These injuries are usually the result of irritation and rubbing caused by poorly fitted shoes. Fig. 135. — Pmiicr siik-s for normal feet. ( Wliilnian.) Fig. 136. — Shopinaker's feet. (Whitman.) Sore feet may be prevented by the use of properly fitted shoes and clean, dry socks. The U. S. Army shoe, built on the Munson last, is a very satisfactory one. The ordinary shoes which cramp the feet are unsuited to the use of persons who expect to walk or stand on their feet a great deal. Sol- diers on the march are required to remove the shoes after a long tramp and wash the feet, carefully drying them and INJURIES TO THE EXTREMITIES 21. 3 changing their socks. Toe-nails should be cut squarely across but not too short. Treatment. — Vaselin well smeared over the feet and between the toes will prevent soreness, or if vaselin cannot be obtained, talcum powder may be dusted over the feet and into the sock. Blisters should not be opened but carefully covered with adhesive plaster. Abrasions should be well washed, dried, and painted with tincture of iodin. A small sterile dressing no larger than the abrasion is then applied and the entire dressing covered with narrow strips of adhesive plaster so that the dressing cannot slip. Ingrowing Toe-nails. — The nail should be cut straight across, never at the side. When there is inflammation the skin is separated from the edge of the nail by packing in a small strip of cotton dipped in alcohol, after having painted the entire area with tincture of iodin. A wet boric dressing applied at night will often relieve the pain and allay the inflammation. Carbolated vaselin may be applied in trouble- some cases. Splinter Beneath the Nail. — A splinter is sometimes run beneath the nail. It should be withdrawn with a pair of forceps and a tooth-pick dipped in tincture of iodin passed along the path of puncture. This will usually prevent inflammation. If it is difficult to secure the splinter a V- shaped piece may be cut from the nail. Blood Blisters. — These are really small contusions. The blister should be protected with a small dressing. It is never opened unless infected. Infection is shown by increased pain and redness about the blister. If this occurs, snip the thin top of the blister away and treat as an open wound. CHAPTER X. POISONING. Generally speaking, anything A\-hic-li, when introduced into the body, causes sickness or death is a poison; but in the following pages the only poisons taken into considera- tion will be those which, swallowed either by accident or intent, cause acute symptoms. Poisons are taken either accidentally, or purposely with suicidal intent. The particular poisons taken for suicidal purposes vary from year to year. Several years ago carbolic acid was largely used for this purpose, but recently bichloride of mercury poisoning is a frequent cause of death. This is be- cause would-be suicides are apt to follow the method which first occurs to them. The frequent references to bichloride of mercury poisoning in the daily papers made the name familiar to the general public, so that when the desire to end life comes to the individual, bichloride of mercury is the first name that occurs to his mind. ^Yithout doubt in a short time there will be a particularly spectacular case in which some other form of poison is used anfl the resulting publicity will serve to "popularize" some other drug. Poisons may be divided into three classes according to their action upon the human body: 1. Those which act chiefly upon the stomach and gastro- intestinal canal. These cause violent pain and irritation, first in the stomach and later in the intestines. Such ])oisons include caustic acids, caustic alkalies, nitrate of silver, croton oil, and sugar of lead. 2. Those which cause little or no local irritation but produce serious general symptoms, such as ojjiiun, chloral, belladonna, or strychnin. 3. Those having both local and general eft'ects. These include bichloride of mercury, cantharides, carbolic acid, phosi)horus, aconite, and animal ptomains. POISONING 215 Symptoms. — The symptoms vary according to the partic- ular poison which has been taken. Irritant poisons are ai)t to cause severe abdominal pain, with vomiting and cramps. There may be burns or signs of irritation about the mouth and throat. The strictly general poisons show no irritation about the mouth, nor is there accompanying abdominal pain. They act specially upon the nervous system, frequently causing unconsciousness or convulsions. If a patient previously in good health is suddenly taken sick after taking medicine, poisoning should be at once suspected. In all cases look for the bottle! Suicides will rarely lie if asked point-blank if they have taken anything which might be poisonous. They frequently have had a change of heart and are very willing to give all desired infor- mation. In other cases the fact that they are giving evasive answers may be easily detected. Treatment. — If an undetermined poison has been taken into the stomach the treatment is as follows: 1. Dilute the poison. 2. Empty the stomach. 3. Give an antidote. 4. Empty the bowels. 5. Support the body strength. To Dilute the Poison. — The poison may be diluted with water or other fluid. The patient should be required at once to drink at least two glasses of the nearest harmless fluid at hand. Tepid, bland fluids are especially desirable for reasons which will be discussed later, but any fluid, such as water, coffee, soup, lemonade, beer or any other compara- tively harmless fluid may be given. This serves to dilute the poison so that the local irritation is less, and at the same time to delay its absorption, so that the general symp- toms are slower in making their appearance. To Empty the Stomach. — After the poison is well diluted the stomach should be emptied. This is best done by tickling the back of the throat with the tip of the finger. It is sometimes sufficient simply to stick the finger down the tliroat, but this often fails, in which case the patient should be instructed to 210 , POISONING pass the finger back over the tongue until the tip barely touches the back of the throat and then to move the tip ra])i(lly up and d()\vn. This almost invariably results in vomiting. The i)rocess may have to be repeated several times before the stomach empties itself satisfactorily. The less time that is allowed to elapse between the time the dose is taken and the vomiting of the diluted poison the better are the chances for the i)a.tient. After the stomach is apparently satisfactorily emptied the patient is required to take two glasses of tepid water or other fluid and again to vomit. This process is repeated several times until it is certain that all the imabsorbed poison has been removed from the stomach. Emetics are advised in poisoning and may be used if avail- able. They are substances which when taken into the stom- ach cause vomiting. They take time to prepare and are infin- itely inferior to the method just described. The chief emetics in common use are salt, mustard, and ipecac. A tablespoonful of mustard or a teaspoonful of salt or syrup of ipecac mixed in a glassful of tepid water will usually result in vomiting. They should be given to patients who are imable to bring on vomiting by the method just described. The same solutions may be given to patients who vomit easily, the nauseating character of the fluids making the induction of vomiting by the finger much easier. Never wait to secure an emetic, however, but give the first fluid that is at hand. One physician always gave dishwater as an emetic, saying that the mere drinking of the dishwater was sufficient to make most persons vomit. Sea water, especially if tepid, is an excellent emetic. If used skilfully the stomach-tube may be employed to wash out the stomach. The Stoinach-tiihc. — The stomach-tube is a mediinn soft- rubber tube about three feet long and about the size of the little finger. It is used to remove poisons and to wash out the stomach, or occasionally to introduce liquid food into the stomach. It is wiser not to attempt to pass a stomach tube unless you ha\'e had a practical demonstration. The method is as follows: The patient is seated in a chair and the end of the POISONING 217 stomach-tube, previously dipped in glycerin or olive oil, is passed to the back part of the tongue. The patient is now Fig. 137. — Stomach-tube and aspirator. (Aaron.) told to close the lips and swallow, gentle pressure being made at the same time on the tube. If there is a choking sensa- tion, or if the patient is unable to breathe, the tube should 218 POISONING be removed, l^siially it must be puslied down about fifteen inches to rcacli the stomacli. When the stomach is reached ^^V ' '^'^^^^^^^1^1 ^^^ "^ -^ '' i M*^ 1 Fig. 138. — This tube is used without a bulb. The tube is passed and water poured into the funnel and allowed to run into the stomach. (Hare.) a funnel can be inserted in the other end of the tube and luke- warm water poured into the stomach. After about two glassfuls have been poured down the tube the funnel is low- POISONING 219 ered'and the fluid is allowed to run out. Repeated washings will remove all the poison from the stomach, but in unskilled hands this method is inferior to the method of emptying the stomach previously outlined. As it is not without danger, it should not be attempted until it has been thor- oughly demonstrated by an instructor. Fig. 139. — Just as the last portion of the water is about to disappear down the tube the funnel end is lowered and the contents of the stomach are siphoned out. (Hare.) Antidotes for Poisons. — An antidote is a substance which neutralizes a poison. It may neutralize it chemically as acids neutralize alkalies, or it may neutralize it by rendering it insoluble. 220 poisnxfxa \Vhilo antidotes have been given third ])laee in the treat- ment of poisoning it is hardly neeessary to state that they should be given at once if possible. Thus milk is the anti- dote for bichloride of mercury and should always be given at once if at hand; but if no milk is a\ailable any other fluid may be given, the point being that it is a mistake to delay the emptying of the stomach in order to secure an antidote. Use the antidote as soon as it is at hand, but dilute the jioison and emj^ty the stomach at once by the best available means. Certain substances are known as general antidotes, that is, they are antidotes for many poisons. Alkalies, such as baking soda or lime-water, are general antidotes for all acids (except carbolic acid), and acids, such as vinegar or lemon juice, are antidotes for all alkalies. Milk and other substances containing albumen (white of egg), are antidotes for all mineral poisons, including nitrate of silver and })ichloride of mercury, as well as for all acids and alkalies.^ Albuminous substances combine with the poison and render it less harm- ful, })ut do not neutralize it, so that the stomach must be emptied before digestion can take place. Tea, because it contains tannic acid, is the antidote for most plant poisons, such as opium, belladonna, and aconite. [Milk should always be borne in mind in case of ])oisoning, because it can nearly always be obtained, and it is the antidote for many poisons. It never causes harm. To Empty the Bowels. — After the patient has vomited several times a cathartic should be given to evacuate, or empty, the bowels. No matter how (piickly the stomach has been emptied it is almost certain that some of the poison has passed out of the stomach into the intestine. This por- tion can only be gotten rid of by the use of a cathartic, and •it is a(h'isable to use a (juickly acting cathartic, such as castor oil or salts,^ so that the poisonous material may be hurried through the bowel. Cascara, rhubarb, calomel, and all the slower acting cathartics are not suitable for this pur- ' Milk is less suitable for the purpose of neutraliziup; acids or alkalies than the chemifal antidote (baking soda or vinegar) , but it is an additional protection and may be given if the fheniieal antidote is not ol)tainable. 