COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX641 72945 RC87 .D74 A manual of instruct RECAP )ICAL BOOKS ,59th St., N.Y "R^^T liT^. in tl|0 flltt^ flf Nem fork lipf^rfttrp ICtbrarg Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/manualofinstructOOdoty General Plan of the Circulation A MANUAL OF INSTRUCTION IN^ THE PRINCIPLES OF PROMPT AID TO THE INJURED mCLUDIKG A CHAPTER ON HYGIENE AND DISINFECTION DESIGNED FOR CIVIL AND MILITARY USE BY ALVAH H. DOTY, M.D. LATE HEALTH OFFICER OF THE PORT OF NEW YORK LATE MAJOR AND SURGEON, NINTH REGIMENT, N. G. N. Y. FIFTH EDITION NEW YORK AND LONDON D. APPLETON AND COMPANY 1913 Copyright, 1889, 1894, 1898, 1902, 1912, By D. APPLETOX AND COMPANY J3 74 Printed in the United States of America *h ip P TO JOSEPH D. BRYANT, M. D., P^ IN ACKNOWLEDGMENT OF HIS HIGH POSITION AS A TEACHER OF ANATOMY AND SURGERY, AND AS A LUCID WRITER AND EXPONENT OF THEIR PRACTICAL APPLICATION^ TRIB MANUAL IS DEDICATED BY THE AUTHOR, PREFACE TO FIFTH EDITION. The fifth edition of this book has been prepared to meet the needs of the more advanced knowledge in medi- cine and snrgery and also to conform more closely to the principles of modern sanitation. Every effort has been made to introduce material which shall be of practical importance in connection with these subjects with the intent to make the book of special value, not only for home use but also in mining districts, manufactories and other places where many persons are brought together and where accidents frequently occur. Alvah H. Doty, M. D. New York City. CONTENTS. CHAPTER I. PAGE Bone- ......... 1 Boxi<> : its composition and function — Periosteum and en- dosteum — Classification of bone — Tlie slieleton — Spine — Bony landmarljs — Slsull — Hyoid bone — Ttiorax — Stex'num and ribs — Scapula — Clavicle — Bones of upper extremity — Pelvis — Bones of lower extremity. CHAPTER II. Joints — Cartilage — Ligaments — Synovial Membrane — Mus- ' CLES ......... 23 Joints : their classification and movement — Cartilage — Ligaments — Synovial Membrane — Muscles — Tendons and aponeuroses — Definition of organs — Glands — Mucous and serous membrane — Excretion and secretion. CHAPTER III. The Blood and Circulatory Organs . . . . .30 Blood : its composition and function — Heart — Pericardium — Circulation of the blood — Endocardium — Blood-vessels. CHAPTER IV. Respiratory Apparatus and Respiration . . . .39 Definition of respiration — Larynx — Trachea — Bronchial tubes — Lungs. CHAPTER V. Alimentation and Digestion ...... 45 Alimentary tract — Mastication — Teetli — Salivary glands — Pharynx — CEsophagus — Stomach — Small and large intes- tine — Liver — Pancreas. ix X CONTENTS. CHAPTER VI. PAGB Kidneys — Bladder — Skix — Spleen . . . . .54 CHAPTER VII. Neevous System . . . . . . . . 59 Cerebro-spinal sj-stem — Brain — Cerebrum — Cerebellum — Pons Varolii — Medulla oblongata — Spinal cord — Cranial and spinal nerves — Sympathetic system. CHAPTER VIII. Bandages, Dressings, etc. . . . . . .68 Bandages : their classification — Material for construction — Methods of application — Roller, Esmarch, or handker- chief bandages — Slings — Knots — Compresses — Tampons — Poultices— Moist and dry heat. CHAPTER IX. Contusions and Wounds ....,•.. 91 Classification and treatment. CHAPTER X. HEMORRHAGE ...... o . . 104 Haemorrhage — Arterial— Venous — Capillary — Means of ar- resting hsemorrhage, and how applied. CHAPTER XI. Fractures ......... 120 Fractures : their classification — Signs of fracture — Method of repair by Nature — Treatment of special fracture — Dis- locations — Sprains. CHAPTER XII. Burns, Scalds, and Frost-bite ...... 140 Burns and scalds : their classification — Treatment of each degree — Frost-bite, and its treatment. CHAPTER XIII. Unconsciousness, Shock or Collapse, and Syncope . . 146 Definition of, and treatment. CONTENTS. Xi CIIArTER XIV. PAGE Concussion and Compression of the Brain — Apoplexy, or Stroke ok I'akalysis— Int(jxication — Epilepsy, Hys- teria, AND Heatstroke or Sunstroke . . . 154 Definition of, and treatment. CHAPTER XV. Asphyxia and Drowning ....... 164 Asphyxia, or suffocation — Treatment — rrevention — Drown- ing — Artificial respiration — Different methods — Sylvester's, Howard's, and Hall's. CHAPTER XVI. Medication . . . . . . . . . 172 CHAPTER XVII. Poisons and Poisoning ....... 176 Varieties of poisons — Narcotics, irritants, and corrosives — Antidotes and treatment. CHAPTER XVIII. Convulsion op Children — Tetanus — Foreign Bodies in Eye, Ear, Nose, Larynx, and Pharynx — Foot-soreness and Chafing ......'.. 189 CHAPTER XIX. Hygiene .......... 197 Baths — Clothing — Food — Water — Air — Exercise. CHAPTER XX. Disinfection ......... 214 Definition — Sulphurous acid gas — Formaldehyde gas — Bi- chloride of mercury — Special disinfection. ILLUSTRATIONS. FIGUEE PAGE 28. Abdominal contents, position of Flint. 50 24. Air-cells and terminal bronchial tubes Flint. 43 G6. Arteries, diagram showing position of important. Pije, modified. Face 109 70. Artery, brachial, digital compression of Esmarch. 115 69. Artery, brachial, line showing course of Tracy. 114 GT. Artery, common carotid, digital compression of. Esmarch, modified. 112 73. Artery, femoral, compression by tourniquet. . Esmarch. 118 72. Artery, femoral, digital compression of Esmarch. 117 71. Artery, femoral, line ..showing course of Tracy. 116 68. Artery, subclavian, digital compression of. Esmarch, modified. 113 84. Artificial respiration : Hall's method : first position. Original. 171 85. Artificial respiration : Hall's method ; second position. Original. 171 82. Artificial respiration : Howard's method ; first part. Original. 169 83. Artificial respiration : Howard's method : second part. Original. 170 80. Artificial respi*ation : Sylvester's method ; first movement Original. 168 81. Artificial respiration : Sylvester's method ; sec- ond movement Original. 168 58. Bandages, cravat, for Land Esmarch, modified. 84 59. Bandages, cravat, for Itnee Esmarch. 84 44. Bandages, four-tailed, for head Esmarch. 75 43. Bandages, four-tailed, for jaw Original. 75 39. Bandages, method of rolling. Reference Hand-hooTc of Medical Sciences. 69 42. Bandages, knotted Esmarch. 74 4.J, 46. Bandages, large square handkerchief.. Esmarch. 76, 77 41. Bandages, spica of shoulder. Reference Hand-hooJc of Medical Sciences. 73 40. Bandages, spiral reverse. Reference Hand-hook of Medical Sciences. 71 xiii XIV ILLUSTRATIONS. IIGFEE PAGE 47. Bandages, triangular, diagram 77 51. Bandages, triangular, for chest, etc, Esmarch, modified. 80 57. Bandages, triangular, for foot Esmarch, modified. 83 48, 40. Bandages, triangular, :&or head.. Esmarch, modified. 78 56. Bandages, triangular, for hip Esmarch, modified. 83 50. Bandages, triangular, for shoulder, hand, etc. Esmarch, modified. 79 52. Bandages, triangular, for shoulder, head, etc. Esmarch, modified. 80 1. Bone, cancellous and compact tissue, arrangement of. Tracy. 2 33. Brain inclosed in membranes Didama. 59 35. Brain, under surface of Tracy. 61 36. Brain, upper surface of Didama. 62 37. Brain and spinal cord Tracy. 65 0. Clavicle (collar-bone) Original. 14 75. Clavicle, dressing for fracture of Pye, modified. 129 18. Corpuscles of human blood, red and white Flint. 31 76. Femur, fracture of ; gun used for temporary splint. Esmarch, modified. 133 13. Femur (thigh-bone) Original. 19 15, Foot, bones of ; . Original. 21 11. Forearm (radius and ulna), bones of Original. 16 21. Frog's foot, web of, magnified Flint. 37 12. Hand, bones of , Original. 17 19. Heart Didama. 32 20. Heart and ribs, relation of Flint. 33 10. Humerus (arm-bone) Original. 15 25. Jaws and teeth Didama. 46 31. Kidney, vertical section of Flint. 55 77. Knot, Gerdy's extension 134 63. Knot, granny Bryant. 85 62. Knot, granny, handkerchief Esmarch. 85 60. Knot, reef Bryant. 85 61. Knot, reef, handkerchief Esmarch. 85 64. Knot, surgeon's Bryant. 86 14. Leg, bones of Original. 20 79. Leg, fracture of : pillow for temporary splint. Original. 136 78. Leg, fracture of ; umbrella for temporary splint. Original. 135 29. Liver Tracy. 51 17. Muscular system Tracy. 26 34. Nerves, cerebro-spinal system Tracy. 60 38. Nerves, sympathetic system Tracy. 66 30. Pancreas (sweet-breads) Tracy. 53 16. Patella (knee-cap) Original. 22 7. Rib, a Original. 12 26. Salivary glands Tracy. 47 8. Scapula ( shoulder-blade) Original. 13 ILLUSTRATIONS. XV FIGURE PAGE 2. Skeleton Tracy. 5 32. Skin, vertical section of Didamu. 50 4. Skull Original. 9 74. Sling, skirt of coat used as a Esmarch, modified. 124 53. Slings, triangular, for arm Esmarch, modified. 81 54. Slings, triangular, for arm Esmarch, modified. 81 55. Slings, triangular, for arm Esmarch, modified. 82 3. Spine, vertical section of Tracy. 6 27. Stomach Didama. 48 65. Suspender, Esmarch's Oriyinal. 108 5. Thorax (chest), anterior view Sappey. 10 6. Thorax (chest), posterior view Sappey. 11 23. Thorax (chest), cavity of, showing position of heart and lungs Didama. 41 22. Trachea and bronchial tubes Sapper/. 40 PROMPT AID TO THE INJURED. CHAPTER I. BONE. Bone is composed of animal and earthy matter ; the former consists chiefly of a material which is converted by boiling- into gelatin, also fat and blood-vessels ; the lat- ter, known as "bone-earth," is composed principally of phosphate of lime. Bone derives its tenacity and elas- ticity from the animal portion, and the " bone-earth " gives to it the necessary hardness. When soup is made by boiling a bone, there is simply a liberation of the gelatin or animal matter; the latter may be extracted, by boiling, from bone two or three thousand years old. In early life the animal part forms about one third and the earthy matter two thirds of bone ; later in life, however, the proportion of phosphate of lime is somewhat increased, and the bone also becomes denser. This will explain why the bones of children are so elastic that, when considerable force is applied, they are apt to bend, like a green stick, rather than break, as in the adult bone under similar circumstances. Rickets is a disease of childhood representing a dimin- ished amount of earthy matter ; in this condition the bones become bent and distorted, the deformities being partic- ularly marked in the bones of the lower extremity, and in the pelvis and chest. 3 PROMPT AID TO THE INJURED. A section of bone (Fig. 1) shows it to be composed of two kinds of tissue — compact, which is exceedingly dense and hard like ivory; and cancellated or "spongy" bone, which is a network of thin plates and columns of bone. The com- pact tissue constitutes the outer por- tion of bone, and is very much in- creased where great strength is re- quired, as in the shaft of the femur or " thigh-bone." The cancellated tissue is internal, and especially abundant where bone expands to form large surfaces for support, as in the extreinities of the bones of the thigh, legs, etc. Cancellated tissue is not only very light, but very strong ; a portion, correspond- ing in size and shape to a piece of loaf or cut sugar, will support a weight of three or four hundred pounds, while a square inch of com- pact tissue, about one half inch in thickness, will support a weight of five thousand pounds. Bone is twice the strength of oak. In the skull, where great strength is necessary to support and protect the brain, we find two layers of com- pact tissue : the external portion, known as the " outer " table, and the internal as the "inner" table, with a small amount of cancellated tissue, known as the diploe, existing between them. The long bones are hollow. This condition admits of the proper length, diameter, and strength, while it greatly diminishes the weight. Tlie " medullary " or " hollow canal " in the shaft, and Pie. 1.— The right femur, or thigh-bone, sawn in two lengthwise. Showing ar- rangement of compact and cancellous tissues. BONE. 3 the cancellated tissue of the extremities of long bones, also the cancellated tissue of other bones throughout the body, contains a substance called marrow or "oil of bone." In the medullary canal it is called yellow marrow, and is composed of about ninety-six per cent of fat, while the "red marrow," which is found in cancellated tissue, is three fourths water and contains but a trace of fat. The medullary canals in the bones of birds communicate with the lungs and contain air instead of marrow, thereby ren- dering" them very light and properly adapted for flight. Bone is supplied with nutrition from two sources ; the periosteum^ and the nutrient arteries. The periosteum is a fii'm and resisting fibrous membrane, pinkish in color, which is adherent to the bone, and covers it at all points except where cartilage exists. This membrane is a struct- ure in which blood-vessels divide, subdivide, and pass into minute openings in the compact tissue, supplying it with nutrition. The cancellated tissue and medulla receive their nutrition from larger vessels (nutrient arteries), w^hicli are branches of the main arteries in the vicinity of the bone, and pass through the compact tissue to their des- tination. When the periosteum is removed from the bone, the compact tissue is deprived of its principal means of nutrition, and death or " necrosis " (corresponding to gan- grene in soft tissues) is apt to ensue. This may happen in disease, or as the result of an injury, jDarticularly to super- ficial bones such as the tibia, bones of the head, etc. A familiar example is a " felon," which demands immediate and special treatment at the hands of the surgeon. When bone is in the normal condition and properly covered with periosteum, it feels smooth and moist, and when struck with a probe it gives a dull sound ; but when the periosteum is removed, it feels rough and hard, and striking it with a probe produces a metallic sound. It is important to the surgeon to recognize these different condi- tions, and be thus easily enabled to decide whether the periosteum is present or absent. 4 PROMPT AID TO THE IXJURED. The endosteum is a tliin, fragile membrane wliicli cor- responds in nutritive function to tlie periosteum, and lines the medullary canal in the long bones. Bones are supplied with nerv^es and lymphatics or ab- sorbents. The lymphatics have been known to remove by ab- sorption ivory pegs used to hold in place the broken ends of a bone which would not unite by the natui'al process. The shape of a bone depends upon the function it per- forms. Bones ai'e divided into long^ short, flat, and ir- regular. The long bones, of which the femur or ''thigh- bone " is a type, are composed of a shaft and two extremi- ties, and. with their muscular attachments, act as levers, and also for support. The short bones are found where a number of joints are required for limited motion com- bined with strength. An example of this class is the carpus or wiist. The flat bones are used in the construction of cavities and to protect their contents, and are also for muscular attachment, as the bones of the skull, the shoulder-blades (scapulgei. etc. Examples of the irregular bones are the upper and lower jaw (superior and inferior maxillary), and the vertebrae. The skeleton (Fig. 2), which represents the bones in their prox)er relations, is the framework to which the soft structui'es of the body ai'e attached. It consists of a cen- tral column (the spine) ; four extremities : two upper (the arms), and two lower (the legs); and three bony cavities: (1) the cranium or skull, containing the brain ; (2) the thorax or chest, containing the heart and lungs ; and (3) the iDelvis or basin, containing the pelvic and some of the abdominal organs. The skeleton is comi^osed of two hundred bones. There are several small bones found in the tendons of muscles, at the union of the skull-bones, and also in the eai% which are not included in this enumeration. This number is divided in the following manner : Fig. 2.— The skeleton. PKOMPT AID TO THE INJURED. The spine or vertebral column.. ,...., 26 Cranium S Face 14 Os hyoides, sternum, and ribs , 26 Upper extremities 64 Lower extremities 62 The spine (Fig. 3), wliicli is about one third the length of the body, is a jointed column consisting of a series of bones (vertebrae) articulated or joined together, forming three slight curves. It supports the skull and its contents, and protects the spinal cord, which is contained in a canal formed by the union of the bony parts. At its base the column rests upon the upper ]3ortion of the pelvis — betv^^een the "haunch-bones." A vertebra consists of two impor- tant parts — a body, in front, and a posterior portion or vertebral arch. The bodies are piled one upon the other for support and strength, the arch behind forming, by its junction with the body, a canal for the passage of the spinal cord. Between the bod- ies of the vertebrae are found layers or pads of a very elastic and flexible substance, known as " intervertebral cartilage," which forms a soft cush- ion for each vertebra to rest upon. Its elasticity prevents or diminishes shock, and also tends to restore the column to its erect position. Continued pressure on this substance during the day diminishes its thickness, consequently a person will lose about half an »^^^\ Fig. 3. — The spine, sawii in two lengthwise. BONE. 7 inch in height during this period ; the rest and recum- bent position of the night restore it to its previous condi- tion. It is important to remember that leaning too much on one side, as at a desk, will cause a permanent change in the cartilage, so that the vertebral column may be ab- normally bent to one side without the bone being primarily involved. The curves in the vertebral column assist in forming cavities for the reception of important organs. It is said that the curves increase the strength of the column ten- fold ; they also aid in destroying shock. The twenty-six bones comprising the vertebral column are divided in the following manner, viz. : Cervical or neck 7 Dorsal or back 12 Lumbar or loins 5 The sacrum, which represents five vertebrae (in fcetal life) fused into a single bone 1 The coccyx or " crupper," which is formed from four bones 1 26 The freest movement in the vertebral column is found in the neck or cervical region, and the least movement in the back, between the shoulders, the spine here being con- nected with the ribs. The weakest part of the spine is at the last dorsal vertebra, and this portion of the vertebral column is very movable. It is very essential to know that different elevations on the surface of the body (bony prominences, etc.) indicate the situation of certain important internal organs ; thus the vertebral column furnishes valuable information. Rubbing the fingers briskly up and down the spine will produce sufficient friction to redden the skin over the bony prominences known as "spinous processes." These pro- cesses are formed by the union posteriorly of the sides of g PROMPT AID TO THE INJURED. the vertebral arches abeady spoken of. With the body- bent forward and the arms folded across the chest, the spinous processes can be made even more apparent. The spinous process of the seventh or lowest cervical vertebra is particularly prominent, and has received the name of "vertebra prominens," and should be carefully sought for, as it will aid in locating others. The lower or inferior angle of the scapula or " shoulder- blade "'' is on a level with the interval between the seventh and eighth dorsal vertebra?. Having located the spinous processes of the different vertebrae, the following points are to be remembered, viz. : Interval between Sixth and Seventh Cervical Spines. — (Esophagus and trachea begin. Seventh Cervical. — Apex or upper part of lung ; con- sequently a knife, or bullet wound, above this line, unless carried downward, would not injure the lung. Third Dorsal. — Upper border of arch of aorta. Fourth Dorsal. — Arch of aorta ends ; upper level of heart ; division of trachea into two portions ; right and left bronchus. Eighth Dorsal. — Left side, lower level of heart. Ninth Dorsal. — Left side, lower end of oesophagus, passing through diaphragm ; upper or cardiac opening of stomach and upper edge of spleen. Tenth Dorsal. — Left side, lower level of lung. First Lumbar. — About the middle of kidneys ; lower edge of spleen. The skull (Fig. 4) is the case for the lodgment and pro- tection of the brain and its membranes, and important blood-vessels and nerves. It is composed of twenty-two bones, enumerated in the following manner : Cranium (8 bones).— Occipital, 1; parietal, 2; frontal, 1 ; temporal, 2 ; sphenoid, 1 ; ethmoid, 1. Face (14 bones).— Nasal, 2 ; superior maxillary, 2 ; lachrymal, 2; malar, 2; palate, 2; inferior turbinated, 2; vomer, 1 ; inferior maxillary, 1. The cranial bones protect the brain, and are uniformly BONE. Occipital. Fig. 4.— The skull. strong and compact; while the hones of the face contain principally the organs of special sense, and give the proper symmetry to this portion of the skull, some of them are extremely thin, and are readily broken. The different bones of the skull are connected by sutures or " seams," and the overriding of these bones lessens the size of the head during birth, and x^ermits variations, in size, for some little time afterward. The f ontanelles, or " soft spots " on an infant's head, cor- respond to the subsequent points of union of two or more bones of the cranium, which have not become fully hard- ened or ossified, but still retain the character of the mem- 10 PROMPT AID TO THE INJURED. brane or soft structure from whicli the cranial bones are originally developed. These spots disappear when the bone becomes f ull^^ develox3ed or ossified, which generally occurs within one and a half or two years after birth. A large opening exists at the base of the skull in the occipital bone, called the " foramen magnum," for the trans- mission of the spinal cord from the brain to the canal in the spinal column. Other and smaller openings are found in the skull which transmit blood-vessels and nerves. The skull is supported by the vertebral column. The first cervical vertebra is firmly attached to the base of ihe skull at the " foramen magnum," while the second cervical acts as a piv- ot, having a vertical or upright portion, called the " odontoid " process, which fits into the first cervical vertebra, and around which the head ro- tates. The hyoid bone is an arch, something like a horseshoe, which is placed above the prominence on the front of the neck called the pomum Ad- ami, or " Adam's ap- ple," and aids in sup- porting the tongue, and gives attachment to certain muscles. The thorax or chest (Figs. 5 and 6) is the bony frame-work which contains the heart, lungs, and important blood-vessels and nerves, It is formed Fig. 5.— Thorax, anterior view (Sappey). 1, 2, 3. Pternum : 4. circumference of the upper portion of the thorax : 5. circumference of the base of the thorax ; 6. first rib ; 7, sec- ond rib ; 8, last two, or floating ribs ; 9, costal cartilages. BONE. 11 by the sternum in front, and the ribs and vertebrae at the side and back, and is sepa- rated from the abdom- inal cavity by a mus- cular partition known as the diaphragm or "midi-iff." The sternwn or '■ breast - bone " is a fiat and narrow bone about seven inches long, situated in the front of the chest, and supporting the clavi- cles or '' collar-bones " and the ribs, with the exception of the last two ribs. The ribs (Fig. 7) are twenty - four in number, twelve on each side, and are numbered from above downward. They articulate posteriorly with the dorsal vertebrae, and the upper ten connect in front with the sternum by means of cartilages (costal cartilages), which are interposed between the ends of the ribs and the sternum, and allow of greater motion and elastic- ity. The two lower ribs, the eleventh and twelfth, are simply connected with the vertebrae, and are known as "floating" ribs, as they have no attachment in front. The peculiar arrangement and attachment of the ribs ren- der them a very important element in respiration ; during this act the ribs are elevated and depressed bj^ the action of the respiratory muscles. When the ribs are elevated during inspiration, the thorax or chest is enlarged and air passes into the lungs ; in expiration the ribs are de- FiG. 6.— Thorax, posterior view (Sappey). 1, 1, spinous processes of the dorsal vertebrae ; 2, 2, laraiiiifi of the vertebrae ; 3, 3, trans- verse processes ; 4, 4, dorsal portions of the ribs ; 5, 5, angles of the ribs. 12 PROMPT AID TO THE INJURED, pressed, the cavity diminislied in size, and the aii' in the lungs is ex- pelled. The elasticity of these bones is illustrated by the fact that chil- dren in Arabia use the ribs of cam- els for bows. Upper extremities. — Each upper extremity is composed of thirty-two bones, and includes the following : scapula, clavicle, humerus, radius, ulna, eight carpal bones, five meta- carpal bones, and fourteen phalanges. The scapifZce, or "shoulder-blades" (Fig. 8), are thin, flat, and triangular bones, which have on their posterior and upper part an elevation or ridge knowTi as the " spine " ; the external extremity of the spine is the acro- mion process, which connects with the outer end of the clavicle. The outer and upper portion of the scap- ula forms the glenoid cavity or "socket" which receives the ball- shaped head of the humerus or " arm- bone." The scapula, in this manner, assists in the formation of the shoul- der-joint. It also furnishes broad sur- faces for the attachment of muscles, and aids in protecting the contents of the thorax. The clavicles or "collar-bones" (Fig. 9), shaped something like the italic letter /, are on the anterior and upper part of the chest, and extend from the upper }3ortion of the ster- num or "breast-bone" to the acro- mion processes of the shoulder- BONE. 13 blades referred to above ; they hold the shoulders upward, backward, and outward. When a clavicle is broken the Fig. 8.— Left scapula, or shoulder-blade. arm drops downward, forward, and inward, its support be- ing gone. Manual labor increases the size, strength, and curvature of the clavicle. The collar-bone is less curved in women than in men. l_j. PROMPT AID TO THE IXJURED. The humerus or "arm-bone '' (Fig. 10) is the longest and strongest bone of the upper extremity. It has a shaft and two extremities : the upper extremity is the largest part of Fig. 9. — Anterior surface of left clavicle, or collar-bone. the bone, and consists of a head joined to the shaft by a very short and constricted x^ortion called the "anatomi- cal " neck. The head is globular in form, covered with cartilage, and articulates with the glenoid cavity of the scapula, already spoken of, forming with it a ball-and- socket joint. The cartilage covering the head protects it and prevents undue friction in the joint. At the point where the anatomical neck joins the shaft are found two rough eminences called tuberosities, which are for muscu- lar attachment. Just below the tuberosities is another constriction — the " surgical " neck — so called from the fact that it is the most common site of fracture of the upper extremity. The shaft is partly cylindrical, prismatic, and flattened, and roughened for the attachment of muscles. The lower extremity is a broad and flattened (from before backward) portion of the bone which articulates with the ulna principally, and to a certain degree, with the radius of the forearm, these three bones forming the elbow-joint. The humerus has a greater range of mo- tion than any other bone in the body, and is oftener dis- located. The radius and ulna (Fig. 11) are the bones that con- stitute the forearm. The radius, so called from its fancied resemblance to BONE, the spoke of a wheel, is the external bone lying parallel with the ulna when the palm of the hand is turned up- ward. It resembles other long- bones in having a shaft and two extremities. The up- per or lesser extremity forms only a small portion of the el- bow-joint, while the lower ex- tremity, w^hich is broad, forms the wrist-joint by articulat- ing with two of the carpal or wrist bones. The low^er end also articulates with the cor- responding portion of the ul- na. The shaft of the radius is more or less irregular and rough for the origin and in- sertion of muscles. The ease with which the forearm and hand may be turned with the palm down (" pronation "), and with the palm up ("su- pination "), is due to the pe- culiar articulation of the up- per end of the radius with the ulna. The upper end of the radius (or head) is somewhat knob-shaped,with a depression or excavation on its ux^per surface ; the excavation artic- ulates with a small portion of the lower extremity of the humerus, and represents the limited part it takes in the formation of the elbow-joint. f.V: -^^' A^y o— i Trochlea. Radial Head. Fig. 10. — T.ef t humerus, or arm-boue PROMPT AID TO THE INJURED. Artie, with Semi-lunar and Scaphoid of Carpus. Fig. 11. — Left radius and ulna, or bones of the fore-arm. Below tlie portion of the radius just described is a constricted portion, called tlie neck ; a ligament in the form of a loop, named the orbicular ligament, is thrown around this part, and attached to the outer side of the ulna ; this ligament, while it holds the radius in position, al- lows the neck of the ra- dius, which it encu'cles, to freely rotate. The ulna, which is composed of a shaft and two extremities, is the companion of the radius, and situated internal to it ; the lower extremity is very small, and, although connected with the radi- us, has no articulation with tlie carpal or wrist bones, consequently it does not enter into the formation of the wrist- joint ; but the upper end is large, and contains a depression or cavity which receives the lower extremity of the humer- us. The prominent point of the elbow is the ex- treme end of the ulna, and is known as the "olecranon process" of BOXE. Articulate with Radius forming Wrist-Joint. 17 Ctrpua. Metacarpus Phalanges Fig. 12.— Bones of the left hniid. Palmar surface. 18 PROMPT AID TO THE IXJUREB. the ulna or " funny-bone," so called from tlie peculiar sen- sation experienced wlien the ulnar nerve, which is closely associated with the inner border of this process, is struck. The upper extremity of the ulna and the lower extremity of the humerus make up the elbow-joint — that is, the prin- cipal part of it ; while, as already described, the upper end of the radius articulates with a small and less important part of the lower extremity of the humerus. The carpus or wrist (Fig. 12) consists of the following small and irregular bones, arranged in two rows : the up- per, composed of the scaphoid, semi-lunar, cuneiform, and pisiform, and the lower row, of the trapezium, trapezoid, OS magnum, and unciform. The large number of bones constituting the carpus, and having so many small joints, increases its strength, motion, and elasticity. They also diminish shock and the tendency to fracture, which would be frequent if the wrist were composed of one bone. The carpus supports the hand and preserves its symmetry. The metacarpus (Fig. 12) consists of five long bones (metacarpal), connecting the carpus with the bones of the fingers and thumb ; they form the bony framework of the palm and back of the hand. The phalanges (Fig. 12) are miniature long bones, hav- ing a shaft and two extremities, and are foui'teen in num- ber, three for each of the fijigers and two for each thumb ; their position can be easily demonstrated by bending the fingers. The bases of the fii^t row of phalanges articulate with the heads of the metacarpal bones ; the remaining phalanges articulate with each other. "When the hand is open, the fijigers do not correspond in length ; but when closed, in grasping an object, there is no apparent differ- ence. If the fijigers when closed were uneven, the grasp- ing power would be diminished. The thi'ee rows of pha- langes grow progressively smaller toward the end of the fingers. The pelvis or " basin " supports the trunk and protects the pelvic, and a portion of the abdominal organs. It is BONE composed of the two innom- inate or "haunch" bones, the sacrum, and the coccyx ; the last two have been described with the spinal column. The innominate bones (Fig. 2) are situated one on each side and in front, and form the greater portion of the pelvis, while the sacrum and coccyx form the posterior portion. On the outer side of an innominate bone is found a depression or socket, known as the cotyloid cavity or ace- tabulum, corresponding in function to the glenoid cav- ity of the scapula, which re- ceives the head of the femur or "thigh-bone." The femur (Fig. 13) is the longest and strongest bone in the body ; its length is characteristic of the human skeleton. In the erect posi- tion, the tips of the fingers reach to about the middle of the thigh, while in the orang- outang, the fingers reach to the ankle. This depends also on the comparative short- ness of the arm in the human skeleton. The femur is divided into a shaft and two extremities, the upper extremity being composed of a globular head, Outer Condyle. Inner Condyle. Fig. 13.— Right femur, or thigh-bone. 20 PROMPI AID TO THE IXJURED. whicli is connected ob- liquely with the shaft by quite a long neck ; at the j)oint where the neck joins the shaft there are two prominences, the higher being the larger, and on the outer side of the bone, and called the gTcat trochanter, the smaller one being on the inner side, and somewhat below, known as the lesser trochanter. The eminences are for the in- sertion of muscles. The head of the femur is con- tained in the cotyloid cav- ity or acetabulum of the innominate or haunch bone. The long neck of the femur keejjs the shaft at the jjroi^er distance from the pelvis, prevents any interference with its action, and allows greater motion. The shaft of the femur is almost cylindri- cal, and furnishes sur- faces which are some- what roughened for the origin and insertion of muscles. The lower ex- tremity is very large and broad, articulates with the upper extremity of the tibia or leg-bone and Fig. 14. — 'Right ifbia or shm-ljoiie, and Sbula or !?p]mt-boi)e. Anterior surface. BONE. 21 the patella or knee- cap, and forms the knee-joint. The femur ar- ticulates \vith the pelvis, tibia, and pa- tella. The tibia, or ''shin- bone " and Jib u J a or " splint - bone " (Fig. l^t) are the bones of the leg. and have the characteristics of long bones. The tibia, wliich is very superficial in front (having only the skin as a cover- ing), is the lai'ger of the two bones, and is consti'ucted mainly for strength, and sup- jDorts the f emiu' : it also furnishes attach- ment for a few mus- cles. The dii'ection of the tibia is verti- cal. The fibula is the companion - bone of the tibia and is ex- ternal to it. It is about the length of the tibia, and is very sKm. and helps to support the tibia and form the ankle-joint. Fig. 15. Dorsal surf ace. 22 PROMPT AID TO THE INJURED. and also furnishes the origin of a number of important muscles. The patella or "knee-cap " (Fig. 16) is situated in front of the knee-joint ; it is in the tendon of a muscle, and as- sists in protecting the joint, and also aids in properly extending the leg. When the leg is ex- tended and the muscles are re- laxed, it will be found that the patella is freely movable. The tarsus or "instep" (Fig. 15) corresponds to the carpus in the upper extremity, and consists of seven bones (tarsal), viz. : cal- caneum or os calsis, astragalus, cuboid, navicular, internal cunei- form, middle cuneiform, and external cuneiform. The metatarsal (Fig. 15) bones correspond to the meta- carpal bones in number (Fig. 12), and in a general way to their description. The phalanges (Fig. 15) are fourteen in number, and arranged in the same manner as the phalanges of the hand. Fig. 16. — The patella, or knee cap. CHAPTER II. JOINTS— CARTILA G E— LIGAMENTS— S YNO VIAL MEM- BRANE—MUSCLES. JOINTS. Bones are joined at different points, constituting articu- lations or " joints " ; some are immovable, as joints of the skull ; others slightly movable, as joints of the spine ; while the remainder are freely movable, as the knee and shoulder joints, joints of the fingers, etc. The movable joints are divided into four kinds : 1. Joints having a gliding movement ; as the tarsus and carpus. 2. Ball-and-socket joints, as where a globular head is received into a cup-like cavity, and admitting of motion in all directions, as shoulder and hip. 3. Hinge-joints, where the motion is limited to two directions ; forward and backward, as the elbow. 4. Pivot joints, where rotation only is permitted, as the joint between the atlas and axis and the joint between the radius and ulna. Other varieties of joints sometimes described are sim- ply modifications of the above. Joints admit of the following movements : flexion, ex- tension, rotation, adduction, abduction, circumduction. Flexion takes place when the forearm is bent upon tlie arm, the leg upon the thigh, etc. ; and extension, when these parts are extended or straightened ; rotation occurs when a part is turned in and out ; adduction is illustrated by the movement which carries the arm or leg toward the one of the opposite side or toward the median line of the body ; abduction, the movement in the opposite direction ; 24: PROMPT AID TO THE INJURED. circumduction is exemplified when the arm is swung in a circle, as at the shoulder- joint. The following structures enter into the formation of a joint, viz. : bone, cartilage, ligaments, tendons, synovial membrane, blood-vessels, and nerves. CARTILAGE. Cartilage or "gristle" is a very firm and dense sub- stance, found principally in joints, and covers the ends of bones entering into their formation ; it protects the adja- cent bony surfaces against friction, and also prevents shock which would occur if the bones were directly ap- plied to each other. The continued pressure brought to bear on cartilage would render it subject to pain, inflam- mation, and disease if it were supplied with nerves and blood-vessels ; consequently, cartilage has no nerve- or blood-supply, and is known as the non- vascular tissue; it absorbs its nutrition from the surrounding tissue by a process known as " imbibition." Cartilage connected with ribs has already been described (see Ribs). Cartilage is also found in tubes such as the air-passages, ears, nose, etc., where it is necessary that these channels should be kept permanently open. LIGAMENTS. Ligaments are of two kinds, viz., the white fibrous and the yellow elastic. The white fibrous ligaments are composed of bundles of white fibrous tissue which are closely interlaced ; they are found at the movable joints, and serve to connect the extremities of the bones forming an articulation ; they are inextensible but very flexible and strong, and, while they admit of the free movement necessary at the joint, they do not allow the articular ends of the bones to be abnormally displaced. When a dislocation occurs, the ligaments are either ruptured or torn from their attachments. The liga- ments composed of yellow elastic tissue are extremely ex- tensible, and are fewer in number than those composed of JOINTS, LIGAMENTS, MUSCLES, ETC. 25 white fibrous tissue. Examples of this variety are the ligaraenta subflava and the ligamentum nuchae. The latter extends from the spinous process of the seventh cervical vertebra to a protuberance on the occipital bone at the base of the skull. It is rudimentary in man, but well developed in animals, where it aids in suj)porting the head, and acts as a substitute for muscular power. The " ligamenta subflava " are small ligaments of the same tissue (yellow elastic) connected with the different verte- brae composing the spinal column ; their action is similar to that of the ligamentum nuchas, and assist in bringing the vertebral column to an erect position. SYNOVIAL MEMBRANE. The synovial membrane is a delicate structure con- nected with movable joints and covering the inner side of the ligaments. It is not found between the articular sur- faces of the bones composing the joints. The synovial membrane secretes a thickish, glairy fluid, resembling in appearance the white of an egg, and it is known as sy- novia or "joint oil," which, passing into the joints, lubri- cates the cartilages and prevents friction. The synovial membrane may become inflamed as the result of injury or disease, producing stiffness of the joint, or anchylosis. MUSCLES. Muscles are bundles of reddish-brown fibers having the power of contraction, and are divided into two kinds, viz., voluntary or striped, and involuntary or unstriped ; the terms striped and unstriped refer to the microscopical ap- pearance of the fibers composing the muscle. The voluntary muscles are under the control of the will, and comprise the bulk of the muscular system ; they are attached to the different parts of the skeleton, and act on the bones as levers ; they are the agents of locomotion and of the movements of all portions of the body; they also protect the different structures beneath them, and give 26 PROMPT AID TO THE INJURED. Fig. it.— The muscular system. JOINTS, LIGAMENTS, MUSCLES, ETC. 27 grace and symmetry to the form (Fig. 17). When mus- cles become diminished in size or illy developed, the per- son is angular or bony. The lean meat used for food is muscular tissue. Muscles are of different lengths and shapes — long, short, broad, etc. The}^ are arranged in pairs — that is, there are corresponding muscles on each side of the body, although some exist singl}^ There are over four hundred nmscles in the human frame. In many situations the outlines of muscles are apparent to the eye, and are utilized as guides to the location of important blood-vessels and nerves. Muscles are surrounded by a thin, web-like tissue known as fascia, which serves as a support for them and allows of their movements without undue friction. Muscles are composed of a belly and two extremities. The more fixed extremity is called the origin, and the movable one the insertion ; however, in some muscles the origin and insertion are equally movable. During con- ti^action their origins and insertions approximate, and mus- cles shorten and thicken ; this can be illustrated by raising a heavy weight with the hand, when the biceps muscle in the arm will be seen to thicken and bulge forward. Mus- cles gradually diminish in size toward their extremities, the muscular tissue being replaced by an extremely firm and resisting substance called white fibrous tissue, consti- tuting a tendon. The tendons are directly and intimately connected with the periosteum covering the bone, and sometimes directly with the bone. They differ from muscular tissue in ap- pearance — being white and glistening. An aponeurosis is simply an expanded tendon, and is found where the muscle has a broad attachment. Muscles are abundantly supplied with blood-vessels, nerves, and lymphatics, but tendons have few blood-vessels and only those of the largest size have nerves. The nerves connected with the muscles transmit to them a stimulus from the brain and spinal cord, which 28 PROMPT AID TO THE INJURED. calls their function into action. In the disease known as tetanus, or " locked- jaw," the stimulus is sometimes so great, and the contraction so intense, that the muscular fibers are ruptured. The stiffness that ensues after death (rigor mortis) is due to a solidification of some of the fluid portions of the muscle, which is succeeded after a short time, however, by relaxation of the body. It is said that this rigidity is not present, or only very transient, in one killed by lightning. If a muscle is not suflBciently used it becomes dimin- ished in size (atrophy), and from continued non-use may undergo degeneration, from which there is no recovery ; consequently a muscle should not be confined or unused too long. Hypertrophy represents the opposite condition to atrophy, the muscles being increased in size, and may be the result of constant exercise ; it is often noticeable in athletes. The contraction of a voluntary muscle is very rapid and abrupt. The involuntary or unsti'iped muscles are not con- nected with bones, but form the muscular ]>ortion of the stomach, intestines, and other mternal organs, and also the muscular coat of the blood-vessels. The contraction of this form of muscular fiber is slow, unequal, and does not affect all portions of tne muscle simultaneously. The involuntary muscles are not, as a rule, under the control of the will ; they have no tendons ; the muscular fibers simply interlace with each other. Although the muscular fibers of the heart are striped, like voluntary muscular fibers, this organ is an involuntary muscle, and not under the control of the will, this being the only exception to the rule. Reference will frequently be made in the following chapters to organs, glands, mucous and serous membranes, and also to secretion and excretion, so then for the sake of convenience these terms will now be explained. An organ is a part of the animal organism having a JOINTS, LIGAMENTS, MUSCLES, ETC, 29 special 'function to perform, as the brain, heart, stomach, kidneys, etc. A gland is an organ, but it also has the additional function of abstracting from the blood, material which it discharges from the body unchanged (excretion), as urine, or, it manufactures from certain parts of the blood, a fluid (secretion) which has a particular function, as the gastric juice. Mucous and serous membranes line the interior of cavi- ties, sacs, tubes, etc. Serous membranes, except the peri- tonaeum in the female, hue cavities and tubes which are closed and have no communication with the outer world (examples : pericardium pleura, and peritonaeum) ; while mucous membranes line structures which open exter- nally (examples : respiratory and alimentary tracts). Both membranes secrete a small amount of fluid, which keeps their surface moist and pliable, and prevents fric- tion ; in addition to this, some mucous membranes have small glands in their structure which produce a secretion having a distinctive function, as the mucous membrane lining the stomach, which secretes the gastric juice. A secretion is a fluid formed in and by a gland or organ for a special purpose. It is peculiar to the organ that produces it and is found in no other part, and conse- quently never exists in the blood ; examples : gastric juice, bile, etc. An excretion represents certain material which is always present in the blood, composed principally of waste matter ; it is not formed in the excretory organ, but is simply removed 'from the blood and discharged from the body. The urine is an example of an excretion, the kidneys being excretory organs. Some organs have both excreting and secreting func- tions ; the liver is an example of this type. CHAPTER III. TEE BLOOD AXB CIRGVLATORY ORGANS. Blood is the great nutritive fluid, of the body. It dis- tributes to the different tissues material necessary for their proper maintenance and activity. It supplies heat and also oxygen, receiving the latter from the air. It is absolutely necessary that the tissues should be constantly furnished with oxygen, otherwise death would ensue from suffoca- tion, as in drowning. The blood has also the important function of removing from the body through certain or- gans, principally the kidneys, lung-s and skin, worn-out and waste matter, which, if retained in the body, would produce serious disease or death. Blood is composed of a liquid and a solid portion. The liquid portion or " plasma," which constitutes about two thirds of the blood, is almost colorless when separated from the solid matter or "corpuscles," and contains the principal elements of nutrition, which it distributes to the different tissues in its course throughout the system, receiving in return waste material which is to be discharged from the body. The corpuscles or solid portion float in the plasma. They are divided into three kinds, viz., red corpuscles, leuco- cytes or white corpuscles, and those known as blood plaques. The red corpuscles are by far the most impor- tant and numerous ; they resemble in appearance a thick coin which has been made thin in the center on both sides, or biconcave. These little bodies are exceedingly small ; thirty-five hundred of them laid side by side on their flat surface would be required to cover the space of one inch. They are, of course, not visible to the naked eye. When examined by the microscope they appear straw-colored ; but when vast numbers are crowded to- gether, as in the normal condition of the blood, they give THE BLOOD AND CIRCULATOUY ORGANS. 