The Home Medical Library By KENELM WINSLOW, B. A. S. , M. D. _Formerly Assistant Professor Comparative Therapeutics, Harvard University; Late Surgeon to the Newton Hospital; Fellow of the Massachusetts Medical Society, etc. _ With the Coöperation of Many Medical Advising Editors and Special Contributors IN SIX VOLUMES _First Aid :: Family Medicines :: Nose, Throat, Lungs, Eye, and Ear :: Stomach and Bowels :: Tumors and Skin Diseases :: Rheumatism :: Germ Diseases Nervous Diseases :: Insanity :: Sexual Hygiene Woman and Child :: Heart, Blood, and Digestion Personal Hygiene :: Indoor Exercise Diet and Conduct for Long Life :: Practical Kitchen Science :: Nervousness and Outdoor Life :: Nurse and Patient Camping Comfort :: Sanitation of the Household :: Pure Water Supply :: Pure Food Stable and Kennel_ NEW YORK The Review of Reviews Company 1907 Medical Advising Editors Managing Editor ALBERT WARREN FERRIS, A. M. , M. D. _Former Assistant in Neurology, Columbia University; Former Chairman, Section on Neurology and Psychiatry, New York Academy of Medicine;Assistant in Medicine, University and Bellevue Hospital MedicalCollege; Medical Editor, New International Encyclopedia. _ Nervous Diseases CHARLES E. ATWOOD, M. D. _Assistant in Neurology, Columbia University; Former Physician, UticaState Hospital and Bloomingdale Hospital for Insane Patients; FormerClinical Assistant to Sir William Gowers, National Hospital, London. _ Pregnancy RUSSELL BELLAMY, M. D. _Assistant in Obstetrics and Gynecology, Cornell University MedicalCollege Dispensary; Captain and Assistant Surgeon (in charge), Squadron A, New York Cavalry; Assistant in Surgery, New YorkPolyclinic. _ Germ Diseases HERMANN MICHAEL BIGGS, M. D. _General Medical Officer and Director of Bacteriological Laboratories, New York City Department of Health; Professor of Clinical Medicine inUniversity and Bellevue Hospital Medical College; Visiting Physicianto Bellevue, St. Vincent's, Willard Parker, and Riverside Hospitals. _ The Eye and Ear J. HERBERT CLAIBORNE, M. D. _Clinical Instructor in Ophthalmology, Cornell University MedicalCollege; Former Adjunct Professor of Ophthalmology, New YorkPolyclinic; Former Instructor in Ophthalmology in Columbia University;Surgeon, New Amsterdam Eye and Ear Hospital. _ Sanitation THOMAS DARLINGTON, M. D. _Health Commissioner of New York City; Former President Medical Board, New York Foundling Hospital; Consulting Physician, French Hospital;Attending Physician, St. John's Riverside Hospital, Yonkers; Surgeonto New Croton Aqueduct and other Public Works, to Copper QueenConsolidated Mining Company of Arizona, and Arizona and SoutheasternRailroad Hospital; Author of Medical and Climatological Works. _ Menstruation AUSTIN FLINT, JR. , M. D. _Professor of Obstetrics and Clinical Gynecology, New York Universityand Bellevue Hospital Medical College; Visiting Physician, BellevueHospital; Consulting Obstetrician, New York Maternity Hospital;Attending Physician, Hospital for Ruptured and Crippled, ManhattanMaternity and Emergency Hospitals. _ Heart and Blood JOHN BESSNER HUBER, A. M. , M. D. _Assistant in Medicine, University and Bellevue Hospital MedicalCollege; Visiting Physician to St. Joseph's Home for Consumptives;Author of "Consumption: Its Relation to Man and His Civilization; ItsPrevention and Cure. "_ Skin Diseases JAMES C. JOHNSTON, A. B. , M. D. _Instructor in Pathology and Chief of Clinic, Department ofDermatology, Cornell University Medical College. _ Diseases of Children CHARLES GILMORE KERLEY, M. D. _Professor of Pediatrics, New York Polyclinic Medical School andHospital; Attending Physician, New York Infant Asylum, Children'sDepartment of Sydenham Hospital, and Babies' Hospital, N. Y. ;Consulting Physician, Home for Crippled Children. _ Bites and Stings GEORGE GIBIER RAMBAUD, M. D. _President, New York Pasteur Institute. _ Headache ALONZO D. ROCKWELL, A. M. , M. D. _Former Professor Electro-Therapeutics and Neurology at New YorkPost-Graduate Medical School; Neurologist and Electro-Therapeutist tothe Flushing Hospital; Former Electro-Therapeutist to the Woman'sHospital in the State of New York; Author of Works on Medical andSurgical Uses of Electricity, Nervous Exhaustion (Neurasthenia), etc. _ Poisons E. ELLSWORTH SMITH, M. D. _Pathologist, St. John's Hospital, Yonkers; Somerset Hospital, Somerville, N. J. ; Trinity Hospital, St. Bartholomew's Clinic, and theNew York West Side German Dispensary. _ Catarrh SAMUEL WOOD THURBER, M. D. _Chief of Clinic and Instructor in Laryngology, Columbia University;Laryngologist to the Orphan's Home and Hospital. _ Care of Infants HERBERT B. WILCOX, M. D. _Assistant in Diseases of Children, Columbia University. _ Special Contributors Food Adulteration S. JOSEPHINE BAKER, M. D. _Medical Inspector, New York City Department of Health. _ Pure Water Supply WILLIAM PAUL GERHARD, C. E. _Consulting Engineer for Sanitary Works; Member of American PublicHealth Association; Member, American Society Mechanical Engineers;Corresponding Member of American Institute of Architects, etc. ; Authorof "House Drainage, " etc. _ Care of Food JANET MCKENZIE HILL _Editor, Boston Cooking School Magazine. _ Nerves and Outdoor Life S. WEIR MITCHELL, M. D. , LL. D. _LL. D. (Harvard, Edinburgh, Princeton); Former President, PhiladelphiaCollege of Physicians; Member, National Academy of Sciences, Association of American Physicians, etc. ; Author of essays: "Injuriesto Nerves, " "Doctor and Patient, " "Fat and Blood, " etc. ; of scientificworks: "Researches Upon the Venom of the Rattlesnake, " etc. ; ofnovels: "Hugh Wynne, " "Characteristics, " "Constance Trescott, " "TheAdventures of François, " etc. _ Sanitation GEORGE M. PRICE, M. D. _Former Medical Sanitary Inspector, Department of Health, New YorkCity; Inspector, New York Sanitary Aid Society of the 10th Ward, 1885;Manager, Model Tenement-houses of the New York Tenement-house BuildingCo. , 1888; Inspector, New York State Tenement-house Commission, 1895;Author of "Tenement-house Inspection, " "Handbook on Sanitation, " etc. _ Indoor Exercise DUDLEY ALLEN SARGENT, M. D. _Director of Hemenway Gymnasium, Harvard University; Former President, American Physical Culture Society; Director, Normal School of PhysicalTraining, Cambridge, Mass. ; President, American Association forPromotion of Physical Education; Author of "Universal Test forStrength, " "Health, Strength and Power, " etc. _ Long Life SIR HENRY THOMPSON, Bart. , F. R. C. S. , M. B. (Lond. ) _Surgeon Extraordinary to His Majesty the King of the Belgians;Consulting Surgeon to University College Hospital, London; EmeritusProfessor of Clinical Surgery to University College, London, etc. _ Camp Comfort STEWART EDWARD WHITE _Author of "The Forest, " "The Mountains, " "The Silent Places, " "TheBlazed Trail, " etc. _ [Illustration: A DESIRABLE METHOD OF CARRYING THE INJURED. By this plan even the unconscious victim of an accident may betransported a long distance, because the bearers' hands are leftentirely free and thus prevented from becoming cramped or tired, aswhen a "seat" is made with clasped hands. In the method illustratedabove the patient is placed in a seat made by tying a blanket, sheet, rope, or strap in the form of a ring. Each bearer then places hisinner arm about the patient's body and with his outer hand holds thepatient's arm around his neck. ] The Home MedicalLibrary Volume I FIRST AID IN EMERGENCIES By KENELM WINSLOW, B. A. S. , M. D. (Harv. ) _Formerly Assistant Professor Comparative Therapeutics, HarvardUniversity; Late Surgeon to the Newton Hospital; Fellow of theMassachusetts Medical Society, etc. _ ASSISTED BY ALBERT WARREN FERRIS, A. M. , M. D. _Former Assistant in Neurology, Columbia University; former Chairman, Section on Neurology and Psychiatry, New York Academy of Medicine;Assistant in Medicine, University and Bellevue Hospital MedicalCollege; Medical Editor, "New International Encyclopedia"_ GERM DISEASES By KENELM WINSLOW, B. A. S. , M. D. (Harv. ) NEW YORK The Review of Reviews Company 1907 Copyright, 1907, by THE REVIEW OF REVIEWS COMPANY THE TROW PRESS, NEW YORK _Contents_ PART I CHAPTER PAGE I. RESTORING THE APPARENTLY DROWNED 27 Reviving the Patient--How