2 Two or three tablesi)oonfuls of castor oil or two rounded tablespoonfuls of Epsom (If Hoclicllc .salts lire the proper doses for an adult. POISONING 221 pose. If the cathartic is vomited the dose should ha repeated after a few minutes. About an liour later a second smaller dose of the same cathartic is given, so that a goofl bowel movement will surely result. To Suyyort the Patient's Strength. — During the period of vomiting it is well to have an assistant preparing a bed so that the patient may be put to bed when the stomach is emptied. This part of the treatment depends largely upon the char- acter of the poison taken and the symptoms which have developed — that is, the treatment is largely symptomatic. If the poison has caused irritation to the stomach the pain may be relieved by a tablespoonful of olive oil and by the use of a hot-water bag. If there is shock, apply external warmth and stimulants. If the patient is comatose, as from opium poisoning, slap the face and hands with cold wet cloths and try to keep him awake. If there are convulsions, keep the patient very quiet and give medicines, such as bromides and opium, to quiet the increased activity of the nervous system. The diet should consist entirely' of fluids, especially where an irritant poison has been taken. Quantities of water should be given in order to dilute that portion of the poison which has been absorbed, and must later be excreted through the kidneys. Special Poisonings. — There are many hundreds of sub- stances which act as poisons, only a few of which can be discussed in detail. In such cases it is to be understood that the general treatment is carried out along the plan already outlined. Some of the more common poisons, because they are frequently met with, will be discussed in more detail, attention being drawn to the special indications for treatment in each case. Caustic Acids. — These include sulphuric, hydrochloric, nitric, and many other acids. In poisoning with caustic acids there are apt to be burns about the mouth and lips. The irritation of the stomach is marked and associated with severe abdominal pains. When you see a case of acid poisoning, always neutralize the acid with some form of alkali. Bicarbonate of soda --- porsoxixa (onliiKirv hakiuii; soda) is to be found in every household. It should be given in solution, one or two teaspoonfuls in a glass of water. Lime-water or milk of magnesia can some- times be obtained. They may be given in full strength or slightly diluted. Borax may be given in the same maimer as bicarbonate of soda, but it should be given in smaller doses and should not be allowed to remain in the stomach. Ammonia is another alkali, but as it is very irritating, it should not be given if the harmless alkalies are available. Aromatic spirits of anmionia or CN'en household ammonia, one teaspoonful to a glass of water, makes an alkaline solution which may be used to neutralize acid ])oisons. Caustic Alkalies. — Including strong ammonia, potash, quicklime, caustic soda, and many others. There are apt to be burns about the lips and mouth, but they are much less noticeable than burns caused by strong acids. The skin has a characteristic soapy feeling after strong alkalies have been applied. Any dilute acid (except carbolic acid) may be used to neutralize the alkali. Mnegar, diluted three or four times, is one of the safest and is almost always obtainable. Sour milk, which contains lactic acid, or lemon juice, which con- tains citric acid, may })e given. If obtainal)le, sulphuric or hydrochloric acid may be given in the proportions of ten to twenty drops of the concentrated acid to a glass of water. After poisoning with either acids or alkalies the pain and burning may be somewhat relie\'e(l by small doses of olive oil at frequent intervals. Of course if the acids and alkalies are taken in dilute solutions there will be no local burns, while the gastric irritation and general symptoms will occur later and be less marked. Carbolic Acid. — Carbolic acid, or phenol, is not a true acid from the chemical view-point. Therefore it does not neutralize alkalies and is not neutralized by them. When strong carbolic acid is applied to the skin it causes a burn. Consequently after taking strong carbolic acid, burns may be noted about the mouth. If the 5 per cent, solution, that is, the one commonly used, is taken the general symptoms \y[\\ occur, but there is no local burn. The characteristic odor of carbolic acid is always present. POISONING 223 When strong carbolic acid (05 per cent.) is applied to the skin and immediately washed oft' with alcohol no })urn results. Advantage is taken of this fact in carbolic acid poisoning and the stomach is washed out with dilute alcohol (10 to 20 per cent.)- Whisky or brandy which are practi- cally 50 per cent, solutions may be used diluted once or twice. A case has recently come to my notice in which a man poured strong carbolic acid directly into his eye in mistake for boric acid. He promptly washed out the eye with alco- hol, the result being that no serious injury resulted. Always remember to associate in your mind carbolic acid and alcohol. Opium.' — The patient is first drowsy and later unconscious. The pupils are contracted to the size of a pin-head or smaller and the respiration is very slow, often ten or less per minute. The patient can sometimes be aroused, but soon drops off to sleep. In addition to the general treatment the patient should be kept awake by striking the face or chest with cold cloths or by shaking him. It is never necessary to keep the patient walking about, as was formerly believed. This only serves to exhaust the strength and serves no useful purpose. Chloral. — ^This is the substance which is found in "knock- out drops," and, as may be imagined from this name, it acts very quickly. The symptoms are marked prostration, dilated pupils, shallow respiration, and a rapid and feeble pulse. Coma may result. Stimulation, combined with treatment similar to that for shock, should be promptly started. The giving of large draughts of very black coffee is one of the best methods of stimulation. Many of the headache and sleeping powders contain drugs very similar to chloral, and consequently the treatment of poisoning with any of these drugs is practically always the same. Strychnin. — There are general convulsions very similar to epilepsy or tetanus. There may be severe abdominal cramps. The patient is usually conscious to the end and dies 1 Morphin is the active principle of opium and consequently the sjTiip- toms of poisoning and the treatment thereof are exactly the same. 224 ruLSONlNG from exhaustion after severe convulsive seizures. As these convulsions may be broufjlit on by a sudden noise or jar the patient should be kei)t as quiet as possible. I have seen a patient who had taken a larjj;e dose of strych- nin sent off into convulsions by the slamming of a door or by simjily touching!; the foot of the bed. Opium or bromides should be ^Wvn in larjiv doses if they are at hand. Belladonna. — Poisoning with belladonna or atropin, which is its active i)rinciple, results in prostration, with full, rapid pulse and dilated pupils. The mind is hyperactive, possibly showing periods of delirium. I^limination by the kidneys and bo\\'els is of the utmost importance. Stimulation by hot coffee and alcoholic drinks, combined with the ordinary treatment for shock and alter- nating hot and cold applications to the face and chest, are all of value. Bichloride of Mercury. — ^This substance, also called corro- sive sublimate, is frequently taken with suicidal intent. The so-called bichloride tablets are antiseptic tablets contain- ing about 7-2" grains of bichloride of mercury, enough to poison several adults. The symptoms are burning and redness of the mouth and throat, with pain and irritation in the region of the stomach, possibly associated with nausea, vomiting, and diarrhea. If the i)atient recovers from the immediate symptoms, the mercury being absorbed into the blood must be excreted by the kidneys. As bichloride of mercury is very irritating, it gives rise to acute inflammation of the kidneys, so that they cease to fiuiction, and death results after about a week or ten days. During this period the patient apparently recovers com- pletely from the irritation of the stomach and throat, and the third or fourth day he may consider himself well ; later the strength is gradually lost and the symptoms of nephritis develop. If the amount of the drug absorbed is not too great recovery results. In a case recently seen which received prompt treatment, enough of the mercury was removed from the stomach so that the nephritis was only of moderate degree, the patient making a complete recovery. The treatment should aim to remove as much of the poi- POISONING 225 son as possible before absorption takes place. Milk forms'a temporary combination with mercury so that it cannot be absorbed, but this must be removed at once from the stom- ach. A large dose of salts should be given to clear out the intestinal canal as well. Bearing in mind the dangers of kidney irritation, a large quantity of water should be given to dilute the urine as much as possible, so as to minimize the irritant action upon the kidneys. Acute Alcoholism. — It is hardly necessary to describe the symptoms of the milder degree of acute alcoholism. Drunk- enness is unfortunately too common an occurrence to require much description. Moreover, first aid is not required in the earlier stages, the intoxicated person being well satisfied with his condition. In the later stages where voluntary control of the voice and the limbs has been lost, but the patient is still conscious, the patient may be "sobered up" by the use of an emetic, such as mustard and water or salt and water, followed by a dose of salts and several cups of hot coffee. It is surprising to see how quiet the man who has been "fighting drunk" becomes after he has been given an emetic. Alcoholic coma is more serious and may even result fatally. The face, commonly flushed and bloated, in the later stages becomes moist and pale. The pupils are dilated and the eyeballs red and congested. The coma may be complete, but usually the patient can be partially aroused. The pulse may be slow and full, but in the later stages it is apt to be rapid and weak. There is always a strong alcoholic odor to the breath, but the converse is not always true. It should be remem- bered that a person who is comatose from apoplexy or fracture of the skull may have been drinking and consequently have a strongly alcoholic breath. Be careful in diagnosing alco- holism to rule out other causes of unconsciousness. ^Yhen in doubt between alcoholism and apoplexy always treat for the latter, in which case vomiting is to be avoided. If you are satisfied that you are dealing with acute alcohol- ism, put the patient to bed, and if the patient is able to swal- low, give a good dose of salts and apply hot-water bottles 15 226 POISONIA^G al>()Ut the feet niul logs. If tlio face is AusIumI ;m ice-cap or cold clotlis may he i)lace(l upon the hea(h l>ut if the face is pale this is imiiecessary. As long as the condition remains good there is little treatment recpiired, but when the j^iilse is weak and the condition described under shock is ])resent, black coiVcc should be gi\en for its stinuilating eiVect. If it is imjiossible to make the patient swallo\\', the colVee may be injected into the rectum. \ilii/ Fig. 140. — Shuwing thu cuiiimuu imislirooni and one of the poisonous variety. The swollen root and sac like envelope mark tlie fungus on the left as poisonous. Naturally, the stomach should be emptied if possible by the use of emetics or a stomach-tube, but emetics should not be given if the i)atient is in a state of extreme collapse. Chloroform and Ether.