31 to it the cliaracteristic red color. Physiologists have cal- culated that there are over fifty billions of them in the human body. The red corpuscles are the agents that re- ceive oxygen from the air in the lungs and distribute it to the tissues throughout the body. The white corpuscles are larger than the red (about ^^V^ of an inch in diameter), and are globular in form. The blood plaques are exceed- ingly small, only about ^ji^ to -roio^ of an inch in diam- eter ; both the plaques and the vv^hite corpuscles are much fewer than the red corpuscles, and their normal function is not defin itely known (Fig. 18). The amount of blood in the human body represents about one twelfth to one thirteenth of its weight. It is an alkaline fluid, and somewhat heavier than water. Arterial blood, or that which has been purified in the lungs, is of a bright red color, while the venous blood is purplish. Some tissues, such as the hair, cartilage, nails, etc., are not supplied with blood, but receive their nutrition by ab- sorption (imbibition) from surrounding parts. Coagulation, which occurs when a blood-vessel is opened, is an effort of Nature to arrest haemorrhage. It also takes place in the blood-vessels in certain abnormal conditions of the blood. Blood circulates throughout the body by Fig. 18.— Human red-blood corpuscles, and two white corpuscles. 32 PROMPT AID TO THE INJURED. means of blood-vessels, which are divided into arteries, veins, and capillaries. The motive power or force that propels the blood through these vessels is furnished by- contractions of the heart. THE HEART. The hearty which is likened to a pump, is a hollow, muscular organ, conical or pear-shaped, about the size of a closed fist, four or five inches long, three inches through, and weighs about eight to twelve ounces (Fig. 19). It occupies a position in the tho- rax or chest, just be- hind the sternum or " breast-bone," and between the lungs, but mainly on the left side. The large end or " base " of the heart is directed up- ward and toward the right side, while the smaller end or " apex " is down- ward and to the left. A line drawn across the sternum at the upper border of the cartilage forming the extremity of the third rib would in- dicate the base of the heart. The ajDex is found in the space between the fifth and sixth ribs, three and a half Fig. 19. — The heart and large blood-vessels. A , right ventricle ; . B, left ventricle ; C, right aui'icle ; D, left auricle ; B, aorta ; F, pul- monary artery. THE BLOOD AND CIKCULATOKY ORGANS. inches to the left of the middle line. At this point the pulsation' of the heart may be distinctly felt (Fig. 20). i •: \ — -... f \ A ■■•-. //' \:\:JJ : V-J "V^. Fig. 20.— Heart and ribs, a, 5, c, d, e, ribs ; 1, 2, 3, 4, 5, intercostal spaces ; X, position of nipple (fourth rib). The heart contains four cavities or chambers — two au- ricles and two ventricles ; the auricles are above and the ventricles are below, or, the heart may be divided into a right and left side, each having an auricle and a ventricle. The ventricles do not connect with each other, nor do the auricles, but an auricle connects with the ven- tricle of the corresponding side. The openings between these cavities are guarded by the auriculo-ventricular valves, and they are so arranged that the blood may pass from the auricles to the ventricles ; but it can not in the normal condition return. If this were possible, the circu- lation of blood would be constantly interfered with. The 4 34 PROMPT AID TO THE IXJURED. ventricles are larger than the auricles and their walls are stronger, particularly the walls of the left ventricle, which drives the blood received from the lungs throughout the en- tire system. The auricles contract simultaneously ; the con- traction of the ventricles follows immediately afterward. Between the end of the contraction of the ventricles and. the beginning of the contraction of the auricles is a pause which it is estimated gives the hearthalf rest and half work. This double action represents a pulsation of the heart, of which there are from sixty to eighty during the minute. The heart and also the beginning of the great vessels at the base of the heart are surrounded by a closed sac (the pericardium) composed of fibrous tissue and lined with a serous membrane. The inner wall or visceral layer of this serous structure is adherent to the heart ; between it and the outer or parietal layer exists more or less of a space, being better marked at the lower portion. The serous membrane lining the space secretes a fluid, of which there is usually about one or two teaspoonf uls present, thus keep- ing the membrane soft and moist, and limiting friction when the two surfaces rub against each other during the action of the heart. The broadest portion or base of the pericardium, which is the outer layer, corresponds in situ- ation to the apex of the heart. This arrangement prevents any interference with the movement of the apex of the heart, which would ensue if the apex or smaller portion of the pericardium were below. The base of the pericar- dium is attached to a portion of the upper surface of the diaphragm or " midriflP." The circulation of the blood in the system is effected in the following manner : The venous blood throughout the body is collected by two large veins — the superior and inferior vena cava ; the superior vena cava receiving the blood from the head, upper extremities, and parts above the diaphragm, while the inferior vena cava collects the venous blood from those parts below the diaphragm. These vessels are connected with and discharge their con- TUE BLOOD AND CIRCULATORY ORGANS. 35 tents into the right auricle, wliicli then contracts, and the blood'is forced into the right ventricle through the right auriculo- ventricular opening. The contraction of the ven- tricle which follows, closes the valves guarding this open- ing ; the blood, being then unable to return to the auricle, is forced out of the ventricle into a large blood-vessel which is continuous with the latter cavity ; valves also guard the opening into this vessel. The latter divides into two branches, which carry the blood to the lung; after reaching these organs, the branches grow smaller and exceedingly numerous, and at last they become mi- nute vessels known as capillaries, which surround the air- vesicles of the lungs. The venous blood has now been carried from the heart to the lungs, and it is at this point that the blood in the capillaries surrounding the air- vesi- cles frees itself of carbonic-acid gas, and receives in re- turn oxygen from the air contained in the vesicles. The blood is now changed in character : the color, instead of being blue or venous, is red or arterial, and thus enriched and purified, and in the condition to nourish the tissues, it is carried from the lungs to the left auricle of the heart by four large blood-vessels, continuous through the me- dium of the capillaries which surround the air-vessels with the blood-vessels which carry the venous blood from the right ventricle, and which have been already referred to. The left auricle, after receiving the blood from the lungs, contracts and its contents pass into the left ventricle, which, being filled, immediately contracts and forces the blood into the aorta and closes the left auriculo-ventricu- lar valve, thus preventing the return of the blood to the auricle. The opening from the ventricle into the aorta is also protected by valves which bar the return of the blood to the ventricles. The aorta, which begins at the left ventricle, is the main artery of the body, and through it passes the arterial blood into the smaller arteries and cap- illaries throughout the system. In these latter vessels the nutrition contained in the blood is fiiven direct to the 36 PROMPT AID TO THE INJURED. tissues, and the blood receives in exchange the waste ele- ments which are to be discharged from the body. After performing this function, the blood passes from the capil- laries into the veins, the latter discharging their contents into the right auricle through the superior and inferior vena cava, as already described ; the blood has then made the circuit of the body, or, in other words, the circulation is completed. The heart is endowed with enormous power. Tlie strength developed in twenty-four hours would raise a ton- weight about one hundred and twenty-five feet from the ground. A very smooth and delicate membrane (the endocar- dium) lines the heart, and is continuous throughout the vascular system, forming the internal coat or lining (endo- thelium) of the arteries and veins, and is the only coat of the capillaries. THE BLOOD-VESSELS. The blood-vessels, by which the blood is carried through- out the system in response to the contraction of the heart, are divided into arteries, capillaries, and veins. Arteries. — Arteries are the vessels that carry blood from the heart. The aorta (the largest artery in the body), which is the beginning of the arterial system, is connected with the left ventricle, the contents of which pass through the aorta into the smaller arteries, and thence into the system. The walls of arteries are comxDOsed of three coats or layers, the external, the middle, and the internal. The external coat consists of white fibrous tissue, which is very strong and tough, and protects the vessel. The resistance of the fibrous coat is well illustrated in the phenomena that follow the ligation, or tying, of an artery. The liga- ture, which is passed around the vessel and tightly drawn together and tied, to occlude the artery, may sever the middle and internal but leaves the external coat prac- tically intact. The middle coat is composed of mus- THE CLOOD AND CIRCULATORY ORGANS. 37 cular and yellow elastic tissues, which exert a normal mean pressure upon the contents of the vessels, and regu- late the blood-supply to the different parts of the body. The yellow elastic tissue is the principal cause of the greater thickness of the walls of the arteries compared with veins; it also accounts for the elasticity which is characteristic of arteries, and the fact that arteries remain open when empty. The latter condition gave rise, years ago, to the belief that these vessels contained air, and they were accordingly named arteries, or " air- carriers." Arteries pulsate, and, when opened, the blood escapes in spurts or jets, the color being scarlet. Capillaries. — When arteries become very small iand lose their external and middle layers, they consist of but one coat, and are known as capillaries. These vessels are often so minute that the red blood-corpuscles, in order to pass through them, are obliged to " double up " and pass through one by one. The thinness of the capillary walls, and the slow and uniform current of blood in these ves- Fio. 21.— Web of frog's foot, magnified, a, a, veins ; b, b, arteries, with capil- laries between tbein 38 PROMPT AID TO THE INJURED. sels, enable them, as has already been described, to give direct to the tissues the elements of nutrition which they contain, and receive in exchange the waste of the body (Fig. 21). Veins. — Veins carry blood tovjard the heart. These vessels, like arteries, are composed of three coats, the ex- ternal and internal being similar to arteries. The middle coat, however, contains but very little yellow elastic tis- sue, which accounts for the comparative thinness of the walls of veins, and also the fact that they collapse when empty. Veins, with the exception of those in the cranial, tho- racic, and abdominal cavities, are supplied with valves, which are formed by a duplication of the internal coat, and allow the blood to flow in but one direction — toward the heart. This is essential, as the current of blood in veins is mainly upward, toward the heart and against the force of gravity ; and also as the pressure of blood in the veins is only about one fourth that of arteries. Sometimes the valves are rendered useless, and distention and distor- tion of the vessel occur, as in varicose veins of the leg. This condition is associated with more or less prominence and deformity of the vein. CHAPTER IV. RESPIRATORY APPARATUS AND RESPIRATION. Respiration is the function wliich provides for the proper entrance of oxygen into the blood, and the exit from the blood of carbonic acid and certain waste matter. The respiratory apparatus for the transmission of air to the lungs includes the following structures : the mouth and nose, larynx, trachea, bronchial tubes, and air vesi- cles or cells, the lungs being chiefly composed of the lat- ter. An examination of the throat will show two open- ings, the back or posterior one being the upper part of the oesophagus or "gullet"; in front of this, and just behind and below the base of the tongue, is the upper part of the windpipe, known as the larynx (Fig. 22) » The larynx is a cartilaginous box, containing fibrous bands, stretching from before backward, two on each side, superior and inferior, and called vocal cords. The upper or superior pair have no special function that is at present known. The lower or inferior cords are extremely impor- tant; the vibration of these during expiration produces the voice. The larynx may be easily located ; externally the prominence known as the " Adam's apple " forms the up- per portion, the lower border being about one inch and a half below. The opening into the larynx is covered by a leaf-shaped piece of cartilage, known as the epiglottis, which prevents food and other substances from entering the windpipe. The trachea or " wind-pipe " is the continuation down- ward from the larynx of a tube about four or five inches 40 PROMPT AID TO THE IXJURED. n ^'iG. 22.— Trachea and bronchial tubes (Sappey). 1, 2, larynx ; 3, 3, trachea ; 4, bifurcation of the trachea ; 5. right bronchus ; 6, left bronchus ; 7. bron- chial division to the upper lobe of the right lung ; 8, division to the middle lobe ; 9, division to the lower lobe ; 10, division to the upper lobe of the left lung ; 11, division to the lower lobe ; 12, 12, 12, 12. ultimate ramifica- tions of the bronchi ; 13, 13, 13. 13, lungs, represented in contour ; 14, 14, summit of the lunsrs ; 15, 15, base of the lungs. long and three quarters of an inch in diameter, composed of cartilaginous rings, fibrous membrane, and a small amount of muscular tissue. These rings have the same use as the RESPIRATORY APPARATUS AND RESPIRATION. 41 cartilag-e forming the larynx — to keep their respective walls separated at all times. The trachea begins opposite the interval between the spinous processes of the sixth and seventh cervical vertebruc and ends at the level of the spinous process of tlie fourth dorsal vertebra, where it divides into two branches, the right and left bronchus. These tubes after entering the lungs divide into a great number of branches, or bronchial tubes, which further di- vide and subdivide until they become exceedingly minute and end in little pouches known as air-cells or vesicles, which are very small and numerous and will be again referred to in describing the lungs. The respiratory tract is lined throughout by a mucous membrane, which is kept moist and prevents friction during the passage of the air through the tube. The construction of this mem- FiG. 23.— Showing the relative position of heart and lungs in the cavity of the chest. 42 PROMPT AID TO THE INJURED. brane in its upper portion is peculiar, inasmuch as it has little hair-like processes which are constantlj^ waving toward the outer world, assisting in preventing the en- trance into the lungs of dust and other irritating particles. The lungs (Figs. 22 and 23) are two pyramidal or cone- shaped organs, longer in the back than in the front, situ- ated in the chest, each weighing about twenty ounces, the right one being a little heavier than the left. They are divided by deep fissures into lobes, the right lung having three and the left two lobes. The small or upper portion or apex, extends to or just above the clavicle or collar- bone ; the larger or lower portion or base, descends in front to about the sixth rib, on the side to the eighth, and in the back to the tenth. Each lung is covered by a closed sac called the pleura, one of its layers being adherent to the lung and the other lining the chest- walls. The cav- ity of the pleura contains a small amount of fluid, to pre- vent friction during the action of the lungs. The lungs are composed of millions of air-cells or pouches, about one two-hundredth of an inch in diameter, which are the ter- mination of the bronchial tubes (Fig. 24). The enormous space represented by the air-cells would, if spread out, cover an area of about six hundred square feet. This will give some idea of the vast surface exposed to the air pass- ing into the lungs. The walls of the air-cells and of the capillaries surrounding them are so very thin that the in- terchange of gases readily takes place. It is here, as has already been explained, that the purification or change from venous to arterial blood occui's. The respiratory act, of which there are from sixteen to twenty per minute, consists of inspiration and expiration. During inspiration the air is carried into the lungs by the descent of the diaphragra, which exerts a suction -force, and by the ele- vation of the ribs, which increases the size of the chest. Expiration, or the expulsion of air from the lungs, is effected by elevation of the diaphragm, descent of the ribs, and a partial collapse of the lungs. Although these are the principal agents of inspiration and expiration, there RESPIRATORY APPARATUS AXD RESPIRATION. 4,3 Fio. 24.— Terminal bronchial tubes ending in air-cells. are other elements, notably the assistance of certain mus- cles, which, although of lesser importance, aid this func- tion ; and, when there is difficulty in breathing, as in some diseases of the lungs, the action of the auxiliary muscles about the neck and shoulders becomes very apparent. The lungs during life are never entirely collapsed, this being prevented by about one hundred cubic inches of air which can not be expelled, and is called "residual air." Another hundred cubic inches of air, known as " reserve air," usually remains in the lungs after expiration, and is used by these organs during any increased physical ex- ertion, as in I'unning, etc., which requires an extra amount of air. 44 PROMPT AID TO THE INJURED. The " tidal air " represents the amount of air taken into the lungs at each ordinary inspiration, and consists of thirty cubic inches. During violent exercise, however, an additional one hundred cubic inches is taken into the lungs at each inspiration, and is known as " comj)leniental air.'' The extreme capacity of the lungs would, conse- quently, be the sum of the residual (100), reserve (100), tidal (30), and complemental (100) volumes of air, amount- ing to three hundred and thirty cubic inches. The " vital capacity " or " respiratory capacity," however, is the amount which can be breathed out after the deepest possible in- spiration, and would include, therefore, Complemental air - - - 100 cubic inches. Tidal air ----- 30 " Eeserve air - - - - 100 " Total 230 cubic inches. The air which we breathe is composed of two gases — oxygen (21 parts) and nitrogen (79 parts). There are also, in varying quantities, vapors, traces of ammonia, etc., the amount depending on location. It is the addition of poi- sonous elements to the air, as in large cities, or where bad sanitary conditions exist, that furnish the causes of cer- tain diseases. CHAPTER V. ALIMENTATION AND DIGESTION. The alimentary tract or canal comprises the several structures or organs through whicli food and drink pass to be properly digested and absorbed. That portion of the food or material which is not needed for nutrition, or can not be acted upon by the different secretions, is discharged from the body. The alimentary canal, which is about thirty feet long, begins at the mouth ; then follows the pharynx or " throat ; " below it is the oesophagus or " gullet," then the stomach, then the small and large intestine, the canal terminating at the lower end of the latter, at the external opening called the anus, the "fundament," or "body." These structures will be spoken of separately in their order from above downward. Other organs upon which the function of digestion depends, and which are con- nected with and discharge their secretions into the aliment- ary tract, will be described in their proper connection. Mastication is the first step in digestion. This takes place in the mouth, and is performed by the teeth,* which are so fashioned and arranged that the food may be cut, torn, and ground, showing that man is adapted to all kinds of food. In animals, such as the cow, that secure their food principally by grazing, the molars or " grinders " are particularly well developed, while in dogs and animals that depend principally upon meat for sustenance, the sharp or tusk-like teeth called canines are very promi- nent, and enable them to tear the meat from the bone. The teeth are inserted in the superior and inferior maxil- ■^ The covering or enamel of which is the hanlest structure in the body. 46 PROMPT AID TO THE INJURED. lae, or tipper and lower "jaw-bones," along their edge, or alveolar process. There are thii'ty-two teeth in all — six- teen in each jaw — and arranged in the manner shown m the diagram (Fig. 25). That portion of a tooth iDroject- ing beyond the gums is called the crown ; the root is imbedded in the bone. The crown is covered with enamel, the hard- est structure m the body, which protects the teeth andpreventsthem from wearing out as the result of the friction dur- ing mastication. Acids, if used too freely or too strong, are very destructive to the enamel, dissolv- ing out the lime of which this structure is com- posed. The use of acids is often indi- cated for medical treatment ; in this case, immediately after the acid is taken the mouth should be washed out with a solution of bicar- bonate of soda (common baking soda), which neutralizes the acid. The teeth cut up and grind the food so that all parts of it may be exposed to the different digestive secretions. Im- proper mastication, or an absence of teeth, will be followed by imperfect digestion. As mastication progresses, the Fig. 25.— The jaws and the teeth. 1, 2, incisors; 3, canines ; 4, 5, bicuspids : 6, 7. 8. molars ; a, vein ; 5, artery ; c, nerve ; d, vein, artery, and nerve. ALIMENTATION AND DIGESTION, 47 food is made soft and wet by an alkaline secretion known as saliva or " spittle," which is secreted ])y three salivary glands— parotid, submaxillary, and sublingual. These open by small ducts into the mouth (Fig. 20). The par rotid is the larg- est one, and is situated behind the angle of the jaWo The charac- teristic deform- ity in the dis- ease known as " mumps " is the enlargement of this gland. The secretion of the parotid is used mainly to moist- en the food, while that of the submaxillary and sublingual is more viscid or Salivary glands (Tracy). slippery, coating and allowing it to pass down the oesopha- gus to the stomach with great ease. In reptiles, where there is no mastication, it is this slimy secretion that en- ables them to swallow substances of very large bulk. Sa- liva also acts chemically on food and changes a part of the starchy matter into sugar. During mastication the cheeks, lips, and tongue keep the food between the teeth. The pharynx, or throat, is the continuation of the mouth, and has no special digestive action while the food is in this portion of the tract. The oesophagus, or gullet, the next portion, is a muscu- lar tube about eight or nine inches long, and is collapsed when not in use. It begins at the lower border of the pharynx, opposite the, interval between the spines of the 48 PROMPT AID TO THE INJURED. sixth and seventh cervical vertebrge, passes downward through an opening in the diaphragm, and becomes con- tinuous with the cardiac end of the stomach opposite the ninth dorsal vertebra. This tube by its muscular action accelerates the passage of food downward to the stomach. The stomach (Fig. 27) is one of the j)rincipal organs of digestion. It appears to be a dilated portion of the aliment- ary canal. In shape it some- what resembles a bag-pipe, hav- ing a greater and lesser curvature it lies crosswise in the abdomi- nal cavity, and has two open- ings, one on the left side, which is continuous with the lower end of the oesophag-us in the vicinity of the heart, and called the cardiac opening, the other or pyloric opening being on the right side ; this opening is the beginning of the small intestuie, and is guarded by a valve-like constric- tion, the pylorus, or " gate-keeper." The stomach is about fourteen inches long, five inches in diameter, and weighs four ounces ; its capacity being about five pints. It is composed of three coats or layers : the external, fibro-serous ; the middle, muscular ; and the internal, mucous. The external coat prevents friction dur- ing the movement of the stomach and also adds strength. The muscular portion produces the movements necessary for the proper digestion of the contents of the stomach. The internal coat or mucous membrane is the most impor- tant layer. In the substance of this membrane are found numerous little glands which open upon the surface of YiG. 27.— The stomach. ALIMENTATION AND DIGESTION. 49 the membrane. These peptic or gastric glands secrete the gastric juice, which is so necessary to digestion. When foods begin to enter the stomach, the contents of these glands, which are considerable, appear on the surface of the membrane, the muscular coat becomes active, and the food is manipulated in such a manner that all portions of it shall be acted upon by the gastric juice. The food is then changed in character and made to assume a uniform mass, part of which in a fluid state is absorbed by the capillaries of the stomach, the remaiiider passes down to be digested and absorbed in the small intestine. The po- sition and shape of the stomach change considerably, par- ticularly during digestion, and consequently can not be well mapped out externally. However, the upper or car- diac opening is at the left of the middle line of the body, just below the level of the junction of the seventh costal cartilage and the sternum. The stomach is collapsed when empty, but when full it lies immediately against the abdominal walls, and also presses upward, and may interfere with the action of the heart and lungs. The distress that often occurs after a full meal is often due to distention of the stomach. The gastric juice is an acid secretion, differing from all of the other digestive fluids, which are alkaline. There is a large quantity secreted in twenty-four hours, probably about fourteen pints. The small intestine (Fig. 28), the most important organ of digestion, is the next portion of the alimentary tract, and begins at the pyloric extremity of the stomach. It is a tube about sixteen feet long and one inch in diameter, and composed of the three coats arranged in the same manner as the coats of the stomach. It is divided into three portions : the first and shortest portion being called the duodenum, which is about eight inches long ; this is followed by the second portion or jejunum ; the last por- tion being known as the ileum. The jejunum is generallj^ empty after death, and receives its name from this fact. In the mucous membrane of this portion of the canal 5 50 PROMPT AID TO THE INJURED. Fig. 28. — Position of abdominal contents. are found glands yielding secretions wliich tend to dis- pose of certain articles of food incompletely digested, or unaffected by tlie secretion of the stomach.. The large intestine begins on the right side of the body, and is continuous with the ileum, or final portion of the small intestine, and, in its construction, is similar to that portion of the canal, although its diameter is considera- bly larger. It is di\dded into ascending^ transverse, and descending colon, sigmoid flexture, and rectum, the lat- ter terminating at the opening known as the anus. The ALIMENTATION AND DIGESTION. 51 digestive power of the large intestine is very feeble. It is mainly a temporary receptacle for undigested and refuse matter which is to be discharged from the body. The trans- verse colon, which lies a little above the umbilicus or " navel," is often the seat of intense pain known as " colic." The liver (Fig. 29) is the largest organ in the body. It is situated in the abdominal cavity, below the diaphragm and above the stomach, principally on the right side, its long- FiG. 29.— Under surface of the liver, showing the gall-bladder and a section of blood-vessels. est diameter being from right to left. This organ, moder- ately filled with blood, weighs about four pounds, and its dimensions are about as follows : Transverse, ten inches ; antero-posterior, six inches ; vertical, three inches. The surfaces of the liver are smooth and the edges are rounded, and it is of a dark-brown color. In the normal or healthy condition the liver extends downward on the right side as far as the lower border of the ribs. However, under 52 PROMPT AID TO THE INJURED. certain conditions, as in tight lacing, it may be pressed below this point. Above and on the same side the liver extends to about one inch below the nipple. It also reaches to the left side of the median line of the body an inch and a half to two inches beyond the margin of the sternum and downward to midway between the lower end, of the breastbone and the " navel."' The liver has three distinct and separate functions : First, it renders very im- portant aid to digestion, through the action of the bile which it secretes. It also produces sugar, which becomes chemically changed and helps to generate the body-heat ; and, finally, it discharges from the body a small amount of waste matter, or, in other words, it excretes as well as secretes. The glands of the skin also secrete as well as ex- crete. The bile, already referred to as the secretion of the liver, is a yellowish-brown alkaline fluid, and very bitter to the taste, and is discharged from the liver through a small tube, about the size of a goose-quill, which opens into the duodenum, or first portion of the small intestine ; in this manner it reaches the food upon which it is to act. Connected with the under surface of the liver is a pouch or sac about four inches long and one inch in width, called the gall-bladder (Fig. 28). It is formed of fibrous tissue and lined with mucous membrane, which is continuous with that lining the bile-ducts. The gall-bladder acts as a reservoir where bile accumulates, being expelled during digestion, when a large amount is required. The secretion of bile is continuous, although it is only discharged into the intestine during digestion. The pancreas or '• belly sweet-bread " * (Fig. 30) is a * " There are three kinds of sweet-breads, viz. : the thyroid-gland, or throat sweet-bread, which is tough, almost like India-rubber; the pancreas, or belly sweet-bread, which is more tender, and is quite com- monly used; and the thymus-gland, or breast sweet-bread, which exists only in young animals, wasting away as they grow up. The thymus- gland, situated just behind tlie upper portion of the breastbone,, at- tains its greatest size in human beings at the age of two years, and disappears before the sixteenth year. Its use is not known. This ALIMENTATION AND DIGESTION. 53 glandular organ situated at the upper and back part of the abdominal cavity, opposite the fii'st lumbar vertebra, and Fig. 30.— The pancreas, partly cut away, so as to show the duct which collects the pancreatic juice and empties it into the duodenum. is mainly on the left side, and behind the stomach. The pancreas is about six inches long and one inch in thickness, secretes an alkaline fluid, the pancreatic juice, and discharges it through a small duct which enters the duodenum at the same opening v>rhich receives the tube conducting the bile from the liver. One function of the pancreatic juice is to prepare the oil and fats of the food for absorption by the process known as emulsification. As the result of this transformation the oils and fats are con- verted into chyle, a fluid resembling milk ; this is absorbed by the lymphatic vessels along the intestinal tract, which are named lacteals or milk-carriers, on account of their white appearance when filled with chyle. This fluid is carried by the lymphatic vessels to the receptaculum chyli, a pouch situated in front of the body of the second lumbar vertebra, and thence, by means of the thoracic duct, to a large vein on the left upper side of the chest, through which it reaches the circulation, and forms a very important element of nutrition. The pancreatic juice also converts meats, albumin, etc., into peptones, and changes starch into sugar. gland, taken from calves and lambs, is the most tender and palatable sweet-bread of all." (Tracy.) CHAPTER VI. KIDNUYS, BLADDER, SKIN, SPLEEN. KIDXEYS. The "kidneys (Fig. 31) are excretory organs, and consist of two large tubular glands situated in tlie back part of the abdominal cavity in the lumbar region on each side of the spinal column. They extend from tbe eleventh rib down- ward nearly to the upper borders of the pelvis or "haunch- bones." The right kidney is a little lower than the left. They are bean-shaped, about four inches in length and two in width, and each weighing about four to six ounces. It will be remembered that the excretory organs simply ab- stract from the blood elements of waste tissue, and dis- charge the same from the body. They exert very little change in this material, but act mainly as an outlet for it. The material excreted by the kidneys is known as the urine, and consists of water holding in solution waste and poisonous matter, as urea, etc. The amount of urine removed by the kidneys in twenty-four hours is about three pints. It is an acid fluid when first discharged, but usually becomes alkaline as the result of decomposi- tion. The ureters are two small tubes (one from each kid- ney) about the size of a goose-quill, and sixteen or eighteen inches long, which conduct the urine from the kidneys to the bladder, entering that organ at its lower portion. Oftentimes, small concretions, varying in size from grains of sand to those of larger diameter, called renal calculi, familiarly known as " gravel," are formed in the kidneys, and during the passage of these little bodies through the KIDNEYS, BLADDER, SKIN, SPLEEN. 55 ureteiJS on the way to the bladder, the larger ones may cause such irritation and press- ure along these tubes as to produce the most intense pain. This condition has received the name of renal or kidney colic. Sudden and intense pain on the side, along the course of the ureter involved, would be the princi- pal symptom. The sudden beginning of the pain would de- note the entrance of one or more of the little bodies into the ureter, and the abrupt ending of the pain in- dicate that they had vr o. ^^ .■ ^ .■ ^ . ■. ^ , -^ Fig. 31.— Vertical section of a kidney, showing the minute tubes which excrete the urine; also the pelvis, or basin of the kidney, which receives the urine before it passes do\^Tiward to the bladder. The beginning of a ureter is also shown. entered the bladdei THE BLADDER, The bladder, or reservoir which re- ceives the urine, is a sac having three coats or layers ar- ranged in a manner similar to that of the layers of the stomach and intestine— fibro-serous externally, muscular tissue forming the middle coat, and the internal being com- posed of mucous membrane. When moderately distend- ed the bladder is about five by three inches and contains about one pint ; however, it may hold considerably more. When a sufficient amount of urine has accumulated, it is 56 PROMPT AID TO THE INJURED. discharged from the bladder, mainly by the contraction of its muscular walls : this act, which in the beginning is voluntary, usually occurs four or five times during the twenty-four hours. The bladder is situated in the lower part of the pelvic cavity, just behind the pubic bone. SKIN (INTEGUMENT). This structure, which covers all portions of the body and protects the deeper parts, is an organ of excretion and secretion, and also of the sense of touch, the lat- ter function being highly developed at the finger- ends. The power of absorption through the unbroken skin of the hu- man being is generally be- lieved to be ex- tremely slight. The skin is composed of two layers, the outer and in- ner ; the form- er being called the epidermis, cuticle, scarf, or false skin, and the latter receiving the name of derma, corium, or true skin (Fig. 32). The epidermis contains nei- ther blood-ves- sels nor nerves, and is simply a scaly layer which protects the true sl-riu underneath, and becomes easi- Fig. 32. — Vertical section of the skin, magnified, a, Scarf-skin ; b, pigment-cells ; c, papilla ; d, true skin ; e, f. fat-cells : g, sweat-glands ; /?, outlets of sweat-glands ; i, their openings on the surface of the skin ; k, hair-follicle ; I, hairs projecting from the skin ; m, hair-papilla ; n, hair-bulb ; o, root of hair ; p, openings of oil-glands. KIDNEYS, BLADDER, SKIN, SPLEEN. 57 ly detached from it uuder certain conditions. A blister shows the separation of the two layers of skin, with a small amount of fluid between them. The derma or true skin is richly supplied with blood-vessels, nerves, and lym- phatics, and in this layer reside the functions above alluded to. The skin contains millions of minute tubes known as sudoriferous or "sweat" glands ; also the sebaceous or fat glands, and hair-follicles. The sweat-glands, by constantly removing from the body a watery vapor known as per- spiration or " sweat,'' in which they are aided by evai^ora- tion, help to regulate the body temperature. It is the won- derful activity of these organs, and the large quantity of perspiration thrown off, that enables one to endure a very high degree of dry heat. In addition to the action just described, they have the important function of eliminating from the system waste material similar to that excreted by the kidneys (urea) ] for this reason the skin, through the sweat-glands, is regarded somewhat as a supplement- ary organ to the kidneys. In warm weather, when the skin is most active, the amount of perspiration is largely increased and the amount of urine correspondingly dimin- ished, while in winter the condition is reversed. An aver- age amount of loerspu^ation formed in twenty-four hours is about two joints. It is very important that the similarity in action of the skin and kidneys should be recognized, and that the one may be induced to relieve the other, for, when the kidneys are impaired, either temporarily or permanent- ly, much relief may be obtained by stimulating the skin. The importance of keeping the skin in a healthy con- dition by proper clothing, exercise, and bathing, can not be overestimated. The product of the fat or sebaceous glands protects the skin, and keeps it more or less oily and pliable. With few exceptions the hair-follicles are found in all portions of the body ; in some parts, however, the hair is BO fine as to be hardly noticeable. The hairs, and also the nails, are regarded as appendages of the skin, affording additional protection. 58 PROMPT AID TO TEE INJURED. SPLEEX. Ttie spleen is a soft and spongy organ, situated in the abdominal cavity, on the left side, near the cardiac end of the stomach, and extends from the ninth to the eleventh ribs. It measui^es about five inches long by three inches ^T.de, and two inches thick, weighing about eight ounces. It is called a ductless gland, not having the characteristics of a secretory or an excretory organ. Its function has not yet been definitely settled CHAPTER VII. NERVOUS SYSTEM. The activity of the mind and body, the correct working of the several organs, and the sympathy existing between the different paints of the organism, depend upon the nerv- ous system, which is divided into the cerebro-spinal axis and the sympathetic system. Cerebro-Spinal System. — Tliis system comprises the brain, spinal cord, and nerves (Fig. 34). Fig. 33. — The brain inclosed in its membranes, and the skull : a, b, c, convolu- tions of the cerebrum; d, the cerebellum ; e, medulla oblongata ; /, upper end of the spinal cord ; g, pons Varolii • h, i, k, central parts. The brain (Fig. 35), which is the seat of the intellect, the will, and the emotions, is contained in the cranial cav- 60 PROMPT AID TO THE INJURED. Fig. 34.— The cerebro-spinal system of nerves NERVOUS SYSTEM. 61 ity (Fig. 33). It is divided ino four principal parts, viz., the cerebrum, the cerebelhim, the pons Varolii, and the medulla oblongata. Cerebrum. Pons Varolii Medulla oblongata. Cerebelhim. Fio. 35.— Under surface of brain, showing the cerebrum, cerebellum, pone Varolii, aud medulla oblongata. The cerebrum (Fig. 86) constitutes over four fifths of the entire brain. It is ovoid in form, being divided into two portions by a deep groove, running from before back- ward, and occupies the upper and greater portion of the cranial cavity. It is composed of gray and white matter, about the consistence of '' sweet-breads " ; the white mat- ter forms the internal and greater portion of the cerebrum, the gray matter forming the external layer. The surface 62 PROMPT AID TO THE INJURED. of the cerebrum is not smooth, hut thrown into folds, called convolutions. This arrangement increases its area, and consequently its func- tion. The convolutions are superficial and not so well marked in the braui of an infant, but grow deeper and larger until the brain has reached its full develop- ment, at about the for- tieth year. The cere- brum is the seat of the mind and of its different functions which distin- guish man from the low- er animals. The exact point in the cerebrum where these functions are located may at some future time be definitely settled, considerable progress having already been made in this direction. The cerebellum, or little brain, corresponds in structure quite closely to the cerebrum, with which it is connected, being situated beneath it and at the back part of the cra- nial cavity. The cerebellum regulates and keeps in perfect harmony the different movements of the body, particu- larly of the extremities (Figs. 34 and 35). The pons Varolii, or " bridge," is a small portion of the brain, and situated in front of the cerebellum. It binds together the different parts of the brain already enumer- ated, and also transmits the different nerves passing be- tween the brain and spinal cord (Fig. 35). The medulla oblongata is below the pons Varolii, and appears to be the upper end of the spinal cord somewhat expanded. In the substance of this organ about three fourths of the motor-nerve fibers passing from the brain Fig. 36.— Upper surface of the cerebrum, showing the convolutions of the brain and its double structure. NERVOUS SYSTEM. 63 to the spinal cord cross cacli other or decussate, decussa- tion of the remainder taking place in the spinal cord ; consequently a motor-nerve fiber having its origin in the right side of the brain crosses to the left when it reaches the medulla oblongata, and becomes identified with the left side of the spinal cord, and furnishes motion to that side of the body. This will explain why an injury to one side of the brain will produce paralysis on the op- posite side of the body, as in apoplexy. The medulla also presides over the function of respiration. The human brain weighs about fifty ounces, being heavier than that of any of the lower animals, with the exception of the elephant and the w^hale. The brain of the elephant weighs about eight pounds, that of the whale somewhat less. The human brain probably reaches its highest development at about the fortieth year. After this period it gradually diminishes in weight, about one ounce in ten years, so that in old age both the size and function of the brain are considerably lessened. The deep convolutions spoken of are characteristic of the human brain, being present in a lesser degree in the lower animals. The spinal cord is that portion of the cerebro-spinal axis contained in the spinal or vertebral canal. It is cylin- drical in shape, extending downward from the medulla oblongata to the first lumbar vertebra, being from fifteen to eighteen inches long, and is composed of gray and white matter, the white matter, however, being outside and consisting of nerve-fibers which act as conductors of sensory and motor influence. The motor fibers of the cord are found in the front and at the sides, and the sen- sory fibers in the back or posterior portion. The spinal cord, through the medium of its branches, to be presently described, transmits nerve influence to and from the brain. It is, to a certain extent, capable of acting as a separate nerve-center and generating force independ- ently of the brain. Nerves are classified as those having a motor and sen- ^4: PROMPT AID TO THE IXJURED. sory influence, and nerves of special sense. Motor nerves are fibers ayMcIi conduct from the brain (and to a certain extent, from the spinal cord) the necessary force to ani- mate muscular fibers, thus xDroducing the different move- ments of the body ; motor nerves therefore transmit an in- fluence from within outward. Sensory nerves are fibers which convey from different portions of the body certain sensations to the brain. For instance, when a finger is burned or injiu'ed, the sensation of pain experienced indi- cates an impression made upon a sensory nei've at the point of injuiy, and which is received at the great nerve- center or brain. Neiwes of special sense, as the name im- plies, have separate functions. They do not transmit motion or common sensation just described, but preside over the special senses, as sight, hearing, taste, etc. Cranial Nerves. — From the under snrface or base of the brain, on each side, are given off twelve nerves, which are known as the twelve pairs of cranial nerves. They are composed of white, glistening fibers, and are numbered anatomically from before backward. These nerves are so very important that a brief description of them will be necessary. The first, or olfactory nerves, supply the special sense of smell, and are distributed to the mucous membrane lining the nose. The second, or optic nerves, supply the special sense of sight, and are distributed to the eyes. The third, fourth, and sixth are motor nerves, and animate the muscles moving the eyeballs. The fifth are the largest of the cranial nerves, and have a mixed function ; the sensitive branches supply common sensation to the teeth, nearly all of the face, the mucous membrane of the eye, nose, and portions of the mouth and throat ; the motor branches supply the muscles of mastication. The seventh supply, with the exception of those directly concerned in mastication, the muscles of the face with motion. A small branch supplies the special sense of taste to the anterior portion of the tongue. The eighth, or auditory nerves, furnish the sense of hearing. The ninth supply the pos- NERVOUS SYSTEM. C5 Nerves to left arm. Nerves to right arm. terior j^art of the tongue with the special sense of taste, and also common sensation to the tongue and pharynx. The tenths which at its origin is a sensory nerve, re- ceives motor branches from the seventh, eleventh, and twelfth, and first and sec- ond cervical nerves. The motor, sensory, and mixed branches of this nerve go to the pharynx, larynx, oesophagus, heart, stomach, small intes- tine, liver, spleen, and kidneys. The eleventh fur- nish part of the mo^ tor supply to one muscle of the neck in front and to a muscle of the shoulder and neck posteriorly (each side). By the branches which join the tenth, these nerves supply the muscles of the larynx concerned in the pro- duction of the voice ; they also contribute to the regulation of the action of the heart. The twelfth are motor nerves, and preside over the move- ments of the tongue. The cranial nerves that supply structures outside of the cranial cavity pass through small openings in the skull on the way to their destination. Nerves to front of left leg. Nerves to back of left legr. Nerves to front of right leg. Nerves to back of right leg. Fig. 37.