to Expel Water from the Stomach and Chest--Instructions for Producing Respiration--When Several Workers are at Hand--When One must Work Alone--How to Save a Drowning Person. II. HEAT STROKE AND ELECTRIC SHOCK 39 First-aid Rules--Symptoms of Heat Exhaustion--Treatment of Heat Prostration--What to Do in Case of Electric Shock--Symptoms--Artificial Respiration--Mortality in Lightning Strokes. III. WOUNDS, SPRAINS, AND BRUISES 50 Treatment of Wounds--Bleeding from Arteries and Veins--Punctured Wounds--Oozing--Lockjaw--Bruises-- Abrasions--Sprains and Their Treatment--Synovitis-- Bunions and Felons--Weeping Sinew--Foreign Bodies in Eye, Ear, and Nose. IV. FRACTURES 80 How to Detect Broken Bones--Fracture of Rib and Collar Bone--Instructions for Applying Dressings--Bandage for Broken Jaw--Fracture of Shoulder-blade, Arm, Hip, Leg, and Other Bones--Compound Fractures. V. DISLOCATIONS 118 Varieties of Dislocations--Method of Reducing a Dislocated Jaw--A Dislocated Shoulder--Indications when Elbow is Out of Joint--Dislocation of Hip, etc. --Forms of Bandages. VI. ORDINARY POISONS 139 Unknown Poisons--Symptoms and Antidotes--Poisoning by Carbolic and Other Acids--Alkalies--Metal Poisoning--Aconite, Belladonna, and Other Narcotics--Chloral--Opium, Morphine, Laudanum, Paregoric, and Soothing Sirups--Tobacco, Strychnine, etc. VII. FOOD POISONS 147 Poisons in Shellfish and Other Food--Symptoms and Remedies--How Bacteria are Nourished--Infected Meat and Milk--Treatment of Tapeworm--Trichiniasis--Potato Poisoning. VIII. BITES AND STINGS 155 Country and City Mosquitoes--How Yellow Fever is Communicated--Treatment of Mosquito Bites--Bee, Wasp, and Hornet Stings--Lice--Fleas and Flies--Centipedes and Scorpions--Spiders--Poisonous Snakes--Cat and Dog Bites. IX. BURNS, SCALDS, FROSTBITES, ETC. 171 General Rules for Treating Burns and Scalds--Hints on Dressings--Burns Caused by Acids and Alkalies--Remedies for Frostbite--Care of Blisters and Sores--Chilblains--Ingrowing Toe Nails--Fainting and Suffocation--Fits. PART II I. CONTAGIOUS MALADIES 191 Symptoms and Treatment of Scarlet Fever--Diagnosis--Duration of Contagion--Difference Between True and German Measles--Smallpox--Cure a Matter of Good Nursing--Chickenpox. II. INFECTIOUS DISEASES 221 Typhoid Fever--Symptoms and Modes of Communication--Duration of the Disease--The Death Rate--Importance of Bathing--Diet--Remedies for Whooping Cough--Mumps--Erysipelas. III. MALARIA AND YELLOW FEVER 247 Malaria Caused by Mosquitoes--Distribution of the Disease--Severe and Mild Types--Prevention and Treatment--Yellow Fever not a Contagious Disease--Course of the Malady--Watchful Care and Diet the only Remedies. INDEX _To First Aid and General Topics_ NOTE. --The Roman numerals I, II, III, IV, V, and VI indicate thevolume; the Arabic figures 1, 2, 3, etc. , indicate the page number. Abrasions, I, 64 Abscess, alveolar, II, 58 Acids, burns by, I, 176, 177 poisoning by, I, 140 Acne, II, 145 Adenoids, II, 61 Adulterated food, tests for, V, 91 Adulteration of food, V, 87 Ague, I, 247 cake, I, 254 Air-bath, the, IV, 159 Albumen, IV, 262 Alcohol, use of, IV, 44, 153 Alcoholic drinks, IV, 153 Alcoholism, III, 47, 52 Algæ, remedy for, V, 56 Alkalies, burns by, I, 177 poisoning by, I, 140 Amenorrhoea, III, 75 Anæmia, III, 174 Ankle, sprain of, I, 65, 67, 68 Ankle-joint fracture, I, 115 Antitoxin, II, 77 Apoplexy, III, 49 Appendicitis, III, 256 Arm, fracture of, I, 91 Arteries, systemic, III, 168 Artery, bleeding from an, I, 51, 52 Arthritis, II, 177 Artificial respiration, I, 28 Asthma, II, 104 Astigmatism, II, 26 Athletics, home, IV, 69 Auricles of the heart, III, 168 =BABY=, bathing the, III, 109 care of the, III, 108 clothing of the, III, 110 diet for the, III, 134 food for the, III, 132; IV, 261 nursing the, III, 114 teething, III, 113 temperature of the, III, 110 weaning the, III, 117 weighing the, III, 112 Bacteria, destruction of, V, 238-253 in food, I, 147-154 in soil, V, 135 Baldness, II, 167; IV, 21 =BANDAGES=, I, 133 forms of, I, 132, 134, 136, 137 for bruises, I, 62-64 for fractures, I, 83-117 for sprains, I, 65-72 for wounds, I, 51-61 Barley water, IV, 263 Bathing, indoor, IV, 19, 155 outdoor, IV, 16 in convulsions, III, 35 in malaria, I, 259 in pneumonia, II, 94 in scarlet fever, I, 197 in skin irritations, II, 140 in smallpox, I, 216 in typhoid fever, I, 231 in yellow fever, I, 266 =BATHS=, cold, IV, 15 foot, IV, 157 hot, IV, 19, 156 tepid, IV, 19 Turkish, IV, 20, 159 warm, IV, 19 Bed sores, I, 233 Bed-wetting, II, 213 Bee stings, I, 158 Beef, broth, IV, 261 juice, IV, 262 parts of, IV, 198 scraped, IV, 262 tea, IV, 261 Bellyache, III, 247 Bilious fever, I, 247 Biliousness, III, 184 =BITES=, cat, I, 170 dog, I, 170 flea, I, 162 fly, I, 164 lice, clothes, I, 161 lice, crab, I, 162 lice, head, I, 160 mosquito, I, 155 snake, I, 166 spider, I, 164 tarantula, I, 164 wood tick, I, 159 Black eye, II, 14 Blackheads, II, 145 Black water fever, I, 256 Bladder, inflammation of the, II, 215 stone in the, III, 264 =BLEEDING=, from an artery, I, 51, 52 from a vein, I, 51, 52 from punctured wounds, I, 52, 53 from the lungs, I, 62 from the nose, I, 61 from the scalp, I, 60 from the stomach, I, 62 from the womb, III, 82 Blood, deficiency of, III, 174 oozing of, I, 54 Bloody flux, III, 222 Boils, II, 157 Bottles, milk, III, 128 Bowel, prolapse of the, III, 143 =BOWELS=, catarrh of the, III, 205 diseases of the, III, 205 inflammation of the, III, 252 obstruction of the, III, 268 passages from the, IV, 247 Bowleg, III, 162 Brain, anatomy of the, III, 22 arteries of the, III, 22 autopsies of the, II, 230 Breasts, care of, after childbirth, III, 105 inflammation of the, III, 140 Breath, holding the, III, 153 Breathing, how to test the, IV, 248 to produce artificial, I, 28, 34, 43, 178, 186 Bright's disease, acute, II, 220 chronic, II, 222 =BROKEN BONE=, I, 80 ankle, I, 115 arm, I, 91 collar bone, I, 85 finger, I, 101 forearm, I, 94 hand, I, 101 hip, I, 104 how to tell a, I, 80 jaw, I, 89 kneepan, I, 109 leg, I, 111 rib, I, 83 shoulder blade, I, 91 thigh, I, 106 wrist, I, 99 Bronchial tubes, diseases of the, II, 87 Bronchitis, II, 88, 91 Broth, beef, IV, 261 chicken, IV, 261 clam, IV, 263 mutton, IV, 261 oyster, IV, 267 veal, IV, 261 =BRUISES=, bandages for, I, 63 treatment of, I, 62, 63 Bunion, I, 72 =BURNS=, I, 171 about the eyes, II, 16 from acids, I, 176 from alkalies, I, 177 from electric shock, I, 45 first class, I, 172 second class, I, 172 third class, I, 173 severe, I, 174 Callus of the skin, II, 156 Camp comfort (See Contents VI) Camp cookery (See Contents VI) Camp cure (See Contents VI) =CAMPING=, in the North Woods, VI, 195 in the Western Mountains, VI, 214 outfit, VI, 212 Cancer, II, 123 of the breast, II, 124 of the lip, II, 125 of the stomach, II, 125 of the womb, II, 125 Canker, II, 68 Capillaries, systemic, III, 168 Carbuncle, II, 161 Carotid arteries, III, 22 Catarrh, II, 41, 54, 55 of the bowels, III, 205 effect of, on the ears, II, 38, 41 of the stomach, III, 185 Catarrhal deafness, II, 39 inflammation of eye, II, 18 Cat bite, I, 170 Catheter, how to use a, II, 219; IV, 252 Centipede sting, I, 164 Cereals as food, IV, 35, 229 Cerebellum, III, 22 Cerebral arteries, III, 22 Chafing, II, 142 Chagres fever, I, 256 Change of life, III, 70 Chapping, II, 142 Chicken broth, IV, 261 Chickenpox, I, 217 Chilblains, I, 182 Childbed fever, III, 107 Childbirth, after-pains in, III, 105 articles needed during, III, 96 bleeding after, III, 86 care after, III, 103 care in, III, 98 =CHILDREN, DISEASES OF=, III, 140 adenoids, II, 61 bed-wetting, II, 213 bowel, prolapse of the, III, 143 bowels, catarrh of the, III, 209 bowleg, III, 162 breath, holding the, III, 153 breasts, inflammation of the, III, 140 chickenpox, I, 217 cholera infantum, III, 211 chorea, III, 155 colic, III, 267 constipation, III, 238 convulsions, III, 34 cord, bleeding of the, III, 142 cough, II, 91 croup, II, 83 diarrhea, III, 208, 209 diphtheria, II, 77 dysentery, III, 213 epilepsy, III, 39 earache, II, 48 fever, III, 146 food for, III, 132-139 foreskin, adhering, III, 141 glands, enlarged, III, 149 hip disease, III, 161 holding the breath, III, 153 knock knees, III, 163 larynx, spasm of the, III, 153 