— If the drug has been taken by inhalation no special .treatment is necessary. Recovery begins at once when the drug is stopped, unless too great a quantity has been taken. Whei'i taken internally' the stomach should be emptied and the patient gi\'en stimulation. Artificial respiration is POISONING 227 most important in these cases })ecause the efl'eet of tlie drug rapidly passes off. Mushroom Poisoning. — There are a variety of ])oisonous mushrooms. Some are simjily gastric irritants and some are general or systemic poisons. A few are very deadly. Never collect and eat any fungus unless familiar with its identifica- tion. The treatment is the same as for ptomain poisoning. Ptomain Poisoning. — Foods which are partially decomposed may contain poisons, although there has been no change in their taste or odor. Milk, fish, and meats which have been allowed to stand during warm weather are specially prone to contain ptomains. Canned meats, especially when kept for several days exposed to the heat of the summer sun, may contain large quantities of poisons. ■ Symptoms. — The symptoms do not make their appearance immediately after taking the poisonous food. There is usually a period of an hour or more after eating during which the patient has no symptoms. Then nausea occurs, associ- ated with vomiting and followed by abdominal cramps. Later purging begins with frequent and watery movements. As a result there is marked prostration. It is characteristic of ptomain poisoning that several persons in the same family are taken violently ill at about the same time. Treatment. — The treatment consists in emptying the stomach as soon as nausea occurs. When a person, who has been perfectly well, suddenly develops nausea after tak- ing food it is almost a certainty that something in the food is acting as a poison, and the sooner the stomach is emptied the better. Do not try to control nausea under these circum- stances, for if the poison enters the intestinal canal it will cause more trouble than it has in the stomach. After the stomach is emptied a dose of castor oil should be given, or if this is not at hand give salts or some other form of catharsis. Meanwhile the patient is put to bed, warmth applied, and stimulants given if necessary. In this connection it may be noted that it is unwise to try to check an acute attack of diarrhea before giving a cathartic, preferably castor oil. After the cathartic has had time to act, paregoric may be given in teaspoonful doses (for an adult) every three or four hours in order to control the diarrhea. 22S POISONING Heady Ueferexce Table of Poisons and Antidotes. The followinjj; table contains sn^^estions for the proper treatment of those forms of poisoning; most hkely to occur: POISON. Nature unknown Acidii— Sulphuric, Nitric, Hydrocliloric, Oxalic, Hijdrocijnnic Acid and Potassium Cyanide . . Carbolic Acid and Creo- sote Arsenic — Paris Rrcen, Scheelc's green, Fowler's solulion, Acetate of Lead . Mercury, Corrosive sublimate, Antimony, Tartar Emetic, Copper Sails Phosphorus Nitrate of Silver \ (lunar caustic), j Iodine TREATMENT. Provoke repeated vomiting; Ciive bland liijuids: Stimulate, if necessary ; keep up breathing. Give an alkali (soap, soda, and whitewash usually at hand I ; limewater; magnesia; Provoke vomiting; avoid stomaeh-i)umj); (iivc ice cream and bland fluids; Secure rest ; relieve pain by opium; Stimulate, if necessary; Feed l)y enema. Stomach-pump or emetic; Stimulate; i>utassium permanganate; Give dilute ammonia-water— by intravenou.s I injection, if necessary; chlorine-water; Cold allusions ; I. Give atropine, gr. bV. hypodermatically. I Give l'4>som salts, dilute sulphuric acid ; atro- pine, hypodermatically; < Stomach-pump or emetics ; White of egg; amyl nitrite; [ Stimulate ; artificial heat. IGive vinegar, lemon-juice, or orange-juice, or other acid or a lixed oil ; Give bland liquids; Secure rest ; relieve pain by opium ; Stimulate, if necessary. {Stomach-pump or emetics ; Give hydrated oxide of iron or dialyzed iron and magnesium oxide ; Give dose of castor oil ; Secure rest; Stimulate, if necessary. f Stomach-pump or emetics ; (iive Epsom salt or dilute sulphuric acid; ■! Milk, raw eggs, and water; Morpliine hypodermatically for i)ain; [ Potassium iodide to eliminate the drug. {Emetics; careful lavage; Give some infusion containing tannic acid ; Give raw eggs and milk ; bland liquids; Give dose of castor oil ; Stimulate, if necessary. iGivo albumin (milk, raw eggs); yellow prus- siate of p(jlas,-ium ; Stomach-). unqi or emetics ; Give bland fluids. (Provoke vomiting by repeated five-grain doses of sulphate of copper; Potassium permanganate (J-J per cent.) ; Give dose of magnesium o.xide, but no oil. f Give strong salt and water; \ repeat many I Provoke vomiting ; J times. C Stomach-i)ump or emetics; ■< (Jive gelatinized starch and water; (. Give bland fluids. POISONING 229 POISON. Opium- Morphiiie, Laudanum, Paregoric, etc., Chloral— \ Paraldehyde, / ne, > in, j Nux Vomica- Strychnine Picrotoxin Aconite— \ Veratrum viride, j Hemlock, 'i Toadstool, > Tobacco, etc., etc.,) Belladonna or Atropine, Hyoscyamus or Hyoscyamine, Duboisia or Duboisine, Stramonium or Daturine, Alcohol , Decayed Meat or Vegetables Poisonous Gases— 1 Carbonic acid or oxide, > Sulphuretted hydrogen, j TREATMENT. Stomafh-pnmp ; emetic; potafisinm per- miiiiK'nniic, t)y moutli ; adnniiiliii : am- moiiiii ; hut strong cofleehy the bowel ; atropine, cocaine, or strychnine hypo- dermatically ; oxygcn-inhalation.s ; ar- tificial respiration ; lingual traction. Stomacn-pump or emetic ; artificial heat ; massage; stimulate; stryclmine; amyl nitrite ; artificial respiration. Stomach-pump or emetic ; animal char- coal or tannic acid ; bromide and chlo- ral ; amyl nitrite ; chloroform by inha- lation ; artificial respiration. Stomach-pump or emetic; stimulate; heat; atropine; artificial respiration. Provoke vomiting and give a purge; tannic or gallic acid ; Stimulate well ; keep up breathing. (Stomach-pump or emetic ; stimulate ; Enema hot strong coffee; artificial heat; morphine; pilocarpine; physostig- mine ; artificial respiration. f Stomach-pump or emetic; t Give ammonia and water. Provoke vomiting ; wash out stomach ; Give a purgative ; give an enema ; Give powdered charcoal and hydrogen dioxide. Fresh air ; oxygen ; Artificial respiration ; Amyl nitrite or nitro-glycerin ; Stimulation. CHAPTER XT. EMERGENCY TREATMl^Nl^ OF DISEASE. TiiK first-aid worker may be called on for advice in case (»f illness dne to disease. Tims a ])atient j^reviously ])erfectly healthy may suddenly develop fever, the question inmiedi- ately arising as to the best plan of management of the condition imtil a ])hysician can be secured. A man known to be snlfering from kidney disease may suddenly have a convulsion, or a stranger may suddenly fall unconscious either with or without convulsions. All these cases have special indications, and if they are not skilfully treated disastrous results may occur. 1 have in mind the case of a boy who, ^^ hile suifering from a rather mild attack of influenza, was allowed to ride about ten miles in an open automobile in midwinter to see a phy- sician, the result being that pneumonia developed, which ended fatally. In another case a man had a se^•ere chill due to malaria. As there were no means of transportation he was obliged to walk home, a distance of about two miles. As a result of the severe strain upon his heart, death resulted soon after he reached home. Even a slight knowledge of the emergency treatiuent of disease would have prevented both of these deaths. It is not expected that the first-aid student will be able to diag- nose the various diseases which may occur, but only that he will recognize certain symptoms which commonly occur and that he will outline an emergency treatment which will, at least, do the patient no harm, while it will probably do much good. FEVER. A rise in temperature is one of the commonest symptoms of di-sease. It occurs in ordinary colds, bronchitis, iuHuenza, local cellulitis, inflammation of the intestines, tonsillitis. CHILLS 231 malaria, and in numerous other diseases. Often when a physician first sees a patient, fever is the only symptom, the characteristic features of the particular disease not becoming evident until several days later. Symptoms. — Fever may be recognized by a flushed face, a sensation of weakness, rapid pulse, and increased body temperature (shown by the clinical thermometer). A tem- perature from 100° to 101° F. indicates a mild fever, from 101° to 103° F. is a moderate rise, and temperatures of 103° F. or above are considered high. Every first-aid student should be accustomed to the use of the clinical thermometer. Treatment. — ^The treatment consists of rest, preferably in bed, and in the strict avoidance of exposure or muscular fatigue. To allow a person with fever to go out in the cold and wet or to continue his work is nothing less than criminal. Many cases of pneumonia and other serious conditions can be avoided if febrile patients are put to bed at once. In the United States Army, where the soldiers receive free medical treatment and do not lose their pay when sick, serious disease conditions are often prevented, because it is the custom to send soldiers who have the slightest fever to the hospital at once. In private life, on the other hand, men struggle to fight oflf the impending illness mainly because their pay stops when they are away from work, the consequence being that they struggle on, continually growing sicker and weaker, until they are finally obliged to stop, the condition then being much more serious than the original complaint. In addition to rest a cathartic may be safely prescribed and the patient put on a fluid diet. He should be encour- aged to drink water freely. In many cases of influenza, or mild gastro-intestinal fever, the treatment above will result in a complete cure within a few days. CHILLS. When the temperature rises suddenly the patient has a chill, when it falls he sweats profusely; consequently, if a patient complains of marked chilliness, or if there is a real 232 EMEROEXCY TREATMEXT OF DISEASE chill, we may siisi)oct that the toni])erature is risinjj, and conversely when a febrile patient breaks into a sweat we may conclude that the temperature is falling,'. In malaria this process is clearly shown. There is first a chill, during which the sufferer comjilains of extreme cold, followed by a short period of high temperature, in which the symptoms of fever are present. After a few hours the body breaks out into a sweat and the temperature falls again. ^Vhen the temperature reaches normal the ])atient feels weak, but otherwise perfectly well. DAY OF MONTH 10 11 12 13 14 15 TIME OF DAY ^':M^I^Mi jUl^liMi jM.'^Ij|.Mi iWi\^^, ^M^m 4z z i 105" '5" 101" £ 103" S 102" ? 101" S 100° S 99° ^ 9«= -=^y\ :- \ : -'■ R ■"' ■ zJ \: ; \ : l\c, ■ i \ : V il: I : \ -ll '-. - \: - \ : '■- V- '■r '■-' \ \ \1 \ ..