— Brain and spinal cord, with the thir- ty-one pairs of spinal nerves. GQ PROMPT AID TO THE IXJURED. Spinal Nerves (Fig. 37). — There are thirty-one nerves given off from each side of the spinal cord, each nerve forming with its fellow on the opposite side a pair similar to the arrangement of the cranial nerves. They also re- semble those nerves in appearance. Each pair of nerves are composed of fibers arising from the anterior and poste- rior columns of the cord, and consequently contain motor and sensory fibers. At a short distance from the spinal cord the nerves divide into anterior and posterior branch- es, the anterior branches supply- ing the trunk and extremities, dia- phragm, and cer- tain organs. The posterior or small- er, branches sup- ply principally the muscles and skin of the back. The brain and spinal cord are each protected by a closed sac, sur- rounding them, after the manner of the pericardium which envelops the heart, and the pleura covering the lungs. The portion of the nervous system just described presides over the func- tions of animal life — the intellect, general sensation, the special senses, and motion. Sympathetic System.— Organic life, or that which relates to secretion and excretion, the proper distribution Fig. 38. — The s^Tiipatlietic or ganglionic nervous system. NERVOUS SYSTEM. (J7 of bloed and nutrition to the tissues, the control of the involuntary muscular tissue which is found in the ali- mentary tract, blood vessels, etc., must be unaffected by the outside world. Were it subject to the will, and to such influences as govern the cerebro- spinal axis, the functions of organic life would soon be disturbed, and the most seri- ous consequences would ensue. This system must work on uninterruptedly, in health and disease, night and day — at all times. For this purpose Nature has supplied a sepa- late and independent nerve-force known as the sympa- thetic or ganglionic system (Fig. 38), which consists of a series of little bodies or ganglia which begin at the under surface of the brain, and continue downward on each side of the spinal or vertebral column to its lower extremity. Although this system is independent of the cerebro-spinal axis, in its special function, it communicates with, and ac- companies the cranial and spinal nerves to organs which are supplied by both systems. It also brings the different organs in communication with each other, and admits of the sympathy which exists between them. This relation between the different organs explains why a disordered stomach will produce headache, or why death may follow a blow at the pit of the stomach, which injures the large sympathetic ganglia back of this organ, the shock con- veyed to the heart being so great as to arrest its action. CHAPTER Yin. BANDAGES, DRESSINGS, ETC. Bandages are used to retain dressings in position, arrest haemorrliage, and support and render immovable different portions of the body. For general use tliey are divided into roller, and Esmarch or triangular bandages. The roller bandage when properly applied is not only a valuable means of employing this form of dressing, but is also attractive in appearance ; considerable sMll, how- ever, is essential in order to make its application effect- ive. The choice and preparation of material necessary for its construction render its use impossible at all times and places ; for this reason the Esmarch or triangular band- age, which can be made from a handkerchief, shu't, or some other material that can be ]3rocui'ed at once, is ac- cepted as being best adapted for emergencies. The materials utilized for bandages include linen, flan- nel, calico, and muslin. Rubber tissue is also often used by surgeons for special purposes, as support in varicose veins of the leg, and flannel where warmth is required. For ordinary purposes, unbleached muslin of a medium textiu'e is the best fabric that can be employed. Bandages should not contain starch, nor should they be pieced, as either condition produces considerable irrita- tion of the skin, and also prevents their proper apphcation. Roller bandages are usually made from thi'ee to eight yards long and from one to six inches wide, depend- ing upon the part of the body to which they are to be BANDAGES, DRt:SSIN(;S, ETC. 69 applied— one inch for tlie fingers, three inches for the up- per extremity, four inches for the lower extremity, and five or six inches for the chest and abdomen. Bandages should always be torn from the piece, unless the material from which they are constructed is very thin. The selv- edge along the edge of the fabric should always be re- moved before the bandages are rolled. In rolling a bandage the following directions are to be observed : One end of the strip should be folded for a distance of about six inches ; this lap should then be folded on itself, and the process continued until the folded portion assumes the form of a roll or cylinder, which should then be held by the thumb and index-finger of the right hand, the loose strip of the bandage ly- ing over the back of the left hand be- tween the thumb and index - finger. The hand holding the bandage should now be turned to- ward the right, when the roll will begin to increase in size ; this manipulation is to be continued un- til the bandage is entirely rolled ; it is very important that the bandage should be wound tightly, particularly at the beginning, otherwise it can not be evenly adjusted (Fig. 39). A. bandage usually has one head or roll, although it may be made double-headed (by rolling from both ends) for special purposes, as in the knotted bandage. The application of a bandage should always be com- menced by laying the outer siu-face against the skin. If Fig. 39.— Method of rolling a bandage. 70 PROMPT AID TO THE INJURED. used to retain a dressing, it may be begun at any part of an extremity, the soft dressing underneath prev^enting any undue interference with the circulation ; but when the bandage is applied for support or pressure, it must be commenced at the extreme end of the limb and bandaged toward the body, otherwise the constriction, particularly if the bandage is drawn tightly, may be followed by stran- gulation and gangrene of the tissues below the bandage. A bandage should be closely applied to a limb, but not made tight, and the degree of pressm^e should be uniform. Should any evidence of strangulation occur, which would be manifested by swelling and discoloration, and also a reduced temperature of the limb below the bandage, the dressing must be at once removed. It is partly for this reason that the toes and the ends of the fingers are left uncovered in bandaging an extremity — that thej'" may serve as an index to the general circulation of the arm or the leg. A bandage applied diy and wetted afterward is followed by considerable shrinking, and sometimes stran- gulation of the tissues. A bandage should not be applied to a limb until the lat- ter is placed in the position in which it is to remain. For example, an arm should never be bandaged while straight, and then bent afterward, otherwise serious constriction will be made at the flexure. For ordinary use the application of the roller bandage is divided into three methods : the circular^ the spiral reverse^ and ih.Q figure of 8 (the latter including spica bandages). The circular variety is the simplest manner in which a roller bandage can be applied, and, when possible, should always be employed. It is indicated when the diameter of the part is nearly uniform, and consists of a succession of circular turns from below upward, each turn overlapping the upper third of the one below. The spu'al reverse bandage is used where the diameter of the part becomes increased or decreased in size, as in the forearm (Fig. 40). BAiNDAGES, DRESSINGS, ETC. 71 The^ figure-of-8 bandage is used about joints or wliere an abrupt enlargeoicnt occurs. The hip and shoulder spica are varieties of this bandage. The manner in which the different layers cross each other give to it something of the ai)pear- auce of a figure of 8 ; hence the name. In order to illustrate the different varieties of band- ages named above, it may be supposed, for example, that the left lower extrem- ity, including the hip, is to be bandaged, which gener- ally necessitates the use of the different forms already enumerated. Several bandages, hav- ing a width of about three and a half to four inches, are procured. The operator places himself directly in front of the limb to be bandaged, which is somewhat ele- vated, the patient being seated or in bed. The operator, holding the bandage in his right hand, unrolls about six inches of it, the outer side of which is laid obliquely across the dorsum or top of the foot from within outward, and continued around the lower part of the ankle to the inner side, and then again over the dorsum of the foot, crossing the first portion applied, and carried downward to the base of the toes on the outer side ; from this point two or three circular turns are made around the foot, extending up- ward, and thence again to the ankle, where the circular form is employed until the calf of the leg is reached. If the circular turns are continued at this point, the lower border will be seen to gape ; for this reason the spiral re- verse method should now be substituted (Fig. 40). From Fig. 40.— Spiral reverse bandage. 72 PROMPT AID TO THE INJURED. the last circular turn, the bandage should be carried spirally upward and outward for about five or six inches. The operator then presses with the thumb of his left hand the body of the bandage against the median line of the leg, to prevent it from slipping, while the right (holding the band- age) is brought toward the operator with a slight inward turn, thus folding downward (reversing) the upper edge of the bandage to a point just above the thumb of the left hand, and held for a moment in this manner until the dis- engaged fingers of the left hand are carried behind the leg and receive the roller or cylinder from the right, which, now being free, retains the fold or reverse in position until the bandage is again passed to it for another reverse. This is to be continued (each turn overlapping the upper third of the turn below) until the portion of the leg above the calf is reached, where the circular turns can be made up to the lower edge of the patella or " knee-cap," where the figure-of-8 bandage is begun in the follov^ing manner : after a circular turn, the bandage is carried obliquely over the patella from within outward and upward, making a circular turn above the knee, then to the inner side of the leg and downward and outward, crossing the portion of the bandage over the patella. A circular turn is now made around the knee below the patella (to retain the spu'al or oblique turns already made), and then carried again obliquely upward and outward, overlapping the up- per half or one third of the preceding turn in this direc- tion, and continued in this manner until the entire knee is covered. Above the knee, the circular form can be used for a short distance and then changed to a reverse as it ascends the thigh, and continued to a point just below the groin ; from this point the application of the hip spica be- gins, the bandage is carried upward and around the hip to the opposite side of the body, just above the great tro- chanter of the right femur ; this bony prominence marks the upper extremity of the thigh-bone, and can readily be found, particularly if the patient be made to move the leg. BANDAGES, DRESSINGS, ETC. 73 Follo^iving this course, the bandage is carried over the belly to the point where it started from (left tliig-h), cross- ing the first turn and passing downward and backward around the thigh. This procedure is to be repeated in an ascending manner until the hip is covered. The bandage, when applied, should not extend above the upper border of the haunch-bones (crest of the ilium). It will be noticed that, in bandaging the foot, the toes and heel are left un- covered. This is the usual mode of applying the bandage, unless an injury exists at these parts. The shoulder spica is applied in a manner similar to the spica of the hip. When the bandage is carried to the opposite side, it passes beneath tlie arm and back again over the shoulder, from where it began. It also is an ascending bandage (Fig. 41). In the spica bandage of the hip and shoulder, the overlapping is greater at the opposite side than at the hip or shoulder which is being covered. The spica bandages (hip and shoulder) are used to retain dressings and apparatus. The double-headed knot- ted bandage is made of a strip of muslin about eight yards long and two inches wide, and rolled into two heads or cylinders. The knotted bandage is used to arrest haemorrhage from the scalp by making pressure upon the temporal artery, which is situated just in front of the ear and extending upward into the scalp. The pulsa- tion of this vessel can easily be felt. Before applying the bandage, a firm compress should be placed over the artery at a level with the upper border of the ear. A piece of Fig. 41. -Ascending spica of the shoulder. 74 PROMPT AID TO THE IXJURED. cork, for example, about half an inch thick and the diam- eter of a silver half-dollar, should be enveloped in a piece of soft muslin and axoplied over the artery. The operator then, holding a roller in each hand, places the outside of the bandage against the compress and carries one roller around the head just above the eyes in front, and the other below the occipital protuberance or " bump " on the back of the head, and to the opposite temple ; at this point the hands of the operator change rollers and return them to the compress, over which they form a knot by twisting and changing theii' dh^ection, one roller being carried over the top of the head and the other beneath the chin, and meet- ing at the opposite side. At this point the rollers are again changed and returned to the compress, over which a second knot or twist is made in the same manner ; two or three knots over the compress are usually sufficient to arrest the haemorrhage (Fig. 42). There are a number of band- ages which can not be classed with either the roller or trian- gular bandage. The following are examples : The FOUR-TAILED bajST)age is made of a strip of muslin about one yard and a half long and four inches wide, folded and torn from the ends to within two inches of the center of the bandage. One jDair of tails is usually made broader than the other. One purpose of this bandage is to support the lower jaw after a fracture or dislocation. It is to be applied by placing the center of the bandage against the chin, with the wide tails below, when the latter are turned upward and tied on top of the head ; the upper or narrow tails are carried backward and tied at the nape of the neck (Fig. 43) ; two handkerchiefs, each folded in the form of Fig. 42.— Knotted bandage. BANDAGES, DKKSSINGS, ETC. 75 a cravat, may be used for this purpose. A four- tailed band- age, for the purpose of protection and retaining dressings about the head, can be made of a piece of muslin, about one yard and a half long and one foot or more in width, folded, and torn. from the ends to within six inches of the center. The bandage is placed on the head, the anterior tails being carried backward and tied at the nape of the neck, while the posterior tails are tied under the chin (Fig. 44). If it is required that the bandage should be applied to the back of the head, the ante- rior or upper tails are tied beneath the chin, while the posterior or lower tails are tied upon the forehead. bandage may also be used at the knee. made of a strip of muslin about eight inches wide and one yard long, and applied by placing the center of the band- age over the patella ; the up- per tails are carried backward, crossed behind the knee, then brought forward and tied in front below the patella ; the lower tails are manipulated in a similar manner, but tied above the patella. The entire head may be covered by the application of a six-tailed bandage, made from a piece of muslin about forty inches long and fifteen inches wide and folded. The ends should be torn into three tails, extending to within six inches of the center of the band- Fig. 43. A four-tailed It should be Fig. 44. 76 PROMPT AID TO THE INJURED. age ; the middle tail should be made wider than the outer ones. The bandage being placed on the head, the middle tails are tied under the chin, the anterior at the nape of the neck, and the posterior on the forehead. The large square handkerchief -bandage is a very valu- able means of covering the head and neck, and is applied by folding a piece of muslm about one yard square, in such a manner that the upper portion or layer is narrower than the lower portion, their borders being two or three inches apart. The bandage is so placed on the head that the border of the upper portion is on a level with the eyebrows, while the lower layer rests on the tip of the nose. The ends of the upper portion are tied beneath the chin ; the border of the lower portion is then turned up- FiG. 45. ward against the forehead, thus exposing the eyes, while the ends of this portion are carried backward and tied behind the neck (Figs. 45 and 46). EsMARCH OR Triangular Bandages (see diagram, Fig. BANDAGES, DRES.^INGS, ETC. 77 47.) — The triangular baiidages, whicli have been brought to the notice both of the medical profession and the laity by Prof. Esmarch, of Germany, are not on- ly easily made from material which is gen- erally procured with- out difficulty, but are effective as a dress- ing and easily applied, and act as a substitute for the roller bandage in all cases except where uniform press- ure is the essential element. If a choice of material is permitted by the existing cir- cumstances, the un- bleached muslin used for roller bandages should be se- lected ; however, a large handkerchief, or a shirt or skirt, may be used. Fig. 46. Fig. 47.— Esmarch bandage. A, base ; B, apex ; C, D, basal ends. It will be unnecessary to enumerate the sizes given for the different triangular bandages. A proper knowledge 78 PROMPT AID TO THE INJURED. of their application will suflBciently indicate this when being used on different portions of the body. The ends of a triangular bandage should be fastened either by tymg with a " reef " or flat knot, or with safety- pins ; the knot, however, is generally used (see Knots). Head (Figs. 48, 49, and 52). — The base {A) is placed downward over the brow, with the apex {B) at the nape Fig. 48. Fio. 49. of the neck. The basal ends (C and D) are carried back- ward above the ears and crossed over the apex below the external occipital protuberance, the " bump " on the back of the head ; this prevents the bandage from slipping up- ward ; the basal ends are then returned to the front and tied, the apex being turned upward and pinned to the body of the bandage. Shoulder (Fig. 50). — The triangle should be applied to the shoulder by placing the base {A) downward across the middle of the arm, the apex {B) being turned upward against the neck. The basal ends (C and D) are carried to the inner side of the arm, crossed, and returned to the out- side and fastened. The apex (B) is tied or pinned to a cravat or sling placed around the neck. Hand (Fig. 50). — In injury to the posterior part, or BANDAGES, DRESSINGS, ETC. 79 dorsum, the hand may be bandaged by placing" the base of the triangle (A) upward at the back part of the wrist, the hand lying on the bandage ; the apex (B) is turned over the fingers upon the palm and carried to the wrist ; the basal ends (C and D) are then carried to the front and crossed, and returned to the back of the wrist and tied, or crossed again, and tied in front. In injury to the palmar Fig. 50. surface of the hand, the base should be first applied to the front of the wrist. Chest (Figs. 51 and 52). — The triangular bandage is applied by placing the base (A) downward across the low- er border of the chest, with the apex (B) over the shoulder of the affected side, the basal ends (C and D) being carried around the sides to the back, and tied together in such a manner that one end of the knot is longer than the other. 80 PROMPT A.ID TO THE INJURED. Fig. 51. The long end is then tied to the apex, which has been car- ried over the shoulder. Fig. 52. BANDAGES, DRESSINGS, ETC. 81 Slijigs. —The ordinary form of an arm - sling made of a trian- gular bandage is as follows (Fig. 53) : For example, suppose that the left arm alone is injured ; the base (A) is placed ver- tically along the outer border of the right side of the chest, with the basal end (C) thrown over the right shoulder, and the apex (B) elbow, the left arm being bent at a front of the bandage. The basal Fig. 54. Fig. 53. placed behind the left right angle and held in end (D) is now carried around the forearm and over the left shoulder, and tied to the basal end (C) at the back of the neck. The apex (B) is then carried around the elbow and pinned to the bandage in front. Should it hap- pen that the left shoulder or clavicu- lar (collar-bone) re- gion is injured as well as the arm, the sling should be 82 PROMPT AID TO THE INJUPiED. so arranged that the affected part is free from pressure, which may be accomplished in the following way (Fig. 54) : The bandage is to be applied in a manner similar to the one just described, with this exception — instead of the basal end {D) being carried over the left shoulder, it is car- ried under the left arm, then upward across the back, and tied to the basal end (O) over the right shoulder. If the right shoulder or clavicular region be injured as well as the left arm, the latter can be placed in a sling, leaving the affected shoulder (the right) uncovered by lay- ing the basal end (C) over the left shoulder, the base {A) being carried from above obliquely downward and to the right, the apex of the bandage and the arm being in the same position as in the slings just enumerated. The basal end (D) is now carried under the left arm and upward over the back, and tied to the basal end (C) at the left shoulder (Fig. 55). Hip. — The tri- angular bandage at this portion of the body is applied in very much the same way as at the shoulder. The cen- ter of the base (A) is placed downward across the middle of the thigh, the ai^ex (B) being carried upward above the crest or upper border of the pelvis or haunch-bone, the basal ends (C and D) are carried around the thigh, and fastened at the outside. The apex (E) is attached above to a cravat around the waist (Fig. 56). Fig. 55. BANDAGES, DRESSINGS, ETC. 83 Fig. 56. Foot. — The foot should be placed on the triangle with the base {A) backward, and laid behind the ankle, the apex being carried upward over the dorsum or top of the foot. The basal ends (C and D) are brought forward, crossed, then carried around the foot, and tied on top (Fig. 57). Cravat-Bandages (Figs. 50, 58, 59). — A triangular bandage folded in the form of a cravat makes a very effective means of arresting hemorrhage and retaining splints, dressings, and poul- tices. The width of the cra- vat, or the number of folds, dei^ends upon the use for which Fig. 57. 84 PROMPT AID TO THE INJURED. it is applied. The center of the cravat should be laid against the affected part, or on the poultice, or whatever the cravat is used to retain, the ends of the cravat being carried around Fig. 58. Fig. 59. the limb and tied over the center of the base. When used to retain splints, they should be tied on the outer side of the limb and against the splint, thus preventing the knot from irritating the skin. Cravats are used to retain di'essings about the head, eyes, ears, neck, etc. When used to re- tain a di'essing in the arm-pit, the center of the cravat should be placed under the arm, and the ends carried up- ward and crossed over the shoulder, and tied in the ax- illary space of the opposite side, thus forming a figure of 8. In retaining dressing about the groin and in that vicin- ity, the middle of the bandage is placed at the inner and upper part of the thigh (the " crotch "), the extremities be- ing carried upward and outward and crossed at the hip, the ends being brought over to the hip at the opposite side and tied. BANDAGES, DRESSINGS, ETC. 85 The cravat may also be used as a sling for the arm where simply sup- port, but not protection, is necessaiy. Knots. — Tlio ends of a triangular and cravat-bandage are fastened by tying with a ''reef" or square or flat knot (Figs. 60 and 61). This Fig. 60.— Reef knot. Fig. 61.— Reef knot. knot is very secure, and does not slip ; it is used by sur- geons in ligating vessels. However, unless care is ob- served, a " granny " knot (Figs. 62 and 63), which is quite insecure, is often substituted. The reef knot is made by holding an extremity of the bandage in each hand, and then passing the end in the right hand over the one in. the left and tying ; the end now in the left hand is passed over the one in the Fig. 62.— Granny knot. Fig. 63.— Granny knot. 86 PROMPT AID TO THE IXJURED. right and again tied. In the '" granny '' knot the end in the right hand is car- ried over that in the left both times and tied (Fig. 63). A surgeon's knot is used in ligating blood- vessels, and is made by Fig. 64 —Surgeon's knot. turning the ends of a ligature twice around each other before tying (Fig. 64), and then securing it as in the reef knot. COMPRESSES. Compresses or pads, as generally used, are of two kinds — simple and graduated. A simple compress consists of a number of even folds of muslin, or other similar material, applied to a part to assist in arresting haemorrhage (by pressure), to hold the edges of a wound together, and also for protection. A graduated compress is made by diminishing the width of each successive layer until the compress has been made pyramidal or pointed, and having a base and an apex. When applied, the graduated compress is inverted, the apex being placed first in the wound. This form of com- press is used to arrest haemorrhage from deep wounds and cavities. Compresses are made of antiseptic or sterilized gauze, lint, muslin, linen, flannel, etc.. the antiseptic or sterilized gauze being the most desirable. If this can not be pro- cured, the material selected should be clean, and, if pos- sible, made aseptic by boiling for at least half an hour. Lint is objected to, as the surfaces — particularly one of them — is downy, and adheres to the wound. The com- mon picked lint is objectionable for the same reason. A compress made of a fabric such as gauze, which admits BANDAGES, DRESSINGS, ETC. 87 of absorption of tlie fluids from a wound, is more valuable than one which resists it. A compress should not be allowed to remain applied after it has become ofPensive or soaked with discharges. TAMPON. A tampon or plug is made of the same material used for compresses, and, in addition, absorbent cotton, lamp- wicking, common muslin bandages, etc., are often utilized. A tampon has no special size or shape, but is formed in such a manner that it can be pressed deeply into a wound in order to arrest haemorrhage, for which it is principally employed. It is of the utmost importance that a tampon should be clean, in order to prevent, if possible, the en- trance of poisonous germs. It should be remembered that, although it is necessary in order to arrest haem- orrhage by tamponing that the wound should be thor- oughly filled from the bottom, too forcible manipulation may be followed by serious consequences, and that even the proper, application of a plug usually prevents union by first intention. A tampon as well as a compress is kept firmly in place by a bandage, which exerts more or less pressure as the case requires. Without the indorse- ment of a surgeon, a tampon should not be left in a wound longer than twelve hours. POULTICES. Poultices are used to supply and retain heat and mois- ture, and thereby relieve internal congestion and pain ; they are sometimes employed to hasten the removal of a slough or dead tissue, and to clean the surface of foul ulcers. However, as they favor the development of bacteria (germs) when applied to an open wound, surgeons do not now use them for this form of injury. Therefore their employment for the purpose of facilitating the removal of 88 PROMPT AID TO THE INJURED. a " slough " or dead tissue is only justified when other means are not available. A much better way of secur- ing this result is by the use of compresses wrung out in a hot solution of bichloride of mercury (1-10,000), or a solu- tion of carbolic acid (one per cent.), and applied directly to the slough and covered with oiled silk to retain the heat. This di'essing should be renewed every two or three hours. Poultices are usually made of ground flaxseed (linseed), although, if this can not be procured, hominy, corn-meal, or bread (not the crust), may be substituted. A bread- poultice, however, becomes sour in a very short time. Flaxseed-Poultice. — A receptacle containing boiling water should be placed on the fire. The flaxseed-meal should then be gradually added, and constantly stirred, until the batter is jelly-like, and about the consistence of oatmeal porridge. This should be evenly spread, with a thickness of about half an inch, on a folded towel, piece of muslin, or some other material prepared for the purpose ; over the surface of the flaxseed should be laid some white tarlatan, mosquito-netting, or a fine cambric hahd kerchief ; while these fabrics allow the poultice to come in direct contact with the skin — an important consideration — they do not interfere with its action, but prevent the flaxseed from adhering to the skin. If one of the above materials can not be obtained, the surface of the poultice may be covered with a small amount of vaseline or sweet-oil as a substitute. After the poultice is applied to the body it should be covered, if possible, with oiled silk, which aids in retaining the heat ; in this way a poultice can be kept warm and moist for two or three hours, or even longer. In lieu of the oiled silk, flannel or cotton wadding may be used. To a certain extent a poultice can be made a deodorant by adding to the boiling water into which the meal is thrown a teaspoonful of carbolic acid to each pint of water, or by adding to the dry meal, before it is thrown into the BANDAGES, DRESSIN(iS, ETC. 89 water; one half of its bulk of powdered charcoal. This mixture should be thoroughly rubbed together, and then added to the water in the manner already described. The addition of the carbolic acid makes the poultice more or less antiseptic. Poultices made of bread, corn-meal, or hominy have nothing in their favor when compared with flaxseed, save that they may be the only available substances when needed. Poultices of these materials are made in the same manner as when flaxseed is used. A teaspoonful of salt should be added to each application, particularly when corn-meal or hominy is used, otherwise considerable irritation of the skin (covered by the poultice) may ensue. The addition of mustard to a poultice renders it more effective in diminishing or relieving deep-seated pain, as in the chest or abdomen, and is far better, for ordinary purposes, than mustard-plasters, which are too indiscrimi- nately used. Mustai'd, properly applied in this manner, is seldom followed by undue irritation of the skin. The mus- tard should not be added to the flaxseed in the form of powder, but should be carefully mixed w4tli a small amount of warm water, and then stirred into the flaxseed just before it is spread upon the cloth. The amount of mustard added depends upon the degree of pain, the age of the patient, etc. ; the proportion ranges from a table- spoonful to one third, or even one half, of the bulk of the poultice, one or two tablespoonfuls, however, being usu- ally sufficient. Hot water and vinegar lessen the efficacy of mustard. Mustard-plasters are used to obtain a rapid and decided effect, as in shock, poisoning, etc. Care should be taken, however, that the mustard does not blister the skin. As a rule, mustard-plasters should not be applied to children and old people, as they generally blister the sur- face, and, if the plaster is quite large, ^veil-marked con- stitutional symptoms may follow, as elevation of temper- ature. 90 PROMPT AID TO THE INJURED. In making a mustard-plaster, it is preferable to mix the powder with the white of an egg, although water may be substituted ; a small amount of flour may be added, and the paste should then be thinly spread over a piece of mus- lin or brown paper, and covered with some thin material. MOIST AND DRY HEAT. Moist Heat. — A hot fomentation consists in the ap- plication of moist heat, and is used to relieve pain, pro- duce relaxation, etc., and in a manner acts as a substi- tute for a poultice. A hot fomentation is made by wringing out of hot water a piece of flannel, old blan- ket, etc., which is applied immediately to the affected part and properly protected, to prevent evaporation and the consequent cooling of the dressing. For the latter rea- son a hot fomentation is not used when heat alone is desired. By stirring in the hot water from one to three tablespoonfuls of spirits of turpentine, the stimulant and anodyne or quieting effects of the fomentation are in- creased. A hot fomentation applied to the forehead and temple, when headache exists, is often followed by imme- diate relief. Dry Heat. — Dry heat is employed when the applica- tion and retention of heat are the essential elements, as in shock, syncope, drowning, etc. Dry heat is used in the form of bottles or India-rubber bags filled with hot water, or bran, salt, or sand, which has been heated in the oven and put in bags. Bran is to be preferred, as it retains heat longer, and is very light. Hot bricks, stones, flat- irons, stove-lids, plates, etc., may also be used; the latter agents should be covered with a towel or some similar substance before being applied. In shock and some other conditions the sensation is so blunted that the skin may be burned by one of the appli- ances just enumerated (except the bran, salt, and sand] without being appreciated by the patient. CHAPTER IX. CONTUSIONS AND WOUNDS, CONTUSIONS— BRUISES. A CONTUSION is an injury inflicted upon a portion of the body by a blow from a blunt instrument, also from a fall, or severe pressure, and resulting in the laceration of blood-vessels (usually small) and other structures beneath the skin, the latter remaining unbroken. The subcutaneous escape of blood is immediately fol- lowed by swelling and discoloration of the skin ; the color being at first black and blue or purplish, then green, yellow, and so on until the extravasated blood is removed by ab- sorption, and the affected part regains its normal color and appearance — usually within two weeks. A ".black eye " is a familiar examj)le of a simple contusion. In severe contusions, although the skin may be at first unbroken, the soft tissues are often so badly injured that death (gangrene) of the affected structures follows. In contusions which extend deeply into the tissues, the discoloration may not appear for a number of days. When a contusion is followed by very rapid and ex- tensive swelling, in which pulsation can be detected, it indicates that a large artery has been divided. Treatment. — Slight contusions need no special consid- eration. In those of a severer nature the treatment depends upon the time that has elapsed since the injury, and its gravity. If seen early, the indications for treatment are — (1) to prevent the further escape of blood in the tissues ; (2) to counteract the pain, shock, or inflammatory action 92 PROMPT AID TO THE INJURED. that may follow ; (3) to preserve the vitality of the part, which may be endangered in severe contusions ; (4) to pro- mote the absorption of the blood which has already es- caped. The first indication can be met by the use of hot (not warm) or cold applications, the latter usually prov- ing more effective — particularly if used in the form of ice broken into small pieces and placed in a rubber bag made for this purpose, or in a bladder or towel, and applied to the part and retained 07ily until the haemorrhage is con- trolled. Although ice is a valuable agent to check the extravasation of blood, it should be used with care, and not in all cases. In slight contusions it is particularly valuable and unattended with danger ; in a severe form of contusion, however, where the vitality of the affected tis- sues is impaired, the use of ice, by still further reducing the vitality, may cause gangrene of the parts. Compresses soaked in dilute alcoholic solutions of whisky, brandy, cologne, arnica, camphor, etc., or, solutions containing ace- tate of lead (sugar of lead), carbolic acid, alum, vinegar, lemon- juice, or common salt, are also very efficacious. Pressure carefully employed, in addition to the applica- tions just referred to, will render the treatment still more effective. Elevation of the affected part diminishes the tendency to further extravasation of blood. If shock ac- companies the contusion, it is to be treated according to the directions given in another chapter. The pain that is commonly present in a contusion is usually quieted by the applications used to fulfill the first indication. The tendency to subsequent inflammation is treated by judicious use of cold, rest, elevation, etc. In severe contusions, where the vitality of the part is greatly impaired by the obstruction to the circulation due to the escape of blood into the tissues and consequent swelling, the temperature of the part is lowered, and cold should not be used. The local application of warmth is then indicated ; and should be applied in a dry form, as bottles filled with hot w^ater; a bag filled with bran or CONTUSIONS AND WOUNDS. 93 oatmeal which has beeD heated in the oven, or whatever form of dry heat can he easily and quickly obtained, will answer. Tlie part should also be surrounded by woolen cloths or any fabric that will retain the heat, and if a limb is the part a£Pected, it should be slightly elevated. The local treatment for a contusion which has existed for some time, consists in stimulating the absorption of the extravasated blood, and may be accomplished by continu- ous mild pressure, gentle friction alone or combined with the stimulating solutions already mentioned, which are useful for this purpose. WOUNDS. A wound is an injury of the outer tissues in any part of the body, associated with more or less division of the skin and deeper soft structures, and produced by a mechan- ical agent. Wounds are classified as follows : Incised, lacerated, punctured, gunshot, poisoned, and contused. Incised wounds are made by sharp cutting instru- ments, as knives or razors. The edges of the wound, when applied to each other, fit accurately, and completely close the opening. Haemorrhage constitutes one of the principal dangers of this form of injury. Lacerated wounds are made by stones, clubs, or imple- ments which are rough or blunt, and produce more or less destruction of tissue about the wound, the edges of which are ragged and torn. Considerable local inflammation and constitutional disturbance often follow lacerated wounds. Punctured wounds are inflicted by bayonets, daggers, swords, arrows, or other weapons which are sharp and narrow-pointed. Although the openings are quite small, these wounds usually penetrate to a considerable depth, and may injure important blood-vessels and vital organs. Gunshot wounds, in a general way, include all injuries resulting from the explosion of gunpowder, the direct cause being bullets, cannon-balls, and other missiles ; also 9i PROMPT AID TO THE INJURED. splinters of wood, pieces of stone, etc. The degree of dan- ger resulting from gunshot wounds depends upon the hsemorrhage — particularly that occurring internally — the sti'ucture or organ involved, the amount of tissue destroyed, together with the shock, and the subsequent inflammation and suppuration, and blood-poisoning which may result. The conical ball used at the present day is more danger- ous than the round one. The latter is quite commonly de- flected or turned aside from its original course by bony prominences, fasciae, or tendons, and thus often i)revents in- jury to internal organs, and when imbedded in the deeper structures is more apt to become encysted — that is, the ball is provided, by the tissues adjacent to it, with a cover- ing or capsule, which prevents the missDe from irritat- ing the contiguous structures. Thus protected, the ball may remain indefinitely without causing harm. Foreign substances, such as bits of clothing, are often carried into the body by bullets and other missiles (fre- quently beyond observation), and constitute an additional element of danger. The point of entrance of a ball is apt to be smaller than the exit, as the result, of the diminished velocity. Poisoned wounds are caused by the introduction into the tissue, through the skin, of some form of virus, as in a snake-bite. These wounds are usually punctured, although they may be lacerated, as in the bite of a rabid dog. Contrary to the general belief, the bite of the venomous snakes in this country, such as the rattlesnake, moccasin, copperhead, and one or two others, is not generally fatal, and, although the virus acts with great rapidity and in- tensity, only about one out of every seven or eight bit- ten succumb to it. Snakes are most dangerous in warm weather and after fasting. A person who has been bitten by a poisonous serpent becomes faint and greatly depressed within a few minutes, the pulse feeble, and the pupils di- lated : more or less delirium occurs, and the extremities CONTUSIONS AND WOUNDS. 05 become-cold and clammy. Considerable swelling and dis- coloration usually take place about the wound ; intense pain is also present. In a certain proportion of cases death ensues within a few hours. A contused wound is one in which the division of the soft structures is associated with more or less contusion at the site of injury. Healing of Wounds. — Although the healing of wounds is divided by surgeons into a number of different varieties, it will be sufficient in this description to recog- nize but two of them — union by first intention; and granulation, or union by second intention. Union by first intention usually occurs when the edges of the wound fit accurately, and are not displaced by haemorrhage or improper dressing ; when foreign bodies are removed and the wound properly cleaned, and the injured part kept quiet. It is always desirable, if pos- sible, to obtain this result, which, besides other advan- tages, prevents disfiguring scars. Wounds associated with considerable destruction of tissue, as in lacerated wounds, burns of the third degree, etc., heal by granulation. The first step in this form of repair is the removal by nature of the destroyed and use- less tissue about the wound by the processes known as suppuration or '' maturation," and sloughing. After the wound has been thus cleaned, granulation becomes ap- parent ; little conical shoots about the size of a pin-head, and pinkish in color, are found filling up the cavity of the wound. These little bodies are very vascular, and when excessive in size, and too rapid in growth, they rise above the surrounding part, and are commonly known as "proud flesh." After granulation has entirely filled the wound, the upper surface becomes smooth, shining, and red, which appearance is the result of the process of cica- trization, and is known as a "scar" or cicatrix. The scar gradually becomes even whiter than the normal skin, and undergoes more or less contraction. The 96 TROMPT AID TO THE INJURED. g-lands of the destroyed skin are not reproduced in tlie scar, consequently hair does not grow from the new for- mation. The proper healing of wounds is often interfered with by severe local inflammation and constitutional disturb- ances. Surgeons believe such phenomena to be due to the existence of microscopical particles in the air, called " micro-organisms," or bacteria, which infect fresh wounds. The theory has developed within recent years a method known as the antiseptic treatment, which means the em- ployment, about the ^vound, of agents which destroy or retard the growth of the micro-organisms. The success of this treatment depends not only on the application of anti- septics to the wound, but on rejidering aseptic everything that comes in contact with it, even the hands of the at- tendant, the dressings, and instruments. Surgeons now use aseptic sutures (stitches) of different substances, most commonly those made of catgut, which are absorbed in the wound — their removal being unnecessary — a very im- portant consideration. If drainage is essential, aseptic tubes are introduced into the wound to favor the free exit of discharges. The wound is then covered with aseptic oi! antiseptic gauze, secured by bandages, and left undisturbed until healing has taken place (about three days), j)rovided the dressings do not become soiled or offensive. It is not expected that members of the ambulance corps, or othei non-medical persons, will be able to comply with the de- tails just given, but the principle should be remembered and followed as nearly as the circumstances will permit. . Treatment of Wounds. — The treatment of a wound consists of the following indications : arrest of haemor- rhage ; examination of the wound, and removal of all for- eign matter therefrom ; support and protection of the in- jured part ; and rest. The variety of hemorrhage should be determined, whether arterial, venous, or capillary, and arrested in the manner described in the chapter devoted to that subject. CONTUSIONS AND WOUNDS. 