measles, I, 198 German measles, I, 203 membranous croup, II, 79 milk poisoning, III, 209, 211 mumps, I, 235 navel, sore, III, 142 pains, growing, III, 146 Pott's disease, III, 157 rickets, III, 151 ringworm, II, 149 rupture, II, 128 scarlatina, I, 192 scarlet fever, I, 192 scrofula, III, 149 scurvy, II, 182 sore mouth, II, 65 spine, curvature of the, III, 157, 159 St. Vitus's Dance, III, 155 stomach, catarrh of the, III, 209 urine, painful passage of, III, 141 urine, retention of, III, 141 wasting, III, 144 whooping cough, I, 238 worms, III, 240 Chills and fever, I, 247 Cholera, III, 228 infantum, III, 211 morbus, III, 226 Chorea, III, 158 Cinder in the eye, I, 176; II, 13 Circulation, the, III, 168 Circumcision, III, 142 Clam broth, IV, 263 Climacteric, the, III, 70 Clothing, proper, IV, 22 Cochlea, II, 46 Coffee, use of, IV, 43 Cold, exposure to, I, 181 in the head, II, 55 sore, II, 147 =COLIC=, III, 247 gallstone, III, 261 in babies, III, 267 intestinal, III, 249 mucous, III, 219 renal, III, 263 Collar-bone fracture, I, 85 Complexion, the, IV, 20 Confinement, III, 97 Congestion of the eyelid, II, 17 Conjunctivitis, II, 16, 18 Constipation, in adults, III, 233 in children, 238 Consumption, II, 96 fresh-air treatment for, II, 102 outdoor life for, VI, 72 prevention of, II, 104 Contagion, in cholera, 229 in conjunctivitis, II, 19 in diphtheria, II, 80 in eruptive fever, I, 191-220 in gonorrhea, II, 199 in grippe, II, 108 in mumps, I, 236 in syphilis, II, 206, 209 in whooping cough, I, 238 =CONTAGIOUS DISEASES=, I, 191 Convalescence (See Contents VI) Convulsions, in children, III, 34 in adults, I, 188 =COOKING= (See Contents IV) baking, IV, 171 boiling, IV, 180 braising, IV, 182 broiling, IV, 172 camp, VI, 220 cereals, IV, 229 eggs, IV, 184 entrées, IV, 219 fish, IV, 188 frying, IV, 175 game, IV, 202 poultry, IV, 202 roasting, IV, 171 sauces, IV, 216 sautéing, IV, 174 shellfish, IV, 195 soups, IV, 207 stewing, IV, 181 time of, IV, 177 utensils, IV, 232 vegetables, IV, 223 Copper sulphate method, V, 52 Copper vessels, use of, V, 67 Cord, bleeding of the, III, 142 Corns, II, 154 Costiveness, III, 233 =COUGH=, acute, II, 87, 91 whooping, I, 238 Cricoid cartilage, II, 70 Cross eye, II, 33 Croup, membranous, II, 79 ordinary, II, 83, 92 Curvature of the spine, III, 157, 159 Cystitis, II, 215 Dandruff, II, 167 Deafness, catarrhal, II, 39 chronic, II, 36 temporary, II, 33 Delirium tremens, III, 50 =DIARRHEA=, acute, III, 205 chronic, III, 217 of children, III, 208, 209 =DIET=, IV, 26, 107, 123, 138, 153 animal, IV, 39 details of, IV, 146 errors of, IV, 107 for babies, III, 132 for brain workers, IV, 126 for long life, IV, 107 for the aged, IV, 112 proper, IV, 138 relation to climate, IV, 108 rules for, IV, 110, 123 simplicity of, IV, 138 vegetable and animal, IV, 39 Digestion, effect of dress on, IV, 42 hygiene of, IV, 26 processes of, IV, 28 Diphtheria, II, 77 =DISINFECTANTS=, chemical, V, 243 physical, V, 240 solutions for, V, 247 Disinfection, V, 238 of rooms, V, 249 =DISLOCATIONS=, elbow, I, 125 hip, I, 129 jaw, I, 118, 120 knee, I, 119 shoulder, I, 122 Dog bite, I, 170 Doses of drugs, IV, 255 Dressings, for bruises, I, 63, 64 for wounds, I, 53, 57 surgical, I, 131 Drink, nutritious, IV, 118 Drinking, steady, III, 52 =DROWNED=, arousing the, I, 27 producing respiration in the, I, 28, 34 restoring the, I, 27 saving the, I, 36 Drowning person, death grasp of a, I, 37 saving a, I, 36 swimming to relief of a, I, 36 Drugs, doses of, IV, 255 Drum membrane, II, 33, 43, 45, 46, 48 Dysentery, in adults, III, 222 in children, III, 213 Dysmenorrhea, III, 71 =DYSPEPSIA=, III, 185 causes of, IV, 27 nervous, III, 190 =EAR=, anatomy of the, II, 33, 37, 46 diseases of the, II, 33 foreign bodies in the, I, 78; II, 39 water in the, II, 42 wax in the, II, 35 Earache, II, 40 moderate, II, 48 Eating, proper mode of, IV, 140-149 Eczema, II, 163 climatic, II, 164 occupation, II, 164 seborrheic, II, 164, 165, 167 Eggnog, IV, 268 Eggs, as food, IV, 33, 184 soft-boiled, IV, 266 Egg water, IV, 262 Elbow, dislocation of, I, 125 =ELECTRIC SHOCK=, I, 43, 46 Enteric fever, I, 221 Enteritis, catarrhal, III, 205 Entero-colitis, III, 209 Enteroptosis, IV, 43 Environment, importance of, III, 65 Epiglottis, II, 70 Epilepsy, III, 39 spasms in, III, 39 without spasms, III, 40 Erysipelas, I, 244 Eustachian tube, II, 37, 38, 41, 46, 49, 50 Exhaustion, mental and nervous, VI, 91-145 =EXERCISE=, IV, 48, 66 corrective, IV, 57 effect of, IV, 51 excessive, IV, 52 for all-round development, IV, 59, 101 for boyhood, IV, 69 for children, IV, 67 for elderly men, IV, 79 for everyone, IV, 66 for girls, IV, 73 for middle-aged men, IV, 77 for women, IV, 76 for young men, IV, 71 for youth, IV, 69 home, IV, 57 regular, IV, 53, 58 results of, IV, 98 without apparatus, IV, 57 =EYE=, anatomy of the, II, 30 astigmatism of the, II, 26 black, II, 14 catarrhal inflammation of the, II, 18 cinder in the, I, 76 cross, II, 33 diseases of the, II, 13 farsighted II, 21 foreign bodies in the, I, 76; II, 13 hyperopic, II, 22 lens of the, II, 30 muscles of the, II, 30 nearsighted, II, 25 pink, II, 19 retina of the, II, 30 sore, II, 16 strain, II, 21 wounds and burns of the, II, 16 Eyelid, congestion of the, II, 17 stye on the, II, 15 twitching of the, II, 15 Eye muscles, weakness of the, II, 28 Eye-strain, II, 21 Facial, neuralgia, III, 28 paralysis, III, 25 =FAINTING=, I, 185; III, 45 Farsightedness, II, 21 Fat as a food, IV, 35 Fatigue, causes of, IV, 50 Felon, I, 74, 75 =FEVER=, bilious, I, 247 black water, I, 256 Chagres, I, 256 chills and, I, 247 enteric, I, 221 gastric, III, 179 intermittent, I, 247 marsh, I, 247 remittent, I, 247 rheumatic, II, 169 scarlet, I, 192 swamp, I, 247 typhoid, I, 221 yellow, I, 261 Fever blister, II, 147 Fevers, eruptive contagious, I, 191 Fish as food, IV, 188 Finger, fracture of, I, 101 =FIT=, I, 188 Flea bites, I, 162 Fly bites, I, 164 Food, adulteration of, V, 87 containing parasites, I, 152 elements of, IV, 29 for babies, III, 132; IV, 261 for the sick, IV, 261 infected, I, 150 laws, V, 88 poisoning, I, 147 preparation of, IV, 171 pure, selection of, V, 89 Foods, advertised, IV, 116 Foot gear, IV, 24 Forearm fracture, I, 94 =FOREIGN BODIES=, in the ear, I, 78; II, 39 in the eye, I, 76; II, 13 in the nose, I, 79; II, 53 Foreskin, adhering, III, 141 Fourth-of-July accidents, I, 56 =FRACTURE= (See Broken Bone) Colles', I, 99 compound, I, 80, 116 how to tell a, I, 81 simple, I, 80 Freckles, II, 150 Freezing, I, 178 =FROSTBITE=, I, 178, 180 Gallstone colic, III, 261 Ganglion, I, 75 Garbage, disposal of, V, 171 Gastric fever, III, 179 Genito-urinary diseases, II, 199 Germs (See Bacteria) Girls, exercises for, IV, 73 physical training for, IV, 72; VI, 39 Glands, enlarged, III, 149 Gonorrhea, II, 199 in women, II, 203; III, 90 Gout, common, II, 183 rheumatic, II, 177 Grippe, la, II, 56, 108 Growing pains, III, 146 Hair, the, IV, 21 Hallucinations, II, 232 Hand, anatomy of the, III, 30 arteries of the, III, 30 fracture of the, I, 101 nerves of the, III, 30 tendons of the, III, 30 =HEADACHE=, constant, II, 120 due to disease, II, 117 due to eye strain, II, 29 due to heat stroke, II, 120 due to indigestion, II, 115 due to poisoning, II, 118 nervous, II, 117 neuralgic, II, 117 sick, II, 113 sympathetic, II, 116 Head gear, IV, 24, 160 Head injuries, III, 46 =HEART=, anatomy of the, III, 167, 168 enlargement of the, III, 169 palpitation of the, III, 171 Heart disease, III, 167 Heat exhaustion, I, 39, 40 Heating, cost of, V, 254 methods of, V, 161 =HEAT STROKE=, I, 39, 41 Hemorrhage (See Bleeding) Hemorrhoids, II, 135 Heredity, III, 57 in consumption, II, 97 Hernia, II, 128 (See Rupture) strangulated, II, 129 umbilical, II, 128 ventral, II, 128 Hiccough or hiccup, III, 21 Hip disease, III, 161 Hip, dislocation of, I, 129 fracture of, I, 104 Hives, II, 143 Hoarseness, II, 80 Hornet stings, I, 158 "Horrors, " the, III, 50 House, proper construction of, V, 141 Housemaid's knee, I, 72 Hypodermic syringe, the, IV, 250 Hysteria, VI, 20 =INDIGESTION=, acute, III, 178 a result of errors, IV, 130 chronic, III, 185 intestinal, III, 202 not disease, IV, 134 Infants, bathing, III, 109 care of, III, 108 clothing for the, III, 110 feeding