^^ , ~^-h '. - V K^ , .*^ V^: . Fig. 141. — Temperature chart in malaria, showing the course of the fever with chills every other day. Notice that the rise of temperature is of short duration. (Osier.) Chills may occur at the onset of any acute fever (espe- cially pneumonia), and are of common occurrence in malaria and septicemia (blood poisoning). Symptoms. — The symptoms during a chill are a sense of extreme cold, e^'en when in warm surroundings, together with a rapid pulse, weakness, and a rising body temperature. The hands and feet are cold and the face is pale or even blue. Treatment. — The treatment consists of rest in bed with as many covers as are desired and several hot-water bottles applied about the body. Hot cofl'ee and hot broth may be given freely. As soon as the febrile stage is reached, as shown by the flushing of the face and the warmth of the hands and feet, the extra covers and hot-water bottles should be removed from the bed. Should sweating occur it should be EPILEPSY OP. FITS 233 allowed to proceed for about half an hour, and then the body should be well dried with a warm, rough towel and warm, dry clothing put on. Of course no patient who is suffering from any stage of a chill should be allowed to con- tinue at work or to be exposed to cold or wet. CONVULSIONS. Convulsions occur in many different conditions. They are seen frequently in epilepsy, nephritis, and injury to the brain. In young children convulsions are more common than in adults, frequently occurring instead of a chill at the onset of an acute fever. In an adult previously well and suddenly seized with a convulsion the first thing to suspect is an epileptic fit. Next in frequency are apoplexy, fractured skull, and nephritis. In a child a "spasm" usually means an acute fever or gastro-intestinal disease. In later child- hood, that is, after puberty, convulsions are less common, epilepsy being practically the only cause of this condition. Treatment. — In the case of a convulsive seizure of unknown origin a physician should be sent for at once and the patient prevented from doing himself harm. The clothing should be opened at the neck and the patient placed quietly in bed. If the face is flushed, apply an ice-cap or cold compress to the head. If the face is pale, external heat may be applied. When the patient is able to swallow, a dose of salts should be given. Nurses and trained attendants are usually per- mitted to give a few whiffs of chloroform or a hypodermic of morphin to a patient having a prolonged convulsion. While the use of these powerful drugs without an order from a physician is generally not permitted, it might be justified in such cases. Fortunately, in most cases, convulsions are of short duration and little need be done. After the spasm has ceased a cathartic should be given and the patient kept quiet and warm between blankets. EPILEPSY OR FITS. In common parlance the term "fits" refers to epileptic convulsions. These are due to a state of increased nervous 2:U EMERCEXCY TREATMEXT OF DISEASE iri'itiibility of the hraiii, tlu' cause of which is not clearly understood. Symptoms. — A person who is subject to epilepsy can gen- erally tell when an attack is about to occur by a peculiar .sensation which he experiences. Followin.i; this the face becomes ])ale antl the eyes dull and stariny the fixed iron legs so that it serves as a temporary bed; and, because of the carrying straps, it is well adapted for carrying patients long distances. Its chief disadvantage is that it is unnecessarily heavy for the ordinary emergency work. The methods of impro^•ising stretchers will be referred to later. 1 Drill Regulations and Service Manual for Sanitary Troops, United States Army, 1014. LITTER TRANHPOIiTATION 257 Litter Drills. — It is not al)S()lutcly necessary that a thor- ough knowledge of first aid should include a knowledge of litter drill, but in all field work, in factories, in schools, and in such organizations as the Boy Scouts, a knowledge of a definite drill will enable a given group of men to accomplish much better results in less time than it is possible without some form of drill. The following drill is modified from the Regulations of the Sanitary Troops, United States Army: In the military service, to secure uniformity and precision in the execution of all movements, commands are invariably given in two parts — the first called the preparatory command and the second the command of execution. Except in very few instances no movement is made at the "preparatory command" but all "prepare themselves" at this command to complete the movement in unison at the "command of execution." The litter squad consists of two men — No. 2, counting from the right, is the squad leader unless a special squad leader is designated. In all cases, even with a special squad leader or captain, No. 2 or the rear litter bearer, should watch the movements of the front bearer and time his own. by them so as to insure ease and steadiness of action. The bearers should keep the litter horizontal, notwithstanding any unevenness of the ground. i As nearly as possible, complementary movements are paired. The commands of execution are given in "sal\ll CAPITALS." The squads having "Fallen In" and their position numbers designated the command is given: Procure litter. March. At the command march the No. 2 or 2's^ proceed to the litter or litters and each man puts one on his shoulder and returns to his position in line. 1 When more than one squad is assembled it is customary to execute this movement as follows: Commands: Procure litter. Right (left) face. MARCH. At litter, each No. 2 steps one pace to the front; at face they face as required, and at MARCH proceed in column of files by the nearest route to the litters. They each take one, place it on right shoulder at an angle of 45 degrees, canvas down, and return in reverse order and resume places in rank. 17 258 77»M X SPORT A TION Being in line, litters at the shoulder: Carry. Litter. At Litter, each No. 2 brings his litter to the vertical position, drops the upper handles forward and downward until the litter is in a horizontal position, canvas up, and grasps the outside handle with his right hand; meanwhile No. 1 steps directly to the front until he is opposite the front handles when he grasps his outside handle with his left hand. Being at the carry: Shoulder. Litter. At Litter, No. 2 advances and plants the left foot one pace forward, reaches forward with the left hand and grasps the litter near its center, grasps the right stirru]") A\'ith the right hand, and brings the litter to the vertical position and then to the shoulder, at the same time replacing the left foot by the right; meanwhile No. 1 steps backward and aligns himself on No. 2. Being at the carry: Ground. Litter. At Litter, the bearers stoop and lower the litter to the ground, canvas up, and stand erect, facing the front. Being at the ground: Carry. Litter. At Litter, the bearers stoop, grasp the handles and raise the litter from the ground to the carry. The above movements are only executed with the closed litter. Being at the carry, litter closed. Open. Litter. At Litter, both bearers face the litter and slip the free loop of each sling upon the ring handle, the bight embracing the opposite handle; they then grasp the left handles with their left hands and drop the other handles, the litter being thus suspended by the left pole, canvas to the right. They then fully extend the braces, lower the litter to the ground, canvas up, and stand between the handles, facing the front. The litter being open and lowered: Close. Litter. LITTER TRANHI'OIITATION 259 At LiTTEE, Nos. 1 and 2, respectively, step outside the right front and left rear handles, and face inward; they stoop and with their hands raise the litter by the handle of tlie left pole; they then fold the braces, and bringing the lower pole against the upper, face to the front and support the litter at the carry. To bring the squad into line, the litter being at the ground or the open, with the men at litter posts: Form. Rank. At Rank, No. 1 advances one pace and No. 2 aligns him- self on No. 1. Original positions at the litter are resumed at the command "litter — posts," all executing an about face, proceeding to their posts at the litter, and facing to the front together. This movement permits the marching of the squad, with- out litter, to any desired point. Posts at the litter may at any time be recovered by the commands : Litter. Posts. If at the ground the numbers take posts, No. 1 on the right of the front handles. No. 2 on the left of the rear handles and close to them, facing the front. If at the open, Nos. 1 and 2 take posts between the front and rear handles, 'respectively, facing the front. The foot, or front, of a grounded or opened (unloaded) litter is the end farthest from the advancing squad, unless otherwise designated. The foot of a loaded litter is always the end corresponding to the feet of the patient. In case a permanently (fixed) open litter only is available the closed litter movements must be dispensed with. The commands for the squad with an open litter are alwaj's the same, whether the litter is empty or loaded; in other words, always treat the open litter as if it were loaded. As a rule the patient should be carried on the litter feet foremost, but in going uphill his head should be in front. In case of fracture of the lower extremities he is carried uphill feet foremost to prevent the weight of the body from pressing on the injured part. To maneuver properly with the open litter, litter intervals 260_ TEA XSPORTA TION must he taktMi. Of course, it is ()b\'ious that tliis is necessary only Nvhen more than one htter stjuad is heinj;' (h-illed. The mo\ement is as follows: Beinjr in line, litters at the shoulder: Take litter interval. To the right (left). March. Detachment. Halt. At the command Maiuu Nos. 2 bring their litters to the vertical position, all face to the right (left), and the leading squad steps ofi", Xos. 1 and 2 of each scpiad i)reserving facing distance with relation to each other. When the leading squad has advanced three paces the squad next in order steps oli" following it in column, and so on, until all the squads are marching in the indicated direction, three paces apart. At Halt, all halt and face to the original front, the litters being returned to the shoulder ])osition. This formation is designated "line of litters" regardless of the position of the litter. To asseiuble, being in line of litters, at the shoulder. Assemble to the right (left). March. At ]\Iarcii, the squad on the flank indicated stands fast in position. The other squads face to the right (left), close in as commanded and face to the front. Being at the open : Prepare to lift. Lift. At the first command the bearers without facing about, stoop, slip the slings off the handles and place them over their shoulders; they then replace the free looj) on its handle, adjust tjie length of the slings if necessary, and firmly grasp the handles of the litter; at Lift they slowly rise erect. Being at the lift: Lower. Litter. At Litter, the bearers slowly lower the litter to the ground. Each number then seizes the free loop and bight of his sling, removes the sling from his shoulders, and places the loop on the ring handle, the bight embracing the opposite handle. Being at the lift: Forward. March. The bearers step off", Xo. 1 with the left and No. 2 with the rigid foot, taking short sliding steps of about 20 inches, LITTER TRANSPORTATION 201 to avoid jolting and to secure a uniform motion to the litter. The cadence is at about 100 steps