97 A , wound should be examined as to its variety — whether incised, lacerated, etc. — and also as to the structures involved. A careful search should be made for foreign bodies, which, if allowed to remain, would inter- fere with the proper healing of the part. Pieces of cloth- ing, splinters, etc., should be picked out with clean fin- gers, and the wound then cleaned with a disinfecting so- lution (see Disinfectants). If this is not available, pure water, or, still better, water which has been boiled (thus destroying the germs it contains), may be used. Further treatment in the absence of the surgeon de- pends upon the character of the wound. If incised, the edges should be brought closely and accurately together and retained in apposition, by applying over the opening a compress made of antiseptic gauze, preferably, and then holding the parts together by strips of adhesive plaster. This is a substitute for the proper closing of the wound by the use of sutures or stitches, which hold the edges closely together and favor accurate union. The strips of adhesive plaster should not entirely surround a limb, as they would then interfere with the circulation. They should be applied with intervals between them, to allow the free exit of any matter or pus which may form at the site of the injury; one end of the strip being placed on one side of the wound, the edges of which are held closely together, the remainder of the strip is carried over the wound and fastened to the opposite side. In removing adhesive plaster, both ends of the strip should be loosened at the same time and carried from the skin toward the wound, thereby preventing the separation of its edges, and thus interfering with the healing process. Great care should be taken that the compresses which support and protect the wound are made of some clean, soft material, such as linen, muslin, lint, flannel, absorb- ent cotton, oakum, or, best of all, antiseptic gauze, which can now be purchased in any drug-store. The compress should be held in place by a bandage, 8 98 PROMPT AID TO THE INJURED. which also helps to keep the edges of the wound together and prevents hsemorrhage (see Baxdages). The dressing should remain undisturbed until healing takes place, un- less it becomes offensive, or severe local pains, chills and fever occur. Lacerated wounds, which are associated with more or less destruction and loss of tissue, heal by granulation; consequently no effort need be made to bring the edges in direct apposition, which might subsequently interfere with the proper escape of discharges; otherwise the same kind of dressing should be applied as in incised wounds. Lacerated wounds should be cleansed and fresh dressings applied whenever indicated by the presence of an offensive odor, or a soiled condition of the compress and bandages. Owing to the very vascular condition of the face and scalp, lacerated wounds of these parts, if not too severe, often heal by primary union, and may be treated as in- cised wounds until some evidence of suppuration or sloughing appears. The immediate local treatment of a punctured wound is very simple, and consists in applying a soothing anti- septic lotion. The result of such a wound is extremely uncertain, and depends upon the implement causing the injury, and should be carefully watched for any evidence of subsequent inflammation. Punctured wounds made by arrows are generally serious, because the arrow-head usu- ally remains in the tissues. In this case the arrow should, if possible, be withdrawn by a rotary movement, or, if near the surface, it can be pushed out through sound tis- sue, its exit being accelerated by making a small cut or incision over the arrow-point. Ji the shaft has been broken off, and the arrow-head remains in the tissues, it will be necessary for the surgeon to cut down and ex- tract it. In gunshot wounds the first effort should be to arrest haemorrhage, to protect the wound with dressings, and treat the accompanying shock. However, all foreign bod- CONTUSIONS AND WOUNDS. 99 ies which are about the surface of the wound and are not retained by blood-clots can be removed. No explora- tion for the bullet should be made except by a surgeon. The wound should, if possible, be dressed antiseptically and splints applied to prevent movement of the limb, and the patient at once conveyed to a place where he can se- cure the proper surgical treatment, for wounds of this character are frequently associated with Tetanus or lock jaw. When a person has been bitten by a snake, the wound should be immediately applied to the mouth, and the poison removed by suction. If the wound be inaccessible to the patient himself, this may be done by some one else present if he is willing to assume the risk. It is believed that the venom has no effect upon the mucous mem- brane of the mouth unless cuts or abrasions are present. If an extremity is bitten, in addition to suction, the part should be immediately surrounded by a tight bandage be- tween the wound and the heart. This is an effort to pre- vent the absorption of the poison into the system. It should not be forgotten that the bandage must occasion- ally be loosened to prevent any serious interference with the general circulation of the part. Cauterization would be of no value in this variety of poisoned wound. The depression that follows the absorption of the poison de- mands the free use of stimulants — whisky or brandy; however, it is not necessary or proper that the patient should be made intoxicated. Ammonia is a very valuable remedy, and may be given in the form of the carbonate of ammonia, ten or fifteen grains in whisky every half- hour, or the spirits of ammonia (hartshorn) may be sub- stituted ; one half to one teaspoonf ul may be administered in water or diluted whisky. If necessary, stimulants (properly diluted) may be given by the rectum, but always in larger doses. A very valuable method of ad- ministering the different stimulants is that commonly used by physicians, viz., by the hypodermic syringe, and is 100 PROMPT AID TO THE INJURED. often resorted to when a patient can not easily swallow, or where the prompt action of the remedy is demanded. (See Medic ATiox.) The treatment of a wound caused by the bite of a dog supposed to be suffering from rabies (hydrophobia) is substantially the same as in snake-bites, although, if suc- tion is impracticable, the wound may be cauterized by heating the blade of a penknife, button-hook, or piece of wire, red-hot and applying it to the wounded surface. The poison introduced does not develop rapidly, and the constitutional symptoms may not appear for weeks; there- fore stimulants are only indicated when shock is present. The suspected animal should be at once closely confined until under professional guidance it is killed and speci- mens secured and forwarded to some laboratory where they can be properly examined to detect the presence of rabies if it exists. The Pasteur treatment of this injury, by the injection of the anti-rabic emulsion, is now regarded as a successful and scientific procedure, if promptly em- ployed, and the patient should immediately be subjected to it; fortunately, this may now be carried out with but little difficulty. The wounds caused by tarantulas, centipedes, spiders, bees, wasps, and other insects, are very rarely dangerous. The local application of dilute ammonia, or a solution of bicarbonate of soda, is regarded as the most effective rem- edy, and generally relieves the pain at once. Wet fresh earth, common salt, or a slice of an onion are also valu- able, or some soothing application, such as solutions con- taining sugar of lead, laudanum, etc., that may be pro- cured, can be substituted. Stimulants may be indicated in some cases. Wounds of the abdominal walls are very dangerous, particularly so if the injury extends to the abdominal cavity (which is frequently the case), the external open- ing being often sufficiently large to allow of the escape of the bowels or intestines. If this occurs the mass should CONTUSIONS AND WOUNDS. IQl be covered with clean cloths, wrung out of hot water for protection until the arrival of the surgeon. Over this ap- plication should be placed other material, which tends to retain the warmth and offer gentle support. A wound of the abdominal walls which does not enter the cavity, although dangerous, should be treated as an ordinary- wound. The shock which accompanies abdominal wounds must receive appropriate treatment. Wounds of the thorax or chest are often associated with injury to the lung. Should this complication exist, it can be recognized by pain and irritation, coughing, dif- ficult breathing, haemoptysis (spitting of blood), and the appearance of blood and mucus, and sometimes air at the external opening. When this condition is present, the external wound should be closed and a compress and bandage firmly ap- plied, and the patient placed in a recumbent position and treated in the manner already described (see Hemopty- sis). Should great distress follow, the dressing must be removed, and the patient turned on the side correspond- ing to the wound, thus favoring the escape of accumu- lated blood in the chest, which probably caused the op- pression. Rest is essential to the proper healing of wounds, and should be insisted upon, particularly if the injury is of a serious nature. The limbs may be kept quiet by the use of splints or slings. Gangrene^ or mortification, is a condition representing destruction or death of the soft tissues, and is analagous to necrosis in bone. It may affect a small part, as a crushed toe, or involve a whole extremity. The latter often happens when the main artery of the arm or leg is torn across as a result of an injury, or when this vessel is subjected to prolonged pressure; this sometimes occurs when a bandage has been too tightly applied. Among the most prominent signs of gangrene are per- sistent loss of heat and sensation^ pallor of the part, 102 PROMPT AID TO THE IXJUPvED. which later becomes dusky and mottled, purplish, and at the end almost black. Decomposition or putrefaction and the formation of offensive gases follow. The presence of the gases gives a crackling sensation to the touch. The condition just described is known as moist gan- grene, and is the form usually met with. This term is used to distinguish it from a less common variety, known as dry gangrene, or inummificaHon. This occurs in very old people, where the arteries are more or less diseased and the circulation is weak. It usually affects the toes, and develops very slowly. As the name implies, the af- fected tissue has the appearance of being dried and shriv- eled. A bedsore is a localized form of gangrene, appearing about the buttock, along the spine, shoulders, and elbows, caused by long-continued pressure on these prominences in invalids who are confined to the bed, and who are often in an emaciated, enfeebled, or paralyzed condition. In order to prevent the formation of bedsores, strict cleanliness should be observed; the bed must be soft, and smoothly made; pressure on the exposed parts must be avoided. An air-cushion beneath the sheets is a valuable means of preventing pressure, or, if possible, the patient should at certain intervals change his position in the bed, or, best of all, be placed on a water-bed. Feather beds should always be avoided for the sick. The skin over the exposed part should be hardened by bathing the exposed part twice daily with alcohol, cologne water, etc. Treatment. — Gangrene represents dead tissue, and must be removed as early as possible. Gangrenous extremities are amputated by the surgeon. In these cases a fatal result often follows, owing to the absorption of septic or poisonous matter into the system. Small gangrenous spots, such as follow the lesser in- juries, and also bedsores, are usually left to Nature to re- move the dead tissue. This is done by a process known as " sloughing." The treatment during this period should CONTUSIONS AND WOUNDS. 103 be directed toward assisting Nature, by the use of warm applications such as carbolized flaxseed poultices, which facilitate the removal of the " slough," and by cleaning out the discharge with warm antiseptic solutions. The latter agents also diminish the offensive odor which is always present. When the slough or gangrenous matter has been cleared away the granulation and healing should be stimulated by the application of carbolic or oxide-of- zinc ointment, balsam of Peru, iodoform, etc., and the ap- propriate dressing applied. Dry or senile gangrene is a slow process, and the treat- ment should be left with the surgeon, if possible; if not, the following simple measures may be observed. In the early stage, when the big toe (the common seat of the affection) is first involved, the part should be enveloped in cotton batting to preserve an even temperature, and the foot should be kept quiet; later, when decomposition occurs, antiseptic solutions should be applied. CHAPTER X. HEMORRHAGE. HEMORRHAGE is the escape of blood as the result of an injury to a blood-vessel, and is classified as arterial^ venous, and capillary. In arterial haemorrhage the blood is thrown from the injured vessel in jets or spurts, and has a bright-red or scarlet color. In venous haemorrhage the blood flows from the wound in a slow, steady stream, the color being dark red or purple. In capillary haemorrhage the blood oozes from the general surface of the wound and not from one point, as in arterial or venous haemorrhage — the color being dark red. Hgemorrhage is arrested in two ways — by natural, and by artificial means. The Natural Mean^s. — The natural means of arrest- ing arterial haemorrhage is as follows : After an artery has been entirely divided, its muscular coat produces a contraction and retraction of the vessel at the seat of in- jury. The contraction duninishes the diameter of the artery, while the retraction draws the end of the di^dded vessel backward into its sheath. The blood at the mouth of the bleeding vessel forms a coagulum or '' clot," which aids in preventing the further escape of blood. Exposure of the bleeding surface to the air, and in severe heemor- rhage the weakened force of the heart and circulation, which often results in syncope or fainting, greatly favor the formation of the clot, and consequently help to arrest HEMORRHAGE. 1C5 the haemorrhage. The clot at the mouth of the injured vessel subsequently becomes organized and fii'nil y attached, and permanently stops the l)leeding. When an artery is only partly divided, the contraction and retraction can not properly take place, and the haemorrhage is very persist- ent. If an artery is severed by a dull or rough instrument, or torn across, the fibers at the end of the vessel being ragged and uneven, more effectually close the opening and assist in the formation of a clot, and may arrest haemor- rhage even in large arteries. This is illustrated in ma- chinery accidents, where an arm has been torn from the body and followed by very little or no bleeding. The manner in which nature arrests venous haemor- rhage is by the contraction and retraction of the end of the bleeding vessel, with the formation of a clot, as above detailed in arterial haemorrhage, and also the collapse of the vein at the point of injury (see Veins). The blood- pressure in veins being mucii less than that of arteries, the haemorrhage is less vigorous and more easily con- trolled. In capillary haemorrhage the minute size of the vessels and the contraction that follows their division, together with the rapid formation of a clot, particularly when the bleeding surface is exposed to the air, usually check the haemorrhage in a very short time. In some persons a condition of the blood exists which retards or prevents the formation of a clot ; for this reason the most trivial wound may be followed by a haemorrhage which can not be arrested, and terminates fatally. These subjects are known as bleeders. Cases of this kind are fortunately rare. The Artificial Means.— The artificial means of arrest- ing haemorrhage are as follows : Position, pressure, cold and heat, torsion, rest, styptics, and ligation. Treatment of Arterial Hcemorrhage. Position.— Eleva- tion of the injured part aids in controlling arterial haemor- rhage only where very small vessels are involved, but is 106 PROMPT AID TO THE INJURED. of very little value where large ones are implicated, owing to the strong pressure of blood in the arteries. Pressure. — This method of arresting haemorrhage is, next to ligation, the most important means that can be em- ployed for this purpose. It may be applied directly to the bleeding surface, or along the coiu^se of the artery. In the latter instance the j)ressure should be always made between the ivound and the heart. In the first variety of pressure the finger (digital pressure), or a pledget or tampon (see Tampons), is pressed into the wound, and constitutes a valuable means of checking the fiow of blood, particularly from small arteries. Pressure with the fijiger can only be of avail for a short time, unless the one making the pressure can be relieved at brief intervals. For this reason, a tampon — if properly applied — is more effective than digital pressure, provided the surgeon is not ex- pected for some time, or in case it is necessary to move the patient. In tamponing, the wound should be thoroughly filled from the bottom. A tampon improperly applied is worse than useless. The material used for this purpose must be absolutely clean, and if possible made antiseptic (see Anti- septics). Should the surroundings permit, choice should be made of one of the following : small strips of anti- septic gauze, linen, or muslin, or absorbent cotton. After the above has been complied with, the tampon should be held firmly in place by a bandage (see Bandages), but should not be allowed to remain longer than twelve or fifteen hours without the advice of a sm'geon. If the haemorrhage recurs at the expiration of this time, it may be necessary to clean the wound and apply a fresh tam- pon, otherwise it should receive the attention of an or- dinary wound. The second variety of pressure (along the course of an artery) is used particularly in haemorrhage from large ar- teries, and is most serviceable when the vessel can be pressed against a bone. Either the finger (digital press- HAEMORRHAGE. 107 ure), (Tr a pad or compress (see Compresses), may be used for this purpose. If the surgeon is expected to arrive in a sliort time, digital pressure is the simplest, quickest, and best means that can be employed. However, if consideral^le time must elapse before the patient can receive the proper sur- gical attention, or if he is to be removed some distance, the pad should be utilized. In digital pressure, the thumb should preferably be used. The function of a pad applied over the course of a bleed- ing artery is similar to that of a tourniquet. A tourniquet is an instrument used by surgeons to arrest arterial haem- orrhage by compression. An excellent tourniquet can be extemporized by folding a large handkerchief in the form of a cravat, placing be- tween the folds a smooth stone, piece of wood, cork, potato, etc., or a good-sized knot may be tied in the handkerchief; the latter, however, is inferior to the stone, etc. The hand- kerchief is then bound loosely around the limb and tied, the portion acting as the pad being placed over the artery, betiveen the icound and the hearty and held securely in this position, while a bayonet, sword, cane, umbrella, stick of wood, etc., should be passed between the handkerchief and the skin at the side of the limb opposite the pad and twisted until the haemorrhage ceases (Fig. 72). As the constric- tion resulting from this form of pressure interferes with the return or venous circulation, the handkerchief should be occasionally loosened if there is evidence of serious obstruction, as swelling and blueness of the part below the constriction ; digital pressure should be substituted while the handkerchief is loose. A handkerchief is given as an illustration of what may be at once secured, although parts of clothing, neck-ties, suspenders or rubber tubing^ rope, etc., are equally valuable, provided they fulfill the re- quirements. Haemorrhage may be checked without the pad by simply constricting the part with one of the agents just enumerated. This, however, is less effective. 108 PROMPT AID TO THE INJURED, Prof. Esmarch has recently devised a suspender made of elastic webbing, and so constructed that, after detaching it from the trousers, the apparatus (straps, etc.), by which it is attached, can be easily and quickly removed, leaving a long elastic ribbon which is to be used in constricting a bleed- ing limb (Fig. 65). Torsion is a method used by sur- geons to check bleeding from small arteries. It consists in catching the end of the injured vessel with for- ceps or clamp and twisting it until the haemorrhage ceases. Ligation or ligaturing (tjong) is the procedure by which the end of the bleeding vessel is tightly constricted and secui'ely closed by an agent called a ligature, which consists of a thread of silk, cat- gut, etc. A ligature is commonly employed to arrest hasmorrhage (particularly in arteries), and is the most valuable method of ac- complishing this result. The use of this means, however, should re- main within the province of the surgeon. Treatment of Venous Hmmor- rhage. Venous haemorrhage is easi- ly controlled if the following rules are observed : Fig. 65.-Suspeader devised -^ Remove everything between y ro . smarc . ^^^ icoiuid and the heart that re- tards the flow of blood, as garters, tight clothing, etc. 2. Elevate the injured part. 3. Apply a good firm compress directly to the wound. HJiMORIlIIAGE. lUl) Coiistriction of the limb beyond or helow the seat of haemorrhage is vahiable, but inferior to the method just described. The importance of the first and second rules will be apparent in rupture of varicose veins in the leg, which often bleed freely ; the valves of these disabled veins being rendered useless, the blood escapes from both ends of the divided vessel. In rupture of varicose veins of the leg a bandage should be applied over the compress, beginning at the toes and extending upward to a short distance above the seat of haemorrhage. In ordinary venous haemorrhage the free return of blood to the right side of the heart, aided by elevation of the limb, relieves the blood-pressure in the veins in the immediate vicinity of the wound, and conse- quently the haemorrhage is not so profuse. Treatment of Capillary Hceniorrhage. Capillary haemorrhage is usually harmless, except in case of '' bleed- ers," and generally ceases when the bleeding surface is exposed to the air. If such means are not successful, hot or cold applications or a compress should be employed. Cold is a very valuable means of controlling venous and capillary haemorrhage, and aids in arresting the bleeding from an artery. It may be applied in the form of cold air (exposure of the bleeding surface), cold water, ice, and snow. Hot applications (temperature 120° to 125° Fahr.) are su- perior to cold. A piece of flannel wrung out in water as hot as can be borne by the skin, and applied directly to the bleeding surface, is followed by a diminution or a cessation of haemorrhage. Both hot and cold applications contract the bleeding vessels and hasten the formation of the clot. The application of alcoholic solutions, or the spirits of turpentine, to the wound by a cloth saturated with either, although very irritating, are sometimes used to check haemorrhage. Styptics, or astringents, although powerful agents for ar- resting haemorrhage, are used by surgeons with great reluc- 110 PROMPT AID TO THE INJURED. taiice and only in special cases, or where other means are not available or less effective. Styptics are objectionable, for the reason that the stronger ones, as solution of the subsul- phate of iron (Monsel's solution), nitrate of silver, and some others, injure the wounded surface, and may be followed by sloughing. The weaker styptics or astringents, such as tannin, gallic acid, matico, cobwebs, and alum, prevent heal- ing by first intention. Alum is the least objectionable of the latter group. The application of styptics to mucous membranes (mouth, nose, etc.) is followed by more favor- able results than when applied to a raw, wounded surface. Rest is extremely important in all varieties of haemor- rhage, as it favors the formation and retention of the clot. Haemorrhage occurring in the scalp may be easily arrested by the use of a compress and bandage (see Band- ages), which press the bleeding vessels against the under- lying skull. Haemorrhage from the mouth may usually be stopped by the use of ice and astringent (alum, tannin) or alcohoKc (brandy, whisky, etc.) solutions ; if not suflBcient, a tampon should be fii^mly held against the bleeding point. In severe cases the common carotid artery (see description of this ves- sel), on the side corresponding to the injury, may be com- pressed, although this should only be used as a last resort. The lips are supplied by arteries which divide at the angles of the mouth, and entirely surround this opening. When the lips have been injui'ed, the haemorrhage i^iay be checked by pressing the sides of the wound between the thumbs and fingers. Severe haemorrhage following the extraction of a tooth can be conti'olled by replacing the tooth, or by the applica- tion of a tampon saturated with a strong solution of alum, or other astringent, to the cavity. Epistaxis^ or ''nose-bleed," is the most frequent form of internal haemorrhage, and may be controlled in the fol- lowing manner : Elevation of the head and arms, removal of all constriction about the neck, cold applications to the HEMORRHAGE. m back of the neck, forehead, or bridge of the nose. Passing two fingers beneath the upper lip and directing pressure against the base of the nose or nostrils is very useful ; snuffing up some finely powdered tannin or cold, salt, or alum water, or, even better, syringing the nasal cavity with some of these remedies. If the mouth is kept open during this operation, the fluid will escape through the opposite nostril. A very valuable method of checking epistaxis is by the use of a thin rubber finger-cot or pro- tector, which should be greased and carefully passed into the nasal cavity of the affected side ; after the cot is in position it should be filled or partly filled with very small pieces of ice. In severe cases of epistaxis which resist the remedies already enumerated, the nasal cavity on the side corresponding to the haemorrhage may be tamponed by carrying into the nasal cavity of the affected side a piece of gauze (antiseptic, if possible) over a pencil or similar agent. When the pencil is withdrawn the cavity left in the gauze is packed with small pieces of cloth or cotton. The tampon sliould be left a number of hours, and never forcibly removed, but should be loosened by injection of water or oil. In order to be able to properly control haemorrhage by pressure, it will be necessary to know the position of cer- tain arteries and their relation to contiguous structures, so that they may be readily found and compressed. For this purpose the following diagrams have been intro- duced, which will afford a guide in locating these blood- vessels. Carotid Artery. — This vessel supplies the head with arterial blood. Its course from below upward corre- sponds to a line drawn from the junction of the collar and breast bones (clavicle and sternum) upward to a point just behind the angle of the lower jaw, or between it and the mastoid process of the skull — a bony promi- nence just back of the ear ; this line also indicates very closely the anterior or front border of the sterno-mastoid 112 PROMPT AID TO THE INJURED. muscle, which extends from the mastoid process to the sternal end of the clavicle already mentioned. The application of digital pressure to the carotid artery- is indicated in severe haemorrhage about the head and Fig. 67. — Digital compression of carotid artery. upper part of the neck (as in " cut throat "), which can not be controlled by other means. The pressure should be applied about midway in the neck at the anterior border of the sterno-mastoid muscle, and directed against the anterior portion of the spinal column in the neck (Fig. 67). The carotid artery is accompanied by a large vein (internal jugular) and a very important nerve (pneumo- gastric) which may be injured if the part be roughly manipulated. In wounds of the hand, forearm, and arm, associated with severe arterial hgemorrhage, pressure may be made upon the subcla\dan, axillary, brachial, or radial and ulnar arteries, according to the situation of the wound. Subclavian Artery. — Pressure should be applied to HiEMOllRUAGE. 113 this vessel in haemorrhage occurring at the upper part of the arm or in the axillary space ("arm-pit"). The outer Fig. 68.— Digital compression of subclavian artery. portion of the subclavian artery passes over the upper sur- face of the first rib. If the thumb is directed downward j beind the clavicle, about two inches from the breast-bone, the artery may be reached and compressed against thft/ first rib (Fig. 68). Pushing the shoulder of the patienfi downward facilitates this procedure. In some persons digital pressure fails to arrest the haemorrhage, as the ar- tery can not be reached by the finger ; then the handle of a door-key or some other agent suitable for the purpose may be substituted. Axillary Artery. — This vessel is the continuation downward of the subclavian artery. It passes through the axillary space, and can not be easily compressed in this 9 114 PROMPT AID TO THE INJURED. situation ; consequently, the subclavian is generally se- lected as the artery to which pressure is to be applied in haemorrhage occurring in the upper part of the arm. Some pressure may be made upon the axillary artery by raising the patient's arm and pressing the vessel against the upper and inner portion of the humerus. A book, or whatever may be used, should be carried well up into the axillary space, and the arm brought close to the side. It should be remembered that undue pressure at this point may injure some of the nu- merous nerves in this vicinity. Brachial Artery. — Owing to the numerous injuries of the upper extremity, the bra- chial artery requires compres- sion oftener than any other vessel in the body. Pressure upon the brachial artery is easily and accurately made. Its course is along the inner side of the biceps muscle, which is found in the front of the arm and stands out very prominently, particular- FiG. 69.— Line showing the course of ly in muscular Subjects (Fig. the brachial artery. gg^ Pressure should be ap- plied at the inner border of the biceps and directed against the humerus (Fig. 70). If the patient is to be removed, a tourniquet should be made and adjusted in the manner already described, or two round pieces of wood about the diameter of a broomstick, and properly covered to prevent injury to the skin, may be used to compress the brachial artery. One piece should be placed transversely on the inner side of the arm against the artery, while the other HiEMORRHAGE. occupies a corresponding" position on the outer side of the arm; the ends of the sticks are then tied to^-ether with suflBLcient force to arrest the haemor- rhage. Haemorrhage in the forearm and hand may be controlled by placing a small pad at the bend of the elbow, and then flexing (bending) the forearm upon the arm and keeping it in this position. The radial and ulnar arteries are branches of the brachial, and continue down the forearm to the hand; they are superficial at the wrist, the only point at which they can be compressed with any degree of success. The radial artery or " pulse " may be found about three quarters of an inch from the outer border of the wrist (when the palm of the hand is turned upward), the ulnar being about one half inch from the inner border of the wrist. These vessels may, to a certain extent, be compressed, but in wounds of the hand associated with haemorrhage pressure upon the brachial artery should be employed. A very persistent form of haemorrhage sometimes fol- lows a wound of the palm of the hand. The bleeding should be checked by plugging the wound and then placing in tlie palm of the injured hand over the tampon a smooth and round piece of wood, potato, apple, lemon, billiard- ball, or whatever may be closely grasped. Tlie hand sliould then be bandaged in this position. The h^mor- FiG. 70.— Digital compression of bra- chial artery. 116 PROMPT AID TO THE INJUREDo rhage may be greatly climinislied or even controlled by having the patient hold tightly one of the agents just men- tioned, without the addition of the tampon. Femoral Artery. — After the external iliac artery (in the abdominal cavity) passes into the leg, it is known as the femoral artery and supplies the lower extremity. It should be compressed in severe hsemorrhage from this portion of the body. The course of this artery is from the middle of the groin downward to the inner side of the knee (Fig. 71). The artery is superficial in the upper part of the thigh, from the groin downward about six or eight inches, and it is in this situa- tion that the pressui'e must be ap- plied (Figs. 72 and 73). It is com- pressed most effectively where it crosses the pelvic bone at the "groin." Popliteal Artery. — This vessel is the continuation of the femoral artery, and is found in the poplit- eal space (behind the bend of the knee), and is only slightly affected by digital pressure, although a pad can be placed in the popliteal space and pressed upon the artery by flexing the leg upon the thigh and securing it in this position. Haemorrhage from the sole of the foot is sometimes controlled by compressing the posterior tibial, sl branch of the popliteal artery, as it winds around the ankle be- tween the internal malleolus (ankle) or lower end of the tibia, and the heel, rather closer to the former. Plugging is also valuable for this form of haemorrhage. Secondary haemorrhage means the reappearance of Fig. 71. — Line showing course of the femoral arterv. HAEMORRHAGE. 117 bleedfng in the wounded part soon after it lia.s been once arrested. It is generally capillary, and is caused by the re- action and increased force of the heart, the relaxation of the blood- vessels at the seat of in- jury, or the immoderate use of stimulants, undue movement of the part, and also increased warmth to the surface that follows when the patient is placed in bed. Elevation of the in- jured part and moderate- ly increased pressure are often all that need be done, although, if the haemorrhage continues, the dressings should be removed, the blood- clots cleaned out of the wound, and fresh dress- ings applied. Seconda- ry haemorrhage may also occur, when sloughing is present, some days after the wound is received. It should be well borne in mind that secondary haemor- rhage may be followed by collapse and death. Clots are not to be removed from a wound unless the means of cleaning and dressing the wound are at hand ; they act as a temporary compress and haemostatic. The constitutional symptoms of haemorrhage follow- ing a great loss of blood are : Pallor of the face, lips, and surface of the body, the skin being often covered with a cold sweat; the features are pinched. Thirst, shortness of breath, restlessness and sighing, vomiting, and disturbance Fig. 72. -Digital compression of the fem- oral artery. 118 PROMPT AID TO THE INJURED. of the functions of the brain, are more or less prominent ; dimness of vision, ringing in the ears, delirium, and un- consciousness or syncope, convulsions, and death may also occur. The se- verity of these symptoms de- pends upon the amount of haem- orrhage. The treatment, besides checking the hemorrhage, consists in the careful internal useof stimulants, application of warmth to the body, hot rectal injections, and the general treat- ment of shock. Hcemoptysis. or hemorrhage from the lungs, is generally rec- ognized by the expectoration of bright-red and frothy blood, also coughing, and pain and rattling in the chest. The usual cause is disease of the lungs, although it may follow a wound of these organs. Treatment. — The fears of the patient should be calmed, and rest in the recumbent position, with the head and shoulder slightly elevated, insisted upon. The tempera- ture of the room should be cool, and the air pure. Among the remedies commonly used are table salt, half a tea- spoonful ; cracked ice ; ten to sixty drops of the fluid ex- tract of ergot every hour for two or three hours, and then discontinued or taken at longer intervals ; five to twenty Fig. '3. — Arresting haemorrhage from femoral artery by the use of an improvised tourniquet. HEMORRHAGE. 1 19 drops of the oil of turpentine on sugar every half hour or hour until three or four doses have been taken, or half a teaspoonful of aromatic sulphuric acid (elixir of vit- riol), in water occasionally. If the affected side is known an ice-bag may be applied. Slight haemorrhage from the lungs is sometimes relieved by the free use of a cathartic. Hwmopiysis is rarely followed hy a fatal termination, un- less it results from a wound of the lung. Hcematemesis, or haemorrhage into the stomach and vomiting of blood, is generally the result of some chronic disease of the stomach, although it may follow a blow or stab of the abdomen. The symptoms are frequently those of profuse haemorrhage (see Constitutional Symptoms of Hemorrhage), also a sense of fullness about the stomach, commonly followed by the vomiting of dark or black blood, which is heavy, not frothy, as in haemoptysis. The vomited matter is mixed with food, provided the haemor- rhage occurs soon after a meal. It should be remembered that the source of haemorrhage in haematemesis may be from the mouth, nose, or throat, the blood having been swallowed, consequently these parts should be examined. The usual treatment is rest in the recumbent position; small pieces of ice should be freely swallowed, and the ap- plication of ice wrapped in a towel or in an ice-bag, or snow, cold water, etc., over the stomach; hot applications may be applied to the extremities. No attempt should be made to administer medicine or stimulants by the mouth. In severe cases of haemoptysis and haematemesis the gen- eral treatment of shock is called for. Stimulants should be used with caution, as they are apt to encourage the haemorrhage. Hsematemesis is commonly associated with some serious condition. The patient should be seen by a physician as promptly as possible. CHAPTEE XL FRACTURES. A FRACTURE is a breaking' or solution of continuity in a bone. Fractures are generally classified as simple, compound, comminuted, multiple, and complicated. In a simple fractui'e the bone is broken into two frag- ments, but does not communicate with the outer world, the skin being uninjured. In a compound fracture the bone is exposed to, or com- municates with, the air by a wound of the soft structures. In a comminuted fractui'e the bone is broken or crushed into a number of pieces at the same point, and communicating with each other. In a multiple fracture the bone is broken into a num- ber of pieces, but at different parts of the bone, and not communicating with each other. In a complicated fracture there is, in addition to the breaking of a bone, an injury to some important adjacent structure resulting from the fracture, as blood-vessels, nerves, or joints. A fracture is either complete or incomplete. A com- plete fracture is the usual variety, and involves the entire separation or loss of continuity of a bone. An incom- plete fracture frequently occurs in children, owing to the elasticity of bone in eai'ly life, and has received the name of '' green-stick " fractm^e. The direction in which the bone is fractured is indi- cated by the terms transverse, oblique, and longitudinal. An impacted fracture occurs when the broken ends of a bone are driven into each other, and remain thus fixed. FRACTURES. 121 The' sign and symptoms of a fracture are deformity, abnormal or increased mobility, bony crepitus, pain, loss of function, and subsequent swelling and discoloration. The deformity is caused by the displacement of the broken ends of the bone, as the result of the violence caus- ing the injury, also the vigorous muscular contraction at the affected i)art, and attempted movement on the i)art of the patient, Avhich cause a shortening and change in the direction of the limb, and considerable deformity at the seat of injury. The deformity, as a rule, is not particu- larly apparent in impacted fractures. Abnormal mobility is the result of the solution of con- tinuity or break in the bone, producing a " false point of motion," which is detected by the surgeon while manipu- lating the part. Crepitus, or grating, is caused by the rubbing together of the broken ends of the bone, and, when detected, is a positive sign of fracture ; it is absent in impacted f ractm-e, and also where muscular or other tissues have fallen be- tween the ends of the broken bone ; consequently, an absence of crepitus does not mean an absence of fracture. Pain is caused by the contact of the fragments of bone with the adjacent structures, also the strong muscular con- traction that occurs at the seat of injury. More or less heat, redness, swelling, and discoloration of the part may be present. Loss of function is the inability on the part of the patient to make use of the affected limb. The swelling and discoloration are due to the subcuta- neous escape of blood and serum at the seat of fracture. The repair, union, or " knitting " of the bone is begun by Nature soon after the occurrence of a fracture, and is accomplished by a substance formed at the seat of injury, known as callus, which is thrown around and between the ends of the broken bone. Although soft at first, the callus gradually hardens, and at the end of varying periods, de- pending on the bone injured, but not usual'ly exceeding 122 PROMPT AID TO THE IXJUPiED. six weeks, the fragments are firmly united. The minute structure of callus becomes in time (about one year) simi- lar to that of bone. Sometimes the formation of callus is imperfect or in- sufficient, and the broken bone does not become united. This "condition constitutes an ununited fracture. The union of bone in a simple fracture is likened to heahng by first intention in wounds, while the repair in a compound fracture resembles healing by granulation. The popular belief that the pain is increased at the seat of fract- ure during the '' knitting " or healing process is without any foundation. Treatment. — The object of a surgeon in treating a fracture is simply to assist Nature. He first carefully reduces the fracture, or "sets" the bone; that is, he en- deavors, as far as possible, to bring the broken extremities in apposition or directly against each other, and by retain- ing them in position for a certain length of time by splints or some other form of support, the permanent union is effected by the callus, and the function of the part gener- ally restored. Although it is best that a fracture should be reduced and the proper dressing applied as quickly as possible after the accident, it should be remembered that the union of the fragments does not begin for some time after the injury, and that a fracture may remain several days before being reduced, and be stni followed by excellent results ; and also that a frequent cause of compound fractm^e is the out- come of unskillful manipulation. Consequently, when one not a surgeon is called upon to attend a person where a fracture is suspected, his duty consists in protect- ing and making immovable the injured part, and convey- ing the subject to a hospital, or wherever he can receive the necessary and proper treatment. However, should this be impossible, as the result of the accident having occurred where the professional services can not be pro- cured for an indefinite period, an effort may then be FRACTURES. 123 madelo reduce the fracture, but the manipulations are to be made only with the greatest care. As a rule, an injured person should not be removed from the position in which he is found until an examina- tion has been made as to the character of the injury. A violation of this rule is a frequent cause of a compound fracture. A brief account of the manner in which the injury was received should be obtained from the patient or a by- stander. An examination should then be made. If the injury is about the ankle or wrist, it can easily be exposed ; however, if the affected part is nearer to the body, the clothing should be cut away, and not removed in the ordi- nary manner, which would be likely to disturb the frag- ments and increase the suffering. The different garments need not be indiscriminately cut, but, if possible, ripped at the seams. If a fracture has occurred, an examination will probably show one or more of the ordinary symptoms and signs already described. If the necessary surgical attendance can be secured within a number of hours, the splints should be applied without an attempt being made to reduce the fracture ; otherwise, an effort in this direction is justifiable. The reduction of a fracture consists in bringing the ends of the broken bone together, and is accomplished by extension and counter-extension. The term extension, when applied to the treatment of a fracture, indicates a procedure whereby the broken limb below the seat of fracture is pulled from the body. In counter-extension, the upper fragment, or the portion of the broken bone nearest the body, is held securely in position, or is carried in an opposite direction from the lower fragment. This manner of reducing a fracture is performed by the sur- geon with the hands or an instrument devised for the purpose. The hands are generally used. The extension and counter-extension should be made in a straight line ; that is, in the long axis of the broken bone. 124 PROMPT AID TO THE INJURED. After the seat of injury has been examined, and the presence of a fracture ascertained or suspected, the cloth- ing j)reviously turned aside can now be replaced and \^'rapped around the i)art, thus affording considerable pro- tection to it. The splint should then be adjusted, and the patient removed to a place where he can receive the prop- er surgical treatment. The slings necessary to support an injured arm have already been described (see Triangular and Cravat Bandages). In addition to these, the skii't of the coat may be utilized for this pur- pose (Fig. 74) ; also other de- vices, such as pinning the sleeve to the waist, etc. If the fracture is com- pound, no effort should be made to apply splints until the wound has been covered as quickly as possible with an antiseptic material or some form of clean dressing. When a blood-clot fills the wound, it should under no circum- stances be disturbed until the patient is in the hands of the surgeon. The protection af- forded by the compress or blood-clot just alluded to, pre- vents the entrance of poison- ous germs into the system. If a point of the broken bone is pushed through the skin, it should not be interfered with, but dressed antiseptically. Splints. — Splints can be made of any material which is capable of rendering the part practically immovable without injuring the soft structures to which they are ap- Fia. 74.