of, III, 118 Infection, V, 238 in erysipelas, I, 244 in malaria, I, 247 in typhoid fever, I, 221 in yellow fever, I, 261 =INFECTIOUS DISEASES=, I, 221 Influenza, II, 108 Ingrowing toe nail, I, 184 Injections, III, 238, 239 =INJURED, CARRYING THE=, I, Frontispiece Insane, criminal, II, 234 delusions of the, II, 233 illusions of the, II, 231 sanitariums for the, II, 245 Insanity, II, 229; VI, 164 causes of, II, 239 false ideas regarding, II, 241 physical signs of, II, 235 prevention of, II, 240 types of, II, 236 Insensibility, III, 44 Insomnia, III, 23 Intermittent fever, I, 247 Invalids, care of, VI, 155 Itching, II, 139 Ivy poison, II, 152 Jaundice, III, 180 Jaw, dislocation of, I, 118, 120 fracture of, I, 89 Joint, injury of a, I, 65, 69 Junket, IV, 266 Kerosene, extermination of mosquitoes by, V, 77 Kidneys, inflammation of the, II, 220 Bright's disease of the, II, 219 stone in the, III, 265 Knee, dislocation of, I, 119 sprain of, I, 67, 70 Kneepan fracture, I, 109 Knock knees, III, 163 Laryngitis, II, 80 Larynx, anatomy of the, II, 70 spasm of the, III, 153 Leeches, use of, II, 43 Leg bones, fracture of, I, 111, 116 Leucorrhoea, III, 86 Lice, body, I, 161 clothes, I, 161 crab, I, 162 head, I, 160 Life-saving service, U. S. , I, 27 Lightning stroke, I, 43 Limewater, IV, 268 =LOCKJAW=, I, 56 Long life, rules for (See Contents IV, Part III) Lotions, II, 145, 151, 152, 155, 166 Lues, II, 206 Lumbago, II, 173 =LUNGS=, bleeding from the, I, 62 diseases of the, II, 87 inflammation of the, II, 93 tuberculosis of the, II, 96 =MALARIA=, I, 247 chronic, I, 253 mosquito as cause of, I, 157, 247 pernicious, I, 255 remittent, I, 254 Malt soup, IV, 267 Marasmus, III, 144 Marketing, hints on, IV, 232 Marriage relations, II, 197 Marsh fever, I, 247 Measles, common, I, 198 German, I, 203 Meat as food, IV, 32 Median nerve, III, 30 Medicine chest, contents of the, IV, 243 =MEDICINES, PATENT=, II, 245 antiphlogistine, II, 258 belladonna plasters, II, 257 dangers of, II, 260 hamamelis, II, 255 headache powders, II, 262 Listerine, II, 256 Platt's Chlorides, II, 259 Pond's Extract, II, 255 proprietary, II, 246 Scott's Emulsion, II, 257 vaseline, II, 254 witch-hazel, II, 255 Medulla oblongata, III, 22 Membranous croup, II, 79 Menopause, the, III, 70 Menstruation, III, 67 absence of, III, 75 arrest of, III, 79 cessation of, III, 78 delayed, III, 79 painful, III, 71 scanty, III, 79 Metals, poisoning by, I, 141 Miliaria, II, 148 =MILK=, as food, IV, 33 curd, IV, 266 mixtures, III, 124 peptonized, IV, 264 poisoning, III, 209, 211 porridge, IV, 267 Mind cure, VI, 31 disorder of the, II, 229 Miscarriage, danger of, III, 80 =MOSQUITO= bites, I, 155, 158; V, 71 destruction of the, I, 258; V, 75 exterminating the, V, 70 malaria due to the, I, 248 yellow fever due to the, I, 261; V, 70 Motor nerve, III, 38 Mouth-breathing, II, 60 Mouth, inflammation of the, II, 64 sore, II, 64 Mumps, I, 235 Muscular action, IV, 48 development, by will power, IV, 63 =MUSHROOM POISONING=, V, 112 Mushrooms, edible, V, 115 how to tell, V, 114 poisonous, V, 124 Mutton broth, IV, 261 Myalgia, II, 173 Myopia, II, 25 Narcotics, poisoning by, I, 142 Nasal cavity, II, 54 Navel, sore, III, 142 Nearsightedness, II, 25 Nervous debility, III, 13 diseases, III, 13 exhaustion, III, 13; VI, 70, 167 =NERVOUSNESS= (See Contents VI) remedy for, VI, 70, 167; III, 20 Nervous system, reflex action of the, III, 38 Nettlerash, II, 143 Neuralgia, III, 27 facial, III, 28 of the chest, III, 29 Neurasthenia, III, 13 =NOSE=, anatomy of the, II, 54 bleeding from the, II, 51 catarrh of the, II, 55 diseases of the, II, 51 foreign bodies in the, I, 79; II, 53 obstructions in the, II, 60 septum of the, II, 51, 54, 61 Nosebleed, I, 61; II, 51 Nostrum, II, 248 Nurse and patient (See Contents VI) Nurse, selection of the, VI, 150 Nursing, VI, 146 Oatmeal water, IV, 263 Olfactory nerves, III, 22 Oozing of blood, I, 54, 55 Optic nerves, III, 22 =OUTDOOR LIFE= (See Contents VI) for consumption, VI, 72 for nervous exhaustion, VI, 70, 167 Overworked, hints for the, VI, 91 Oyster broth, IV, 267 Palmar arch, III, 30 Pains, growing, III, 146 Palpitation of the heart, III, 171 Paralysis, facial, III, 25 Paranoia, II, 237 Parasites, malarial, I, 247 yellow fever, I, 261 Paresis, II, 237 Patent medicines, II, 247 Peritonitis, III, 252 Petit mal, III, 40 Pharyngitis, II, 69 Phthisis, II, 96 Pigeon breast, II, 63 Piles, external, II, 135 internal, II, 136 Pimples, II, 145 Pink eye, II, 19 Plumbing, connections, V, 194 defects in, V, 231 drains, V, 206 fixtures, V, 216 joints, V, 194 pipes, V, 191, 206 tests, 233 traps, V, 198 Pneumonia, II, 93 =POISONING= (See Poisons) by canned meats, I, 150 by fish, I, 148 by meat, I, 148, 150, 151 by milk, I, 148, 150, 151 food, bacterial, I, 147 food, containing parasites, I, 152 food, infected, I, 150 mushroom, V, 112 potato, I, 154 Poison ivy, II, 152 =POISONS=, acetanilid, I, 146 acid, carbolic, I, 140 acid, nitric, I, 140 acid, oxalic, I, 140 acid, sulphuric, I, 140 acids, I, 140 aconite, I, 142 alcohol, I, 143 alkalies, I, 140 ammonia, I, 141 antidotes, I, 139 antimony, I, 142 arsenic, I, 141 belladonna, I, 142 bichloride of mercury, I, 141 blue vitriol, I, 141 bug poison, I, 141 camphor, I, 142 caustic soda, I, 141 chloral, I, 143 cocaine, I, 145 copper, I, 141 corrosive sublimate, I, 141 digitalis, I, 142 ergot, I, 142 Fowler's solution, I, 141 headache powders, I, 146 hellebore, I, 142 ivy, II, 152 knockout drops, I, 143 laudanum, I, 144 lobelia, I, 142 lye, I, 141 matches, I, 142 mercury, I, 141 metals, I, 141 morphine, I, 144 narcotics, I, 142 nux vomica, I, 145 opium, I, 144 paregoric, I, 144 Paris green, I, 141 phenacetin, I, 146 phosphorus, I, 142 potash, I, 141 "rough on rats, " I, 141 silver nitrate, I, 141 sleeping medicines, I, 143 soothing sirup, I, 144 strychnine, I, 145 tartar emetic, I, 142 tobacco, I, 144 unknown, I, 139 verdigris, I, 141 washing soda, I, 141 white precipitate, I, 141 Polypi, II, 54, 62 Pons Varolii, III, 22 Pott's disease, III, 157 Poultry as food, IV, 201 Pox, II, 206 Pregnancy, III, 91 diet during, III, 91 exercise during, III, 91 mental state during, III, 95 signs of, III, 80, 93 Prickly heat, II, 148 Proprietary medicines, II, 248 Pruritus, II, 139 Pulse, how to feel the, IV, 247 Punctured wound, bleeding from, a, I, 52, 53 Pure food bill, II, 249 =PURE FOOD, SELECTION OF=, V, 89-111 canned articles, V, 107 cereals, V, 98 chocolate, V, 107 cocoa, V, 107 coffee, V, 104 flavoring extracts, V, III meat, V, 92 meat products, V, 95 olive oil, V, 110 shellfish, V, 94 spices, V, 108 sugar, V, 108 tea, V, 104 vegetables, V, 96 vinegar, V, 110 Purifying water supply, V, 52 Quinsy, II, 75 Radial nerve, III, 30 Recipes, for babies, IV, 261 for the sick, IV, 261 Reflex action illustrated, III, 38; IV, 49 Remittent fever, I, 247 Renal colic, III, 263 Respiration, to produce artificial, I, 28, 34, 43, 178, 186 Respirations, counting the, IV, 248 Rest cure, III, 20 Reversion, III, 59 Rheumatic fever, II, 169 gout, II, 177 =RHEUMATISM=, acute, II, 169 chronic, II, 175 effect on the heart, II, 170 inflammatory, II, 169 muscular, II, 173 of the chest, II, 174 Rhinitis, II, 77 Rib, broken, I, 83 Rice water, IV, 264 Rickets, III, 151 Ringworm, of body, II, 149 of scalp, II, 149 =RUN-AROUND=, I, 73 Rupture, II, 128 Salt rheum, II, 163 Sanitariums for the insane, II, 245 =SANITATION= (See Contents V) Sarcoma, II, 124 =SCALDS=, I, 171 Scalp wounds, I, 60 Scarlatina, I, 192 Scarlet fever, I, 192 Sciatica, III, 31 Scorpion sting, I, 164 Scrofula, III, 149 Scurvy, common, II, 180 infantile, II, 182 Seasickness, III, 195 Self-abuse, II, 192 Semicircular canals, II, 46 Sensory nerve, III, 38 Septum, II, 54 deviation of the, II, 60 Serum, antivenomous, I, 169 Sewage, V, 170 disposal of, V, 172 Sewer gas, V, 187 Sewers, V, 182 Sexual organs, care of the, II, 191 diseases of the, II, 199 Sexual relations, II, 194 Shingles, III, 29 Shoulder, dislocation of, I, 122 sprain of, I, 67 Shoulder-blade fracture, I, 91 Sick, food for the, IV, 261 Sick room, the, VI, 150 =SKIN=, callus of the, II, 156 chafing of the, II, 142 chapping of the, II, 142 cracks in the, II, 156 discolorations of the, II, 150 diseases of the, II, 139 irritation