to the miiuite. The marching movements with the htter are very similar to those of the squad in the Army Manuul except that com- mand "litter" replaces that of "fours" and ordinarily a litter squad turns or "wheels" on its own ground. The Loaded Litter. — In moving the patient either with or without the litter, every movement should be made delib- erately and as gently as possible, having special care not to jar the injured part. The command steady will be used to prevent undue haste or other irregular movements. The loaded litter should never be lifted or lowered without orders. The handles of the litter should be held in the hands FiG. 147. — Method of lifting a patient on or off the litter. at arm's length and supported by the slings. Only under most exceptional conditions should the handles be supported on the shoulders. Under exceptional circumstances, as in ascending or descending stairs, when the patient is very heavy, the ground difficult, or an obstacle over 3 feet high has to be surmounted, it may be necessary to use additional bearers. In this case the additional man or squad is aligned on the left, and, when necessary, assigned to any position designated by the squad leader. To load the litter: the litter being at the open: two ways designated : 1. Right (left) side. Posts. At the command Posts the bearers go to the right (left) 202 T RAX SPORT AT lOX side of patient and take ])()sitions, No. 1 at ri'. The back should be sponged with alcohol and well powdered with talcum at least once daily. NURSING METHODS 277 Bed-sores. — In poorly nourished patients who are confined to bed for long periods the pressure of the })ody against the bed may cause the formation of large ulcers on the liips, shoulders, or over the lower end of the spine, liarely these sores may occur on the elbows or heels or at othci- parts of the body. They are usually the direct result of carelessness and neglect. ^^W' :MV m ^ ^^^^^^r ''-'^!«W™ .m. ■«H ^^^^B "i m W^^^^ ^\ 'Si L'-^"^ ' '- ■ A ,^-*^lto^„ --------•-■---^'' ..-^ Fig. 155. — Enormous bed-sore of the back in a patient, aged seventy- eight years. (Ashhurst.) In order to avoid this trouble, persons confined to bed for long periods should be frequently moved in bed so that the same spots are not continually pressed upon and the bed and body kept dry and clean. When a bed-sore is threat- ened, as shown by a slight redness of the skin, the bed should be arranged so that absolutely no pressure comes at the threatened point. This can be accomplished by the use of pillows, air rings, air cushions and other simple appliances. The affected part should be bathed daily with 50 per cent, alcohol. Temperature. — A patient's temperature is taken with the ordinary clinical thermometer. The average normal tem- perature on the Fahrenheit scale is said to be 98. G°. As a matter of fact the temperature varies at different times during the day and is apt to be as low as 97° and is as high as 99° F. in normal persons. A temperature above 99° F. 278 NURSING AND TECH NIC is generally considered to indicate disease, although in a few cases, such as after \'iolent exercise and in very wai-ni weather, a rise to 100° F. may be without significance. "^rhc temperature is most conveniently taken in the mouth, tiu' l)ulh of the thermometer being placed beneath the tongue and kept in place from oiu' to five minutes, depending on the thermometer used. In unconscious ])atients and in cliildren it is better to take the temperature by the rectum. The thermometer bulb is smeared with ^'aselin or other lubricant and inserted into the anus for an inch or more and allowed to remain until the temperature has registered. The rectal tem])erature is usually one-half to a full degree higher than the temperature in the mouth. In some cases the t.emi)erature is taken in the armpit (axillary temperature), but this is unreliable. Of the three methods the rectal is the most accurate and the axillary the least. When the temperature is of great im])or- tance, and in children and unconscious, or delirious, i)atients the rectal method should be used exchisiveh'. The clinical thermometer contains only a slender thread of mercury, which is most difficult to read. In order to over- come this difficulty the thermometers are usually made tri- lateral in shape, the front edge which is curved serving as a magnifying glass which enlarges the thread of mercury. Consequently, to read the level of the mercury it is neces- sary to hold the thermometer directly in the line of vision with the front of the angle toward you. \Yith a little prac- tice the le\'el of the mercury can be easily made out. All thermometers are self-registering. That is, the level of the column of mercury remains at the highest point. Thus a patient may take his temjierature and then place the thermometer aside to be read by the })hysician several hours later. Because the mercury does not return to the bulb of its own accord it must be shaken down before use. This is accomplished by holding the thermometer in the hand and swinging sharply downward, as though "cracking" a whip. In practice the mercury need not be shaken entirely down into the bulb. Usually a point between 90° and 97° is sufficient. NURSING METHODS 279 Some thermometers are graduated according to the centi- grade scale. In this scale 1° equals 1.8° F. As the zero of the centigrade scale corresponds to 32° ¥., to change a centigrade reading to the Fahrenheit multiply by 9/5 and add 32. Conversely, to change F. to C. subtract 32 and mul- tiply by 5/9. For example, to convert 98.6° F. to centigrade: 98.6 — 32 = 66.6 X 5/9 = 37. Pulse. — If the fingers are laid gently on any superficial artery the beat can be felt and counted. This is called the pulse. The radial artery is usually the most convenient for the purpose of taking the pulse. It is located on the thumb side of the wrist and may be easily felt and counted. The pulse should be counted for a minute and the rate given as so many beats per minute. Ordinarily we speak of the pulse-rate as 72 or 80, meaning 72 or 80 beats per min- ute. In addition to the rate, the size and regularity of the pulse should be noted. An intermittent pulse is one that drops a beat occasionally, while an irregular pulse is one which noticeably varies in rate or size. We say that the normal pulse is about 72, but it varies considerably in different people, and in the same person at different times during the day. After exercise the pulse may reach 120 per minute or even higher, but in healthy individuals it should return to normal within a short time. When the pulse is below 60 it should cause suspicion of heart disease, and when above 90 it would suggest the possibility of fever. A pulse which is irregular in either force or frequency usually indicates some form of heart disease. With a tem- perature of 100° we would expect a pulse count of 100 and when the temperature is 103° the pulse is apt to be between 110 and 120. However, these figures are subject to wide variations, such a simple thing as the excitement of a physical examination often sending the pulse to 120 or higher. In children the pulse is normally much faster. The normal rate in infancy varies between 100 to 120 and may rise to 140 or higher during tnild febrile attacks. As the child grows older the pulse becomes slower. Respiration. — The rate of respiration has a definite rela- tion to the pulse, being approximately one-fourth the pulse- 280 NVR.'^IXC; AXD TECIIXIC rate. ^Yhen the rate of respiration is increased, especially when it is increased relatively more than the pulse, it may indicate disease of the lungs, such as pneumonia. In opium- ])ois()nin,»; the res])iration may be very slow, sometimes not over eight per minute. In taking the respiration-rate it must be remembered that breathing is partially controlled by the will, so that if the patient realizes that you are watching him l)reathe he will imconsciously change the rate. It is a good ])lan to take the pulse, and then while still holding the wrist obser\'e the patient's breathing without his being aware of the fact. We may say that breathing is noisy, regular, irregular, quiet, easy, difficidt, using any descri})tive term. Dyspnea means difficult breathing from any cause. Tongue. — The condition of the tongue should be noted. It is clean and moist in health, but in disease may be dry or coated. A coated tongue usually indicates some disturb- ance of the gastro-intestinal tract. In fever the tongue is apt to be dry, and may become cracked and sore if neglected. During sickness the mouth and tongue should be scrupulously cared for, the teeth should be brushed, and an alkaline mouth wash^ should be used after each meal. If the tongue is dry or cracked it should be wiped off' with a mixture containing equal parts of glycerin, lemon juice, and water. BATHS AND BATHING. Baths are given for purj^oses of cleanliness or for purposes of treatment. In general, baths may be given: 1. To cleanse the body. 2. To reduce fever. 3. To cjuiet the nervous system. 4. To induce sweating. Baths may be classified according to temperature as hot ' Bicarbonate of soda solution, 1 teaspoonful to a glass of water, may be used, or almost any of the widely advertised mouth washes may be substi- tuted for the soda solution. The aromatic- flavor of the commercial washes is sometimes desirable. BATHS AND BATHING 281 baths (100° to 105° F.), tepid baths (90° to 100° F.), and cold baths (70° to 85° F.). Naturally, when a patient is not too sick the tub bath should be given for cleansing purposes. It must be remem- bered, however, that the bath may be very weakening, so that when a sick person attempts to take a tub bath a close watch should be kept by the attendant in order to be sure that fainting does not take place while the patient is in the tub. Sponge Baths. — Patients confined to bed should receive a daily sponge bath. In order to give the sponge bath, a rubber sheet covered M'ith a blanket should be placed over the bed in the same manner as has been outlined for changing the lower sheet. The patient is covered with a sheet and the body sponged with a sponge or wash cloth wet in warm, soapy water. One part of the body is washed at a time, rinsed off with clean water and dried before starting on another part. The daily bath is usually given in the morning and the bedding changed after the bath. The sponge bath is sometimes given to reduce temper- ature. When it is given for this purpose the entire body is exposed and the water applied at a temperature of about 80° F. If the patient seems chilly during the bath a little broth or hot milk may be given. Alcohol Sponge. — ^This is very easy to give. It tends to reduce temperature and acts as a sedative to the nervous system. A wash cloth or sponge is wrung out of a mixture of equal parts of alcohol and warm water and used to sponge off the body. To be the right temperature the cloth should feel a little more than tepid to the hand (about 100° F.). In giving the sponge all the covers are removed from the patient but the sheet, and the alcohol is applied to the body beneath the sheet, without exposing the patient. After the front of the body has been well gone over with the sponge the patient is turned over and the remainder of the body sponged in the same way. The body is not dried, the alcohol being allowed to evaporate. In fever patients, a fall in temperature of a degree, or a degree and a half, after an alcohol sponge is not unconunon. 