— Skirt of coat used as a slino;. FRACTURES. 125 plied^ They should be long enough to extend some dis- tance above and below the injury, and generally including the nearest joint, and at times two or three joints, as in fracture of the thigh. Their diameter should exceed that of the limb to which they are applied, although this is not absolutely necessary, as a cane or a sword makes a very fair support. Two splints are generally used, one for the inner and one for the outer side of the limb. Splints should always be padded on the side next to the skin with some soft material, so as to prevent undue pressure and in- jury. After a splint has been fitted to the limb, it should be retained by the necessary bandages; the latter, how- ever, should not surround the limb at the point of fract- ure, nor should they be drawn sufficiently tighi: to increase the suffering of the patient. This should be particularly observed in unreduced fractures. Although thin wooden boards are regarded as the most desirable material for splints (at least for temporary use), being light, and easily formed to suit special cases, other substances may be employed with good results. Among those Avhicli can be secured in emergencies are shingles, laths, fence-boards, cigar-boxes, barrel-staves, bark and branches of trees, the latter being bound together with cord or green twigs. Binders' board, cut into the proper shape, makes an excellent splint. Book-covers may be used ; also sole-leather, newspapers tightly and thickly folded, hay or straw bound in the same manner as the branches of trees; canes, umbrellas, broomsticks, coat- or shirt-sleeves or boot-legs stuffed with hay, grass, leaves, etc., can be utilized. A pillow, or an article of clothing properly folded, makes a very valuable temporary splint and pad combined, and is particularly useful in fracture of the leg (Fig. 79). In military service, in addition to the above articles, guns, swords, scabbards, bayonets, leather from a saddle, etc., can be made available. Padding. — For padding, cotton or any soft substance, 126 PROMPT AID TO THE INJURED. as an article of clothing, oakum, furniture-stuffing, straw, hay, moss, grass, leaves, etc., may be used- Bandages for the purpose of retaining the splint may be formed of handkerchiefs, neck-ties, suspenders, strips of clothing, straps, green twigs, rope, cord, wire, etc. Care should be taken that when using such substances which are small, as wire and cord, that the skin he well protected, so that it shall not he injured or cut. Special fractures will now be considered. Fractures of the cranial bones are usually followed hy symptoms of concussion and compression of the brain. A fracture occurring at the base of the skull is usually caused by a blow about the forehead or opposite the point of fracture, or by a fall from a height, the person striking on the head or upon the feet or buttocks, and has, in addi- tion, special symptoms which point directly to this form of injury, viz. , an escape of blood from the nose and ear, and heneath the thin membranes covering the eye ; or, what is still more positive, an escape of a colorless fluid from the ear. Treatment. — The patient should be placed on his hack in a cool^ dark room, and kept perfectly quiet. Cold, in some form, should he applied to the head, to prevent ex- cessive reaction. For the same reason, the internal use of stimulants is to be avoided. Fracture of the inferior maxillary bone (lower jaw) is caused hy kicks, blows, or falls. The body of the bone (the portion into which the teeth are inserted) is the usual seat of fracture, which is generally compound, hav- ing a communication with the cavity of the mouth. The deformity is shown by the u'regular line of the teeth on the aflPected side. Crepitus, swelling, dribbling of saliva, and bleeding from the mouth, are also generally present. Treatment. — The teeth should he brought together, thus allowing the superior maxillary bone (upper jaw) to act as a splint. A four-tailed bandage (Fig. 43) should then he applied to retain the parts in this position. FRACTURES. 127 Fracture of thk spinal column should be suspected when, following an injury to the back, there appears more or less paralysis beloiv the point of injury (paraplegia), as the result of pressure upon the spinal cord. The ordinary symptoms of fracture are not usually present, nor should they be sought for, as efforts made to elicit crepitus, etc., might increase the injury to the spinal cord. Paraplegia may also be caused by a dislocation of the vertebrae. Treatment. — The patient should be allowed to assume the position (lying down) which is most agreeable to him, provided he does not lie face downward. An ice-bag, or some form of cold, may be applied to the seat of injury, and perfect rest enjoined. If necessary, the patient can be moved on a stretcher which is so prepared that undue movement of the spine is prevented (see Transportation). The after- treatment, consisting of efforts made to adjust the frag- ments of bone and to prevent subsequent inflammation and injury to the spinal cord, and relieving the paralyzed bladder of urine, should be attended to only by a surgeon. Fractures of the ribs are caused by direct or indirect violence, as the result of a fall or a blow, or being sub- jected to severe x^ressure, as in a crowd, or by muscular contraction. Muscular action during a paroxysm of cough- mg or sneezing, has been known to produce a broken rib. The seat of fracture is usually between the third and eighth ribs, and about on a line downward from the axillary space. The floating ribs — eleventh and twelfth — are rarely broken, owing to their single attachment (verte- bral column), which allows sufficient freedom whereby to escape injury. Fractured ribs are usually diflB.cult to recognize, in a large number of cases the injury being mistaken for con- tusions. Embarrassed and shallow breathing, associated with a sharp and lancinating or " stabbing " pain at the injured part, or a " stitch in the side," is almost alwaj^s complained of. Crepitus may sometimes be detected by placing the 128 PROMPT AID TO THE INJURED. hand or the ear against the injured side, and then having the patient take a long breath or cough. It is uncommon to find any external evidence of fracture, and great care should be observed in examining so as not to inflict a greater injury by the manipulation. A broken rib may be followed by serious consequences, as an injury to the lung, which w^ould be demonstrated by shock, spitting of blood, and, in some cases, a crackling sen- sation when the hand is carried over the skin at the seat of pain, due to the presence of air under the skin (emphysema). Treatment. — The treatment consists in limiting the ac- tion of the affected side or sides as much as possible. This indication is met by the application of bandages or adhe- sive plaster. A triangular bandage, folded in the form of a cravat, and bound snugly around the chest, would answer for a temporary dressing ; a flannel or muslin bandage, about three inches wide, and made to encircle the chest a number of times, would be still better. At the present time, however, the most effective means of treating a frac- tured rib is by the use of adhesive plaster, applied either entirely or two thirds of the way around the chest as fol- lows : Strips of plaster, one and a half or two inches wide, and sufficiently long to surround the entire chest, are made ready. The strips are heated and then applied firmly around the chest from above downward, follow- ing, as nearly as possible, the course of the ribs, each strip overlapping the lower third of the preceding one. The space covered by the strips should be about eight inches in width. Or, for instance, if the fracture is on the right side, the adhesive plaster may be first applied about four inches to the left of the spinal column, and carried around the right side of the chest to about the same distance to the left of the breast-bone, thus restrain- ing the action of the injured side without materially affecting the opposite one. In the use of bandages or the strips of plaster, as already described, it is very important that they (particularly the plaster strips) should be ap^ FRACTURES. 120 plied at the end of expiration, as at this time the chest is diminished in size and the broken fragments are brought closer together ; however, care must be taken that the application does not seriously interfere with respiration. The above treatment may also be used in severe con- tusions of the chest. Fracture of the Clavicle. — The collar-bone is more frequently broken than any other bone in the body, and is usually the result of indirect violence, as falling upon the shoulder. The recoil of a gun may cause direct fract- ure. It will be remembered that the collar-bones hold the shoulders upward, backward, and outward; conse- quently, the deformity following this injury would be dropping of the shoulder downward, forward, and in- ward, with some change in the outline at the site of the fracture. Treatment. — The patient may be laid down, with a pillow between the shoulders, or, if he is to be removed, the following temporary sup- port may be used : A soft pad is placed well up in the ax- illa or arm-pit, the forearm being laid against the chest and the shoulder raised by pressing the elbow upward, and held in this manner by an assistant, or by the patient himself, until supported by the bandages to be now de- scribed. A triangular or Es- march bandage, folded in the form of a cravat, or a long strip of cloth, should be placed under the elbow, and one end carried upward, across the chest, and the other across the back, and the two ends fastened over the opposite shoul- der ; a similar bandage is then placed against the outside 10 Fig. 75. — Temporary dressing for fracture of clavicle. 130 PROilPT AID TO THE INJURED. of the arm, on the injured side ; the ends of the second bandage are carried across the chest and fastened at the opposite side. The dressing- fulfills, to a great extent, the indications for treatment, viz., carrying the shoulder up- ward, backward and outward (Fig. 75). Fracture of the Scapula or shoulder-blade is of rare occurrence, and the result of du'ect violence, as a heavy- wagon- wheel passing over the part. The signs and symptoms are usually obscure, the bone being so thickly covered with muscular tissue that it does not exhibit much deformity. Treatment. — In a suspected fracture, the arm of the corresponding side should be placed in a sling and kept quiet by the side of the chest. Fracture of the Humerus or arm-bone may be the result of direct or indnect violence or of muscular con- traction. The signs and symptoms are usually well marked, and there is considerable shortening. If the seat of fracture is at the surgical neck, a bony prominence may be found in the axillary space or arm-pit. Treatment. — When reduction is to be made, the fore- arm and elbow should be pulled downiward (extension), the shoulder acting as the counter - extension. If the fracture is about the middle of the bone, an internal and external splint should be applied. Great care must be taken least the internal one should be carried into the arm- pit and made to press upon important blood-vessels and nerves. If the fracture is in the upper part of the bone, through the surgical neck, a soft pad may be placed in the arm-pit aud held in place by a flgure-of-8 bandage, or spica, around the shoulder. The hand and wrist only should be suspended in a sling, thus allowdng the elbow- to drop, thereby diminishing the tendency to shortening of the arm. Fracture of the Forearm generally occurs at the lower end of the radius, about two inches or less from the joint, and is known as Colles' or " silver-fork " fracture. FRACTURES. 131 It receives the latter name from the peculiar appearance about the wrist, which has a fancied resemblance to a sil- ver fork. Colles' fracture is almost as frequent as fracture of the clavicle, and is g-enerally impacted. Treatment. — The arm should be placed at right angles, the thumb pointing toward the chin — midway between pronation and supination. An internal splint, extending from the upper part of the forearm to the wrist, and an external splint extending to the base of the fingers, should be applied. Care should be taken that the internal splint does not press upon the vessel at the bend of the elbow. Eeduction may be accomplished as f ollo\^^s : Should the fracture be on the right side, for instance, the attendant should grasp the right hand of the patient with the corre- sponding one of his own, and extension be carefully made ; counter-extension being performed with the left hand, which grasps the forearm above the seat of fracture. Fracture of the Middle of the Forearm may occur as the result of direct violence. One or both bones may be broken. When the latter occurs, the appearance is very characteristic. However, w^hen either the radius or ulna is broken, the companion-bone acts as a splint, and the de- formity and other signs are not so marked. In fracture of the shaft of the radius, which is uncommon, the usual symptoms of fracture are noted, and, in addition, the loss to a greater or less degree of pronation and supination, or turning the hand inward and outward. Fracture of the ulna sometimes follows an attempt to ward off a blow, and is not uncommon among pugilists. Treatment. — Fracture at the middle of the forearm should be treated in the manner already described for Colles' fracture — internal and external splints applied while the arm is bent at an angle, with the thumb point- ing to the chin, the injured limb then being supported by a sling. Fracture of the Metacarpal Bones.— Indirect vio- lence, as a fall upon the hand, or striking a blow with the 132 PROMPT AID TO THE INJURED. fist, is a common cause of fracture at tins situation. A swelling on the back or dorsum of the hand usually fol- lows, and the knuckle corresponding to the broken meta- carpal bone is sunken, and appears to be effaced. Treatment. — A roller-bandage, wad of cotton, oakum, or other similar material, or a potato, lemon, tennis ball, etc., should be placed in the palm, the hand closed, and retained in this position by a bandage. Fractures of the Phalanges are generally detected without much difficulty, the common signs of fracture being well marked. Treatment. — After reduction has been accomplished, splints should be applied to the palmar and dorsal sides of the broken finger. A piece of a cigar-box may be used for this purpose, although a piece of tin or sheet-zinc, entirely covered with adhesive plaster, would be preferable; or, after the fracture is reduced, the finger may be bound to a companion finger, or covered with a narrow roller-bandage, and stiffened (after being applied) with flour and white of an egg, which makes a very good temporary dressing. Fracture of the Femur is one of the common frac- tures of the body. The great size of the bone — it being the largest in the skeleton — and the fact that more or less limp- ing due to the shortening of the affected limb may follow this injury (particularly in the adult), makes the treatment a matter of great importance to the surgeon. The femur may be broken either at the neck, extremities, or shaft, the most frequent situation being about the middle of the bone. The fracture is more commonly caused by indirect violence, as falling, etc., and is oblique (in adults), which principally accounts for the shortening that follows. The signs and symptoms are usually well marked. The foot and leg are turned outward, particularly if the shaft of the bone is broken. Fracture of the neck of the femur occurs in old people, and is in a great measure due to the composition of bone at this period of life, which is more dense than at any other time, and also to the change in FRACTURES. 133 the ang-le of the iicck of the bone, and may in the aged follow a most trivial cause, as tripping-, etc. Treatment. — A long external splint, extending from about four inches below the axillary space or arm-pit to a short distance below the foot, is sufficient for a temporary dressing. If a gun is used as a splint, the stock should be placed beneath the arm-pit, and the barrel (turned downward) laid against the leg (Fig. 7Gj. A fence-board, which is usually about six inches wide, makes an excellent splint. Before applying the splint, the thigh should be surrounded by a coat properly folded, or shawl, etc. A bandage should then be carried around the waist, two around the thigh (one above and one below the seat of fracture), one around the leg and foot each — the bandages being tied on the outside of the splint. If no better support can be devised, the affected limb may be bandaged to the one of the opposite side. If a fracture of the femur can not be attended to by a surgeon within a short time, temporary ex- tension and counter-extension can be made. The patient, for ex- ample, can be laid upon a bed, the foot of which is raised six or eight inches, thus carrying the body of the patient away from the seat of fracture (counter-ex- tension). A large wad of cotton, or a fold of flannel or other soft material, should be wrapped around the ankle 134 PROMPT AID TO THE INJURED. and instep to prevent the bandage about to be described from injuring the part. The next step consists in arrang- ing some means by which temporary extension can be made. This indication is very effectively met by the use of Gerdy's " extension-knot," which not only holds the foot in a firm grasp, but prevents the undue constriction that would ensue if an ordinary knot were employed for this purpose. Gerdy's knot can be made out of a strip of muslin five or six feet long and about six inches wide. This should be folded into a cravat (two inches in width). The center of the cravat is placed upon the ankle-joint behind, the ends being brought forward and crossed over the instep. They are then continued downward under the sole of the foot, recrossed and carried upward on the sides to the malleoli (the bony prominences at the inner and outer sides of the ankle-joint), and then under the first turn around the ankle and down- ward, and tied below the foot in the form of a loop, in order that the weight shortly to be described may be attached (Fig. 77). A pail, bag, or some other receptacle should now be pro- cured and in it placed stones or sand, or weight in some form, amounting to from ten to fifteen pounds, and so ar- ranged that it can be readily attached, at the proper time, to the loop connected with the patient's foot. Extension and counter-extension should now be made by the attendants, as follows : While one holds the body in position, anoth- er grasps the leg and foot on the affected side, and makes steady extension ; a third attendant should place his hands over the seat of fracture to support and protect it. Fig. 77. — Gerdy's extension-knot. FRACTURES. L35 When the proper length has been regained, or nearly so, and while the limb is held in this position, the weight al- ready prepai'ed should be carefully and slowly attached. The weight should hang suspend- ed over the foot-boai'd of the bed, if the lat- ter is low enough (on a level with the affect- ed extremity), or over a board placed upright. After extension and counter - extension are made, and the weight is attached, the splints should be applied— 920^ before. If the attached weight causes pain, it should be diminished. Fracture of the Leg. — Fractures of this portion of the body usu- ally affect both bones, although either the tibia or fibula may alone be fractured, the fibula probably oftener than the tibia. The fibula is generally bro- ken near its lower ex- tremity, and is known as Pott's fracture. More or less injury to the ankle-joints accompa- nies the latter. In fracture of both bones, which com- monly occurs about the middle, the signs are generally 136 PROMPT AID TO THE INJURED. well marked, more so than when either the tibia or fibula only is broken. Pott's fracture is attended with eversion or turning outward of the foot, producing a characteristic deformity. Fracture of the tibia, as the result of its superficial situ- ation, is very often compound; the wound communicating with the fracture being frequently caused by efforts on the part of the patient to walk immediately after the injury. Treatment. — The limb should be handled very care- fully, and an internal and external splint applied. A pillow placed under the leg, folded over the sides, and properly retained, is particularly adapted as a temporary support for this fracture (Fig. 79). If the lower end of Fig. 79.— a pillow used as a temporary splint in fracture of the leg. the fibula is broken, and the foot is turned outward, a splint, well padded, should be placed along the inner sur- face of the leg, extending from above the knee to beyond the foot, and the leg and foot bound to it, thereby over- coming the tendency to eversion. Fracture of the patella may be the result of direct vio- lence or muscular action. The more common signs of the injuries are inability to straighten the leg ; the patient, however, is able to walk backward. An examination shows a transverse separation of the knee-cap, with an in- terval varying in width between the pieces. The knee is swollen, tense, and painful. At the moment of the injury the patient often hears a sudden snap. FRACTURES. I37 As a temporary measure, a long posterior splint may- be applied, carefully bound above and below the knee. Tbe skill of the surgeon is directed toward keeping the pieces in close contact until union takes place. The treatment of fractures of the metatarsal BONES AND PHALANGES OF THE TOES consists in binding the affected toe to the one next to it, or by supporting the fragments with compresses or light splints. When the foot is seriously injured by crushing, amputation is often inevitable. DISLOCATIONS. A DISLOCATION or luxation is a forcible displacement of one articular (joint) surface of a bone from another, and may be the result of direct or indirect violence, or of mus- cular contraction. More or less rupture of the ligaments always takes place. The chief signs of a dislocation are deformity and loss of function of the joint. The mobility of the part is greatly diminished, while in fractures there is increased mobility. In dislocation the deformitj^ is at the joint, while in fracture it is usually about the shaft. The reduction of a dislocation requires considerable technical skill, and should be performed by a surgeon. Exceptions to this rule, however, may be made in disloca- tion of the shoulder, lower jaiL\ smd fingers. Dislocations of the humerus usually take place down- ward below the coracoid process (see Scapula). The indi- cations for reduction are, to disengage the head of the humerus from its abnormal position by extension, coun- ter-extension, and fulcrumage. This may usually be ac- complished in the following way : A firmly compressed ball of cotton or similar material should be placed in the axilla or arm-pit ; the attendant should then remove the shoe from his foot nearest the affected side of the patient (facing the latter), and press the heel upward against the ball already in the arm-pit ; he should also grasp the pa- tient's hand and arm, and pull downward, thus making extension and counter-extension. In this manner the 138 PROMPT AID TO THE INJURED. liead of the humerus is disengaged, and, if the foot of the attendant can be turned outward and the arm of the pa- tient brought toward the chest during extension and counter-extension^ the bone will generally slip back into its proper position. After the reduction the arm should be bandaged to the chest, to prevent redislocation . It should not be forgotten that the axillary space contains many im- portant blood-vessels and nerves, and too forcible manipu- lation may be followed by very serious consequences. Dislocation of the lower jaw (inferior maxillary bone) is comparatively rare. It may be the result of a blow, but usually follows the act of gaping, laughing, or vomiting. The deformity is striking : the jaw is pro- truded and remains open, the patient being unable to bring the teeth together. The articular surfaces of the bone in this injury beuig carried foricard, and somewhat upward, the reduction should be accomplished by depress- ing the articular portion (condyles) of the lower jaw, and forcing them backward. This may be performed in the following manner: The patient should be placed in a chaii', with the operator standing before him, having his thumbs wrapped in a handkerchief, or some similar material, to guard against injmy dm^ing the sudden closure of the pa- tient's jaws at the moment the dislocation is reduced. The attendant then places a thumb upon each posterior molar tooth of the inferior maxillary bone of the dislocated jaw, and presses firmly downward, and with his fingers he tilts the chin upward. While the bone is being carried down- ward in this manner, a backward pressure with the thumbs should then be added which helps to carry the articular surfaces to then' proper position. The jaw should then be held in place by a four-tailed bandage (Fig. 43). Dislocation of the phalanges may be reduced by bending the dislocated bone further back, at the same time making extension and counter-extension, then suddenly flexing the joint. The subsequent adjustment of a dorsal and palmar splint is necessary. FRACTURES. 139 SPRAINS. A SPRAIN is a wrenching or twisting of a joint, associ- ated with considerable stretching, and even tearing, of the tendons and ligaments of the affected part. Sprains usu- ally occur at the ankle or wrist. Pronounced swelling and pain rapidly ensue, and are characteristic of the in- jury ; though it is often difficult to diif erentiate between a sprain, dislocation, or fracture. The proper relation of the ends of the bone composing the joint, and the absence of the jDrincipal signs of dislocation or fracture, indicate that a sprain exists. A sprain is always troublesome, and may be followed by serious results, a common sequel being anchylosis, or stiffness of the joint. Treatment. — When the patient is seen soon after the injury, the part should be elevated, and a cold application made, preferably the rubber bag (manufactured for this purpose), or a pig's bladder partly filled with cracked ice. Should neither of these be obtainable, the cracked ice may be placed in a handkerchief or towel, and, if possible, the dressing enveloped with oiled silk or rubber cloth. If ice can not be procured, cloths wrung out in cold water should be substituted. A roller-bandage, carefully applied from the extremity upward, is also valuable in preventing the continuation of the swelling. The ice or cold-water appli- cations can be applied over the bandage ; it must, however, be borne in mind that a bandage that has been wet will shrink, and may make too much pressure, or even cause strangulation of the part. After the acute symptoms have subsided and the heat and swelling have diminished, the cold applications should be discontinued and gentle fric- tion substituted ; or the joint may be rubbed with a stim- ulating lotion, as soap-liniment, alcohol, or salt water. Massage is also a valuable remedy. In severe sprains affecting the larger joints these parts should be kept quiet for two or three weeks, and motion then be gradually per- formed. CHAPTEE XII. BURNS, SCALDS, AND FROST-BITE. BURNS AND SCALDS. Burns are caused by the action upon the tissues of some form of dry heat, or by a chemical agent. For practical purposes burns are di^nded into three degrees : (1) Simple redness of the skin; (2) vesication or the for- mation of blisters ; (3) more or less destruction or char- ring of the skin and deeper structui^es. Burns of the fii'st and second degrees are usually unattended by serious con- sequences, but when they involve one half or more of the surface of the body a fatal result usually follows. Burns of the thu'd degree are dangerous according to then' situ- ation, extent of injury, and complication. Burns of the thoracic and abdominal walls are often attended with great danger. Death following burns is the result either of shock (during the first twenty-four hours), internal in- flammation, ulceration and haemorrhage, blood-poisoning, tetanus, or exhaustion. The temperature of the body falls immediately after a severe burn ; this is temporary, however, and is soon fol- lowed by more or less fever. In burns of the third degree, which heal by granula- tion, the contraction of tlie scar and subsequent deformity of the part are particularly marked. Treatment. — The treatment of burns is divided into local and constitutional. The local treatment depends upon the degree to which it belongs. In BURNS OF THE FIRST DEGREE, remedies which are BURNS, SCALDS, AND FROST-BITE. ]41 sootliiiig and protective ag-ainst atmospheric air and cold should be applied. Among those which generally can be procured at once are bicarbonate of soda (common baking- soda, not ivashing-socla), starch, flour, chalk, magnesia, or charcoal. One of these may be thickly dusted over the burned surface. Vaseline, cosmoline, lanoline (made from wool-grease), olive, linseed, or castor oil ; also lard and butter, provided they are not salted nor rancid ; white lead paint, or lime-water, whitewash, or even ink, mucilage, or molasses may be employed, although inferior to some others. Carbolated cosmoline, vaseline, oil, lanoline, etc., are valuable applications. They are not only protective and antiseptic, but the carbolic acid which they contain pro- duces anaesthesia of the affected surface ; that is, it dimin- ishes the sensibility of the skin. " Carron-oil,'' composed of equal parts of linseed or olive oil and lime-water, is regarded as a very valuable remedy. The cosmoline, vaseline, carron-oil, etc., should be spread on a piece of lint, soft linen, or muslin, and laid on the burn. The part should then be enveloped in cotton batting, or two or three folds of flannel, or some other soft material which will properly protect the part ; the dressing should then be retained by a bandage. During the examination of severe burns of any degree, and also while the applica- tion of dressings is being made, great caution should be observed that the part is not unduly exposed to the air ; serious results have followed the careless exposure of a burn of this character. Such danger can be avoided by examining or dressing one part of the burn at a time. In BURNS OF THE SECOND DEGREE the blisters require special treatment. If attached to the burn, the clothing should never be forcibly removed, but carefully cut off with scissors as close to the burn as possible. The small pieces adhering to the skin may be washed away with warm w^ater, or softened with oil, and detached later. If the blisters are large, they should be pricked at their low- est part, and the contents allowed to escape, or should be 142 PROMPT AID TO THE INJURED. absorbed with clean blotting-paper. The oily substances i»ecommended for burns of the first degree may then be used, or the part carefully washed with an antiseptic so- lution, and dry antiseptic gauze applied. The dressings should not be disturbed of tener than every two days unless they become moist or offensive. In BURNS OF THE THIRD DEGREE, where there is destruc- tion of the tissues and more or less sloughing, antiseptic applications (carbolized vaseline, oil, etc.) are particularly indicated ; offensive discharges should not be allowed to accumulate, but must be removed by warm antiseptic solu- tions, and fresh dressings applied. The removal of the slough or dead tissue may be hastened in the manner al- ready described. (See Compresses and Poultices.) In burns caused by acids (generally sulphuric, nitric, and muriatic), water should not be applied, for, when combined with an acid, an elevation of temperature of the mixed fluids immediately follows. The proper remedy would be the application of an alkaline powder, bicarbonate of soda, magnesia, chalk, or lime ; the latter may be scraped from whitewashed walls. These agents neutralize the acid, and should be left on the sm'face but a few moments and then washed off. If an acid is splashed into the eye, lime-water or a so- lution of soda or magnesia should be applied at once, also a few drops (three or four) of a four-per-cent solution of cocaine ; the latter relieves the excessive pain. Burns of the mouth and tlu'oat from the same cause (acids) are also to be treated by the free use of the alkalies already men- tioned. (See Poisons.) Burns produced by caustic alkalies (caustic soda, potash, lime, ammonia, also quicklime and lye) should be treated by the application of acid solutions, as diluted vinegar, lemon juice, hard cider, etc. Nitric, muriatic, sulphuric, and acetic acid may be used, but only when ivell diluted^ and with great circumspection. After the acid or alkali causing the burn has been neu- BURNS, SCALDS, AND FliOST-BITE. ]\i] tralized, the oily substances already referred to should be applied as in ordinary burns. Catching Fire. — Some of the severest forms of burns follow catching fire of some portion of the wearing- apparel. A person in this condition should at once be en- veloped in a blanket, coat, mat, piece of carpet, or what- ever may be at hand to extinguish the flames, or she (the victim is usually a woman) should be rolled over and over on the floor to smother the flames. Water must be freely used and the clothing carefully examined to ascertain if the fire has been entirely extinguished. The burned sur- faces should then receive the proper attention, according to their degree and intensity. In some burns continuous fanning will relieve the pain — submersion in water kept warm will also in some instances have a soothing effect, particularly as air is ex- cluded. Consiltutional Treatment of Burns. — Shock, which is always present in severe burns, requires the administra- tion of stimulants. Pain is more constant and intense in burns than in any other form of injury, and requires sed- atives, which should be administered by the medical at- tendant. Later on, the appearances of inflammation and other complications are to be carefully watched for. Scalds are injuries produced by the application of moist heat, as boiling water, steam, etc. Children com- monly suffer from these injuries as the result of pulling over kettles containing hot coffee, tea, or water. Scalds should be treated as burns of the first and second degrees. Certain positions assumed by the patient to relieve pain in burns, particularly about the arm pit, fingers or toes, if not looked after may cause webbing or limited motion on recovery. FROST-BITE. Prolonged exposure of the body to a very low temper- ature results in a general or local loss of vitalitv. While 144 PROMPT AID TO THE INJURED. the air is still, or snow is falling, it is favorable to the one •exposed. Snow is a bad conductor of heat, and offers con- siderable protection; but when the wind is blowing, the warm air close to the surface of the body is rapidly re- moved, and the destructive effect of the cold is consider- ably increased. An exposure of one or two hours, inade- quately clad, to intense cold may be followed by a fatal result. Those who are thus unfortunately situated are soon overcome by an irresistible sense of drowsiness and desire to sleep ; to yield to the inclination is usually fatal. This disposition to stupor is due to the great diminution in the blood-supply to the surface, and consequent conges- tion of internal organs. In this condition the brain is unable to properly perform its function and drowsiness follows. In those who are frozen, the limbs become stiff and the skin white; the latter is preceded by a blue or purplish tint, which may still be apparent at the tips of the nose, toes, and fingers. This change in color denotes that the circulation and nourishment of the surface of the body are profoundly interfered with, and is commonly followed by excessive reaction and inflammation or gangrene. Treatment. — A person who is frozen should never be taken to a warm room, or have warmth applied to the body. An abrupt change in temperature would be almost necessarily fatal. The temperature must be gradually raised. Consequently, the patient should be carried to a cool apartment, the clothing removed, and the body rubbed with snow or cold water. After a short time, par- ticularly if consciousness returns and the limbs lose their rigidity, the use of a piece of flannel, or, still better, the hand, can be substituted for the cold application. The continuous rubbing may now be discontinued, and oc- casional friction resorted to. These measures must be pursued very gently, as rough manipulation might destroy the skin. It may be necessary to resort to artificial res- piration in extreme cases. BURNS, SCALDS, AND FROST-HITE. ] 45 Stimulants carefully administered are indicated if the patient can swallow; until this is possible, they should be given by the rectum, or ammonia or smelling-salts by in- halation ; nourishment in the form of beef -tea or milk may be given as soon as the patient can take it. The surface of the body should be carefully protected, but not sub- jected to heat, as some time must elapse before the circu- lation of the affected part regains its equilibrium. If por- tions of the surface subsequently become dark bluish or mottled, gangrene has commenced. If the latter takes place dry and not moist dressing should be employed, as moisture encourages decomposition. 11 CHAPTEE Xin. UNCONSOIOUSNESS, SHOCK, AXD SYNCOPE, UNCO^'^scIOUSXESS is associated with a number of differ- ent affections, and in order to intelligently treat this con- dition it is necessary that one should he fsfmiliar with the different causes producing it ; among which are apoplexy, opium -poisoning, alcoholism, syncope, concussion and compression of the brain, and ei)ilepsy. This is very im- portant, as the remedies suitable for one would be unfit for another : for instance, the unconsciousness due to syncope demands stimulants, which, if administered in apoplexy, might cause or hasten a fatal result. Ignorance of this subject has often been responsible for the humili- ating and seinous mistake of regarding a case of apoplexy as intoxication. As the result of complications, it sometimes happens that the cause of the unconsciousness may not for the moment be apparent ; however, a careful examination for signs indicating the different affections giving rise to this condition will generally clear up existing doubts". During this period of uncertainty the xoatient should be placed in the recumbent position, with the head slightly ele- vated or depressed, according to the appearance of the face, whether congested or pale. The clothing about the neck and body should be loosened, and fresh au' freely supplied. Stimulants should be used with caution, and only when positively indicated. Artificial respiration may be resorted to in extreme cases. SHOCK. 147 SHOCK— COLLAPSE. Shock is a condition in which there is a more or less (Uniinished energy of the heart and circulation, and is the result of a severe impression made upon the nervous sys- tem, produced by either a physical injury, or a mental onotion. The majorit}^ of cases met with are the result of extensive burns or other grave injuries, particularly those produced by gunshot wounds and railway accidents, which are generally associated with great laceration and crush- ing of the tissues, and mental excitement. Severe cases of shock may be produced by fright alone. Shock may be of a veiy mild character, as the result of a trifling injury or fright, the symptoms being hardly noticeable, of short du- ration, and demanding no treatment ; or, it may assume a form which is rapidly fatal. The symptoms of shock depend upon the severity of the cause ; in some, where the injury is slight, they may be hardly apparent, or, only a pale face and a weak and rapid pulse, a slight nausea, and a general sense of prostra- tion may be evinced. The form that fully illustrates a case of severe shock would be that following a serious railway injury, and can hardly be mistaken. There is no other condition which so closely resembles death. The extreme pallor and coldness of the skin are startling ; the surface of the body is covered with moisture ; large beads of sweat cover the forehead ; the pulse at the wrist may be lost, or if perceptible, is weak, rapid, and irregular ; the features are shriveled, particularly about the nose, which appears pinched; the eyes are lusterless, sunken deeply in the sock- ets, and turned upward, the pupils being generally dilated; tha fingers and nails are of a bluish color. The patient is conscious, but dazed and flighty, can not realize his condi- tion, and apparently only appreciates loud and repeated questions ; articulation is difficult, although there is no pa- ralysis present. The sensibility to pain may be so blunted that an operation can be performed without the cogni- 148 PROMPT AID TO THE INJURED. zance of the patient. As a result of the depression of the circulation, the heat of the body is diminished, the tem- perature in some cases being below the normal register. The respu'ations are sighing in character and irregular, and the patient is restless. These symptoms may continue for a ie^v minutes or a number of hours, and often end in death. In cases which end favorably, there appear, usually within an hour or so, symptoms denoting an increase in the strength of the heart and circulation ; this change is known as reaction, and generally indicates, so far as the shock is concerned, a happy termination. When reaction occurs, the color and warmth gradually return to the skin, the eyes are brighter and the mind clearer ; the pulse be- comes stronger, and the symptoms indicate an approach to the normal condition. Vomiting is regarded as a favor- able symptom, and generally denotes reaction. Reaction, however, does not always insure the safety of the patient, as it may be interrupted suddenly by haemor- rhage or failure of the heart and death ; or, in injuries about the head, the reaction may be so intense as to go beyond the normal activity of the circulation, and produce seri- ous cerebral diseases, such as congestion or inflammation of the brain ; for this reason the patient should be care- fully watched, and excessive reaction obviated by posi- tion, quiet, cold applications to the head, and wannth to the extremities. Cases of shock from severe injuries, associated with complete unconsciousness, almost always prove fatal. Treatment. — It will only be necessary to refer to the condition indicated by shock to clearly understand the means necessary to bring about reaction; consequently, whatever can safely be used to stimulate the heart and circulation constitutes the proper treatment. As an illus- tration, we will suppose that a man has been injured by a railway accident and is found in a condition of shock. Whoever is to attend to the case should at once loosen SHOCK. 149 tlie clothing", and make a rapid examination to ascertain whether severe haemorrhage exists (which fortunately is not common in shock, owing to the feebleness of the circu- lation), or whether some other symptom may be present de- manding innnediate attention, which being promptly alle- viated, the patient should be carefully conveyed to a place near by, more suitable for the subsequent treatment. While being removed the head should be as low as or somewhat lower than the body, or the extremities may be slightly ele- vated, so as to favor the flow of blood toward the brain. If possible, four persons should be selected to carry the pa- tient, one for each extremity and the contiguous portions of the body. If one or more of the bones of an extremity have been broken, a temporary splint ought to be applied to prevent any movement of the fragments of bone at the seat of fracture during transportation, and should be at- tended to as rapidly as possible, and before the man is lifted from the ground. Arriving at the place selected, the clothing of the patient should be removed carefully, or cut away, if necessary, rather than have too much delay. He should then be placed in a warm bed, his head being still kept low. The treatment now consists in applying warmth to the surface of the body, and internal stimulation. The first indication can be met by surrounding the patient with bottles containing hot water, placing them about the arms and legs, inside the thighs, and under the arm-pits and about the body, but not about the head, as the heat might favor a subsequent congestion when reaction oc- curs; hot bricks, stones, plates, etc., will also answer the purpose, dry heat being the essential elemejit. It must be re- membered that the sensibility of the patient is blunted, and that the bottles or bricks may be so hot as to bum the skin and not inflict any pain. A hot plate, enveloped in a towel, may be placed over the region of the heart, and, when un- usual vomiting occurs, mustard plasters applied over the stomach. Friction is a method of some value in exciting 150 PROMPT AID TO THE INJURED. the circulation, and should be resorted to when heat can not be supplied as indicated above. The second indication — the use of internal stimulation— is of course governed by the condition of the patient. If able to swallow, he should be given about two teaspoonfuls of whisky or brandy, with a small amount of hot water, or, still better, hot milk ; this may be repeated every ten or fifteen minutes, until four or five doses have been taken, or reaction becomes apparent. When the latter occurs, the stimulant should be dimin- ished or discontinued. There are cases where a greater amount of liquor may be required, but it should be given with caution, as too much may produce undue vomiting and favor excessive reaction. If a number of large doses of a stimulant have been given with no effect, it is evident that the stomach is unable to absorb the fluid, and its further administration by the mouth would be useless. A large number of persons suffering from shock are unable to swallow, as the result of extreme prostration ; this should be carefully ascertained before giving anything by the mouth, as strangulation may ensue, the fluid entering the larynx. In such cases a tablespoonful or more of liquor in half a cupful of warm milk or water can be intro- duced into the rectum (lower bowel) by a syringe, and may be repeated about every fifteen or twenty minutes ; also pint injections of water as hot as can be borne by the hand. The value of the liquors depends upon the percentage of alcohol they contain, which in brandy and whiskj^ is about forty to fifty per cent, and consequently more than in wines, which contain but from fifteen to thirty-five per cent. One half the amount of alcohol diluted as above would therefore be a substitute for the liquors. Beer and ale, containing only two or three per cent of alcohol, would be worse than useless, simply filling up the stomach, with no satisfactory results. A small amount of spirits of ammonia or ether, or about four or five drops of nitrite of amyl, on the hand or a handkerchief, and placed near the patient's nose, has a decided stimulant effect. Warm turpentine rubbed up SYNCOPE. 