of the, II, 142 itching of the, II, 139 Sleeplessness, III, 23 Sling, how to make a, 87, 88 Smallpox, I, 206 Snake bite, I, 166, 168 Soap, use of, IV, 32 Soil, bacteria in, V, 135 constituents of, V, 131 contamination of, V, 136 diseases due to, V, 139 Soil, improving the, V, 140 influence of, V, 137 Sore mouth, aphthous, II, 66 gangrenous, II, 67 simple, II, 65 ulcerous, II, 67 Sore eyes, II, 16 Sore throat, II, 69 Soup, malt, IV, 267 Soups, IV, 207 Spider bite, I, 164, 165 Spinal cord, III, 38 Spine, curvature of, III, 157, 159 Spleen, enlargement of, II, 254 Splinters, removing, I, 54 Splints, I, 61, 71, 93, 97, 102, 107, 110, 111, 114, 128 =SPRAINS=, bandages for, I, 65, 67 treatment of, 65, 66 Sprue, II, 66 Squint, II, 33 St. Vitus's Dance, III, 155 Stiff neck, II, 174 =STINGS=, bee, I, 158 centipede, I, 164 hornet, I, 158 scorpion, I, 164 wasp, I, 158 Stitching a wound, I, 58 =STOMACH=, bleeding from the, I, 62 catarrh of the, III, 185, 209 diseases of the, III, 178 neuralgia of the, III, 251 Stomachache, III, 247 Stone, in the bladder, III, 265 in the kidney, III, 263 Strabismus, II, 33 Stye, II, 15 =SUFFOCATION=, from gas, I, 186 Sunstroke, I, 40 Surgical dressings, I, 131 Swamp fever, I, 247 =SYNOVITIS=, I, 69 Syphilis, II, 206, 212 Syringe, the bulb, III, 239 the fountain, III, 238 the hypodermic, IV, 250 Tan, II, 150 Tapeworm, I, 152 Tarantula bite, I, 164 Tea, use of, IV, 43 Teeth, artificial, IV, 119 care of the, IV, 26 Teething, III, 113 Temperature, how to tell the, IV, 246 proper, IV, 161, 162 Tetter, II, 163 Thermometer, clinical, use of the, IV, 246 Thigh-bone fracture, I, 106 =THROAT=, diseases of the, II, 51, sore, II, 69 Thrush, II, 66 Tic douloureux, III, 28 Toe nail, ingrowing, I, 184 Tongue, noting appearance of the, IV, 249 Tonsilitis, II, 71 Tonsils, enlarged, II, 63 Tooth, ulcerated, II, 58 Toothache, II, 58 Training, physical, IV, 124; VI, 38 Trichiniasis, I, 153 Truss, use of the, II, 130 Tuberculin, II, 101 Tuberculosis of the bones, III, 157 of the lungs, II, 96 =TUMORS=, II, 123 Turbinates, enlarged, II, 60 Typhoid fever, I, 221 complications of, I, 228 Ulcerated tooth, II, 58 Ulnar nerve, III, 30 =UNCONSCIOUSNESS=, III, 44 due to drunkenness, III, 47 due to epilepsy, III, 48 due to fainting, III, 45 due to head injuries, III, 46 Unconsciousness, due to kidney disease, III, 48 due to opium poisoning, III, 48 due to sunstroke, III, 48 Underclothing, proper, IV, 22 =URINE=, incontinence of, II, 213 involuntary passage of, II, 213 painful passage of, III, 141 retention of, II, 218; III, 141 stoppage of, II, 218 suppression of, II, 218 Urticaria, II, 143 Vaccination, I, 211-215 Varicocele, II, 134 Varicose veins, II, 132 Varioloid, I, 211 Veal broth, IV, 261 Vegetables as food, IV, 34, 223 Vein, bleeding from a, I, 51, 52 Veins, systemic, III, 168 =VENTILATION=, artificial, V, 157 forces of, V, 148 methods of, V, 150 natural, V, 151 Ventricles of the heart, III, 168 Vision, defects of, II, 21-33 Vocal cords, II, 70 =VOMITING=, III, 194 of blood, III, 200 of indigestion, III, 199 of pregnancy, III, 196 Wakefulness, III, 23 Warming, V, 160 Warts, flat, II, 154 moist, II, 154 seed, II, 153 threadlike, II, 153 Wasp stings, I, 158 Wasting, III, 144 =WATER=, barley, IV, 263 egg, IV, 262 lake, V, 27 lime, IV, 268 oatmeal, IV, 263 pure, V, 21, 52 rain, V, 26 rice, IV, 264 spring, V, 29 well, V, 31-37 wheat, IV, 264 Water cure, for nervous exhaustion, III, 20 Water distribution, V, 39 engines for, V, 42 hydraulic rams for, V, 40 pressure systems for, V, 47 storage tanks for, V, 46 windmills for, V, 41 Water supply, laws of, V, 37 plants which pollute, V, 54 pollution of, V, 22 purifying the, V, 52 sources of, V, 19 system for country, V, 47 Wax in the ear, II, 34 Wear and tear (See Contents VI) Weaning, III, 117 =WEEPING SINEW=, I, 75 Wen, II, 126 Wheat water, IV, 264 Whey, mixtures, IV, 265 wine, IV, 266 Whites, III, 87 Whitlow, I, 74, 75 Whooping cough, I, 238 Womb, hemorrhage from the, III, 82 Women, exercises for, IV, 76 Wood tick, bite of, I, 159 =WORMS=, pin, III, 243 round, III, 242 tape, III, 245 =WOUNDS=, I, 50 about the eyes, II, 16 caused by pistols, I, 56 caused by firecrackers, I, 56 cleansing, I, 59 foreign bodies in, I, 54, 56 scalp, I, 60 stitching, I, 58 treatment of, I, 50, 57 Wrist, fracture of the, I, 99 sprain of the, I, 65, 67 Yellow fever, I, 261 mosquito as cause of, I, 157, 261, 265 Preface Medicine, as the art of preserving and restoring health, is therightful office of the great army of earnest and qualified Americanphysicians. But their utmost sincerity and science are hampered bytrying restrictions with three great classes of people: those on whomthe family physician cannot call _every day_; those on whom he cannotcall _in time_; and those on whom he cannot call _at all_. To lessen these restrictions, thus assisting and extending thehealer's work, is the aim of the pages that follow. Consider first the average American household, where the familyphysician cannot call _every day_. Not a day finds this householdwithout the need of information in medicine or hygiene or sanitation. More efforts of the profession are thwarted by ignorance than byepidemic. Not to supplant the doctor, but to supplement him, carefullyprepared information should be at hand on the hygiene ofhealth--sanitation, diet, exercise, clothing, baths, etc. ; on thehygiene of disease--nursing and sick-room conduct, control of thenervous and insane, emergency resources, domestic remedies; above all, on the prevention of disease, emphasizing the folly of self-treatment;pointing out the danger of delay in seeking skilled medical advicewith such troubles as cancer, where early recognition may bringpermanent cure; showing the benefit of simple sanitary precautions, such as the experiment-stations method of exterminating themalaria-breeding mosquito. The volumes treating of these subjectscannot be made too clear, nontechnical, fundamental, or too wellguarded by the supervision of medical men known favorably to theprofession. Again, the physician cannot come _on time_ to save life, limb, orlooks to the victim of many a serious accident. And yet some bystandercould usually understand and apply plain rules for inducingrespiration, applying a splint, giving an emetic, soothing a burn orthe like, so as to safeguard the sufferer till the doctor'sarrival--if only these plain rules were in such compact form that nooffice, store, or home in the land need be without them. Finally, the doctor _cannot come at all_ to hundreds of thousands ofsailors, automobilists, and other travelers, to ranchers, miners, andcountry dwellers of many sorts. This third class has had, hitherto, little choice between some "Practice of Medicine, " too technical to behelpful, on the one hand, and on the other, the dubious literature ofunsanctioned "systems"; or the startling "cure-all" assertionsemanating from many proprietors of remedies; or "Complete FamilyPhysicians, " which offer prescriptions as absurd for the layman aswould be dynamite in the hands of a child, with superfluous andloathsome pictures appealing only to morbid curiosity, and with ageneral inaccuracy utterly out of touch with twentieth-centuryknowledge. What such people need, much more than the dwellers insettled communities, is to learn the views of modern medicine upon thetreatment of the ever-present common ailments--the use of standardremedies, cautions against the abuse of narcotics, lessons ofdiscrimination against harmful, useless, or expensive "patentmedicines, " and proper rules of conduct for diet, nursing, and generaltreatment. Authentic health literature existed abundantly before the preparationof these volumes, but it was scattered, expensive, and in most casesnot arranged for the widest use. Not within our knowledge has the bodyof facts, most helpful to the layman on Sanitation and Hygiene, FirstAid, and Domestic Healing, been brought together as completely, asclearly, as concisely, with a critical editing board so qualified, andwith special contributions so authoritative as this work exhibits. "Utmost caution" has been a watchword with the editors from the start. Those to whom the doctor _cannot come every day_ have been