2S2 NVRSIXC AXD TECIIXIC It also often liai)i)ens that after tlio spoii.i2;o the patient, previously nervous and restless, will drop quietly ott" to sleep. Tub Baths. — A hot bath may be given for the purpose of inducing ])erspiration, or for relaxation in certain nervous conditions. Tiie temperature of the l)ath is usually about 10.")° F., and the duration from ten to fifteen minutes. In order to o;i\'e a tub bath properly in typhoid fever a movable tub is required which can be moved next to the patient's bed. Typhoid baths are usually <2;iven at about S()° to 90° F. The patient is carefully lifted into the tub by four attendants and allowed to lie quietly, the head resting on a sui)port at one end of the tub, and a wet cloth applied to the forehead. During the bath the entire body should be rubbed contiiniously, in order to increase the superficial circulation. While in the bath the patient feels cold, the teeth chatter, and the skin turns bluish. If the \n\he grows rapid and weak the bath should be stoi)pe(l. After removing the patient from the tub he should l)e placed in bed on a blanket and I'ubbed l)riskly with a rough towel. A drink of hot broth is then gi\'en and a hot-water bottle placed at the feet. Ice Baths. — In cases of sunstroke, baths may be given as described above, except that the water may be much colder, about 50° to 60° F. In order to keep the temperature low, cold water must be constantly added or a few pieces of ice may be put into the tub. During the bath the rectal temperature should be taken at intervals and the patient removed from the tub while the temperature is still several degrees above normal. The after-treatment is the same as for cold baths. Hot Packs. — These produce sweating nearly as well as hot l)aths, and are less disturbing to the patient. The bed is protected with a rubber sheet, over which a blanket is placed, and the patient's clothes entirely removed. A blanket is now wrung out of hot water (about 120° F.) and the patient wrapped in this wet l^lanket. The blanket when it reaches the patient is usually not more than 1 10° F. Plenty of drinking water should be given, so that the perspiration BATHS AND BATHING 283 will be profuse. The patient is allowed to remain in pack from fifteen to twenty minutes. An ice-cap or cold com- press is kept on the head and the pulse taken at intervals during the pack. If the pulse becomes rapid and weak the treatment should be stopped. After the pack the body is rubbed dry with a towel and the patient left between dry blankets for about an hour. At the end of this period an alcohol rub is given, the body dried, and the patient made comfortable with clean, dry linen. Fig. 156. — A hot pack being given in a case of uremia. Note the arrangement of the blankets. (Hare.) Sweat Baths. — ^There are several methods of inducing sweat- ing by the use of modified hot packs. The simplest consists of placing the patient between blankets surrounded by hot- water bottles (ordinary glass bottles filled with hot water serve very well in an emergency) and then covering him with several blankets. This usually quickly induces sweating. Another method, sometimes called a "rimi sweat," con- sists in surrounding the patient with hot bricks well wrapped in cloths. On these bricks raw whisky or rum is poured and the patient covered with several layers of blankets. The steam from the hot bricks surrounds the patient and soon causes sweating. Care must be taken that the hot steam does not cause burns. 284 NURSING AND TECHNIC Of course the ])atient must be given plenty of water during the sweat and the head must be kept cool, just as during the hot pack. The after-treatment is the same as that after the hot ]);u'k. Ncxcr allow tlie body and bed-linen, wet with perspiration, to remain unchanged for more than an hour or two after the sweat. Foot-baths.— It is sometimes desirable to secure dilatation of the vessels in one part of the body so that the blood may be drawn from another part. Thus, a hot foot-bath is sup- posed to have a fa\'oral)le action in colds in the head and some cases of headache. The patient, well wrapped up, places the feet in hot water, which comes to a level well above the ankles. The water is kept as hot as can })e borne by ])ouring hot water into the tub from time to time and the bath continued for about fifteen minutes. Sitz Baths. — This is somewhat similar to the foot-bath, exce])t that the patient is seated in the water, the level of which extends up o\'er the hips. Medicated Baths. — In some cases, for purposes of counter- irritation or stimulation, other substances may be added to the water. Thus sea salt, or common salt, is valuable in certain diseases, the quantity to be added to the water vary- ing from one to three pounds. Ordinary Epsom salts have recently been advised for the purj)()se of reducing weight. About a pound is added to a tub half-full of water and a twenty-minute bath taken. The value of this treatment is largely due to the hot bath and only slightly to the content of salts. Two or three tablespoonfuls of mustard are often added to hot foot-baths or even to the general bath. It is commonly believed that the counter-irritation adds to the efl'ect of the liot hath. EXTERNAL APPLICATIONS. The Apphcation of Heat. — Heat may be a])i)licd dry or wet. Tlic most common form of dry heat is the hot-water bag. Although in connnon use the correct method of using the hot-water bag is not generally understood. The bag should be only two-thirds full and shcMild never EXTERNAL APPLICATIONS 285 contain boiling water. Patients are frequently burned witli bags containing water which is too hot, so that it is always advisable to test the bag by placing it against the forearm for a short period. If it cannot be borne against th(; skin it should not be placed in the patient's bed, especially if the patient is asleep or only partially conscious. If there are not sufficient hot-water bags at hand, tin cans, glass bottles, or any other suitable receptacles may be used. Hot salt-bags, hot bricks, electric heaters, or dry air may also be used. Recently the ordinary incandescent lamp has been widely used for the local application of heat. Hot-water bags may burst or leak in the bed. They should be carefully tested before use. Hot bricks are heavy and awkward, but they retain their heat for a long time. Moist heat is supposed to be more penetrating and relax- ing than dry heat. It may be used in the form of hot com- presses, poultices, or stupes. Hot Compresses. — Several layers of gauze are wrung out of hot water and applied to the body before they have an oppor- tunity to cool. They may be covered with cotton or oiled silk and left in place for ten minutes or longer, or they may be changed after a few minutes when they begin to grow cold. Stupes. — ^A stupe consists of about two layers of flannel wrung out of hot water and covered with a towel or piece of oiled silk. To wring out a stupe it should be placed in a towel and the water wrung out by twisting the dry end of the towel; or a hem may be sewn in each end of the towel large enough to admit the passage of a thin stick of wood at each end. These two sticks serve as handles with which to wring out the stupes which are lifted from the water with a stick. After it is wrung out, a stupe is tested with the hands and placed in position as soon as the patient can stand it. It should be changed every five minutes. Turpentine Stupes. — These are given exactly as the ordi- nary stupes, except that the counter-irritation is increased by the use of turpentine. The most satisfactory way to apply the turpentine is to wet the surface of the skin with spirits of turpentine before applying the stupes. These 286 . NURSING AND TECH NIC stupes should never be applied continuously, or the skin at the point of treatment will become irritated and inflamed. When continuous action is reciuired the stupes may be used for thii-t\' iiiimitcs (>\'cry three or four hours. Flaxseed Poultice. — This is made by mixing flaxseed meal slowly into boiling water until a thick paste is formed. It is then cooked for about five minutes and removed from the fire and well beaten to make it light. The mass is then spread upon a piece of cotton cloth, forming a layer about one-fourth of an inch in thickness. The excess of cloth should extend about one inch on all sides. This edge is turned over, preventing the spread of the flaxseed, and the surface of the poultice is covered with a i)iece of very thin gauze. The gauze is i)laced against the i)atient's skin, care being taken not to burn him. A poultice may be left in ])lace for about an hour and should never be used a second time. If continuous poulticing is desired the second j)oultice should be ready before the first is removed. If flaxseed is not obtainable, oatmeal or cornmeal may be used. Mustard Plaster. — One part of mustard is mixed with four or hve parts of flour,' sufficient lukewarm ^^'ater being added to make a paste. This mixture is smeared in a thin layer upon a thin piece of gauze and the plaster held in place by a bandage. Never make a mustard plaster with hot water, for by this means part of the strength of the mustard is destro\'ed. The plaster should be left in place until the skin is red- dened — about twenty minutes — and then removed. Never go away and forget the plaster, for if it is left on too long l)listering will surely result. After the plaster has been removed a little vaselin may be applied to the reddened skin. Cold Compresses. — These are very similar to hot compresses, except that they are wrung out from cold water. Consid- erable reaction may be secured from the cold compress applied to the body and then covered with a towel or piece of oiled silk. At first the skin is pale, but after a short period 1 For children the plaster should be weaker, 1 part of mustard to 8 or 9 parts of flour. COUNTER-IRRJTANTS 287 reaction sets in and the skin })ecomes flushed and warm. These compresses should be changed about once an hour. When compresses are applied solely for the effect of cold they should be changed every few minutes because the com- press becomes quite warm after ten to fifteen minutes. The Ice-bag. — ^This is a rubber bag with a large screw top. Small pieces of ice are placed in the bag with a little water and the top screwed on, care being taken to expel all the air before fastening on the top. Never apply an ice-cap directly to the skin. If it is not separated from the skin by the use of thin gauze, or other material, a frost-bite of the skin may result, a so-called "ice- cap burn." The ice-cap, if the skin be protected in the manner just described, may be left on continuously. The ice must be renewed about every two hours. COUNTER-IRRITANTS. These are usually chemicals which, when placed in contact with the skin, cause redness and irritation. They relieve pain and deep inflammation by their action upon the blood- vessels, increasing the circulation not only in the skin but also in the deeper parts. Counter-irritants may cause sim- ply a reddening of the skin (rubefacients) or they may pro- duce blisters (vesicants) . While the ordinary counter-irritants are chemical sub- stances, such as iodin or oil of mustard, yet, under certain circumstances, physical forms of counter-irritation may be used. The simplest form of physical counter-irritation is that due to the rubbing of the skin. We all recognize that many of the small pains may be "rubbed away." In general it is better to rub toward the heart. That is, in such a manner as to empty the superficial veins by rubbing them in the direction of the venous flow. INIassage is simply scientific rubbing. In rubbing a painful area of the body the skin is soon apt to become sore as a result of friction vmless some form of lubricant is used, such as vaselin or talcum powder. 