151 and clown the spine can be used with benefit, if it does not interfere with the treatment already begun. The usual and most effective method of introducing stimulants into the system, now employed by physicians, is by the hypodermic method, which consists of injecting under the skin, with the hypodermic syringe, stimulants- brandy, whisky, or ammonia-water ; the amount so in- jected being generally from twenty drops to a teaspoonful of the undiluted stimulant, and is repeated as often as is indicated by the condition of the patient. Artificial respiration may be resorted to in desperate cases, but it is of doubtful value. When reaction has taken place, the stimulants are gradually diminished, and some form of nutriment may, if required, be administered; it must be given in small doses, and of such a character as to be readily absorbed. Warm beef -tea or milk, or an occa- sional sip of kumyss, will be sufficient for the time being. SYNCOPE— FAINTING. Syncope is a condition of suspended animation associ- ated with a gTeat diminution of blood in the brain and unconsciousness, and caused by sudden enfeeblement of the heart's action. Syncope may be the result of disease of the heart, haemorrhage, pain, excessive emotion, as grief, fear, and joy; tight lacing, certain drugs, indigestion, hunger, ex- haustion, and the hot and vitiated air of public assemblies, are also exciting causes of this condition. Before the stage of unconsciousness, the person affected experiences a weak and sinking feeling, associated with dizziness, dimness of vision, roaring in the ears. The face and extremities be- come pale, cold, and clammy. The stage of unconsciousness may last a few seconds or a number of hours ; hoAvever, it usually extends over a period of but a few minutes, during which time the pulse is either very weak or lost, and the respirations are shal- low and sometimes apparently cease. 152 PKOMPT AID TO THE INJURED. Fainting is of common occurrence and not usually fatal. Treatment. — The treatment is ver^^ simple, and consists in stimulating the heart and circulation, and increasing the amount of blood in the brain. The j^atient should be laid down, with the head considerably lower tlian the body, to favor the flow of blood toward the brain. Fresh air is one of the essential elements in the treatment of fainting. All tight clothing, as collars, corsets, skirts, or trousers, should be at once loosened, and stimulation in some form begun. Smelling-salts, ammonia, and other stimulants may be poured on a handkerchief or the palm of the hand and given by inhalation, care being taken that none is dropped into the eyes, and that the remedy is not held too close to the nose or mouth, otherwise violent irritation of the air-passages may follow. The head and face may be bathed with an alcoholic solution, as camphor, bay-rum, cologne, or whisky, or friction can be applied to the limbs and over the heart. No attempt should be made to ad- minister stimulants by the mouth unless the patient is able to swallow. The means just described are usually sufficient to bring about reaction. In some cases, however, it will be neces- sary to resort to more active measures, such as the intro- duction of stimulants into the rectum or lower bowel, in the manner described in shock, or the inhalation of nitrite of amyl — about five drops on the palm of the hand or on a handkerchief — held to the nose of the patient, the appli- cation of mustard over the heart, or it may be necessary to employ artificial respiration. A person after recovery from an attack of syncope should be kept quiet until the action of the heart and cir- culation is properly strengthened. Syncope and shock are similar, and may be the result of the same cause ; however, in syncope the patient is un- conscious, while in shock he is more or less conscious. Shock usually follows a severe injury, whereas fainting SYNCOPE. 153 may follow a very trivial cause. Syncope differs from apoplexy in the following" manner : In syncope, the face is pale, the pulse weak, and the respiration shallow, and the attack is generally of short duration ; while in apo- plexy the face is usually congested, the pulse is slow, full, and sometimes irreg-ular, the arteries in the neck throb violently, and the breathing is noisy and labored or snoring (stertorous), and paralysis exists on one side of the body. CHAPTEE XIV. CONCUSSION AND COMPRESSION OF THE BRAIN— APOPLEXY —INTOXICATION-EPILEPSY— HYSTERIA— HEAT-STROKE. Concussion of the brain is a term applied to a shaking* up or jarring of this organ. More or less contusion of the cerebral tissue probably occurs in severe cases. This form of injury is the result of a fall or blow upon the head, or the shock may be transmitted upward through the spinal column, as in jumping from a height, etc. The in- jured person may only be stunned or dizzy for a moment, with no loss of consciousness ; the face is usually pale, and more or less weakness and trembling of the limbs are present. These transient symptoms are generally fol- lowed by a rapid restoration to the normal condition ; although in apparently mild cases serious cerebral dis- turbance may subsequently occur — usually within a week. In severe cases there is partial stupor and a feeble pulse ; the pupils may be contracted or dilated, but generally react to light ; the surface of the body is cold, and i^est- lessness and vomiting are usually present. As a rule, the breathing is natural. In grave cases the patient is in the condition of shock, which has already been de- scribed. There is one point connected with the shock following concussion of the brain which must be empha- sized, viz., that the reaction is usually excessive, being more pronounced than in shock following injuries of other parts of the body, and often terminates in inflam- mation of the brain. Treatment. — In mild cases the treatment consists in keeping the patient quiet, with a cooling application to the head. The more serious cases of concussion of the brain which assume the form of shock should receive the treat- ment appropriate to the latter affection, particular atten- tion being paid to the extreme reaction that may occur. APOPLEXY. 155 For this reason, internal stimulants should not be given. Warmth to the extremities, and cold applied to the head, are also indicated. Kest and quietude must be insisted upon in all cases of concussion of the brain. COMPRESSION OF THE BRAIN. Compression of the brain comniouly follows fracture of the skull, a portion of the broken bone being driven into the cerebral tissue and causing pressure. The lodg ment of a bullet, or cerebral haemorrhage, may also pro- duce this condition. It is often difficult to differentiate between concussion and compression of the brain. How ever, in compression, the stupor is more profound, the pulse is slow, the pupils are dilated and do not respond to light, and the breathing stertorous, similar to that in apoplexy. There is more or less paralysis present, and convulsions may occur. Treatment. — Aside from keeping the patient quiet and applying cold in some form to the head, and preventing the administration of stimulants, very little can be done by an unprofessional person, and the case should be placed in the hands of a surgeon as early as possible. If a wound is present, it should be protected by an antiseptic compress. APOPLEXY— STROKE OF PARALYSIS. Apoplexy is a sudden loss of consciousness associated with paralysis, and generally due to the failure of a certain portion of the brain to perform its function, as the result of pressure following the escape of blood (haemorrhage) from a diseased cerebral vessel. Embolism, which is very similar to apoplexy in its manifestations, is caused by the plugging up of a large artery within the skull, which is followed by a loss of vitality and function of a portion of the brain. The paralysis is confined to one half of the body (hemi- plegia). For example, if the hipmorrhage is on the left side of the brain, the muscles of the corresponding side of the face and of the right arm and leg are rendered power- 156 PROMPT AID TO THE INJURED. less. The paralysis may sometimes affect the opposite side of the face. The paralysis occurring on the opposite side of the body from the seat of pressure is due to the crossing of the nerves already referred to (see Nerves). The form of apoplexy caused by cerebral haemorrhage affects persons advanced in years. A jDerson may suffer from a number of attacks in quick succession, or at long intervals, or the first may prove fatal. The common be- lief that one dies during the third attack is unfounded. Apoplexy is apt to occur after a meal or during sleep. Although an apoplectic attack may be gradual, and preceded by pain in the head, nausea, confusion of thought and a slight convulsion, it is more commonly abrupt, and not preceded by any sign or symptom which indicates its approach. The subject usually falls to the ground as though struck down, although in some cases the attack is less sudden, and preceded by a sharp outcry. If unconsciousness does not occur immediately, it fol- lows in a very short time — within a few minutes. In this condition the patient can not be aroused, which is an im- portant point in distinguishing this from some other affec- tions. The face becomes reddened or congested, and the pupils are usually dilated, but not always ; one may be- dilated and the other remain in the normal condition or contracted. The respirations are slow, labored, and snor- ing (stertorous breathing), the cheeks being puffed out during expiration. The pulse, although generally slow, does not differ very much from that of health. Convul- sions and vomiting may occur. Apoplexy is often mistaken for intoxication — a very disagreeable and unfortunate error. It may also be mis- taken for opium-poisoning and epilepsy. It should be remembered that in intoxication, hemi- plegia does not exist ; the pulse is frequent, and the alcoholic odor of the breath is always present (this may sometimes be present in apoplexy) ; also that vomiting is common, and the subject can be more or less aroused by pinching, douching with cold water, etc. INTOXICATION. 157 Inr opium-poisouiiig there is iui absence of liemiplegia, the respirations are very slow, sometimes being reduced to four or five during the minute. The face is pale and the pupils are uniformly contracted. The absence of hemiplegia, the convulsive movements, and foaming at the mouth, and the comparative short du- ration of the attack, are usually sufficient to distinguish epilepsy from apoplexy. If improvement does not follow an attack of apoplexy within ten or twelve hours, the case usually terminates fatally. Treatment. — The object of treatment is to arrest the further escape of blood within the skull ; consequently the head should be slightly elevated, and cracked ice or some other form of cold applied. The clothing about the neck and waist should be loosened. Internal stimulants, which tend to increase the haemorrhage, must not be used. If possible, warmth should be applied to the extremities. The further treatment must be indicated by the medical attendant. INTOXICATION. Intoxication is a condition of such common occurrence that a lengthened description would be unnecessary. The important element in the consideration of this subject is to impress upon the reader the necessity of particularly distinguishing this condition from apoplexy, and has already been referred to in the article on the latter subject (see Apoplexy). If any doubt exists, the patient should be laid upon his back, ^vith the head slightly elevated, and all constriction about the neck and waist removed, and perfect quietude and rest maintained until the arrival of the medical attendant. Treatment. — The treatment of intoxication consists usually of rest and quiet. Nature being generally able to effect the desired result. If vomiting does not take place, mustard may be given to produce emesis (vomiting). In some cases it may be necessary to apply warmth to the 158 PROMPT AID TO THE INJURED. extremities and over the heart, also ammonia or nitrite of amyl by inhalation, and rectal stimulation (coffee, etc.). EPILEPSY— EPILEPTIC FITS- FALLING SICKNESS. Epilepsy is an affection of the brain which at variable intervals gives rise to an attack characterized by convul- sive movements and unconsciousness. Subjects of this disease are usually warned of the ap- proach of a paroxysm by certain sensations which imme- diately precede the convulsion; the premonitions, how- ever, are generally of very short duration. The attacks usually occur singly, although one may follow another in rapid succession. The person affected utters a sharp, piercing cry, and falls to the ground in an unconscious and helpless con- dition, and is thus frequently seriously injured about the face. This is followed immediately by more or less rigid- ity, and a few moments later the convulsive movements commence. The eyes are usually opened and turned up- ward, the pupils being dilated. The face becomes livid and congested, the jaws are brought together with consid- erable force, and the tongue is very commonly badly wounded by the teeth. There is considerable foaming or frothing at the mouth. The paroxysm lasts but a few minutes, when con- sciousness gradually returns, the patient being in a stupid and drowsy condition for a short time afterward. Malingerers and hysterical subjects who endeavor to simulate epilepsy do not bite their tongues, and usually select a convenient place in which to fall. Treatment. — The treatment of an epileptic attack con- sists in laying the patient on his back, loosening the clothing, particularly about the neck, and preventing in- jury to the tongue by placing between the teeth a cork, piece of wood, or handkerchief-knot. The stupor that follows the convulsion requires no treatment, unless the IIVbTEKlA. 150 patiei>t is quite weak, when stimulants may be very cau- tiously given. It must not be forgotten that following an epileptic seizure sometimes a temporary mental aberration may fol- low, therefore the person affected should be carefully watched for some little time after the seizure. HYSTERIA— HYSTERICS— HYSTERICAL ATTACK. Hysteria is a functional affection of the mind and nervous system, occurring in paroxysms, usually affecting females, and characterized by temporary loss of will-power and considerable emotional display on the part of the one affected, who laughs and sobs immoderately, without any regard to the surroundings. Hysteria sometimes assumes a form which may be mistaken for syncope, apoplexy, or epilepsy, according to the manifestations of the patient. Hysterical subjects should not be treated as malinger- ers; the perverted condition of the nervous system leads them to believe that the illness assumed is real. One un- accustomed to observing cases of hysteria may be easily misled, therefore the following distinctive characteristics should be remembered. A case of hysteria may be distinguished from syncope in the following manner: In hysteria the extremities and face are warm instead of cold, and the pulse is normal; and when an effort is made to open the eyelids, it is met with considerable opposition, wdiich does not occur in un- consciousness. In the hysteria that simulates epilepsy the tongue is not injured, and, if the patient falls, a suit- able place is selected for this purpose, in order to avoid injury. There is no frothing at the mouth in hysteria, unless produced by soap or other agents held in the mouth. Although hysteria may be associated with temporary paralysis and mistaken for apoplexy, it will be noticed that the facial muscles are not involved, and that the 160 PROMPT AID TO THE INJURED. paralysis does not always affect one side of the body (hemiplegia), and there is no stertorous breathing and flapping of the cheeks, which are so prominent in apo- plexy. Treatment. — The best treatment for a case of hysteria is to let the patient alone. To sympathize with one in this condition simply prolongs the attack and can do no good. Firmness on the part of the attendant, with an intimation that the condition is fully understood, is gen- erally all that is necessary. When considerable demon- stration is made, it is a common practice to douche the patient with cold water. If this method is used, it should be confined to the face; pouring a large quantity of cold water indiscriminately over a weak and delicate woman is not always followed by the most desirable results. When it is suspected that unconsciousness is feigned ammonia water applied to the nose will almost always have the de- sired effect. HEAT-STROKE— SUNSTROKE— INSOLATION— SUN-FEVER— HEAT-APOPLEXY. The term heat-strohe is now used to denote the serious manifestations which sometimes follow exposure to in- tense heat. This condition may be due to the direct rays of the sun, or to a high temperature caused by solar or artificial heat. Those who are employed in hot and close apartments, where the air is impure, as in mines and in the fire-rooms of steamers, are particularly liable to be affected by heat-stroke from artificial heat. It is a fact worthy of notice that those who generally suffer from this malady are either addicted to the use of stimulants or are in a weak or debilitated condition. Locality has considerable influence in causing sun- stroke, the vitiated air of the city in the hot summer months being particularly favorable to it. The high de- gree of temperature which can ordinarily be borne by the body is mainly dependent upon the proper action of the HEAT-!STliOKE. 161 skin;* the large amount of perspiration being rapidly evaporated, cools the surface and indirectly the blood. Evaporation takes place more rapidly when the air is dry; consequently, heat-stroke is more frequent when the air is moist. The heavy woolen shirts worn by work- men in hot weather are cooler than those made of cotton, because the former increase the activity of the sweat-glands, and indirectly diminish the temperature of the body. Heat-stroke is not always developed abruptly, nor does it generally occur at the beginning of a heated term, but usually after the hot weather has been persistent for two or three days. There are certain symptoms which indicate the approach of this affection and should be recognized as a warning, viz. : an irritable and depressed condition ; headache, congestion of the eyes, and flushing of the face, and also a dryness of the skin and sometimes nausea. Unless the person affected seeks relief, the symptoms just enumerated are followed by those which are more serious, as delirium, convulsions, and unconsciousness. The tem- perature of the body sometimes rises to a great height, 108°-110° (normal temperature being 98-iV°). The pupils are generally dilated, although sometimes contracted. The pulse at first is strong and rapid, but subsequently becomes weak. Death may occur suddenly in consequence of the action of the high temperature upon the nerve- centers, or, at a later period, as the result of exhaustion. Quite a large percentage of those who recover from the immediate effect of sunstroke subsequently suffer from some temporary or permanent affection of the nervous system. Those who have been overcome by the heat are pecul- iarly susceptible to this element for some time after- ward. Heat exhaustion is a mild type of the condition just described and is very common. The symptoms are usually dizziness or faintness, and often some nausea and weak- 13 162 PROMPT AID TO THE INJURED. ness. These conditions, however, generally respond to simple treatment. Treatment of Heat-Stroke. — There are two impor- tant indications for treatment — reduction of temperature and the use of stimulants. The use of cold is regarded as the best method of meeting the first indication, and the manner of its application depends upon the facilities at hand. The patient should first be removed to a cooler spot if possible, or at least vrhere shade can be secured, or, if a person succumbs in a place where the ventilation is defective (in addition to the heat), he should be carried to the fresh air. The treatment should be begun at once. Efforts are often made first to remove the patient to his home, which involves the loss of considerable valuable time and may still further exhaust him. The clothing about the neck and body must be either loosened or re- moved. Cold is particularly indicated in cases where there is great heat of the body, and delirimn and convulsive movements are present. This means of reducing the tem- perature may be applied in the shape of cracked ice about the head and spine, or the use of cold water, by means of a sponge or by pouring it from a sprinkling-pot, or the patient's head may be held under a pump; however, the best plan is to remove the clothing and sponge the head and body with cold water at frequent intervals. If the heat of the body is very great, it may be necessary to wrap the patient in sheets wet with cold water. The sheets are to be kept wet by frequently pouring water over them while on the body, until consciousness returns or there is an evidence of marked diminution of temperature. After the cold has been discontinued, should serious symp- toms, such as unconsciousness or the previous high tem- perature, recur, the cold application should again be employed. If there is, besides the great heat, evidence of serious depression, stimulants must be used while the cold is being applied. HEAT-STROKE. 163 There are some cases of heat-stroke where stimulants alone are indicated, as when the signs of a high fever are absent and great depression is present. In these cases, in addition to the use of internal stimulation, the application of mustard over the heart and to the calves of the legs is indicated. The treatment of heat exhaustion consists in rest, bathing the face with an alcoholic solution, or the internal use of a stimulant. CHAPTER XV. ASPBYXIA AND DROWNlNa. ASPHYXIA— SUFFOCATION. Asphyxia is a condition of unconsciousness due to a great diminution of oxygen in the blood, resulting either from an obstruction to the passage of air to the lungs, or to the presence of poisonous gases which render the air unfit for respiration. Among the numerous causes of suf- focation are drowning, hanging, and obstruction in the respiratory tract, either by the lodgment of foreign bod- ies, or by certain maladies affecting this part, as croup. Asphyxia also follows the inhalation of the fumes of char- coal or coke, and the carbonic-acid gas contained in empty wells, caves, beer- vats, and mines ; in the latter situation it is known as "choke-damp." Coal-gas from stoves, and illuminating and sewer gases, are frequent causes of suf- focation. The appearance of a j)erson suffering from as- phyxia is well marked. The face is of a dusky or purplish hue (showing deficient oxygenation of the blood), and swol- len. The respirations are extremely labored, and associ- ated with convulsive movements and delirium. If relief is not promptly at hand, these symptoms are rapidly fol- lowed by unconsciousness and death. Treatment. — The treatment consists in removing the cause, m order that the lungs may be supplied with the proper amount of pure air, and restoring the different functions to their normal condition by stimulants and artificial respiration. (See Drowning.) Precautions. — In rescuing a person from an empty ASPHYXIA AND DROWNING. 1^5 well, care should be taken that the mouth and nose of the person making- the descent are protected by holding- against them a cloth saturated with water, or vinegar and water. A rope should also be tied around the waist of the rescuer, by which he can be brought rapidly to the open air. Matches should not be ignited while in the well, nor should any artificial light be carried down ; for, while carbonic acid gas, which constitutes the bulk of poisonous gases in these receptacles, is not a supporter of combustion, other gases may be present which are ignitible, and a serious ex- plosion would probably follow. Sewer-gases are often in- flammable, and illuminating gases always so. A light should never be taken into a cellar or any apartment where gas has escaped, until the room has been thoroughly ventilated by open windows and doors. It is often necessary to enter empty w^ells and cess-pools in order to examine or clean them. The carbonic acid which they contain, and which is heavier than air and consequently settles to the bottom, should be stirred up and removed pre- vious to making any descent for examination. This may be done by free ventilation, and by pouring into the well large quantities of water or lime-water, or by lowering and quickly withdrawing- an opened umbrella, or throwing down lighted papers and straw. Should the latter means be used, care should be taken not to remain near the opening, as gases may be present which are inflammable. Discharg- ing a gun into the receptacle may be employed for this pur- pose. It is also a good plan to lower a cat or a dog to the bottom of the excavation and allow it to remain there for a while to ascertain if the air at that point is respirable. DROWNING. The asphyxia or suffocation that follows submersion is due to the fact that air is preveiited from reaching the lungs. More or less \vater is found in the air-passages, but not in such quantities as is generally supposed. In some cases very little if any water reaches these organs, on ac- 166 PROMPT AID TO THE INJURED. count of the rapid closure of the epiglottis. Water, how- ever, enters the stomach, and considerable is found mixed with mucus in the throat. Death is usually the result of suffocation. However, in some cases it may be due to sudden heart-failure before the person sinks. When such is the case the face of the drowned would be pale and flabby, and very little water and mucus would be found in the respiratory tract. There is a better chance of resusci- tating one who sinks as the result of syncope than when suffocated, as the demand for oxygen in the former is less than when asphyxiated by submersion. Persons who are submerged for four or five minutes or more are not usually restored to life; although numerous cases are recorded where resuscitation was effected after an interval of twenty minutes. In such cases it is sup- posed that syncope occurred, or, on account of the exist- ing excitement, an error was made in calculating the actual time of submersion. The action of the heart usu- ally continues some little time after respiration ceases. Treatment. — This consists first in re-establishing res- piration, then stimulating the action of the heart and cir- culation by stimulants and warmth, friction, etc. When a person has been under water but a few moments, simple means may restore respiration, and should be tried. The water, sand, and mucus should first be quickly re- moved from mouth and nose, and the attendant should then carry his finger to the back or base of the patient's tongue, which must be pulled forward, thus enabling wa- ter and mucus in the throat and respiratory tract to es- cape, and also to favor the entrance of air into the lungs; while this is being done the patient should be turned on his side (left, if possible), face down, to favor the escape of water from the stomach and air passages. He should then again be turned on his back, while the hands of the attendant are placed on the belly or abdomen and pressure directed upward and inward toward the diaphragm. This movement tends to stimulate respiration and should be re- DROWNING. 167 peated two or three times at intervals of two or three sec- onds. The mouth in the mean time should be kept open by a cork or piece of wood, or a knot tied in a handker- chief, etc., in order that the passage of air to the lungs should not be interfered with. Smelling-salts, ammonia, or two or three drops of nitrite of aniyl, may be admin- istered by inhalation, or the nose may be tickled with a feather or straw. When breathing commences and con- sciousness returns, the patient should be carefully divested of all wet clothing (if necessary, the clothing should be cut to avoid delay), well rubbed, and wrapped in warm covering, and stimulants given in the manner already de- scribed. (Shock.) If the simple measures just enumerated are productive of no good result after a short trial, artificial respiration should be at once resorted to. Three methods of artificial respiration are accepted as being particularly efficient, viz., Sylvester s, Howard's, and Hall's. The first (Sylvester's) is generally regarded as being the best. The methods of Sylvester and Howard may be performed by one person. Before artificial respiration is begun, the patient should be stripped to the waist, and the clothing around the latter part should be loosened so that the necessary manipula- tions of the chest may not be interfered with. Further- more, it should be remembered in artificial respiration not to exceed the normal respiratory rhythm of about eighteen respirations per minute. This is often overlooked. Sylvester's Method. — The water and mucus are sup- posed to have been removed from the interior of the body by the means above described. The patient is to be placed on his back, with a roll made of a coat or a shawl under the shoulders; the tongue should then be drawn forward and retained by a handkerchief which is placed across the ex- tended organ and carried under the chin, then crossed and tied at the back of the neck. An elastic band or small rubber tube or a suspender may be substituted for the same purpose. If no other means can be made avail- 168 PROMPT AID TO THE INJURED. able, a liat- or scarf-pin may be thrust vertically through the end of the tongue without injury to this organ. The attendant should kneel at the head and grasp the elbows of the patient and draw them upward until the hands are Fig. 80.— Sylvester's method. First movement (inspiration). carried above the head and kept in this position until one, two, three, can be slowly counted (Fig. 80). This move- ment elevates the ribs, expands the chest, and creates a vacuum in the lungs into which the air rushes, or, in other words, the movement produces inspiration. The elbows are then slowly carried downward, placed by the side, and Fig. 81.— Sylvester's method. Second movement (expiration) pressed inward against the chest, thereby diminishing the size of the latter and producing expiration (Fig. 81). These movements should be repeated about fifteen times during DROWNING. IGD each minute for at least two hours, provided no signs of animation present themselves. Howard's method is divided into two parts. Part first consists in removing the water, etc., from the respira- tory tract and stomach, and is as follows: The patient should be i)laced face downward, with a pillow or roll of clothing" under the pit of the stomach, the head resting on the forearm, which keeps the mouth from the ground and renders traction on the tongue unnecessary. The attendant, standing over the drowned person, should then place his left hand on the lower and back part of the left side of the chest, while the right hand is laid on the Fig. 82.— Ho\vard"s method. Part first. spinal column about on a line or a little above the left hand ; firm pressure is then made by the operator throw- ing the weight of his body forward on his hands ; this is to be continued while one, two, three, are counted (slowly), and ended with a push w^hich helps to raise the operator to an upright position and forcibly expel the fluid. These movements should be repeated tw^o or three times if fluid continues to flow from the mouth (Fig. 82). 170 PROMPT AID TO THE INJURED. Part Second : Artificial Respiration. — Tlie patient should now be turned on his back, face directly upward, with the roll placed under the shoulders ; it should be made thick enough to allow the head and neck to be fully thrown back. The hands of the patient should be carried above his head and tied with a handkerchief, suspenders, etc. The attendant should then kneel astride the patient's hips and place the palm of his open hands upon the lower part of the patient's chest with the thumbs at the lower border of the breast-bone, the JQjigers being applied to the spaces between the ribs, the little finger being laid along the lower border of the ribs, in front. The hands are then pressed slowly and firmly upward and inward toward the diaphragm or midrrff, with the body of the operator thrown forward until his face is nearly in contact with that of the patient. A sharp push is then made upon the chest, which helps to bring the operator to an upright posi- tion. A rest of two or three seconds should then follow, and the movement repeated. These procedures should be continued for about two hours before being abandoned, unless the patient is sooner restored (Fig. 83). Fig. 83.— Howard's method. Part second. Hall's Method. — The drowned person should be placed face downward, the head resting on his forearm with a roll or pillow placed under the chest; he should DROWNING. 171 then be turned on his side, an assistant supporting the head and keeping the mouth open ; after an interval of two or three seconds, the patient should again be placed face downward and allowed to remain in this position the same length of time. This operation should be repeated fifteen or sixteen times each minute, and continued (unless the patient recovers) for at least two hours (Figs. 84, 85). Fig. 84.— Hall's method. First position. If, after using one of the above methods, evidence of recovery appears, such as an occasional gasp or muscular movement, the efforts to produce artificial respiration must not be discontinued, but kept up until respiration is fully established. All wet clothing should then be removed, Fig. 85.— Hall's method. Second position. the patient rubbed dry, and if possible placed in bed where warmth and stimulants can be properly administered. A small amount of nourishment, in the form of warm milk or beef -tea, should be given, and the patient kept quiet for two or three days. CHAPTEE XVI. MEDICATION. In poisoning or in other emergencies where the ser- vices of a physician are urgently needed but can not be secured, relief is often afforded, or life saved, by the prompt action of some one present who can intelligently administer medicinal agents. Therefore even a general knowledge of this subject may at any time prove of great value. Medicine is given by the mouth, under the skin, or by the rectum, the first being the method usually employed, although the action of a drug is much more rapid and effective when given beneath the skin (hypodermically) ; besides, in some instances, it is impossible or impracticable to administer remedies by the mouth, for instance, when the patient is unconscious or when doubt exists as to the ability of the stomach to absorb them. Under these cir- cumstances the use of the hypodermic syringe is partic- ularly indicated, although it must not be forgotten that this procedure is not without an element of danger if pre- cautions are not taken to prevent it. Cleanliness should be observed to prevent contamination, as infection may be introduced into the system in this manner; besides, abscesses at the seat of injection sometimes occur even when care is used. Whatever agent is' employed should be thoroughly dissolved in fresh water received in a clean glass. After the solution is slowly drawn into the syringe the piston should be forced forward until a drop or two of the solution escapes from the point of the needle, indi- cating that the air has been expelled from the cylinder. MEDICATION. IJl] A comirion and favorite site for hypodermic injection is on the anterior part of the arm, between the bend of tlie elbow and shoulder, over the biceps muscle. However, the injection may be given in the legs, back, or abdomen. The needle should not be introduced at a right angle with the surface, but almost parallel with it, being pushed through a portion of integument raised by the thumb and forefinger of the opposite hand. The active principle or alkaloid of a drug should be selected for hypodermic administration, inasmuch as mi- nute doses will produce the constitutional effect; besides, its action is more rapid and effective. For example, morphine is an active principle, or alkaloid of opium, atropine of belladonna, and strychnine of nux-vomica. As little water as possible should be used in making the solution. Stimulants such as brandy and whisky in full strength are frequently used hy podermically in collapse, etc. A medicine given hypodermically should be from one third to one half less than vvhen given by the mouth. For instance, when introduced in this way one eighth of a grain of morphine will cause about the same effect as one fourth of a grain given by the mouth. ' The following medicinal agents are commonly found in mixtures given to allay pain or coughing, or to pi'oduce sleep, or in the form of tonics, and therefore frequently cause poisoning by improper administration, etc. The doses given are for an adult and for administration by the mouth. For children the amount should be dimin- ished according to age : Opium : Tincture (laudanum), dose, 10 to 20 drops. Camphorated tincture (paregoric), dose, 2 to 3 teaspoonfuls. Morphine, the important active principle or alkaloid, dose, i to ^ gr. Belladonna : Tincture, dose, 5 to 15 drops. Atropine, active principle or alkaloid, dose, y^ to /j gr. 174 PROMPT AID TO THE INJURED. Nux-vomica : Tincture, dose, 5 to 10 drops. Strychnine, active principle or alkaloid, dose ^ to 3^ gr. Arsenic : Fowler's solution, dose 2 to 10 drops. Arsenious acid, dose, gV to -^ gr. Autipyrin, antifebrin, and other similar agents, known as coal-tar products, are frequently used without the ad- vice of a physician ; it must be remembered that compara- tively small doses not infrequently cause serious depres- sion of the heart. Bromide of soda, or bromide of potash, dose ten to thirty grains, or even in larger doses. Bromide prepara- tions are fi^equeotly used to allay nervousness, produce sleep, etc., and may be regarded as comparatively safe, as enormous doses have been taken without a fatal result. Chloral (hydrate of chloral), dose, five to ten grains ; larger doses are commonly taken to cause sleep, but it is not unattended with danger. In the treatment of poisoning (see next chapter) opium, belladonna, and nux vomica are frequently referred to as antidotes ; it must be understood that this refers to the most available and effective preparations of the drug. For instance, if opium is mentioned, it is understood that it can be given in the form of the powder (dose, one grain — not commonly used), the tincture, camphorated tincture, or the most important active principle, morphine, the physiological effect of all being practically the same. The condition of the patient should rather decide which prep- aration shall be given, provided a choice can be made. However, in poisoning, or in intense pain, the use of the active principle or alkaloid of the drug, and the hypoder- mic method of administration, are manifestly preferable. In the use of certain drugs, such as opium and bella- donna, etc., it must be understood that a cumulative effect may be produced, and therefore, when they are used as an MEDICATION. 175 antidote in poisoning or to allay pain, the dose should not be repeated more than once, after an interv^al of lialf an hour or an hour, and then not given again for a much longer period, six to eight hours, unless so advised by a physician. This should be particularly observed when atropine is used for opium poisoning or vice versa. The use of the rectum for the administration of drugs and nourishment is to be considered when other means are not available or practicable. Whatever is given in this way should be well diluted (about a cupful at each injection). The solution should be warmed and as bland as possible. When medicine is given in this manner, it should be at least one third more than when taken by the mouth. If time permits, medicine may be administered by the rectum in the form of suppositories, which are little cone- or cartridge-shaped bodies prepared by drug- gists, composed of cocoa butter, containing the medicine. These, if introduced sufficiently far up, rapidly melt and are absorbed. Solutions containing medicine or nourish- ment in the form of tepid milk, or both together, may be introduced into the rectum by a common Davidson or rectal syringe ; care should be taken that the air in the syringe is expelled before the nozzle is introduced. CHAPTEK XVII. POISOm AND FOISONINa. Certain agents whicli are invaluable in the treatment of the sick and injured become deadly poisons when im- properly used. This may be the result either of accidents, eiTors in administration, or attempts at self-desti'uction. Poisons may be divided into narcotics and irritants. Some of the irritants are exceedingly destructive to the tissues with which they come in contact, and are known as corrosive poisons. Narcotics are employed in the practice of medicine to produce a soothing effect or sleep. When these di'ugs are taken in poisonous doses, they are followed by symp- toms which in a general way are common to all of this class, and by which they can be recognized in cases of poisoning, viz., delirium, stujDor, insensibility, and sterto- rous breathing. Narcotics cause very little, if any, local irritation. IiTitants are used medicinally both for a constitutional and local effect. Theu' poisonous action is particularly noticeable by the local m'itation they produce. Great destruction of the tissues with which they come in contact follows the use of the corrosives. This is markedlj^ ap- parent about the lips, mouth, and throat. Intense abdomi- nal pain, associated with vomiting and purging, and also shock, are more or less constant. Treatment of Poisoning. — The treatment of poison- ing is both local and constitutional. The local treatment consists in preventing the further POISONS Ai\D POISOXING. 177 absorption and irritating elfect of the poison by remov- ing it from the stomach by the use of emetics and the stomach-pump. Remedies are also used which in a measure render the operation of the poison liarmless (an- tidotes). T]u> constitutional treatment is directed toward an- tagonizing the action of the poison, and stimulating the patient. Agents which directly counteract the local and consti- tutional effect of a poison are known as antidotes : for ex- ample, when an acid is taken in a poisonous dose, an alkali, such as soda, is given as the antidote; or, w^hen opium is the poison introduced, belladonna is administered as one of the physiological antidotes. These examples demon- strate local and constitutional antidotes. Local Treatment. — Emetics. — Under this heading may be included the introduction of the forefinger or a feather into the throat, and by passing either backward as far as possible can be employed to induce vomiting (eme- sis). This means may also be used to stimulate the action of emetics which have been given internally. Mustard. — One tablespoonful added to half a pint of tepid water. Mustard is a stimulant emetic, and very valu- able in narcotic poisoning. Chloride of Sodiiini (common salt). — Two tablespoon- fuls added to half a pint of tepid water. Not very certain as an emetic, but generally on hand. Alum. — Tablespoonful in half a pint of tepid water. Rather a feeble emetic. Sulphate of Zinc (white vitriol).— Twenty to thu^ty grains in half a glass of water. Very efficient and safe. One of the best emetics. Ipecac. — Thirty grains of the powder or two table- spoonfuls of the wine or sirup of ipecac ; the latter prepa- ration is apt to be found in the house. Carbonate of Ammonia. — Thirty grains in half a glass of water. 13 178 PROMPT AID TO THE INJURED. Sulphate of Copper (blue vitriol, blue-stone). — Five to ten g-rains in half a glass of water. The dose recommended of each of the above emetics is for adults, the amount should be proportionately small for children. The contents of the stomach may be removed by si- phonage. This method is effective, and can be carried out without much trouble, and is performed as follows : One end of a small rubber tube about six feet long, after being oiled, is passed into the stomach. This procedure requires considerable care, as the tube may be introduced into the air-passage by mistake, instead of into the oesophagus ; for this reason the tongue should be depressed and the end of the tube carried backward as far as possible and then down- ward. After this has been accomplished, the end project- ing from the mouth is raised and a funnel attached, through which tepid water (about two or three pints) should be poured into the stomach. The upper end of the tube (still raised) should be pinched between the thumb and finger, and in this condition lowered below the level of the stomach. When the thumb and finger are removed, the water held in the tube acts as a siphon, and the con- tents of the stomach are withdrawn, provided the poison- ing does not occur soon after a meal. This operation may be repeated a number of times, until the poison has been removed. It is always best, particularly in cases of sui- cide, to place a cork, or, still better, a spool of thread, as a gag between the teeth, to prevent the tube from being bit- ten in two. The use of a stomach- tube is not indicated when the poisoning is due to corrosives^ as the mucous membrane is greatly swollen, and the introduction of the tube is productive of gi'eat pain and danger of laceration of the soft tissues. The ordinary fountain syringe, which is found in almost every house, is an excellent instrument for washing out the stomach. The rubber or metal end being cut off, the tube can be introduced. The attached fountain makes the use of a funnel unnecessary. POISONS AND POISONING. 179 Constitutional Treatment.