repeatedlywarned of the follies of self-treatment, and reminded that to-day itis the patient that is treated--not the disease. Those to whom thedoctor _cannot come in time_ are likewise warned that the "First-aidRules" of this Library are for temporary treatment only, in allsituations where it is possible to get a physician. And the utmostconservatism has been striven for by the author and the severalrevisers in every part of the work that appeals particularly todwellers in localities so removed that the doctor _cannot come atall_. Especial delicacy was also sought in the treatment of a chapterwhich, it is hoped, will aid parents to guide their children in sexualmatters. The illustrations represent helpful, normal conditions (withthe exception of some necessary representations of fracture, etc. )with instructive captions aimed to make them less a sensation than areal benefit; and no pictures appear of a sort to stimulate meremorbid curiosity. The greatest sympathy and appreciation of this work have been shown bythe progressive and recognized practitioners who have seen earlycopies. They recognize it as a timely attempt to create and compilehealth literature in a form most complete within its limits of space, and in a manner most helpful and sane. The eager curiosity regarding_themselves_ that has been sweeping over the American people has beendiverted into frivolous and harmful channels by much reckless talk andwriting. A prominent newspaper, in its Sunday editions, recently tookup the assertion, in a series of articles, that appendicitisoperations resulted from a gigantic criminal conspiracy on the part ofsurgeons; that a sufficient cure for appendicitis, "as any honestdoctor would tell you, " is an injection of molasses and water! Theendless harm done by such outright untruth is swelled by a joiningstream of slapdash misinformation and vicious sensation, constantlyrunning through the press. Education is sorely needed from authority. People _will_ read abouttheir bodies. They have a right to information from the highestaccredited source. And to apply such knowledge Dr. Winslow has laboredfor many years during his practicing experience, condensing andsetting into clear order the most vitally important facts of domesticdisease and treatment; an eminently qualified staff of practicingspecialists has coöperated, with criticism and supervision ofincalculable value to the reader; and the accepted classics in theirfield follow: Dr. Weir Mitchell's elegant and inspiring essays onNerves, Outdoor Life, etc. ; Sir Henry Thompson's "precious documentsof personal experience" on Diet and Conduct for Long Life; Dr. DudleyA. Sargent's scientific and long-prepared system of exercises withoutapparatus; Gerhard's clear principles of pure water supply; Dr. Darlington's notes and editing from the unequaled opportunity of a NewYork City Health Commissioner--and many other "special contributions. " It is the widely accepted modern medicine, and no school or "system, "that is reflected here. While medicine, as a science, is far frombeing perfect, partly because of faulty traditions and misinterpretedexperience, yet the aim of the modern school is to base practice on_facts_. For example, for many years physicians were aware thatquinine cured malaria, in some unexplainable way. Now they not onlyknow that malaria is caused by an animal parasite living and breedingin the blood and that quinine destroys the foe, but they know aboutthe parasite's habits and mode of development and when it most readilysuccumbs to the drug. Thus a great discovery taught them to givequinine understandingly, at the right time, and in the right doses. An educated physician has at his command all knowledge, past andpresent, pertaining to medicine. He is free to employ any means tobetter his patient. Now it is impossible to cure, or even better, allwho suffer from certain disease by any one method, and a follower of aspecial "system" thus ignores many agencies which might proveefficient in his case. While there is a germ of good and truth in thevarious "systems" of medical practice, their representatives possessno knowledge unknown to science or to the medical profession at large. Many persons are always attracted by "something new. " But newness in amedical sect is too often newness in name only. These systems rise andfall, but scientific, legitimate medicine goes ever onward with an eyesingle to the discovery of new facts. That these volumes will result in an impetus to saner, quieter, steadier living, and will prove a helpful friend to many a physicianand many a layman, is the earnest wish of THE PUBLISHERS. Part I FIRST AID IN EMERGENCIES BY KENELM WINSLOW AND ALBERT WARREN FERRIS _Introductory Note_ With the exception of the opening chapter, which contains the valuableLife-saving Service Rules _verbatim_, the Editors have adopted theplan of beginning each article in Part I of this volume with a fewsimple, practical instructions, telling the reader exactly what to doin case of an accident. For the purpose of distinguishing them fromthe ordinary text, and making them easy of reference, these_"First-aid Rules" are printed in light-faced type_. CHAPTER I =Restoring the Apparently Drowned= _As Practiced in the United States Life-Saving Service_ NOTE. --These directions differ from those given in the last revision of the Regulations by the addition of means for securing deeper inspiration. The method heretofore published, known as the Howard, or direct method, has been productive of excellent results in the practice of the service, and is retained here. It is, however, here arranged for practice in combination with the Sylvester method, the latter producing deeper inspiration than any other known method, while the former effects the most complete expiration. The combination, therefore, tends to produce the most rapid oxygenation of the blood--the real object to be gained. The combination is prepared primarily for the use of life-saving crews where assistants are at hand. A modification of Rule III, however, is published as a guide in cases where no assistants are at hand and one person is compelled to act alone. In preparing these directions the able and exhaustive report of Messrs. J. Collins Warren, M. D. , and George B. Shattuck, M. D. , committee of the Humane Society of Massachusetts, embraced in the annual report of the society for 1895-96, has been availed of, placing the department under many obligations to these gentlemen for their valuable suggestions. =IF SEVERAL ASSISTANTS ARE AT HAND. = RULE I. _Arouse the Patient. _--Do not move the patient unless indanger of freezing; instantly expose the face to the air, toward thewind if there be any; wipe dry the mouth and nostrils; rip theclothing so as to expose the chest and waist; give two or three quick, smarting slaps on the chest with the open hand. If the patient does not revive, proceed immediately as follows: RULE II. _To Expel Water from the Stomach and Chest_ (see Fig. 1). --Separate the jaws and keep them apart by placing between theteeth a cork or small bit of wood, turn the patient on his face, alarge bundle of tightly rolled clothing being placed beneath thestomach; press heavily on the back over it for half a minute, or aslong as fluids flow freely from the mouth. [Illustration: FIG. 1. TO EXPEL WATER FROM STOMACH AND CHEST. Patient lying face downward; roll of clothes beneath stomach; jawsseparated by piece of wood or cork; note rescuer pressing on back toforce out water. ] RULE III. _To Produce Breathing_ (see Figs. 2 and 3). --Clear the mouthand throat of mucus by introducing into the throat the corner of ahandkerchief wrapped closely around the forefinger; turn the patienton the back, the roll of clothing being so placed as to raise the pitof the stomach above the level of the rest of the body. Let anassistant, with a handkerchief or piece of dry cloth, draw the tip ofthe tongue out of one corner of the mouth (which prevents the tonguefrom falling back and choking the entrance to the windpipe), and keepit projecting a little beyond the lips. Let another assistant graspthe arms, just below the elbows, and draw them steadily upward by thesides of the patient's