2S& NURSING AND TECH NIC Electricity. — Electricity is anotlicr form of couuter-irrita- tioH. It may be used either in the form of an electric cur- rent or throuj^h the medium of the .r-rays or thermic spark. The action of the .r-rays and electricity is only partially com- prehended and their use is not without danfi;er. They should, consequently, be employed only under skilled direction. The Cautery. — This is sometimes called the actual cautery and is simply a metal instrument heated to a cherry-red color used to relieve pain, to cause absorption of efl'usion, and to control bleeding. In hosi)itals the Paquelin cautery is used. This is an instrument with a platinum tip, hrst heated in the flame of an alcohol lamp and maintained incandescent by a small stream of gasoline or benzine vapor which is pumped into the tip by a small rubber bulb. This is similar to the cautery which has come into po})ular usage in the art of pyrograi)hy. In using the actual cautery the red-hot instrument is made to touch the skin lightly at many separate points over the painful area. The instrument is kept in motion and touches the skin only for a fraction of a second. If this is properly performed the skin will barely be seared and there will be no })lister formation. Cupping. — Dry cups not only cause counter-irritation but actually cause an extravasation of blood beneath the skin. They act through suction caused by the application of a cup containing heated air against the skin, the cooling of the air in the cup causing a vacuum which tends to draw the skin upward into the cup.^r To cup a ])atient about a dozen cujis are required. These are small thick glasses about one-third the size of the ordi- nary tumbler. A swab is made by wrajjping a little cotton tightly about the end of a probe. This is dij)ped in alcohol and lighted, forming a small torch. One of the cups is now taken in the left hand and the burning torch held inside of it for an instant to exhaust the air, after which the cup is placed quickly against the skin and held in place. The skin can be seen to be drawn up into the cup. This procedure is repeated until the required num- COUNTER-IRRITANTS 289 ber of cups are applied. In applying the cuj)S be careful not to get the edges too hot, and not to allow the alcohol to trickle down inside of the cup. A little practice on yourself will soon tell you how long the torch should be left inside the cup, and will demonstrate to you how necessary it is to avoid heating the edges of the cup. To remove the cup, press the skin away on one side, thus allowing the air to enter the cup, which then falls off. Each cup is left in place from three to ten minutes. It is then removed and replaced after exhausting the air again. After use the inside is covered with moisture so that each cup must be dried before it can be reapplied. Cupping may be Fig. 157. — Cups applied to the back. (Hare.) done several times daily, usualh" being carried on over a period of fifteen to thirty minutes at each application. There is no danger in placing a cup several times over the same spot. In some cases the suction may be so great that a black- and-blue spot results. This has no harmful consequences and will disappear after a few days. Wet cups are sometimes given by a physician. They are exactly the same as dry ones, except that small incisions are first made in the skin with a sharp knife. Tincture of lodin. — ^This is a chemical irritant and is applied to the skin with a brush. If the skin is tender it may blister. Ordinarily it is painted on the skin and is allowed to dry, 19 290 NURSlXa AXD TECIIMC reciniriiiix no further ctuv. It sliould l)o ap])lie(l licavily eiiouji;li to give a moderately dec^p brown color. After a few minutes there is a slight hurning sensation. If there is a severe l)urniug sensation it has been used in too strong solution or too much has been applied. The excess should be remo\'ed with alcohol. The action of tincture of iodin as a counter-irritant nuist not be confused with its use in wounds. In wounds it is used solely for its antiseptic properties and in no way for counter-irritation. It is merely a coincidence that it ha])pens to be usefid for both purposes. Liniments. — INIany difi'ereiit liniments are used for counter- irritation. The rul)}>ing that accompanies the application of the liniment often does more good than the liniment. All the \arious liniments contahi some substances which in themselves act as irritants, (liloroform, capsicum, men- thol, and camphor in watery or alcoholic solutions are the substances most commonly used. Chloroform liniment is generally harmless and widely used. It should l)e allowed to evaporate before a bandage is applied, as other\\'ise it may cause blistering. Cantharides, or Spanish fly, is extremely irritating to the skin. It is sometimes used in the form of cantharides plas- ter and left on for six to eight hours, to cause blister forma- tion. If the blister does not occur by that time the canthar- ides plaster should be removed and a flaxseed ])oultice applied. This usually raises the blister promptly. Blisters are seldom used, because they may !)ccomc infected and result in troublesome sores. Ointments. — Many of the drugs (menthol, camphor, oil of wintergreen, etc.) commonly used in the form of liniments may be combined with vaselin or other similar vehicle to form ointments. These may be rubbed into the skin or smeared on and covered with cotton. Because ointments may sometimes be used as counter- irritants it does not follow that all ointments are irritating to the skin. The name ointment sim])ly indicates a semi- solid oily substance which may be ai>plicd to the skin. Ordi- narily, ointments are bland any hoiliiit;. Tu jHTpariug solutions for the i)liysici;m it is well to have two large \essels of boiled water, one hot and another which has been allowed to cool. When needed these may be mixed together so that a solution of the ]>ro])er temperature may be obtained. Antise])ti{' solutions should ])referal)ly be made with boiled water, but when it is not obtainable they may be prepared from ordinary tap water which, as a rule, contains very few l^acterla. Glassware and Graniteware. — Boiling is a suitable method for the sterilization of basins, jars, bottles, glass, graduates, and other similar supplies, but, owing t(i their bulk, it is frequently impracticable to boil them all. In such cases a large tank of bichloride of mercury solution (1 to 1000) is prei)ared and the sui)])lies left in this solution for several hours. If the ware is clean this solution will kill ])ra('tically all the organisms. If desired, weak carbolic acid may be used in the same way. Never place the bichloride solution in direct contact with any form of metal, as the mercury combines with tlie metal, causing rapid corrosion. Towels and Dressings. — In hospitals and surgical supi)ly houses towels and dressings are sterilized in a special appa- ratus called an autoclave, by the use of steam under ])ressure. In emergency practice they are the most difficult form of sup])lies to sterilize satisfactorily. Consequently, it is advisable to carry a sufficient supply sterilized, wra]>ped in cotton, or muslin, covering or in sealed i)ackets, ready for use. The interif)r of such packets remains sterile for a long time. For an emergency dressing a jnece of gauze may be boiled, or wet with 50 per cent, alcohol, })ut this is far inferior to dry gauze. A sterilizing apparatus similar to the Arnold sterilizer may be impro\'ised by making a wire basket which will hang inside an ordinary wash-boiler and placing small packages of dressings or towels, carefully wrapped in a protective covering of muslin, in this improvised basket. Water is then poured into the boiler, which is then covered and placed on the stove. After the water has boiled for at least STERILIZATION 2% an hour the dressings are removed and placed in the oven to dry. When fully dry the dressings are ready for use. Care must be taken not to burn the dressings in the hot oven. Fig. 158. — Autoclave sterilizer used in hospitals. (Brewer.) Hands and Skin. — The sterilization of the hands has already been discussed in the chapter devoted to Wounds. Remember that a thorough scrubbing ^^■ith soap and water is much better than perfunctory dipping in antiseptic solutions. 294 XrRSIXa AM) TKCIIXIC III (ii-(k'r to pivparc the ]);iti(Mit"s skin for minor siiru-ical operations it shoukl be woll washed with soap and water and then ruised ofi' with boiled water followed 1)\ alcohol, or it may be rapidix' i)rei)ared by sim])ly i)aintin.i!; it with tinetnre of iodin. Kemember that after the hand or skin, or anything else for that matter, has been sterilized, it no longer remains sterile after it has been in contact with some non-sterile object. Consequentl\- sterile supplies and utensils should never be handled except after sterilization of the hands. Fig. 159. — Arnold sterilizer for use in private houses and in idiy.sician's office, (Brewer.) Rubber Gloves. — These may be sterilized either by boiling or by immersing in bichloride of mercury solution for an hour or longer. When a great many cases are being dressed, as in the receiving ward of a hospital, rubber glox'cs may be worn and washed in water and then dipped in bichloride solution between dressings. DIET. The diet of the sick depends largely ujxjn the orders of the physician, in attendance. When patients are feverish and sick and there has been no si)ecial diet ordered by the physician it is wisest to give only fluid food. DRUGS 295 The forms of fluids which may ahiiost invariably }>c ^iv(;n without dauber are: clear broth, boc^f tea, orau3 snake, 101 Bladder, 64 injury to, 208 rui)ture of, (i4 Blood l)hster, 213 composition of, 43 jwisoning, 232 Boils, 240 ^ Bones of head, 30 location of, 27 of lower extremity, 34 of upper extremity, 32 wounds of, 147 Boric acid, 78, 297 for eye wash, 240 ohitment, 151 Boxer's ear, 199 Boy scout first-aid case, 25 Brain, 53 injury, 30 Breast, bandage of, 107 Breath, shortness of, 246 Bromide of soda, 296 for epilepsy, 234 Bronchi, 59 Bronchioles, 59 Bullet wounds, 147 liurns, 149 chemical, 153 ice-cap for, 156 infected, 152 severe, 152 treatment of, 151 a-ray, 158 Cai^oaiel, 296 Canal, alimentarj', 01 Cantharides, 290 Capillaries, 48 Car, hospital, 273 Carbolic acid, 297 for bites, 160 burns, 154 as disinfectant, 78 Carbon monoxide jjoisoning, 188 Carbuncle, 242 Carinis, (lescrii)tion of, 33 Carron oil for burns, 151 Castor oil for convulsions, 235 for ptomain poisoning, 228 Catliartics, 29t) for poisoning, 220 vegetable, 2i)6 Cautery, 288 Paquelin, 288 Caustic acid i)oisons, 221 alkali poisons, 222 Cells, air, 59 Cellulitis (jf scalp, 193 Cerel)e]hnn, 54 Cerebrum, 54 Chair litter, 267 Chemical burns, 153 Chest, bandage of, IOC), 107, 109 contusion of, 204 triangular bandage of, 87 wounds of, 204 Chills, 231 in malaria, 232 symptoms of, 232 treatment of, 232 Chin, Ijantlage for, 90 Chloroform, 290 for convulsions, 233 Choking, 184 Circular bandage, 109 Circulation, 49 Clamjis, arterj', 70 Clavicle, 32 dislocation of, 138 fracture of, 125 Clot, 44 Clotting, 45 ('oagulation, 45 Coat litter, 267 Cocci, 75 Coffee for shock, 168 Cold baths, 172 compresses, 286 for throat, 243 use of, 240 INDEX :m Cold to control bcmorrhago, 71 exposure to, 154 pack, 172 water coil, 172 Colds, 243 Colic, 248 Collar bone, fracture of, 125 Colles's fracture, 130 Coma, 174 Command of execution, 257 preparation of, 257 Common emergencies, 236 Compound fractures, 112 Compress, cold, 