— Tlie constitutional anti- dotes will be referred to with tlie special poisons. Stimu- lants are indicated to overcome the depressing action of the different poisons, particularly the narcotics, and may be administered by the mouth (if the patient can swallow), provided the poisoning is not due to corrosives^ or by the rectum (lower bowel), by inhalation, or by hypo- dermic injection. The stimulants administered are those ordinarily used, and in addition strong coffee ; the latter is of great value in narcotic poisoning, and it may be given in the same manner as other stimulants, either by the mouth or rectum. Alcoholic stimulants should not be given in opium poisoning. When stimulants are given by the rectum, the amount should be considerably larger than when given by the mouth, and they should be diluted with sufficient warm water or milk to make a cupful. Ammonia and nitrite of amyl can be given by inhala- tion ; they should always be administered by dropping a sufficient amount on a handkerchief or the palm of the hand. The bottle should never be held to the nose, as the contents might be spilled into the mouth or nasal cavity. Stimulants should be given by inhalation with great cau- tion, where corrosive poisons have been taken, as they are liable to irritate still more the inflamed membrane. Nitrite of amyl, which is given by inhalation, is a power- ful heart stimulant, but should be used with care and in small amounts — three to five drops. This remedy is now obtained in small glass capsules, which contain about five drops, and are broken when the nitrite of amyl is needed. Strychnine, particularly by hypodermic admin- istration, is a valuable stimulant. The following list of narcotics and irritants comprises those which are commonly the cause of poisoning. NARCOTICS. Aconite.— (Monk's-hood, wolfs-bane.) The tincture has the appearance of sherry wine, for which it has been 180 PROMPT AID TO THE INJURED. mistaken. Aconite is commonly found in fever-mixtures, neuralgia "cures," liniments and ointments, and is exceed- ingly poisonous. Symptoms. — Great prostration ; tingling of the lips, mouth and throat, and extremities — the latter become numb ; slow and weak pulse ; shallow respiration ; the mind is generally clear ; convulsions may sometimes occur. Treatment. — Emetics ; free use of stimulants ; warmth to extremities ; twenty drops of tincture of belladonna, re- peated (once) in half an hour ; mustard over heart and calves of legs ; artificial respiration. Alcohol. — Acute poisoning is very uncommon. A large amount is sometimes taken for a wager, or by one unaccustomed to its use. Symptoms.— i^QQ Intoxication.) Treatment. — Evacuate stomach if possible. Keep the patient aroused by pinching, slapping with wet towel, or hot and cold douches to head and spine ; coffee in large amount by stomach or rectum ; inhalation of ammonia, and artificial respiration ; strychnine. Belladonna. — (Deadly night-shade.) Contained in cough-mixtures, etc., liniments, ointments, and plasters. Atropine, the active principle of belladonna, is commonly found in eye medicaments. Poisoning sometimes follows the use of an external application containing either bella- donna or atropine, it being absorbed through the unbroken skin. >S'?/?7ipfoms.— Headache ; intense dryness of mucous membrane of mouth, throat, and nasal cavity ; inability to swallow ; eyes brilliant (belladonna is often used for this purpose) ; pupils dilated ; face usually flushed ; delirium and stupor, or convulsions. Pulse accelerated. Treafmenf. — (Belladonna and atropine.) Emetics; opium, repeated (once) in half an hour; stimulants; warmth to extremities ; artificial respiration. Camphor.— Usually taken in the form of a tincture (spirits), or the gum. POISONS AND POISONING. Jgl Symptoms.— ChsLvacieristic odor ; surface of body cold and clammy ; disturbances of vision ; noise in ears ; de- lirium and convulsions. Treatment. — Emetics; stimulants; warmth to extremi- ties ; hot and cold douches. Hydrate of Chloral.— (Chloral.) Odor similar to bananas or pears. Chloral is often an ingredient in sleep- ing- potions, cough mixture, and liniments. Symptoms. — Face congested ; weak pulse ; labored res- pirations, stertorous breathing; stupor and unconscious- ness, sometimes convulsions. Treatment. — Stimulants, including strychnine ; warmth to extremities, coffee by rectum ; mustard over heart and calves of legs ; artificial respiration. An emetic may be given, if the patient is seen immediately after a poisonous dose has been taken. Chloroform.— When poisoning is caused by inhala- tion, the patient's tongue should be drawn forward and artificial respiration performed ; hot and cold douches ; also friction ; plenty of fresh air ; the patient's head should be low, or it may be allowed to drop down, the body being elevated by carrying the legs over the shoul- der of the attendant. When poisoning follows the internal use of chloro- form, large doses of bicarbonate of soda in water should be given internally, in addition to other means of resusci- tation. Digitalis.— (Purple foxglove.) Generally given for heart maladies. Symptoms. — Purging and vomiting ; great pain in ab- domen ; face pale ; pupils dilated ; skin cold and clannny ; pulse feeble and slow ; great depression ; gasping respira- tion ; delirium, and convulsions. Treatmeyit. — Emetics (only in case one large dose of digitalis has been swallowed) ; about twenty grains of tannin in solution, or white-oak l)ark, or strong tea, re- peated ; mustard, especiall^^ ovei* tlie lieart, and the calves 182 PROMPT AID TO THE IXJURED. of the legs, and stimulants internally. The patient should be kept in the recumbent position for some time after the serious symptoms have ceased. Fungi. — Poisonous mushrooms. Symptoms. — Colic ; vomiting- and purging ; dilated pupils ; extreme muscular weakness ; mental excitement. Symptoms usually occur within an hour. Treatment. — Emetics ; castor-oil ; stimulants ; heat. Belladonna, repeated once. "It is always dangerous to warm up a dish containing mushrooms." (Murrel.) The treatment of mushroom-poisoning is applicable to poisoning by eating mussels. Hydrocyanic Acid. — (Prussic acid.) The dilute acid is the form in which this poison is generally used, and is a colorless fluid. Prussic acid is one of the deadliest poisons known. The poisonous symptoms begin almost immediately. Symptoms. — Great and sudden prostration, or uncon- sciousness and slow pulse ; surface cold and clammy ; pu- pils dilated ; eyes fixed ; blueness of face, locked jaws ; gasping respiration and convulsions. Death may occur almost immediately. Treatment. — Dilatory treatment is of no avail in poi- soning by this agent; whatever is to be done must be done at once : no time should be lost in trying to give emetics, or use the stomach-pump ; stimulants should be given freely ; flapping with wet towel ; hot and cold douches ; artificial respiration. In poisoning by this drug, stimulants should be given by hypodermic injection, particularly strychnine ; brandy or whisky, or ammonia- water (not spirits), introduced into the calf of the leg, and repeated in five minutes ; inhalations of nitrite of amyl. The symptoms of poisoning which may occur after cyanide of potassium, peach-pits, and bitter almonds have been taken internally are dependent upon the presence of prussic acid, and should be treated accordingly. POISONS AND POISONING. 183 Opium. — The preparations generally used are morphine (the active principle of opium), tincture of opium (lauda- num), camphorated tincture of opium (paregoric), Mc- Munn's elixir, codeine, and narceine. Opium is an active ingredient in many preparations, particularly sedative and cough mixtures, soothing syrups for children, and numer- ous patent medicines. Symptoms. — Usually begin with more or less mental ex- citement, followed by great depression, headache, sensation of weight in the limbs, an irresistible desire to sleep, which soon deepens into a stupor ; the pupils are contracted and the respirations are greatly diminished in number, some- times to four or five a minute, and the skin is cold and clammy and the face pale. Convulsions sometimes occur. Treatment. — Emetics ; cold and hot douches alternately to head, face, and spine ; flapping with wet towel ; strong coffee by mouth or rectum. Wines and liquors must not he given. Belladonna repeated (once) in fifteen minutes. Artificial respiration for two or three hours ; inhalation of oxygen. The patient should be carefully watched for some time after the dangerous symptoms have subsided. IRRITANTS. Arsenic. — This agent is used medicinally, generally in the form of Fowler's solution and arsenious acid ; it is also contained in rat-pastes, fly and vermin killers, and is employed to a large extent in the arts, for coloring flowers, wall-paper, stuffing birds, etc. Realgar is a red, and Orpi- ment, or King's yellow, is a yellow preparation of arsenic. Arsenite of copper (Paris green, or Scheele's green) is com- monly taken hj suicides. Symptoms. — Intense burning pain in pit of stomach ; faintness and depression ; vomiting and purging ; vomited matter streaked with blood ; sensation of constriction in throat. Abdomen tender and painful ; skin cold and clammy. If Paris green has been taken, the green color is generally apparent about the mouth, hands, or clothing. 184 PROMPT AID TO THE INJURED. Treatment. — Emetics; large draughts of hot, greasy Trater, or salt and water ; dialyzed or tincture of iron in solution ; a large amount of magnesia may be given ; or lime which may be scraped from the walls or ceiling, white crayons, tooth powders, etc, ; castor-oil ; sweet-oil, or equal parts of sweet-oil and lime-water, or lime-water alone; raw eggs ; milk: stimulants (well diluted if given by the mouth), preferably by hypodermic administration ; opium to allay the pain, Caxtharides. — (Spanish fly.) Symptoms. — Burning sensation in mouth and throat , violent pain and soreness in abdomen ; vomiting and purging, vomited matter containing streaks of blood ; great irritation of urinary organs and passage of bloody urine ; delirium and convulsions. Treatment. — ^Emetics, raw eggs, milk, opium. Stimu- lants; heat; poultices over abdomen. Copper, Sulphate of (blue vitriol, blue-stone), or subacetate of copper (verdigris), is sometimes the cause of poisoning, although copper-poisoning is more frequently due to substances which have been cooked in copper ves- sels, which is an unsafe method of preparing food. Symptoms. — Vomiting and purging ; griping pain in abdomen ; metallic taste in mouth : great thirst and weak- ness ; labored respirations and rapid pulse ; dimness of vision ; and sometimes convulsions. Treatment. — Emetics, if vomiting has not occurred. Copious draughts of warm water ; raw eggs ; milk ; stimu- lants ; opium. Croton-Oil. — Has been mistaken for castor-oil. Symptoms. — Vomiting : purging ; violent pain in ab- domen ; great depression ; skin cold and clammy. Treatment . — Emetics, if vomiting has not occurred. Raw eggs ; stimulants ; spirits of camphor, ten drops in water every five minutes until five or six doses have been taken ; opium by mouth, or ^ grain of morphine hypo- dermically. POISONS AND POISONING. 185 Iodine. — As generally used is in the form of the tinct- ure — a dark reddish fluid Sym2)toms.—Grea,i]oc£il irritation and pain; the mu- cous membrane of the mouth is discolored yellow ; vomit- ing and i)urgijiff, the vomited matter having a bluish color, as the result of the admixture of the iodine and starchy matter of the food (iodide of starch). Blue color also no- ticed when vomited matters come in contact with starched articles of clothing. Treatment. — Free use of starch, then emetics, raw eggs, chalk, magnesia, and stimulants. Strychnine. — (The active principle of nux- vomica). Symptoms. — An irritable condition of the muscular system, and twitchings and discomfort, soon followed, usu- ally within less than an hour, by severe convulsions, which occur at intervals of two minutes to half an hour. The contractions of the powerful muscles of the back cause the body to assume the form of a bow, the patient resting on the head and heels (opisthotonos) ; great pain is present as the result of the intense muscular contraction. The mind is usually clear. The respu'atory muscles are promi- nently involved in this affection, and death by asphyxia, as the result of rigidity of these muscles, may follow, or death may occur later, as the result of exhaustion. Strychnine-poisoning can only be mistaken for tetanus (locked- jaw). The distinction is to be made as follows : In strychnine-poisoning the attack is sudden ; there is gener- ally evidence of poison ha\ang been taken, and no injury has been received. In tetanus, the development of the dis- ease is more gradual ; no poison has been taken, but some form of injurj^ is present. In strychnine-poisoning the muscles of the jaw are only slightly affected, if at all, but the upper extremities are always involved ; while in teta- nus, the rigidity of the muscles of the jaws (locked-jaw) is the first and prominent S3''mptom, and continues to the end, the upiDcr extremities are only affected in the severe cases, and then only slightly. In strychnine-poisoning, the dura- 186 PROMPT AID TO THE IXJUP.ED. tion of the attack covers but a few hours, while in tetanus a number of days may be involved. Treatment. — The stomach-tube can only be used if the patient is seen immediately after the poison is taken, as the convulsive movements prevent the introduction of the tube. Tannic acid, followed by an emetic ; then large . doses of bromide of sodium or potassium (thirty grains in solution), repeated every hour until three or four doses have been taken, together with nitrite of amyl ; opium ; artificial respiration may also be called for. Phosphorus. — Poisoning frequently occurs as the re- sult of sucking or swallowing the heads of matches. This substance is also contained in " rat-pastes." Symptoms. — Vomiting and purging; vomited matter has a garlicky odor, and is luminous in the dark. Intense pain in abdomen. Treatment. — Emetics, sulphate of copper preferably; free use of magnesia ; French turpentine, given in an alco- holic or alkaline solution, half teaspoonful every half- hour, until a number of doses have been taken (five or six) ; also two or three grains of sulphate of copper as an antidote every five minutes ; white of egg ; opium. Tartar Emetic. — (Antimony, or Stibium.) Symjjtoms. — Vomiting and purging ; vomited matter contains streaks of blood ; skin cold and clammy ; collapse. Treatment. — Warm water; mixtures of tannic acid; white-oak bark ; also strong tea ; stimulants, and warmth ; opium. Zinc. — The sulphate or chloride is generally used. The chloride is far more dangerous and corrosive. Symptoms. — Pain and vomiting, with great depression, and, if the chloride has been taken, the mucous membrane of the mouth is inflamed. Treatment. — Large quantities of bicarbonate of soda (baking-powder) or carbonate of potash in solution ; milk; eggs ; mixtures of tannic acid or strong tea, or oak-bark ; opium. r^ POISONS AND POISONING. 187 CORROSIVES. Acids. — Sulphuric (oil of vitriol) ; muriatic (spirit of salt) ; nitric (aquafortis) ; acetic; carbolic, and oxalic acids. Symptoms. — Mucous membrane of lips, mouth, and throat greatly inflamed and swollen, with more or less de- struction of the tissue, and symptoms of shock. When taken in a concentrated form, muriatic and sulphuric acids discolor the lips and mouth hlacTx, while nitric acid stains these yellow; when oxalic and carbolic acids have been taken, the membrane has a ivhitish appearance. Treatment. — For sulphuric, muriatic, nitric, and acetic acids; immediate use of alkalies, as mixtures of soda, pot- ash, magnesia, chalk, white crayons, lime, soap-suds, or tooth-powder (chalk) ; raw eggs, milk, oil. Rectal stimu- lation for shock. Oxalic Acid.— Is sometimes mistaken for Epsom salts. Is used for cleaning kitchen boilers, etc., and sometimes introduced accidentally into food. Symptoms. — Same as other corrosive poisons. Treatment. — Magnesia or lime in some form should be administered — the latter may be scraped from the wall or ceiling — white crayons; tooth-powders, etc. Soda, potash, and ammonia should not be used. Castor-oil or sweet oil should be administered by the mouth, and hypodermic or rectal stimulation resorted to. Poisoning by salts of lemon and sorrel, which are derivatives of oxalic acid, should be treated as above. Carbolic Acid (Phenol) Creasote. Symptoms. — Same as other corrosives, also characteristic odor is present; urine small in amount and of smoky color. Treatment. — Alkalies, particularly sulphate of mag- nesia (Epsom salts) or sulphate of soda (Glauber's salts) given in large doses; raw eggs; castor oil, and sweet-oil. Emetic if necessary. CoRRosR'E Sublimate. — (Bichloride of mercury.) Used largely as a disinfectant, and to preserve specimens, etc. 188 PROMPT AID TO THE INJURED. Symptoms. — Similar to those of arsenical poisoning. Vomiting and purging; intense pain in abdomen; mem- brane of mouth and tongue white and shriveled; metallic taste in mouth. Treatment. — Emetics, if vomiting is not present. White of egg in large amount; milk or mucilage in abundance; flour and water or arrowroot or barley-water; chlorate of potash. Stimulants by hypodermic or rectal administration. Alkalies. — Caustic potash and soda; pearlash; strong solution of ammonia. Symptoms. — Similar to poisoning by corrosive acids. Intense swelling and inflammation of lips and mouth. Treatment. — The treatment consists in the administra- tions of acid^ — vinegar, lemon or orange juice, hard cider; also acetic, nitric, muriatic, and sulphuric acids largely diluted; raw eggs; olive-oil; milk; arrowroot, and bar- ley-water. Stimulants by hypodermic or rectal adminis- tration. Opium may be given to allay pain. Coal-Gas. — Symptoms. — Headache, giddiness, or un- consciousness; cyanosis; labored respiration; pupils gen- erally dilated. Treatment. — Fresh air; oxygen; artificial respiration; stimulants. When the case is in the hands of a surgeon saline venous infusion is often performed in extreme cases. Poison Ivy or Oak. — Symptoms. — A vesicular erup- tion of a brownish-red color appears; this may be associ- ated with the formation of large blebs or blisters ; the skin becomes very red, swollen, hot, and irritable, with intense burning and itching. Treatment. — As the poison is due to a volatile acid, an alkaline application is indicated; for this purpose a solu- tion of baking soda or saleratus may be used, or, still better, strong soap-suds. Later, an application of a solu- tion of the acetate, or "sugar" of lead, thirty to sixty grains to a pint of water, is beneficial. Dry starch dusted over the affected part is also used at this stage. Avoid ointments or other oily substances. CHAPTER XVIII. THE CONVULSIONS OF CHILDREN. Convulsions affecting children are of common occur- rence, but do not carry with them the gravity which is associated with a like affection in adults. The convulsions are often the result of trivial causes, as indigestion, teeth- ing, worms, etc. They may sometiuies, however, usher in serious affections, as scarlatina (scarlet fever). At the time of the convulsion the thumbs are carried across the palm of the hand ; the eyes are set and turned upward ; then suddenly the patient becomes rigid, with some con- traction of the facial muscles ; the face and lips become dusky, as the result* of considerable interference with respiration. This rigidity lasts but a few moments, and is generally followed by a stupor, which often terminates in a natural sleep and recovery. Treatment. — The head should be enveloped in a cloth wet with cold water, and the child at once placed in a hot bath (about 100°). A tablespoonful of mustard may be added to the water, the efficiency of the bath being there- by increased. The child should remain in the bath about two or three minutes, and should be again immersed if the convulsion is repeated. TETANUS— LOCKED-J AW Tetanus is a disease characterized by spasmodic rigidity of the voluntary muscles, and is sometimes the result of a wound of the foot or hand, made by a blunt or jagged im- plement, as a rusty nail. Tetanus may also follow burns. Cases of the disease are not frequent. An interval of from 190 PROMPT AID TO THE INJURED. five to fifteen days generally follows the reception of the injury before tlie sj^mptoms become apparent. The first well-marlved symptoms of the disease are pain and stiff ness "about the neck and jaws, which is commonly mistaken for rheumatism. This increases in severity, and the muscles of mastication become involved and the pa- tient is unable to open his mouth (trismus). The name by which the disease is commonly known (locked-jaw) is due to this fact. The rigidity about the neck soon extends to other portions of the body. The strong muscles of the back being so forcibh' contracted, the body is bent in the shape of a bow and rests on the head and heels (opisthot- onos). The upper extremities are but slightly affected in mild cases. The contraction of the facial muscles elevates the corners of the mouth, and produces a characteristic ap- pearance known as risus sardonicus, or canine laugh. This affection is usually followed by a fatal result. Tetanus is to be distinguished from strychnine-poison- ing. (See Strychnine-Poisoning.) Treatment. — Medicine is of very little use in tetanus ; however, large doses of bromide of potassium (thirty to forty grains) may be given with safety three or four times daily). The value of tetanus antitoxin as a relief for this condition is now fully confirmed. Operative measures are sometimes undertaken by the surgeon. The patient's strength should be kept up as well as possible by nour- ishment, such as milk, beef -tea, and kumyss, which may be carefully poured into the mouth between the teeth and cheeks; in this way it reaches the stomach. Excitement of all kinds should be avoided. FOREIGN BODIES IN THE EYE, EAR, NOSE, LARYNX, AND PHARYNX. Eye. — Eoreign bodies in the eye usually consist of cinders, sand, dust, and minute scales of iron. The latter have become a frequent source of annoyance since the ele- vated railroads have been in operation. FOREIGN BODIES IN THE EAR. 191 T^reatment. — The foreig-n bodies just described are usually lodged about the center and under surface of the upper lid, and are often washed out of the eye by the increased flow of tears which follows their introduction. If the foreign body still remains lodged, the upper lid should be gently pulled away from the eye with the thumb and finger, and carried downward and pressed against the lower lid, to which the particle may be transferred. Should this not be successful, the upper lid may be turned upward and folded on itself over a pencil, when the foreign body can generally be seen and removed by lightly touch- ing it with a small fold of a clean handkerchief or other similar substance. The operation of eversion, or turning the lid upward, usually requires considerable practice be- fore it can be done dexterously. The lower edge of the upper lid should be carried away from the eye and some- what upward by seizing the lid with the thumb and fore- finger of the left hand — the operator standing in front of the patient — while with the tip of the index-finger of the other hand, or the shaft of a lead-pencil, the center of the lid is pressed downward, and the inner surface is exposed. The particles of iron already referred to, and also some other foreign bodies, have sharp cutting edges, and often penetrate the eyeball, usually over the pupil, and can not be dislodged by the ordinary process. All unskillful manipulation, and also the common practice of rubbing the eye, press the substance still deeper into the structures. This condition should, if possible, be attended to by a sur- geon. The pain and reddened condition of the eye may be relieved by applications of warm water, tea, or rose- water, or two or three drops of a four-per-cent solution of cocaine dropped in the inner corner of the eye. Ear. — Grreater danger, probably, results from the un- skillful, unnecessary, and rough manipulation, in cases where foreign bodies have, been introduced into the ear, than from the presence of the article itself. A foreign body, even of large size, which does not cause immediate 192 PROMPT AID TO THE INJURED. pain and distress, may remain in the ear for some time without causing any serious result. It can, at least, re- main until removed in a proper manner by a surgeon. Only the simplest and gentlest measures should be em- ployed by a non-medical person. Among the foreign bodies which are found in the ear are insects, bugs, peas, beans, pebbles, cherry-pits, and shoe-buttons. Children commonly introduce the latter articles into their own ears or the ears of playmates. It is well to be reasonably cer- tain that a foreign body exists in the ear before an attempt is made to dislodge it. Treatment. ^-Bugs and insects are readily removed by carefully syringing the affected ear with warm water ; or, if a syringe can not be procured, then water can be poured into the ear. This procedure either drowns the insect or drives it out, and is so uniformly successful and simple that it is regarded as the best treatment for this pui'pose. Another method, which is commonly employed, consists in applying a piece of cotton saturated with salt water or vinegar to tlie ear, and when the cotton is re- moved, after an interval of a few minutes, the insect is usually found attached to it. Gentle syringing may also be employed to remove other foreign bodies from the ear ; exception should, Jioicever, be made zchen the substance is likely to be increased in size by the use of ivater, as peas and beans. Tooth-picks, button-hooks, and other similar instruments, should never be used ; for when they are employed, the foreign body is almost always pushed further into the canal, and its subsequent extraction by the surgeon made more difficult, besides the drum of the ear is very liable to be perforated, or other unpleasant accidents ensue. Nose. — Foreign bodies are often inserted into the nose by children and insane persons, or as the result of accident. The article introduced may be small and not particularly irritating, and may remain in the nasal cavity for a long time before its presence is known. FOREIGN BODIES IX THE LARYNX. ]9:» Treatment. — Tickling the opposite nostril with a feather until sneezing is induced, is very often all that is necessary, particularly if the foreign body has recently been inserted. If some such simple procedure just de- scribed is not followed by the desired result, the case should be seen as early as possible by a surgeon. Larynx. — Foreign bodies may enter the larynx during a fit of laughing, or when a sudden act of inspiration is made ; this occasionally occurs while eating. A piece of meat is often a cause of strangulation. The obstruction to the entrance of air into the lungs is immediately followed by a violent paroxysm of coughing, which usually expels the foreign body ; if not dislodged, evidences of suffocation immediately follow. The face becomes congested and the eyes protrude ; the inspirations are gasping in character, and the patient makes frantic efforts for relief. The sub- stance causing the obstruction is usually in such a position that some air reaches the lungs. Treatment. — The nearest surgeon should at once be sent for, and always informed as to the character of the case, in order that he may bring with him the instruments necessary for an operation, which usually consists of an external opening into the windpipe. In the mean time the subject should be slapped violently on the upper por- tion of the back between the shoulder-blades, particularly at the moment of coughing. If this is not successful, in- vert the body — that is, hold the patient by his feet with the head down — and again slap the back. This should at once be discontinued if it increases the distress. If the accident occurs during a meal, the finger should be passed into the throat, with a possibility of dislodging the piece of meat or whatever may cause the mischief. If the patient becomes unconscious from the consequent asphyxia, artificial respiration should be employed until the surgeon arrives. Fresh air, or the use of oxj'gen con- tained in cylinders, is of value in the treatment. Pharynx. — The local distress caused bv foreign bodies 14 194 PROMPT AID TO THE INJURED. in the pharynx — which usually consist of articles of food, coins, fish-bones, pins, needles, false teeth — depends upon their size, which, if large, produce more or less pressure over or upon the aii^-passage, together with symptoms sim- ilar to those of foreign bodies in the larynx ; or, if sharp- pointed, the article may cause great pain and irritation. Treatment. — Foreign bodies in the pharynx are often removed by acts of vomiting or coughing ; if not so ex- pelled, an examination of the throat should be made, and, if possible, the substance removed ; if this can not be done, and the foreign body is not too large or sharp, it may be pushed downward into the stomach. A fish-bone, pin, or needle is almost always found sticking into the mucous membrane, and care should be observed, while trying to remove it, that it is not forced still further into the tissues. Children often swallow coins, buttons, etc., and some- times substances of very large bulk. When this occurs, emetics and cathartics should not be given. Emetics are objectionable, because it is safer to have the foreign body pass downward through the alimentary tract. Instances have occurred where coins, etc., have been brought up by the use of emetics and have entered the air-passages before they could be expelled from the mouth. Cathartics should not be used, for the reason that they irritate the intestinal tract without doing any good. The cliild should receive the usual food, with the addition of wheat or rye flour in the form of a gruel; this material adheres to the foreign body, and prevents it from irritating the canal on its way down. After a foreign body, such as is usually swallowed, reaches the stomach, it is rarely followed by a serious result. The passages from the bowel should always be carefully examined for the substance, which usually makes its ap- pearance within three days. The medical attendant must be at once informed if the child becomes restless or fever- ish, or is affected with pain. FOOT-SORENESS. 195 The following" very valuable remarks, in regard to foot- soreness, are made by Prof. Parkes (Parkes' " Manual of Hygiene ") : "Foot-soreness is generally a great trouble, and fre- quently arises from faulty boots, undue pressure, chafing, riding of the toes from narrow soles, etc. Rubbing the feet with tallow or oil, or fat of any kind, before marching, is a common remedy. A good plan is to dip the feet in very hot water before starting, for a minute or two ; wipe them quite dry, then rub them with soap (soft soap is the best) till there is a latlier ; then put on the stockings. At the end of the day, if the feet are sore, they should be wiped with a wet cloth, and rubbed with tallow and spirits mixed in the palm of the hand (Galton). Pedestrians fre- quently use hot salt and water at night, and add a little alum. Sometimes the soreness is owing simply to bad stockings ; this is . easily remedied. Stockings should be frequently washed, then greased. Some of the German troops use no stockings, but rags folded smooth over the feet. " Very often the soreness is owing to neglected corns, bunions, or in-growing nails. If blisters form on the feet, the men should be directed not to open them during the march, but at the end of that time to draw a needle and thread through ; the fluid gradually oozes out. " All foot-sore men should be ordered to report them- selves at once." A powder composed of salicylic acid three parts, starch ten parts, and talc eighty-seven parts, maj^ be dusted over the feet daily, or every two or three days. CHAFING. Chafing is particularly common among soldiers, and is generally due either to the friction caused by badly fitting clothes or where surfaces of the skin rub together, as tlie inside of tlie thigh, or at the flexures or bendings of the different joints of the body. 196 PROMPT AID TO THE INJURED. Treatment. — The cause of irritation should be re- moved if possible, and the affected parts washed with cold water, dried thoroughly, and then dusted with fuller's earth, bismuth, Ijcopodium, oxide of zinc, starch, oatmeal, or flour. Fuller's earth is superior to the others men- tioned for this purpose; equal parts of lycopodium and talc is excellent to prevent chafing ; flour and starch are apt to become sour, and increase the local irritation. Unless the affection is promptly attended to, inflamma- tion of the skin may follow, Avhich requires rest together with active and sometimes prolonged treatment. CIIAPTEU XIX. HYGIENE. The subject of hygiene, which relates to the care and preservation of health and prevention of disease, may very properly be introduced by indicating in a general way the manner in which the body should be cared for. In order to intelligently understand this matter, a general knowl- edge of anatomy and physiology is necessary. It will be seen that the skin is an exceedingly active organ, constantly throwing off the perspiration, which contains considerable waste matter; in addition, the seba- ceous follicles supply an oily substance for lubrication; these, with the worn-out, scaly, or superficial layer of the skin, produce a large amount of effete or decomposed ma- terial, which, if not promptly removed, embarrasses the function of this organ and favors the formation of un- pleasant odors. It will thus be appreciated that cleanli- ness is essential to health. 5a#^s.— Considerable has been written upon the sub- ject of baths, and numerous and complicated methods have been advocated. These in a great measure are luxuries, and are not necessary to the well-being of the body. A cold bath upon rising, the water to be applied by the hand and followed by moderate friction, is, as a rule, sufficient to keep the skin properly cleansed and stimulated. This applies to healthy adults, and is not recommended for children and old people. In the latter subjects a warm bath at bedtime, two or three times weekly, will suffice. Plunging into a tub of cold water, particularly in the 198 PROMPT AID TO THE INJURED. winter time, is of questionable value, and can only be done with safety by the strongest. If the desired effect is ob- tained, the use of cold water should be promptly followed by a glow or reaction. Warm baths during the day should be followed by the application of cold water, which renders a person less sus- ceptible to exposure. The temperature of a bath can be changed without any ill effects. Baths (except those upon rising in the morning) should not be taken just before or after a meal. Cold baths should not be taken when hungry or fatigued. "Warm baths are soothing, and allay nervous irrita- biUty. While Russian and Turkish baths are often valuable for therapeutical purposes and as extreme cleansing agents, they are rather sources of pleasure, and are not essential to the welfare of the skin. Sea-bathing is usually over- done, and often followed by unsatisfactory results. Per- sons suffering from head and chest affections should not go into the sea. Adults should not remain in the surf longer than fifteen or twenty minutes, and children and old and delicate subjects even less. Noon is perhaps the best time of day for sea-bathing, and the bath should not be taken close to meal-time. The bather should not wait to cool off, but plunge in at once and immerse the whole body ; when warm, a person can better stand the shock of the cold water. After the bath the body should be quickly dried, and a brisk walk taken. The addition of alcohol, cologne, ammonia, etc., make the bath particularly pleasant and stimulating. The effect, however, is local, as the skin has very little if any absorb- ent power. The different nutritive and medicinal baths given with this end in view are practically worthless. Shipwrecked persons and those who are in the water a good portion of the time require less drink, not because the skin absorbs water, but because the long-continued contact of the water lessens the activity of the sweat HYGIENE. lf)(j glands, and consequently less water is thrown oflp from the body. When a daily bath is taken, unless the weather is very warm, soap is unnecessary, except to apply to those portions of the body which are exposed and where sur- faces are in contact with each other. Too much soap re- moves the oily substances and renders the skin dry and harsh. Soldiers and others who are moving about and can not enjoy a regular bath should, if possible, bathe the portions of the body just referred to. Special care should be given to the feet, not only as a matter of cleanliness, but to aid the proper locomotion. An ingrowing nail or neglected corn often renders a sol- dier unfit, for duty. The feet should be bathed morning and evening; the nails frequently trimmed — not too close, as this causes the toes to become clubbed. Corns should be soaked in warm water and scraped, not cut. The mouth and teeth should be cleaned twice daily with a soft brush ; good soap may be used for this pur- pose. This procedure removes particles of food, etc., helps to preserve the teeth, and prevents oftentimes an unpleas- ant breath. Dandruff is the scaly layer of the scalp ; the excess can generally be removed by brushing ; a fine comb should not be used. The scalp can occasionally be washed with warm water and soap or borax, and afterward washed with cold water. Too much soap or cosmetic changes the color of the hair. Inferior soap frequently irritates the skin, and should not be used. Clothing . — It is generally accepted that woolen is the best material for clothing of all kinds. Its hygroscopic properties — i. e., the power which it possesses for absorb- ing water and its action as a nonconductor — make it par- ticularly valuable for the above named purpose. As a nonconductor it does not transmit the sun's rays in warm weather nor the body heat in winter. The latter heat is in a great measure regulated by the perspiration, which is readily absorbed by wool, and helps to cool the surface 200 PROMPT AID TO THE INJURED. during a high temperature. Cotton and linen, being good conductors, transmit the sun's rays and also the warmth of the body. The chilly and clammy feeling which is often experienced when cotton is worn next the skin does not occur when the material is woolen. For this reason the latter is particularly indicated for wear by those who are subject to chest affections, rheumatism, etc. When it is necessary that the surface of the body should be kept uniformly w^arm, woolen should be worn at night as well as during the day. A common prejudice exists against the use of woolen as underwear, the objection being that it u'ritates the skin. At the present day woolen under- garments may be procured almost as soft as silk, and very thin. Silk as an article of clothing for underwear stands next to wool in value, linen and cotton last. More or less cotton is generally found in woolen goods. If the amount is small, it does not materially interfere with the properties of the wool, and helps to prevent the excessive shrinking which would otherwise take place. Besides, 25 or 30 per cent of cotton renders the garment more serviceable. The shrinking may be in a measure controlled if the garments are soaked and stirred in hot soap-suds and transferred to cold water (to remove soap) without wringing. Woolen stockings are often objectionable, because the leather foot-wear, being also a bad conductor, keeps the feet tender, moist, and offensive. The popular notion that red woolen flannel is superior to the uudyed is fallacious. This material is disagreeable, as the dje increases the ab- sorption of offensive odors. Head- wear should be worn as little as possible. It should be easy fitting, light in weight, and ventilated. Baldness frequently follows a disregard of these rules. Comforters and other articles worn about the neck, ex- cept on special occasions, are to be condemned ; they keep the skin moist and tender. A number of coverings of clothing is warmer than HYGIENE. 201 ODe of equal thickness, due to the air between the several garments. Leather clothing is a bad conductor, and very warm, but should only be worn in extremely cold, dry, or windy weather. Rubber clothing prevents proper evaporation and keeps the body and underwear moist, and should be worn only in wet weather and when other protection is not available. Ordinary garments can be transformed into fairly good waterproof material in one of the following ways : 1. Moisten the cloth on the wrong side with a weak solution of isinglass, and when dry further moisten with an infusion of nutgall. 2. Moisten the cloth on the wrong side with a solution of soap, and when dry with a solution of alum. 3. Thoroughly rub the wrong side of the cloth with pure beeswax until it presents an even gray appearance ; a hot iron is then to be passed over it, and the cloth brushed while still warm. Shoes should be made with broad soles, not too thick, to prevent the proper bending of the feet. . Boots or shoes should never be worn on alternate feet. Boots sweat the legs, and should be worn only when necessary. Parke's water-proof dressing is a very valuable prepara- tion, and is made as follows : Dissolve carefully with heat half a pound of shoemaker's dubbing in half a pint of linseed-oil and half a pint of solution of India-rubber, and use on boots and shoes every two or three months. Tight lacing, garters, and straps about the waist should be avoided ; the latter is said to favor the formation of hernia or rupture. Food. — The function of food has been likened to the fuel which supplies the engine, but, aside from supplying material which keeps the difPerent functions of the body in activity, it furnishes material for new tissue to supply the waste which is constantly going on. Food may be divided into organic and inoriranic substances. 202 PROMPT AID TO THE INJURED. An organic substance is one which supplies the body with nourishment, heat, and motion, and forms new tissue to replace that which is worn out. In performing* this it loses its identity, and when eliminated from the body is in the form of waste tissue. Organic substances are divided into organic nitrogen- ized and organic non-nitrogenized. Organic nitrogenized matter or albuminous material contains nitrogen, and is the most important of all foods. It rebuilds worn-out tissue, supplies motion, strength, and nourishment. The white of egg, caseine of milk, and gluten of flour are examples of this class. The organic non-nitrogenized substances, examples of which are starches and sugars (carbohydrates) and fats (hydrocarbons), are necessary to sustain proper nutrition, supply heat as the result of oxidation, protect the deeper structure, and give symmetry to the body. Recent investi- gators have shown that the non-nitrogenized substances have considerable to do with the production of force or energy in addition to their other functions. It will thus be understood why an athlete chooses a diet composed principally of organic nitrogenized food, which forms muscles without materially increasing the body weight. Inorganic substances are those which are taken into the system, perform a definite function, and are then removed from the body unchanged. Water and salt are examples of this class. Water exists in every tissue of the body, and is essential to their integrity. In cholera, where the water is rapidly removed, the body has a shrunken and pinched ap- pearance, the features in some cases being unrecognizable. Salt is necessary to the proper interchange of nutrition. When deprived of this substance the body rapidly suffers. All tissues of the body are constantly undergoing phys- iological change, and for this the food we eat must contain the different materials above enumerated. This is im.pera- tive, and has been confirmed by numerous experiments. HYGIENE. 20:3 Ordinary articles of food contain 50 to 60 per cent of water. It is generally accepted tliat a diet should contain one part of nitrog-en (contained in organic nitrogenized matter) and twelve to fifteen parts of carbon (found in organic non-nitrogenized food). Parke states that a man in good health and doing a good day's work must have about two thirds of an ounce of nitrogen and eight to twelve ounces of carbon. The following interesting facts are given by Dr. Wil- son : One ounce of albuminous material (organic nitro- genized) contains 70 grains of nitrogen and 212 grains of carbon ; one ounce of the fat (hydrocarbon) contains 336 grains of carbon ; one ounce of the starches and sugars (carbohydrates) contains 190 grains of carbon. With these facts in view, a proper diet can be easily selected from the following table of Dr. Letheby, which includes the ordinai'y articles of food (uncooked) ; 20 per cent should be deducted for bone, and the same percentage for cooking : Split peas Indian meal Barley meal Rye "Seconds" flour. Oat meal Baker's bread . . . . Pearl barley Rice Potatoes Turnips Green vegetables. Carrots Parsnips Sugar Treacle Buttermilk Whey Skimmed milk. . . QRAn r PER 1 POUND. Carbon. Nitrogen. 2,699 248 3,016 120 2,563 68 2,693 86 2,700 116 2,831 136 1,975 88 2,660 91 2,732 68 769 22 263 13 420 14 508 14 554 12 2,955 , , , 2,395 • ■ « 387 44 154 13 438 43 New milk Skim cheese.. . . Chedder cheese . Bullock's liver. . Mutton Beef Fat pork Dry bacon Green bacon . . . Whitefish Red herring. . . . Dripping Suet Lard Salt butter Fresh butter . . . Cocoa Beer and porter ORAIN PER POUND. Carbon. Kitrogea. 599 44 1,949 483 3,344 306 934 204 1,900 189 1,854 184 4,113 106 5,987 95 5,426 76 871 195 1,435 217 5,456 4,710 4,819 4,585 6,456 3,944 iio 274 1 204 PROMPT AID TO THE INJURED. The following table is given by Dr. Dalton. A man in good health, taking active exercise in the open air and restricted to a diet of bread, butter, and fresh meat, with water and coffee for drink, consumes in one day : Meat, 16 ounces. Bread, 19 ounces. Butter or fat, 3'5 ounces. Water, 54 ounces. Climate has considerable to do with the formation of the quantity and quality of the dietary. This is well marked in the arctic regions, where an enormous quantity of fat is consumed, thus furnishing, besides food, heat and protection. Cojnposition of Different Articles of Diet. Table from " Hygiene," Notter and Firth, 1900. Im 100 Parts. Watei' Pro- teids. Arrowroot 15 ■ Bacon (Letheby) 15 ' Barley meal (de Chaumont) 11' Barley pearl (Church) 14- Beef, best quality (Konig) 72 ■ Beef as supplied to army 75 ' Beef, salted .' 49' Beef, corned or Chicago (Parkes). . 52' Beetroot (Konig) 8' Biscuits Bread (Rubner) Bread, average wheaten Butter, English fresh (Bell) 112 Butter, very best (Bell). . . Butter, salt (Bell) Butter, highly salted (Bell) Cabbage (Konig) Cabbage. Brussels sprouts Carrots (Konig) Cheese, Dutch (Bell) Cheese, single Gloster . . . Cheese, poor quality (Bell) •40 0^ •00 9^ •30 12 • •70 7- •00 21- •00 15 • •10 29 • •20 23 • •00 1^ •00 15 • •50 8- •00 8- •00 2- •00 1- •00 . . . •00 1- •00 2- •50 5^ '•80 1- •00 28- .•00 31 • i^OO 32 • Fats. •80 •00 70 ■40 •00 ■00 ■60 ■30 •50 •60 ■00 •00 •00 •00 •66 00 00 ■00 •00 ■00 •00 00 00 10 00 40 •20 •00 Car- bohy- drates 71^00 75-80 30 00 •50 ■00 ■00 •00 •00 •00 ■50 •20 •00 ■50 •00 10-50 73^40 50^00 49-20 Salts. 0-30 3-00 3-00 1-00 1-00 1^60 21-10 00 00 70 50 30 00 00 3-00 8-00 5-50 7-80 10-00 1-00 ■00 50 ■20 ■00 •00 •50 •00 HYGIENE. 