head to the ground, the hands nearly meeting(which enlarges the capacity of the chest and induces inspiration). (Fig. 2. ) While this is being done let a third assistant take positionastride the patient's hips with his elbows resting upon his own knees, his hands extended ready for action. Next, let the assistant standingat the head turn down the patient's arms to the sides of the body, theassistant holding the tongue changing hands if necessary[1] to let thearms pass. Just before the patient's hands reach the ground the manastride the body will grasp the body with his hands, the balls of thethumb resting on either side of the pit of the stomach, the fingersfalling into the grooves between the short ribs. Now, using his kneesas a pivot, he will, at the moment the patient's hands touch theground, throw (not too suddenly) all his weight forward on hishands, and at the same time squeeze the waist between them, as if hewished to force something in the chest upward out of the mouth; hewill deepen the pressure while he slowly counts one, two, three, four(about five seconds), then suddenly let go with a final push, whichwill spring him back to his first position. [2] This completesexpiration. (Fig. 3. ) [Illustration: FIG. 2. TO PRODUCE BREATHING. First Position: Patient lying face upward; roll of clothes under back;tongue pulled out of mouth with handkerchief; note rescuer drawingarms upward to sides of head to start act of breathing in. ] [Illustration: FIG. 3. TO PRODUCE BREATHING. Second Position: Forcing patient to breathe out; note rescuer withthumbs on pit of stomach, pressing against front of chest over lowerribs; also, assistant drawing down arms to body. ] At the instant of his letting go, the man at the patient's head willagain draw the arms steadily upward to the sides of the patient's headas before (the assistant holding the tongue again changing hands tolet the arms pass if necessary), holding them there while he slowlycounts one, two, three, four (about five seconds). Repeat these movements deliberately and perseveringly twelve tofifteen times in every minute--thus imitating the natural motions ofbreathing. If natural breathing be not restored after a trial of the bellowsmovement for the space of about four minutes, then turn the patient asecond time on the stomach, as directed in Rule II, rolling the bodyin the opposite direction from that in which it was first turned, forthe purpose of freeing the air passage from any remaining water. Continue the artificial respiration from one to four hours, or untilthe patient breathes, according to Rule III; and for a while, afterthe appearance of returning life, carefully aid the first short gaspsuntil deepened into full breaths. Continue the drying and rubbing, which should have been unceasingly practiced from the beginning byassistants, taking care not to interfere with the means employed toproduce breathing. Thus the limbs of the patient should be rubbed, always in an upward direction toward the body, with firm-graspingpressure and energy, using the bare hands, dry flannels, orhandkerchiefs, and continuing the friction under the blankets, or overthe dry clothing. The warmth of the body can also be promoted by theapplication of hot flannels to the stomach and armpits, bottles orbladders of hot water, heated bricks, etc. , to the limbs and soles ofthe feet. RULE IV. _After Treatment. Externally. _--As soon as breathing isestablished let the patient be stripped of all wet clothing, wrappedin blankets only, put to bed comfortably warm, but with a freecirculation of fresh air, and left to perfect rest. _Internally:_ Givewhisky or brandy and hot water in doses of a teaspoonful to atablespoonful, according to the weight of the patient, or otherstimulant at hand, every ten or fifteen minutes for the first hour, and as often thereafter as may seem expedient. _Later Manifestations:_After reaction is fully established there is great danger ofcongestion of the lungs, and if perfect rest is not maintained for atleast forty-eight hours, it sometimes occurs that the patient isseized with great difficulty of breathing, and death is liable tofollow unless immediate relief is afforded. In such cases apply alarge mustard plaster over the breast. If the patient gasps for breathbefore the mustard takes effect, assist the breathing by carefullyrepeating the artificial respiration. =IF ONE PERSON MUST WORK ALONE. = MODIFICATION OF RULE III [_To be used after Rules I and II in case no assistance is at hand_] _To Produce Respiration. _--If no assistance is at hand, and one personmust work alone, place the patient on his back with the shouldersslightly raised on a folded article of clothing; draw forward thetongue and keep it projecting just beyond the lips; if the lower jawbe lifted, the teeth may be made to hold the tongue in place; it maybe necessary to retain the tongue by passing a handkerchief under thechin and tying it over the head. [3] Grasp the arms just below the elbows and draw them steadily upward bythe sides of the patient's head to the ground, the hands nearlymeeting. (See Fig. 4. ) Next lower the arms to the side, and press firmly downward andinward on the sides and front of the chest over the lower ribs, drawing arms toward the patient's head. (See Fig. 5. ) Repeat these movements twelve to fifteen times every minute, etc. [Illustration: FIG. 4. ONE PERSON WORKING. First Position: Note arm movement same as in Fig. 2; also, tongue heldbetween teeth by handkerchief tied under chin pressing teeth againstwooden plug. ] [Illustration: FIG. 5. ONE PERSON WORKING. Second Position: Note rescuer lowering arms to patient's sides andpressing downward and inward over lower ribs. ] =INSTRUCTIONS FOR SAVING DROWNING PERSONS BY SWIMMING TO THEIRRELIEF. = 1. When you approach a person drowning in the water, assure him, witha loud and firm voice, that he is safe. 2. Before jumping in to save him, divest yourself as far and asquickly as possible of all clothes; tear them off, if necessary; butif there is not time, loose at all events the foot of your drawers, ifthey are tied, as, if you do not do so, they fill with water and dragyou. 3. On swimming to a person in the sea, if he be struggling do notseize him then, but keep off for a few seconds till he gets quiet, forit is sheer madness to take hold of a man when he is struggling in thewater, and if you do you run a great risk. 4. Then get close to him and take fast hold of the hair of his head, turn him as quickly as possible on to his back, give him a suddenpull, and this will cause him to float, then throw yourself on yourback also and swim for the shore, both hands having hold of his hair, you on your back, and he also on his, and of course his back to yourstomach. In this way you will get sooner and safer ashore than by anyother means, and you can easily thus swim with two or three persons;the writer has even, as an experiment, done it with four, and gonewith them forty or fifty yards in the sea. One great advantage of thismethod is that it enables you to keep your head up, and also to holdthe person's head up you are trying to save. It is of primaryimportance that you take fast hold of the hair, and throw both theperson and yourself on your backs. After many experiments, it isusually found preferable to all other methods. You can in this mannerfloat nearly as long as you please, or until a boat or other help canbe obtained. 5. It is believed there is no such thing as a _death grasp_; at least, it is very unusual to witness it. As soon as a drowning man begins toget feeble and to lose his recollection, he gradually slackens hishold until he quits it altogether. No apprehension need, therefore, befelt on that head when attempting to rescue a drowning person. 6. After a person has sunk to the bottom, if the water be smooth, theexact position where the body lies may be known by the air bubbles, which will occasionally rise to the surface, allowance being, ofcourse, made for the motion of the water, if in a tide way or stream, which will have carried the bubbles out of a perpendicular course inrising to the surface. Oftentimes a body may be regained from thebottom, before too late for recovery, by diving for it in thedirection indicated by these bubbles. 