286 use of, 240 Compression of brain, 196 Concussion, 194 Conjunctivitis, 239 Contusion of abdomen, 205 of chest, 204 of eye, 197 Contusions, 65 Convulsions, 233 in children, 235 from rabies, 160 in tetanus, 164 Cord, spinal, 54 Cords, vocal, 59 Corpuscles, red, 44 white, 44 Cot as litter, 272 Cotton, sterilization of, 78 Cough, 246 Counter-irritants, 287 Counter-irritation for toothache, 238 Cranium, 27 Crepitus, 115 Croup, 244 diphtheritic, 246 spasmodic, 244 tent, 245 Crushing injuries, 208 Cupping, 288 Cups, wet, 289 Death from malaria, 230 Defoi-mity from fracture, 115 Demigauntlet bandage, 100 Diaphragm, 60 Diarrhea, 249 Diet, 294 in al^dominal injury, 207 Diphtheria, 146 Diplococci, 76 Disability from fracture, 115 Disease, bacterial, 77 emergency treatment of, 230 Disinfectants, 78, 297 Dislocation, habitual, 136 persistent, 136 symptoms of, 136 treatment of, 136 Dislocations, 135 Dog bite, 159 Doses of drugs, 295 Dressings, sterilization of, 292 wet, 85 Drills, litter, 257 Drowning, 184 Drugs, 295 Dyspnea, 280 E Ear, bandage of, 103 * boxer's, 199 foreign body in, 200 Earache, 239 Ecchymosis, 65, 116 Elbow, bandage of, 96 dislocation of, 140 fracture of, 127 Electricity, counter-irritant, 288 injuries by, 157 Elevation to control hemorrhage, 71 Emergencies, common, 236 Emergency supplies, 23 treatment of disease, 230 Emetics, 298 P^mphysema, subcutaneous, 204 Epiglottis, 59 Epilepsy, 233 symptoms of, 234 Epsom salts, 296 Equipment, 22 Esophagus, 61 European War, gas poisoning in, 189 Exhaustion as cause of shock, 166 heat, 173 Expiration, 60 Exposure as a cause of shock, 166 302 IXDEX Extension of joint, 40 Kxtornal applications, 284 Kxtroniitics, injuiios to, 208 Eye, bandage of, 102 contusion of, 1V)7 foreifin body in, IDS inHannnation of, 239 pink, 240 wounds of, 198 pAINTINf;. UiS False ])oint of motion. 1 lo Feet, rare of, 212 Femur, 34, 35 Fever, 230 symptoms of, 231 treatment of, 231 Finger bandage, 97 dislocation of, 141 fracture of, 131 infection of, 81 sjmiin of, 146 First-aid case, boy scout, 25 definition of, 17 general i)rincii)lcs of, 17 rules for, 17 household outfit, 25 kits, 23 organization, 25, 26 outfit, 23 packet, U. S. Army, 24 rules for U. S. Troops, 22 squads, 25, 26 members of, 26 team work of, 26 Fish hook, injiuy with, 23 Fits, 233 Flame projectors, 191 Flaxseed poultice, 286 Flexion to control hemorrhage, 70 of joint, 40 Foot, bandage of, 100 baths, 284 dislocation of, 143 fracture of, 135 injuries of, 212 Forearm, description of, 33 fracture of, 128 Foreign body in ear, 200 in nose, 200 in throat, 203 Foreign body in tissues, 211 in windi)ipe, 184 Formalin as disinfectant, 78 Four-tailed bandage, 89 ' Fracture, comitound, 112 j green-stick, 112 I gunshot, 1 13 j impacted, 112 simple, 112 skull, 30 symptoms of, 1 13 treatment of, 1 18 union of, 1 17 Fiactures, 111 Frost-bite, 155 G Gangrene, carbolic, 85, 298 from cold, 150 (largle for sore throat, 243 (ias helmet, ICO poisoning in war, 189 (launtlct bantlage, 99 Gauze, sterilization of, 78 General rules for accident, 20 for first aid, 17 Glassware, sterilization of, 292 Granvilation, SO Green-stick fractures, 112 Groin, lianrlage of, 95 Cndlet. 61 Gum l)oil, 238 Gunshot fractures, 113 injuries, 209 H Habitual dislocation, 136 Hand, l)ones of, 34 infected, 83 preparation of, 79 Head, 27 bandage, 87, 103 bones of, 30 Headache, 236 Healing of wounds, SO Heart, 45 rate, 46 Heat, application of, 284 asepsis by, 77 to control hemorrhage, 71 INDEX 303 Heat exliaustion, 178 Heel, bandage of, 101 Helmet, gas, 190 Hematemesis, 202 Hemoptysis, 202 Hemorrhage, 67 arterial, 68 capillary, 67 cause of shock, 166 control of, 68-74 from bladder, 208 from lungs, 202 from mouth, 201 from nose, 200 from rectum, 208 from stomach, 202 from varicose veins, 68 from veins, 49 internal, 202 subcutaneous, 65 venous, 68 Hemorrhoids, 250 Hernia, strangulated, 207 Hiccough, 242 Hip, bandage for, 88 dislocation of, 143 Hoarseness, 243 Hospital pouch. Army type, 24 train, 272 Hot compresses, 285 packs, 282 Household first-aid outfit, 25 Humerus, 32 Hydrophobia, 160 Hysteria, 176 Ice baths, 282 Ice-bag, 287 for appendicitis, 248 Ice-cap burn, 156 Impacted fractures, 112 Improvised ambulance, 272 Indigestion, 247 Infection, 74 of finger, 81 of hand, 83 of scalp, 193 in war, 75 Inferior maxilla, 30 Inhalations for croup, 245 Injury to brain, 31 Injury cause of shock, 166 to extremities, 208 intracranial, 195 to nerves, 210 Inspiration, 60 Instruments, sterilization of, 78, 291 Internal hemorrhage, 202 Intestine, rupture of, 64 small, 61 Intestines, large, 61 Intracranial injury, 195 Involuntary movements, 51 lodin as antiseptic, 78 burns, 154 as counter-irritant, 287 tincture of, 289, 298 Ivy poisoning, 252 Jaav, dislocation of, 141 fracture of, 125 Joints, 36 classification of, 36 painful, 257 wounds of, 147 Kidneys, 64 Kits, first-aid, 23 Knee, bandage of, 97 dislocation of, 143 Knee-cap, dislocation of, 143 fracture of, 131 Laryngitis, 243 Larynx, 59 Leg, bandage of, 93, 101 bones of, 36 fracture of, 132 Leukocytes, 44 Ligaments, 38 Ligatures, 70 Liniments, 290 Litter, blanket, 267 chair, 267 coat, 267 304 INDEX Litter, description of, 256 drills, 257 improvised, 206 loaded, 261 transportation, 256 Liver, 61 Lockjaw, 163 Lower extremity, bones of, 34 Lung, hemorrhage from, 202 motor, 182 Lungs, 59 M jMagnksia, 296 Malaria, chills in, 232 death from, 230 Mandible, 30 Mangle injuries, 208 Manual, litter drill, 257 Mask, gas, 190 Massage, 287 Mastitis, 239 Maxilla, inferior, 30 ^Mechanical respiration, 182 Medicated baths, 284 Membrane, sj-novial, 38 Meniscus, dislocation of, 143 Menthol, 290 Mercur\-, bichloride of, 297 Metacarpus, 33 Metatarsus, 36 Moles, 252 Mouth, hemorrhage from, 201 wounds of, 201 Movements, involuntary, 51 voluntary, 51 Muscle, rupture of, 212 Muscles, 40 action of, 40 involuntary, 43 painful, 252 voluntary, 43 Mustard plaster, 286 N Nail, splinter beneath, 213 Nasal passages, 58 septum, 58 Nausea, 247 treatment of, 236 Neck, bandage of, 106 Nerve impulse, 55 Nerves, 54 action of, 54 injury to, 210 of skin, 52 Nervous system, 51 Neuralgia, 238 Nose, 58 foreign body in, 200 fracture of, 123 Nosebleed, 200 Nursing mc^tliods, 275 Nux vomica, 296 Oil, mineral, 296 of mustard as counter-irritant, 287 Ointments, 2m Olive oil for burns, 151 Organization of first-aid, 25 Organs, reproductive, 64 injury to, 64 Outfit, first-aid, 23 Packet, first-aid, 24 Packs, hot, 282 Pain from fracture, 113 relief of, 17 Paciuelin cautery, 288 Paregoric for diarrhea, 249 for i)tomain poisoning, 228 Pasteur treatment, 161 Patella, 35 dislocation of, 143 Pathogenic bacteria, 74 Pelvis, contents of, 31, 32 description of, 31, 32 Peritonitis, 205 I Peritonium, 64 j Persistent dislocation, 136 Phagocytes, 44 ! Phalanges of hand, 33, 34 ! of foot, 36 Phenacetin, 296 for headache, 237 Phenol, 297 ' for boils, 241 INDEX 305 Phenol as disinfectant, 78 Physician, necessity for, 19 Physiology, 27 Piles, 250 Pink eye, 240 Plasma, 44 Plaster, mustard, 296 Pneumonia, 232 from exposure, 230 Poison ivy, 252 Poisoning, 214 alcoholic, 225 bicliloride of mercury, 224 carbolic acid, 222 carbon monoxide, 188 chloral, 223 chloroform, 227 caustic acids, 221 alkalies, 222 ether, 227 mushroom, 227 opium, 223 phenol, 222 ptomain, 227, 236 strychnin, 224 symptoms of, 215 treatment of, 215 Poisons, table of, 228 Pott's fracture, 133 Pouch, hospital, 24 Poultice, flaxseed, 286 Pressure for hemorrhage, 69 Ptomain poisoning, 227, 236 Pulmonary artery, 46 Pulmotor, 182 Pulse, 46, 48, 279 Pupils in brain injury, 197 R Rabies, 160 Radius, 32 Rectum, injury to, 208 Recurrent bandage, 101, 104 Red blood corpuscles, 44 Reflex action, 57 Repair of wounds, 79 Reproductive organs, 64, 208 Respiration, 60, 178 artificial, 178 rate of, 60, 279 Respiratory system, 58 Ribs, description of, 31 Ribs, fracture of, 125 Rochellc salts, 296 Roller bandage, 90 Rubber, sterilization of, 294 Rubefacients, 287 Rules for first aid, U. S. Troops, 22 Rupture of muscle, 212 of tendon, 210 of varicose vein, 21 Saline cathartics, 296 Salts, Epsom, 296 for ptomain poisoning, 228 Rochelle, 296 Scalp, bandage of, 87, 90 infection of, 193 wounds, 193 Scapula, 32 description of, 32 Schaefer, artificial respiration, 179 Sedatives, 296 Septum, nasal, 58 Serum, 44 Sheets, changing of, 276 Shock, 166 electric, 157 symptoms of, 166 treatment of, 167 Shoes to prevent foot injuries, 212 Shoulder, dislocation of, 138 Shrapnel wounds, 209 Sick room, 257 preparation of, 275 Simple fractures, 1 12 Sitz baths, 284 Skeleton, 27 Skin, care of, 276 preparation of, 294 Skull, fracture of, 30, 121 Sling for arm, 88 Smoke, suffocation by, 187 Snake bite, 161 Sodium bicarbonate, 297 bromide, 296 Solutions, steriUzation of, 291 Sore throat, 242 Spasmodic croup, 244 Spasms, 233 Special senses, 51 Spica of groin, 95 Spinal column, 31 ;joi) IXDEX S])iii;il conl, ")■} Spine, ilislocation of, \'A7 frarturc dI', 121 Splintor, reiiioval of, 211, 21 o yjilints, liandagc for, b!5 for fractiuT. 119 Sponiio 1 laths, 281 Sprains, 144 Staphylococci, "(i Sterilization, 291 oi cotton. Is of f^au/.e, 7S of instruments, 7S Sterilizer, Arnold, 21)4 improvised, 292 Stimulants, 295 StinuUation for shock, U'S Stomach, hemorrhage from, 202 tui:e, 21G Strain, 211 Stranjiulatcil hernia, 207 Streptococci, 75 Stretcher (see Litter) Strychnin, 296 Stumj), bandage of, 101 Stupes, 2S5 turpentine, 285 Stye, 240 Styptics, 74 Subcutaneous emi)hysema, 204 Suffocation, 177 Sunstroke, 170 symptoms of, 171 treatment of, 171 Supplies, 22 emergency, 22 Supjjuration, 74 l)actcria in, 76 Sweat baths, 283 Sylvester, artificial respiration, ISO Syncope, 168 Synovial membrane, 38 Synovitis, 38 System, nervous, 51 resjiiratory, 58 Table of poisons and antidotes, Tarsus, 36, 37 Temperature, 277 in sunstroke, 170 Tendon, action of, 40 rupture of, 210 wounds of, 210 'i'ent, croup, 245 Tetanus, 163 treatment of, 165 Thermometer, clinical, 278 Thigh, fracture of, 131 Throat, foreign body in, 203 infhunmation of, 242 Tlunnb, dislocation of, 141 sprain of, 146 Til)ia, 34 Tincture of iodin, 289, 298 Toe-nail, ingrowing, 213 Toes, dislocation of, 143 Tongue, condition of, 280 Tonsillitis, 242 Tooth, ulcerated, 238 I Toothache, 237 Tourniciuet, 71 application of, 72 dangers of, 72 I for snake bite, 162 ; improvised, 72 to improvise, 89 wrongly applied, 68 Towels, sterilization of, 292 I'rachca, 59 Train, hosjiital, 272 trans])ortation, 272 Transportation, 255 train, 272 water, 274 wheel, 270 Travois, 269 Treatment, emergency, 230 ^ Pasteur, 161 Triangidar bandage, 86 Trunk, 31 Tub baths, 282 Turjientiiie stupes, 285 U ' Ulcehated tooth, 238 rina, 32 Tnconsciousness, 174 from shock, 166 Union of tract in-{\ 1 17 Upper extremity, bones of, 32 Ureter, 64 Urine, cxx-retion of, 64 U. S. rules for sanitary troops, 22 INDEX :i()7 Valves of heart, 46 Varicose vein, hemorrliage from, G8 rupture of, 21 Vegetable cathartics, 26(5 Vein, varicose, hemorrhage from, 68 Veins, 48 hemorrhage from, 49 Velpeau bandage, 110 Ventilation of room, 275 Ventricle of heart, 45, 49 Vesicants, 287 Vocal cords, 59 Voluntary movements, 51 Vomiting, 247 of blood, 202, 206 to remove poisoning, 216 W War, wounds in, 75 Warts, 252 Water transportation, 274 Wet dressings, 85 Wheel transportation, 270 White blood corpuscl(!s, ruiicfion of, 44 Wounds, 65, 66 of abdomen, 207 about eye, 198 of chest, 204 contused, 66 examination of, 20 healing of, 80 incised, 66 infected, 81, 84 lacerated, 66 of mouth, 201 punctured, 66 repair of, 79 scalp, 195 shrapnel, 209 tendons, 210 treatment of, 66, 82 Wrist, dislocation of, 141 sprain of, 146 X-RAYS for fracture, 117 iKiii-aK5'^"v' ~2:>^^ %