205 In 100 Parts. Cream (Letheby) Eel(Konig) • Eggs Fish, salmon (Konig) Fish, sole (Konig) Fish, herrings fresh (Konig) Flour, wheaten fine Flour, wheaten average Goose (Konig) Horse-flesh (Konig) Lentils Macaroni (Konig) Maize (Pozziali) Margarine Milk, average cow's Milk, Devon preserved (Blyth) . . . . Milk, average town Milk, condensed English (Bell). . . . Milk, condensed Swiss, sweetened. . Milk, condensed Swiss, unsweetened Mutton, ordinary Oat meal Parsnips (Parkes) Peas Pork (Konig) Potatoes Rice Turnips (Konig) Veal, lean (Konig) Water Pro- teids. 00 2 5012 Fats. 70 26 50128 50|11 00 7 00 00 00 00 00 70 80 00 00 75 70 20 00 00 30' 11 35III OOi 5 00! 6' 30 Car- bohy- drates 2- 08- 71- 58- 76- 64- 4- 3- 4- 50- 48- 13- 63- 14- 58- 21- 84- 6- 80 30 20 40 80 50 26 50 30 80 70 35 06 50 00 84 40 80 Salts. •80 •50 •40 •00 •50 •00 •70 •80 •50 •00 •50 •80 •40 •22 •70 •70 •70 •00 •40 •00 •00 •00 •00 •40 •50 •00 •50 •00 •50 The term " Froteids " which appears in the above table refers to organic nitrogenized matter. Milk contains the essential elements necessary to a varied diet, and is the sole nourishment during infancy and the principal article of diet during the first five or six years of life, and even later. Milk is capable of sustaining life and health indefinitely in an adult. The different forms of aliment, however, may after childhood be ad- vantageously taken in a more condensed form, as milk 206 PROMPT AID to THE IXJURED. contains about 86 per cent of water. The specific gravity of good milk is between 1,017 and 1,036. There should be 10 or 12 per cent by volume of cream. When used for in- fants under six months of age the milk should be diluted with 25 to 100 per cent of water, and the addition of a small amount of sugar and cream. Milk is highly absorb- ent, and rapidily becomes tainted in an impure atmos- phere. When the purity of milk is questioned, or during* the presence of cholera, typhoid fever, diphtheria, etc., it should be boiled (212° Fahrenheit). If this is properly car- ried out, the infectious germs which it may contain will be destroyed. However, as boiling more or less impairs the value of milk as an article of nutrition, it is better under ordinary circumstances for infant feeding to depend on Pasteurization for safety. In this process the milk is sub- jected to a temperature of 156° Fahrenheit for a half or three-quarters of an hour. While this greatly diminishes the danger of impure milk, it does not interfere so materi- ally with its normal constituents. The most careful attention should be given to the fre- quent cleaning and sterilization of cans and other recep- tacles for milk. Indifference to this important detail is a common means by which infectious diseases are trans- mitted. Both brown bread and eggs represent a varied diet, and are very nutritious. Fresh eggs, when held to the light, are more transparent in the center, and stale ones at the ends. In a solution of one part of salt and ten of water good eggs sink and bad ones float. Of the meats, beef has the greatest nutritive value, and can be taken indefinitely without becoming unpalatable. Peas and beans are exceedingly nourishing. White bread is also of gi'eat value as an article of diet, particu- larly so when combined with milk. Sour bread may be utilized for food by toasting, as heat volatilizes the acid. Cheese is rich in nitrogen, but hard to keep, and decays rapidly. Beef extracts and juices are very inferior to HYGIENE. 207 meats. They may be used as nutrients and stimulants for a short time ; they do not, however, supply tissue waste. Potatoes are very rich in starch, contain a large amount of water, and vegetable acids. Fresh fruits and vegetables are of great value ; they assist in regulating the assimilative process, and act as a stimulus to the gastro-intestinal apparatus. They contain a large amount of vegetable acids. Scorbutus or " scurvy," an exceedingly disagreeable and oftentimes fatal disease, is generally attributed to the absence from the diet of potatoes and other vegetables and fresh fruit which contain acids. The disease is more com- monly seen among sailors who are many days in transit, and who are deprived of the above articles of food and restricted to a diet of salt meats. This disease comes on slowly, with a feeling of general debilitj^ and mental apathy, with a pale yellowish tint of skin, and insomnia ; the gums become soft, and bleed ; the breath has a fetid odor. There are also pains in the legs which may simulate rheumatism, great prostration, haemorrhage from different portions of the body, diarrhoea, and often some chest affec- tion is present. The treatment, if it can be promptly car- ried out, is very effective ; it consists mainly in supply- ing the needed dietary articles, combined with tonics, etc. The articles of food which are used as a preventive as well as in the treatment of this disease are known as " an- tiscorbutics," and comprise fresh fruits, potatoes, onions, cranberries, pickled cabbage, lime and lemon juice, cheap light wines and beers ; raw walrus meat is highly recom- mended. As potatoes contain a certain amount of vege- table acids, they are regarded as antiscorbutics. Sugar, raisins, currants, yellow mustard, cresses, dandelions, and all varieties of cactus are said to be good. Pemmican, a mixture of dried meat pulverized and mixed with fat, is generally found among the stores of an arctic explorer. It is of great importance to bear in mind that the pre- vention of scurvy is far more important tha*i its treat- 208 PROMPT AID TO THE IXJUPvED. ment, inasmuch as' those affected with this disease are at the time of its appearance usually where they are unable to secure proper treatment. Therefore, those who con- template being a long time away from centers where proper food can be secured, should be very careful to provide themselves with such supplies as are known to prevent the appearance of this disease ; these can now be secured in a compact form prepared for transportation and change of climate. A " ration " represents the daily allowance of food for one person. Water. —An adult requires about 70 to 100 ounces of water daily ; 20 to 30 ounces of this is contained in the food. Horses and cattle need about six gallons daily. The water-supply is derived from rain-water, springs, rivers, lakes, wells, etc. Springs are the outlets of underground water, and, as a rule, give a pure and sparkling stream, the character of which is determined by the composition of the bed from which it is collected. As the rain-water, which contains considerable carbonic acid, passes through the ground, more or less change takes place, dependent upon the qual- ity of the strata beneath. Spring-water is frequently rich in the salts of lime and magnesia. The presence of these salts in large quantities make insoluble compounds with soap, and give to water which contains them the name of "hard water." Mineral springs are caused by the chem- ical change which takes place under the surface. Rain-water, if collected in the country and upon a proper receiver, is pure, whereas, if collected in cities or towns is suspicious, as the air in the vicinity of these places contains large quantities of organic and other mat- ter which is injurious. Rain-water for drinking purposes should not be collected upon the roofs of houses unless specially prepared ; neither are the ordinary wooden cis- terns the proper receptacles for rain-water used for drink- ing ; for this purpose they should be made of stone, slate. HYGIENE. 201) or other similar substances. For immediate use or in emergencies rain-water may be collected upon pieces of canvas and other material capable of holding water. Rain- water contains a comparatively small amount of the lime and magnesia salts, and is consequently "soft water." The value and safety of river-water for drinking pur- poses depends upon its proximity to cities and large towns and the sewerage therefrom, which is a source of con- tamination ; however, considerable of this matter is de- stroyed by the oxidation combined with the constant mo- tion which is present. The numerous fresh-water plants also cause the destruction of organic matter. River-water may be classed as a "soft water." Lake-water, although apparently stagnant, contains agents which keep up a more or less constant motion. Among these are the numerous springs which are found in the bottom of the lakes. Considerable of the organic matter present is oxidized by the sunlight and air, and the tranquillity of the water allows a large amount of the organic matter to be precipitated. The vegetable growth in lakes also acts as purifiers, consequently water taken from a large lake should be pure; however, water from small lakes or ponds should not be used for drink. Deep wells in the country and small towns constitute the usual means of securing drinking-water in these places. Well-water contains considerable lime and magnesia, and is consequently more or less. hard. While deep wells in the country and small towns represent probably the best means of securing a good and wholesome drinking- water, it must be remembered that they should not be within 100 feet of any privy, cesspool, or other means of pollution, which will soak through the earth for a long distance. Typhoid fever in the country is commonly con- tracted by drinking from a well in close contact with a privy-vault containing the discharge of persons suffering from this disease. Water from wells in cities and large 15 210 PROMPT AID TO THE INJURED. towns should never be used for drinking purposes. Boil- ing or filtering through a Pasteur or Berkefeld filter is the only sure means by which suspicious water can be rendered safe for drinking. Boiling is simple and easily performed, and should be done whenever there is reason to believe that the water may be polluted, as during the prevalence of cholera and typhoid fever. Boiled water is more or less flat, resulting from the removal of the gas or air which it contains by the action of the heat. It may be aerated or livened up by agitating in an open churn, or pouring from one receptacle to another, thus entangling some air, which makes the water more palatable. Boiling usually renders water somewhat softer. A simple means of filtering water is to tie a piece of double thickness canton flannel over the water tap, or over a receptacle, and allowing the water to pass through it. The filter should be frequently changed. Turbid water can be cleaned by adding five or ten grains of alum to a gallon ; then boil and filter. Other means for effecting this purpose are by pieces of cactus- leaves, or five or six grains of tannin to a gallon, exposure to sun and air, and filtering through sand. Air. — Pure air is essential to health; the different tissues of the body demand an uninterrupted supply of oxygen for their maintenance ; this is derived from the air, the composition of which is as follows : In 100 parts — Oxygen, 20-96 ; nitrogen, 78 ; argon, 1 ; carbonic acid, '04. Ammonia, ozone, watery vapor, organic matter, and mineral salts — traces. With the exception of the latter group, the relative proportions of the different ingredients of air remain about the same everywhere. The impurities in the air are derived from filthy and badly ventilated rooms and buildings, apartments inhabited by unhealthy persons and those suffering from contagious diseases, offensive HYGIENE. 211 trades, emanations from sewers, cesspools, marshes, mines, etc., and may be divided into suspended and gaseous matter. The former includes material from the animal and vegetable world, germs of disease, etc. Among the gaseous matter, carbonic acid is the most con- stant and prominent ; a small amount of this gas is always present in what may be called pure air, and represents about "04 part per 100. It is the increased amount of this gas, associated with organic matter, watery vapor, etc., which is responsible for the uncomfortable sensation experienced in public gatherings, improperly ventilated schools, etc. Persons subjected to continued defective ventilation suffer from depression, headache, gastric dis- turbance, etc., and are particularly susceptible to disease. The increased amount of carbonic acid in the air in large assemblages is derived mainly from the expired air of those present ; about four per cent of the oxygen taken in with each inspiration is appropriated by the blood passing through the lungs. An equal amount (four per cent) of carbonic acid, representing effete or worn-out matter, is thrown off in the expired air, and is unfit for respiration ; in addition to the carbonic acid, a varying amount of watery vapor and organic matter is also exhaled. In an overcrowded room wdth improper ventilation the oxygen becomes rapidly diminished and replaced by car- bonic acid; this change may not be noticed until some time has elapsed ; the air of the room becomes offensive, and those present feel sleepy, with more or less headache, and embarrassment of respiration. Among the more ter- rible results of defective ventilation may be mentioned the tragedy that occurred in Calcutta about the middle of the last century, when one hundred and forty-six English prisoners were thrown into the jail or "Black Hole" of Calcutta. This consisted of a room about eighteen feet square, with two small windows covered with iron bars. The prisoners w^ere put in this apartment in the latter part of tlie day or evening, and when the door was opened in 212 PROMPT AID TO THE INJURED. the morning' all but twenty-three were found dead. Some of the survivors subsequently died as the result of this confinement. The fresh air necessary to ventilate an apartment should be enough to destroy all sensible odors or impu- rities which would result from imperfect ventilation, so that a person coming from the outside should from the odor appreciate no diflPerence in the air. Apartments occupied by the sick always require rela- tively more fresh air, as there is an increased exhalation from the skin and langs containing a larger amount of organic matter, etc. An increased amount of fresh air is also needed where artificial light is used (excepting electricity), as this method of illumination consumes a good amount of oxygen. Con- tamination of the air may also occur where coal is used for heating purposes, particularly in defective stoves. Fu'eplaces constitute a most excellent means of ventilat- ing a room, the impure air being drawn up the chimney and replaced by fresh air which is admitted through cracks under doors, etc. The vitiation of the air by artificial light is shown in the following table published by Notter and Firth : Candle-power. Equivalent vitiation of atmosphere. Candles 16 16 16 50 11-12 adults. Kerosene 7 " Coal-gas Bat's- wing burner No. 5 . . . Welsbach burner 5 " 3 " Electric light is in many ways superior to other forms of artificial light, inasmuch as it consumes no oxygen, and gives ofp no product of combustion by which the air ma}^ become polluted ; it also gives off a much smaller amount of heat. At least four or five hundred cubic feet of air space HYGIENE. 213 sliould be allowed for every occupant of an apartment. It may not be out of place in this connection to speak of the importance of fresh air where cases of plithisis or tuberculosis (consumption) exist. It is now known that this disease is due to a special germ or bacillus which is present in large numbers in the expectoration or sputum ; the latter becomes dried and diffused as dust in the air, and by being inhaled may infect other persons, particu larly those who are in close and continued contact with the patient. In other words, consumption is due to the reception of the tubercle bacilli communicated from one infected with the disease to another, and can be prevented if the proper precautions are taken (see Disinfection). Exercise. — Organs and muscles which do not receive the proper exercise become smaller, or undergo what is known as "atrophy." Therefore exercise of all portions of the body is necessary. Insufficient exercise favors the accumulation of carbon in the system, with the conse- quent bad results. Those who follow sedentary habits and are confined at desks, etc., are prone to chest troubles from diminished lung capacity. Work in a gymnasium, etc., does not represent the exercise essential to health. It should be in the open air, and not too violent. Golf and horse-back riding, particu- larly the former, are valuable means of exercise combined with pleasure, the latter being an important consideration. In the selection of exercise, golf-playing or walking may be considered as the best method by which the different portions of the body may be properly exercised. It has been estimated that a walk of ten miles distributed over the day is about the proper amount of exercise which should be taken by a healthy adult in twenty-four hours. This is said to be equivalent to lifting one hundred and fifty tons one foot from the ground daily. Too much or too violent exercise is injurious, particularly in the weak and delicate. CHAPTEE XX. DISIFFEGTION. A DiSDs'FECTAXT is an agent which destroys infectious material. This term as a rule is loosely applied, and is frequently confounded with deodorants, — which are not necessarily disinfectants, but simply neutralize ofiensive odors, — and with antiseptics, which inhibits or holds in cheek the propagation of infectious germs without always destroying them. Innumerable articles, proprietary and otherwise, are advertised or recommended as disinfectants. These are frequently worthless, and it should be accepted as a rule that no article or mixture recommended for dis- infection is entitled to any consideration unless its com- position is fully known. The number of agents at present employed in scientific disinfection is limited, and is gen- erally confined to heat, sulphur dioxide, formaldehyde, bi- chloride of mercury, carbolic acid, and preparations of lime. Even a brief description of this subject is incom- plete without a reference to Nature's disinfectants — air and sunlight — ^the value of which has been fully proven by bacteriological research and practical experience. Al- though their germicidal action is not rapid they are al- ways available — a very important consideration. Were it not for the protection which Nature gives us in this way, our effort to prevent the extension of infectious dis- eases would meet with doubtful success. The importance of this, as well as the great value of cleanliness, must always be borne in mind in the care of infectious diseases. Of the disinfectants which it is within our power to create, steam is the most valuable for the treatment of DISINFECTION. 215 clothing:, bedding, and other textile fabrics, both on ac- count of its prompt germicidal action and the power of deep penetration which it possesses. The uncertainty which has heretofore existed as to the temperature of moist heat and the exposure necessary to kill micro-organisms has been practically removed by the result of recent scien- tific experiments,* which have shown that a temperature of 230° Fahr. for a period of fifteen minutes will kill all known pathogenic organisms (germs which cause infec- tious disease), even in the center of large bundles tightly packed. Steam destroys goods composed of leather, rubber material stiffened with glue, etc., etc., and is apt to injure silks and other fine fabrics. Clothing, bedding, etc., are as a rule unharmed. Unfortunately the apparatus neces- sary for steam disinfection, which is more or less compli- cated and expensive, has thus far been available only in cities. However,. as the value of this agent is now better known, there is good reason to believe that a steam disin- fecting chamber will soon be found in every community for public disinfection. Boiling Water. — What is more often required are means by which thorough disinfection may be performed in the household or in emergencies. For this purpose boil- ing water constitutes one of the most effective and prac- tical disinfectants known. It is certain in its action, costs nothing, is harmless, and an apparatus for its prep- aration can always be improvised. It is only re- quired that there shall be a metal receptacle in which the water may be boiled and that the material treated shall be continuously boiled for twenty minutes. This is im- perative, and, unless it is properly carried out, disinfec- tion cannot be depended upon. Simply placing articles in boiling water and allowing it to cool does not insure disin- fection. The range of usefulness of boiling water is very great. It is more commonly used for household linen, china, glassware, kitchen utensils, cutlery, etc., also dis- * Doty, American Journal of the Medical Sciences, August, 1897. 216 PROMPT AID TO THE INJURED. charges, dressings, and, in fact, anything which may be immersed in this agent. It is well known that boiling water usually shrinks woolen goods. This should not be considered if it is required that the material be disin- fected, provided steam disinfection is not available. Sulphurous Acid Gas (sulphur dioxide) is the oldest known disinfectant, and is generated by burning ordinary sulphur. Although we are not yet in possession of such definite scientific facts relative to the value of sulphur dioxide as bacteriological research has given us regard- ing steam, recent investigation has shown that sulphur dioxide is a germicidal agent provided moisture is pres- ent. In the summer, when considerable humidity exists, sufficient moisture necessary to render this gas effective is probably present. However, in the winter, when apartments are kept closed and heated, and become dry, a small amount of moisture should be supplied before the sulphur is ignited. This may be done by generating steam in some simple way. The ordinary sulphur which is used for the manufacture of this gas is always avail- able even in very small towns, and an effective apparatus for burning it can easily be improvised in the following manner : On the bottom of an ordinary washtub are placed two or three bricks to support a metallic receptacle in the shape of an ordinary milk pan, or a galvanized-iron wash basin, etc. The tub should be filled with water to a height above the bricks and the bottom of the pan. This prevents the burning of the floor of the apartment and bot- tom of the receptacle; besides, by this arrangement the spluttering of the burning sulphur causes no damage. If a washtub is not available, a metallic pail containing the sulphur can be placed in another partly filled with water : the same protection is thus afforded. The capacity of the apartment to be disinfected should be ascertained, and for every thousand cubic feet of space, four pounds of sulphur should be burned. The sulphur should be broken in small pieces before placing in the pan or pail referred to. If DISINFECTION. 217 the room is large, it is better to have more than one re- ceptacle in order that the sulphur can be easier exposed to the air, and the gas more evenly diffused. If possible, the sulphur should be ignited by carefully pouring alcohol over the mass, upon which is dropped a lighted match or piece of paper, the operator at the time standing as far from the receptacle as possible. If alcohol can not be ob- tained, a lighted coal may be placed in the mass of sul- phur, although this does not as a rule insure satisfactory or complete combustion. The apartment should be closed for at least six hours. Before the gas is generated (this also applies to the use of formaldehyde) care should be taken that all windows and other openings are tightly closed and sealed. The latter can be accomplished by the use of slips of newspapers about two inches wide made fast with common flour paste. These are afterward easily removed. The most careful attention should be given to these details. Formaldehyde Gas, which is generated by the imper- fect combustion of wood or methyl alcohol, was acciden- tally discovered in 1868 by Hoffman, a German chemist. It was not, however, until twenty years afterward that the attention of the medical profession was called to its value as a disinfectant. Since that period this agent has been exhaustively investigated, and its germicidal value estab- lished. Formerly its employment required a complicated apparatus, which was manufactured by different instru- ment makers ; however, it may now be generated by adding to one pound of unslaked lime eight ounces of a commer- cial product known as formalin for every 1,000 cubic feet of space to be disinfected. This may be generated in any spacious metallic receptacle. In comparing the value of sulphur dioxide and formaldehyde, it may be said that while sulphur dioxide and formaldehyde are equally good germicidal agents, sulphur bleaches and otherwise injures certain fabrics, such as colored silks, satins, wall paper, gilded articles, etc., although the ordinary woolen and cot- 218 PROMPT AID TO THE INJURED. ton wearing apparel, etc., is not affected; whereas these articles can be subjected to formaldehyde without injury. It may be said that in the disinfection of apartments con- taining gilt or colored paper, delicate hangings, etc., it is better to use formaldehyde; whereas, in schoolhouses and apartments where valuable decorations are not present, sulphur is equally good and more easily employed. Fur- thermore, sulphur is promptly destructive to rats and other vermin, and insects, whereas formaldehyde can not be depended upon for this purpose. In the use of gaseous disinfectants such as sulphur and formaldehyde it must be distinctly understood that while they are serviceable for superficial disinfection, they can not he depended upon to penetrate. Therefore mate- rial presented for disinfection which can not preferably be treated with steam or boiling water should be opened and carefully spread out in order that all surfaces are exposed. Mattresses which are soiled with discharges should be burned, if steam disinfection is not available. The use of gaseous disinfectants such as sulphur di- oxide and formaldehyde is commonly and improperly re- ferred to as fumigation. Bichloride of Mercury (corrosive sublimate). — This substance, which occurs in the form of white crystals, is a powerful germicide, and is very largely used as a disin- fectant, always in the form of a solution. Corrosive sub- limate is exceedingly poisonous when taken internally. If a solution of this agent is prepared for disinfection and is not immediately used, it should be colored for identifi- cation, inasmuch as the solution has no odor or color, and may be mistaken for something else. For this purpose five grains of f uchsin or permanganate of potassium may be added to each gallon. The receptacle in which it is con- tained should be conspicuously labeled "POISON," be- sides something to indicate the strength of the solution. Fortunately this agent is very cheap (less than one dollar per pound), and a gallon of a 1-1,000 solution can be made DISINFECTION. 219 for one cent. Therefore on the ground of economy no excuse can be offered for the use of proprietary solutions, the composition and strength of which are unknown. Corrosive sublimate is decomposed by copper, tin, lead, etc.; consequently, solutions of this agent should not be prepared or kept in metallic receptacles, but in glass, porcelain, or wooden vessels. A solution of bichloride for general use in disinfection is prepared as follows : Bichlo- ride of mercury, one drachm (sixty grains) ; common salts, two tablespoonfuls dissolved in one gallon of hot water (constituting a 1-1,000 solution). This may be diluted with water when weaker solutions are called for. Carbolic acid, a very valuable disinfectant, but not equal to corrosive sublimate in germicidal power, although more generally used for the disinfection of excreta, inas- much as it is believed to more readily penetrate this sub- stance. Its odor is well known, and in the pure state it usually appears as a white crystallized substance, which becomes liquid at a temperature of 95° F. For general disinfection, dissolve six ounces in one gallon of hot water. This practically makes a five-per-cent solution, which may be diluted (see Special Disinfection). The colored im- pure carbolic acid should not be used for this purpose. Great care should be taken not to let the undiluted car- bolic acid come in contact with the skin, which it vio- lently attacks. The extremely poisonous character of bi- chloride of mercury and carbolic acid should not be for- gotten. (See Poisons.) Milk of lime, made by adding one quart of freshly slaked lime to four or five quarts of water. Air-slaked lime should not be used as a disinfectant. Chloride of Lime. — An agent in common use. Chlo- ride of lime, to preserve its value as a disinfectant, should be kept in tightly closed packages. 220 PROMPT AID TO THE INJURED. SPECIAL DISINFECTION. Apartments, bedding, clothing, etc. (See Steam, Boil- ing Water, Sulphur Dioxide^ and Formaldehyde. Tlie Hands. — The hands, after having been in contact with persons sick with infectious diseases, should be im- mersed in a 1-1,000 solution of bichloride or a two-per- cent solution of carbolic acid for a short time and after- ward thoroughly scrubbed in soap and hot water with a brush : this applies particularly to the nails. Textile Fahrics. — ^Linen and cotton material such as handkerchiefs, napkins, sheets, etc., which are too valu- able to be burned, and which can not be subjected to steam, should be kept in boiling water for at least fifteen minutes, or kept in a 1-2,000 solution of bichloride or a five-per-cent solution of carbolic for at least two hours, and afterward washed out in water. As already stated, bichloride solutions should not be put in metal vessels, as the solution is not only decomposed, but the material to be disinfected is stained. Excreta and other discharges may be disinfected by the free use of chloride of lime in the proportion of four to eight ounces of the lime to a gallon of water, according to the consistence of the discharge, or with milk of lime, or a five-per-cent solution of carbolic acid or bichloride (1-1,000) — the disinfecting solution should equal twice the amount of discharge. The sputum from patients suf- fering from consumption (tuberculosis) should be re- ceived in covered cups containing one of the preparations just referred to. However, boiling water when practicable is far superior for the disinfection of the above material. Cess-pools, drains, stables, urinals, privy-vaults, cel- lars, spaces under refrigerators, etc., should be disinfected by the use of chloride of lime or milk of lime freely used. These agents, besides their germicidal power, are de- odorants. For this reason cellars, air-shafts, etc., should be frequently whitewashed, which constitutes an efficient DISINFECTION. 221 superficial disinfectant; the use of carbolic acid in these instances leaves the peculiar odor of this agent, which is not always agreeable; besides, carbolic acid is far more expensive and dangerous than lime. Knives, forks, spoons, and other metal implements, dishes, etc., should preferably be disinfected by boiling or may be treated by immersion in a five-per-cent solution of carbolic acid for two hours, afterward washed with hot water and soap. Some infectious diseases, such as typhoid fever and cholera, are communicated through the medium of food and drink receptacles, etc., which have become contam- inated by the discharges of persons suffering from these diseases. Therefore during the prevalence of the latter all fluids taken for drink should be boiled and the food thor- oughly cooked. Uncooked fruit, vegetables, etc., should be avoided. In the treatment of dead bodies such as are recovered from fires, accidents, etc., particularly where decomposi- tion has ensued, and filthy cess-pools, drains, etc., occurring in the summer, the employment of a deodorant is urgently called for. For this purpose no more effective agent than a combination of lime and copper, one pound each of un- slaked lime and sulphate of copper (blue vitriol) added to and dissolved in 10 gallons of water, which constitutes the most practical and simple deodorant in use, bromine, which is purchased in sealed bottles, and in appearance resembles tincture of iodine, may be used; however, this is poisonous and dangerously irritating to the respiratory tract, and should be used with the greatest caution; the bottle should not be opened, but broken under water with a crowbar or poker. In making the solution, about four ounces of bromine to a hogshead containing two hundred gallons is sufficient for general use. After the bromine has been thoroughly mixed, it can be distributed over the decomposed organic matter by the ordinary garden sprinkling pot, in the same manner that the solution of 222 PROMPT AID TO THE INJURED. lime and copper is used; however, it is far inferior to the latter combination, and dangerous and more expensive. Open wounds may be washed out with a 1-5,000 solu- tion of bichloride of mercury or a one-per-cent solution of carbolic acid. If the disinfectants which have already been referred to are not available, it must be remembered that fresh air, sunlight, and cleanliness are extremely valuable agents in preventing the extension of disease and abating offensive odors, and should be made use of to the fullest extent. The bodies of those dying of infectious diseases should be wrapped in a sheet soaked in a five-per-cent solution of carbolic acid or a 1-1,000 solution of bichloride of mer- cury, preferably the latter, and then be placed in a recep- tacle, which is afterward hermetically sealed. The different forms of antiseptic material (gauze, etc.) are made by treating tarlatan, absorbent cotton, and other fabrics with a disinfectant solution. These are found in the shops in compact form, and should be kept in her- metically sealed glass jars and other proper receptacles until used, otherwise their value soon becomes impaired. Attention must again be called to the fact that steam and boiling water are superior to all other disinfectants and should be employed whenever it is practical to do so. INDEX. Acetic acid, poisoning by, 187. Acids, poisoning by, 187. Aconite, poisoning by, 185. " Adam's apple," 39. Air cells, or vesicles, 41. Air, quantity of, respired, 43. Alcohol, poisoning by, 186. Alimentation, 4.5. Alkalies, poisoning by, 188, Ammonia, poisoning by, 188. Antiseptics, 91, 221. - Aponeurosis, 27. Apoplexy, 15.5. heat, 160. treatment of, 157. Arm -bone, or humerus, 14. Arm slings, 81. Arsenic, 174. poisoning by, 183. Arteries, anatomy of, 36. nutrient, 3. Artificial respiration, 167. Hall's method, 170. Howard's method, 169. Sylvester's method, 167. Asphyxia, 164. precautions in rescuing, 164. treatment of, 164. Atropine, 173. poisoning by, 180. Axillary artery, compression of, 113, Bandages, 68. application of, 69, 71. circular, 70. cravat, 83. double-headed knotted, 73. Bandages, Esmarch or triangular, 76. Esmarch, a triangular, for chest, 79. for foot, 83. for hand, 78. for head, 78. for hip, 82. for shoulder, 78. figure-of-8, 71. four-tailed, 74. head, 73. hip spica, 72. large, square handkerchief for head, 76. materials for, 68. method of roiling, 69. roller, 68. shoulder spica, 73. six-tailed, 75. sling, 81. spiral reverse, 70. triangular, 76. Basin, the, or pelvis, 18. Bed-sores, 102. Belladonna, 173. poisoning by, 180. Bladder, urinary, 55. Blood, 30. amount of, in human body, 31. arterial, 31, 35. circulation of, 34. coagulation of, 31. composition, 30. corpuscles, 30. venous, 31, 34, vessels, anatomy of, 36. Bone, cancellous tissue, 2. 223 224 PROMPT AID TO THE INJURED. Bone, compact tissue, 2. composition of, 1. hyoid, 10. innominate, 19. marrow of, 3. necrosis of, 3. oil of, 3. spongy tissue, 2, Bones, classification of, 4. Bony landmarks, artificial, 7. Brachial artery, compression of, 114. Brain, 59. compression of, 155. concussion of, 154. weight of, 63. Brandy, 99, 110, 173. Bread poultices, 89. Breast-bone, or sternum, 11. Bromine, solution of, 221. Bronchial tubes, 41. Bruises, 91. Burns, 140. constitutional treatment of, 143. of first degree, 140. treatment of, 140. of second degree, 140, 141. treatment of, 141. of third degree, 140, 142. treatment of, 142. Camphor, poisoning by, 180. Cantharides, poisoning by, 184. Capillaries, anatomy of, 37. Carbolic acid, or phenol, 218. poisoning by, 187. Carpus, or wrist, 18. Cartilage, or gristle, 24. Catching fire, 143. Caustic potash, poisoning by, 188. Caustic soda, poisoning by, 188. Cerebellum, 62. Cerebro-spinal system, 59. Cerebrum, 61. Chafing, 195. Chest, or thorax, 10. bandages, 79. Chloral, 174. poisoning by, 181. Chloroform, poisoning by, 181. Clavicle, or collar-bone, 12. Colic, kidney, 55. Collapse, 147. Collar-bone, or clavicle, 12. fracture of, 129. Common carotid artery, compres- sion of, 112. Compresses, 86. Compression of axillary artery, 113. of brachial artery, 114. of brain, 154. treatment of, 155. of common carotid artery, 112. of femoral artery, 116. of popliteal artery, 116. of radial and ulnar arteries, 115. of subclavian artery, 112. Concussion of the brain, 154. treatment of, 154. Contusions, 91. Convulsions of children, 189. Copper, poisoning by, 184. Corn-meal poultices, 89. Corrosive sublimate, or bichlor- ide of mercury, 218. poisoning by, 188. Cranial bones, fracture of, 126. Cravat bandages, 83. Creasote, poisoning by, 187. Croton-oil, poisoning by, 184. Cuticle, 56. Deodorants, 98. Derma, or true skin, 57. Diaphragm, 42. Digestion, 45. Digitalis, poisoning by, 189. Diploe, 2. Disinfectants, 214. bichloride solution, 218. boiling water, 215. carbolic-acid solution, 218. dry chloride of lime, 219. formaldehyde gas, 216. milk of lime, 219. steam, 215. INDEX. 225 Disinfectants, sulphurous acid gas, 215. Disinfection, metliods of effecting, 214. of closets and sinks, 220. of clothing, towels, etc., 219. of dead Ixidy, 221. of discharges, 220. of dishes, knives, etc., 220. of food and drink, 220. of hands and person, 219. of rags, cloths, etc., 219. of rooms and contents, 214. of sputum from consumptives, 220. Dislocations, 137. of humerus, 137. of lower jaw, 138. of phalanges, 138. Dog-bite, treatment of, 99. Drowning, 165. treatment of, 166'. Hall's method, 170. Howard's method, 169. Sylvester's method, 167. Ear, foreign bodies in, 191. Emetics, 177. Endocardium, 36. Endosteum, 4. Epidermis, 56. Epiglottis, 39. Epilepsy, 158. treatment of, 158. Epistaxis, or nose-bleed, 110. Excretion, 29. Eye, foreign bodies in, 190. Fainting, 151. treatment of, 152. Falling-sickness, 158. Femoral artery, compression of, 116. Femur, the, or thigh-bone, 19. fractures of, 132, Fever, sun, 160. Fibula, the, or splint-bone, 22. fractures of. 135. 16 Fingers, dislocation of, 138. fractures of, l.*{2. Fits, epileptic, 158. Flaxseed poultices, 88. Fontanelles, the, 9. Food, 201-208. Foot bandages, 83. Foot-soreness, 195. Forearm, fractures of, 130. Foreign bodies in ear, 191. in eye, 190. in larynx, 193. in nose, 192. in pharynx, 193. Formaldehyde, as a disinfectant, 216. Fractures, 120. classification of, 120. diagnosis of, 121. of clavicle, 129. treatment of, 129. of cranial bones, 126. of femur, 132. treatment of, 133. of forearm, 130. treatment of, 131. of forearm, middle of, 131. treatment of, 131. of humerus, 130, treatment of, 130. of inferior maxillary bone, 126. of leg, 135. treatment of, 136. of metacarpal bones, 131, treatment of, 132. of metatarsal bones, 137. of patella, 136. treatment of, 137. of phalanges of fingers, 132. of ribs, 127. treatment of, 128. of scapula, 130. treatment of, 130. of spinal column, 127. treatment of, 127. of tibia and fibula, 135. of toes, 137. of vertebral column, 127. 226 PROMPT AID TO THE INJURED. Fractures, splints for, 124. treatment of, 122. Frost-bite, 144. treatment of, 153. " Funny-bone," 18. Gangrene, 101. treatment of, 102. Gastric juice, function of, 49. Gland, definition of, 29. Glands, salivary, 47. sweat, 57. Gravel, 54. Gristle, or cartilage, 24. Gullet, or oesophagus, 47. Haematemesis, or haemorrhage from stomach, 119. Haemoptysis, or '• spitting of blood," 118. Haemorrhage, arrest of, 104. arterial, 105. capillary, 109. classification of, 104. from axillary artery, 114. from brachial artery, 114. from common carotid artery, 112. from femoral artery, 116. from lips, 110. from mouth, 110. from popliteal artery, 116. from radial artery, 115. from scalp, 110. from subclavian artery, 112. from ulnar artery, 115. nasal, 110. secondary, 116. symptoms of, 117. treatment of, 118. after extraction of teeth, 110. venous, 108. Hair-follicles, 57. Hand bandages, 78. " Haunch," or innominate bone, 19. Head bandages, 78. Heart, 32. anatomy of. 33. Heart, power of, 36. Heat, dry, application of, 90. moist, application of, 90. Heatstroke, 160. Hip bandages, 82. Hominy poultices, 89. Humerus, or arm-bone, 14. Hydrocyanic acid, poisoning by, 182. Hygiene, 197. air, 210. effects of bad, 211. baths, 197. addition to, of alcohol, etc., 198. cold, 197. Russian or Turkish, 198. sea, 198. warm, 198. clothing, silk, cotton, and linen, 200. woolen, 199. dandruff, 199. exercise, 213. food, 201. constituents of, 202-207. scurvy, 207. skin, activity of, 197. soap, the use of, 199. water, 208. amount required daily, 208. lake, 209. rain, 208. spring, 208. well, 209. Hyoid bone, 10. Hypodermic medication, 172. Hysteria, 159. treatment of, 159. Hysterics, 159. Inferior maxillary bone, dislo- cation of, 138. fracture of, 126. Innominate, or " haunch " bone, 10. Instep, or tarsus, 22. Integument, or skin, 56. appendages of, 57. INDEX. 227 Integument, care of, 57, 107. functions of, 57. Intestine, large. 50. small, 40. Intoxication, 157. treatment of, 157. Iodine, poisoning by, 185. Irritant poisons, 183. Joints, classification of, 23. composition of, 24. movements of, 28. Kidney colic, 55. Kidneys, 54, Knee-cap, or patella, 22. Knots, 85. Landmarks, superficial bony, 7. Larynx, 39. foreign bodies in, 193. Laudanum, poisoning by, 173, 183. Ligaments, 24. Lime, as a disinfectant, 219. Lips, hemorrhage of, 110. Liver, 51. functions of, 52. Lower jaw, dislocation of, 138. fracture of, 126. Lungs, 42. capacity of, 44. Lye, poisoning by, 188. Lymphatics, 4. Marrow of bone, 3. Mastication, 45. Matches, poisoning by, 186. Medication, 172. Membranes, mucous, 29. serous, 29. synovial, 25. Mercury, bichloride of, 218. Metacarpal bones, 18. fracture of, 131. Metacarpus, the, 18. Metatarsal bones, 22. fracture of, 137. Milk, food valu(> of, !.'(»."». Moi'phine, 173. poisoning by, l.S.'i. Mouth, hipniorrhage of, 110, Mucous memhrani's, I'O. Muriatic acid, poisoning by, 187. Muscles, 25. atrophy of, 28. involuntary, 28. rigidity of, at death, 28. voluntary, 25, Mushrooms, poisoning by, 182. Mussels, poisoning by, 182, Mustard poultices, 80. Narcotic poisons, 179. Necrosis of bone, 3. Nerves, 63. cranial, 64. motor, 64. sensory, 64. spinal, 66. sympathetic, 66. Nervous system, 59. Nitric acid, poisoning by, 187. Nose-bleed, or epistaxis, 110. Nose, foreign bodies in, 192. Nux-vomica, 174. poisoning by, 185. CEsophagus, or gullet, 47. Opium, 173. poisoning by, 183. Organ, definition of, 28. Oxalic acid, poisoning by, 187. Padding for splints, 125. Pancreas, 52. function of, 53, Paralysis, stroke of, 155. Paregoric, 173. poisoning by, 183. Paris green, poisoning by, 183. Patella, the, or knee-cap, 22. fracture of, 136. Pearlash, poisoning by, 188. Pelvis, the, or basin, 18. Pericardium, 34. Periosteum, 3. 228 PROMPT AID TO THE INJURED. Phalanges, 18, 22. dislocation of, 138. fractures of, 132, 137. Pharynx, or throat, 47. foreign bodies in, 193. Phosphorus, poisoning by, 186. Pleura, 42. Plugs, or tampons, 87. Poisoning, by acetic acid, 187. by aconite, 179. by alcohol, 180. by ammonia, 188. by arsenic, 183. by atropine, 180. by belladonna, 180. by camphor, 180. by cantharides, 184. by carbolic acid, 187. by caustic potash, 188. by caustic soda, 188. by chloral, 181. by chloroform, 181. by copper, 184. by corrosive sublimate, 188. by creasote, 187. by croton-oil, 184. by digitalis, 181. by hydrocyanic acid, 182. by iodine, 185. by laudanum, 183. by lye, 188. by matches, 186. by morphine, 183. by muriatic acid, 187. by mushrooms, 182. by mussels, 182. by nitric acid, 187. by nux-Yomica, 185. by opium, 183. by oxalic acid, 187. by paregoric, 183. by Paris green, 183. by pearlash, 188. by phosphorus, 186. by poison oak or ivy, 188. by prussic acid, 182. by salts of lemon and sorrel, 187. by Spanish fly, 184. Poisoning, by strychnine, 185. by sulphuric acid. 187. by tartar emetic, 186. by zinc, 186. treatment of, 176. constitutional, 179. local, by emetics, 177. by stomach-pump, 178. Poison oak or ivy, poisoning by, 188. Poisons, classification of, 176. irritant, 176, 183. narcotic, 176, 179. Potash, caustic, poisoning by, 188. Poultices, 87. bread, 89. corn-meal, 89. flaxseed, 88. hominy, 89. . mustard, 89. Prussic acid, poisoning by, 182. Radial artery, compression of, 115. Radius, 14. Rectal medication, 175. Respiration, 39. Ribs, 11. fracture of, 127. Salivary glands, 47. Salts of lemon, poisoning by, 187. Scalds, 143. Scalp, haemorrhage of, 110. Scapula, or shoulder-blades, 12. Secondary haemorrhage, 116. Secretion, 29. Serous membranes, 29. Shin-bone, or tibia, 21. Shock, 147. treatment of, 148. Shoulder bandages, 78. Shoulder-blade, or scapula, 12. Skeleton, the, 4. Skin, or integument, 56. appendages of, 57. care of, 57, 197. INDEX. 229 Skin, false, 56. functions of, 57. true, 56. Skull, division of bones of, 8. Sling bandages, 81. Snake-bite, treatment of, 99. Sorrel, poisoning by, 187. Spanish fly, poisoning by, 184, Spinal cord, 62. Spine, the, 6. changes in, 6. " Spitting of blood," or haemop- tysis, 118. Spleen, 58. Splint-bone, the, or fibula, 22. Splints, 124. padding for, 125. Sprains, 139. treatment of, 139. Sternum, the, 11. Stomach, 48. anatomy of, 48. capacity of, 48. Stroke of paralysis, 155. Strychnine, 174. poisoning by, 185. Stunning, 154. Suffocation, 164. Sulphur, as a disinfectant, 215. Sulphuric acid, poisoning by, 187. Sunstroke, 160. treatment of, 161. Sweat-glands, 57, Sweet-breads, 52. Sympathetic system, 66. Syncope, 151. treatment of, 152. Synovial membrane, 25. Tampons, or plugs, 87. Tarsus, or instep, 22. Tartar emetic, poisoning by, 186. Teeth. 45. haemorrhage following extrac- tion of, 110. Tendons, 27. Tetanus, or lockjaw, 189. Thigh-bone, or femur, 19. Thorax, or chest, 10. Throat, or pharynx, 47. foreign bodies in, 193. Tibia, or shin-bone, 21, Toes (phalanges), fracture of, 137. Trachea, or windpipe, 39. Ulna, 16. Ulnar artery, compression of, 115. Unconsciousness, 146. Ureters, 54, Urine, 54. quantity secreted, 57. Veins, anatomy of, 38. Vertebrae, the, 6. Vertebral column, curves of, 7. division of, 7. fracture of, 127. Vesicles, or air-cells, 41, Vitriol, oil of, poisoning by, 184. Whisky, 99, 110, 173, Windpipe, or trachea, 39. Wounds caused by insects, 100. classification of, 93. contused, 95. gangrenous, 101. gunshot, 93. healing of, 95. incised, 93, lacerated, 93. of abdominal walls, 100. of thorax, 100. poisoned, 94, punctured, 93. treatment of, 96, Wrist, or carpus, 18. Zinc, poisoning by, 186. THE END (15) COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special arrange- ment with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE m\ ' 2 7,J945 ot^ 7 ^'^^ • / / / / . / / / / / * C28(n4l)M100