7. On rescuing a person by diving to the bottom, the hair of the headshould be seized by one hand only, and the other used in conjunctionwith the feet in raising yourself and the drowning person to thesurface. 8. If in the sea, it may sometimes be a great error to try to get toland. If there be a strong "outsetting tide" and you are swimmingeither by yourself or having hold of a person who cannot swim, thenget on your back and float till help comes. Many a man exhaustshimself by stemming the billows for the shore on a back-going tide, and sinks in the effort, when, if he had floated, a boat or other aidmight have been obtained. 9. These instructions apply alike to all circumstances, whether asregards the roughest sea or smooth water. FOOTNOTES: [1] Changing hands will be found unnecessary after some practice; thetongue, however, must not be released. [2] A child or very delicate patient must, of course, be more gentlyhandled. [3] If there is stuck through the tongue a pin long enough to restagainst the teeth and keep the tongue out of the mouth, the desiredeffect may be obtained. --EDITOR. CHAPTER II =Heat Stroke and Electric Shock= _How Persons are Overcome by Heat--Treatment of Sunstroke--PeculiarCases--Dangers of Electric Shocks--How Death is Caused--Rules andPrecautions. _ =HEAT EXHAUSTION. = _First Aid Rule 1. --Carry patient flat and lay in shade. Loosenclothes at neck and waist. _ _Rule 2. --Raise head and give him (a) teaspoonful of essence of gingerin glass of hot water, or give him (b) half a cup of hot coffee, clear. _ _Rule 3. --Put him to bed. _ =HEAT STROKE. = _First Aid Rule 1. --Send for physician. _ _Rule 2. --Remove quickly to shady place, loosening clothes on theway. _ _Rule 3. --Strip naked and put on wire mattress (or canvas cot), ifobtainable. _ _Rule 4. --Sprinkle with ice water from watering pot, or dash it out ofbasin with hand. _ _Rule 5. --Dip sheet in ice water and tuck it snugly about patient. _ _Rule 6. --Sprinkle outside of sheet with ice water; rub body, throughthe sheet, with piece of ice. Put piece of ice to nape of neck. _ _Rule 7. --When temperature falls to 98. 5° F. Put to bed with ice capon head. _ =SUNSTROKE. =--There are two very distinct types of sunstroke: (1) Heatexhaustion or heat prostration. (2) Heat stroke. Heat prostration or exhaustion occurs when persons weakened byoverwork, worry, or poor food are exposed to severe heat combined withgreat physical exertion. It often attacks soldiers on the march, butalso those not exposed to the direct rays of the sun, as workers inlaundries, in boiler rooms, and in stoke-holes of steamers. The attackbegins more often in the afternoon or evening, in the case of thoseexposed to out-of-door heat. Feelings of weakness, dizziness, andrestlessness, accompanied by headache, are among the first symptoms. The face is very pale, the skin is cool and moist, although thetrouble often starts with sudden arrest of sweating. There is greatprostration, with feeble, rapid pulse, frequent and shallow breathing, and lowered temperature, ranging often from 95° to 96° F. The patientusually retains consciousness, but rarely there is completeinsensibility. The pernicious practice of permitting children atseaside resorts to wade about in cold water while their heads arebared to the burning sun is peculiarly adapted to favor heatprostration. Heat stroke happens more frequently to persons working hard under thedirect rays of the sun, especially laborers in large cities who are inthe habit of drinking some form of alcohol. It often occurs inunventilated tenements on stifling nights. Dizziness, violentheadache, seeing spots before the eyes, nausea, and attempts atvomiting, usher in the attack. Compare it with heat prostration, andnote the marked differences. The patient becomes suddenly andcompletely insensible, and falls to the ground, the face is flushed, the breathing is noisy and difficult, the pulse is strong, and thethermometer placed in the bowel registers 107°, 108°, or 110° F. , orrarely higher. The muscles are usually relaxed, but sometimes thereare twitchings, or even convulsions. Death often occurs withintwenty-four or thirty-six hours, preceded by failing pulse, deepunconsciousness, and rapid breathing, often labored or gasping, alternating with long intermissions. Sometimes delirium andunconsciousness last for days. Diminution of fever and returningconsciousness herald recovery, but it is a very fatal disorder, statistics showing a death rate of from thirty to fifty per cent. Evenwhen the patient lives, bad after effects are common. Peculiarsensibility to moderate heat is a frequent complaint. Loss of memory, weakened mental capacity, headache, irritability, fits, other mentaldisturbances, and impairment of sight and hearing are among the moreusual sequels, occurring in those who do not subsequently avoid thedirect rays of the sun, as well as an elevated temperature, and whoindulge in alcoholic stimulants. A high degree of moisture in the airfavors sunstrokes, but it is a curious fact that sunstroke is muchmore frequent in certain localities, and in special years than atother places and times with identical climatic conditions. This hasled observers to suggest a germ origin of the disease, but this isextremely doubtful. =Treatment. =--Treatment for heat exhaustion is given in the"first-aid" directions. Little need be added to the directions fortreatment of heat stroke. In place of the ice cap suggested in Rule 7, ice in cloths, or in a sponge bag may be substituted. The friction ofthe body, as directed in Rule 6, is absolutely necessary to stimulatethe nervous system and circulation, and to prevent the blood frombeing driven into the internal organs by the cold applied externally. The cold-water treatment is applied until the temperature falls downto within a few degrees of normal--that is, 98. 6° F. Then the patientshould be put into bed, there to remain, with ice to the head, untilfully restored. It often happens that the fever returns, in which event the wholeprocess of applying cold water must be repeated. The simplest way ofreducing the fever consists in laying the patient, entirely nude, on acanvas cot or wire mattress, binding ice to the back of his neck, andhaving an attendant stand on a chair near by and pour ice water uponthe patient from a garden watering pot. While the patient is insensible no attempt should be made to giveanything by the mouth; but half a pint of milk and two raw eggs with apinch of salt may be injected into the rectum every eight hours, afterwashing it out with cold water on each occasion. Two tablespoonfuls ofwhisky may be added to the injection, if the pulse is weak. If theurine is not passed spontaneously, it will be necessary to draw itonce in eight hours with a soft rubber catheter which has been boiledten minutes and lubricated with glycerin or clean vaseline. =ELECTRIC SHOCK OR LIGHTNING STROKE. = _First Aid Rule 1. --Protect yourself from being shocked by the victim. Grasp victim only by coat tails or dry clothes. Put rubber boots onyour hands, or work through silk petticoat; or throw loop of rubbersuspenders or of dry rope around him to pull him off wire, or pry himalong with dry stick. _ _Rule 2. --Do not lift, but drag victim away from wire toward theground. When free from wire, hold him head downward for two minutes. _ _Rule 3. --Assist heart to regain its strength. Apply mustard plaster(mustard and water) to chest over heart; wrap in blanket wrung out ofvery hot water; give hypodermic of whisky, thirty minims. _ _Rule 4. --Induce artificial respiration. Open his mouth and grasptongue, pull it forward just beyond lips, and hold it there. Letanother assistant grasp the arms just below the elbows and draw themsteadily upward by the sides of the patient's head to the ground, thehands nearly meeting (which enlarges the capacity of the chest andinduces inspiration, Fig. 2). While this is being done, let a thirdassistant take position astride the patient's hips with his elbowsresting on his own knees, his hands extended, ready for action. Next, let the assistant standing at the head turn down the patient's arms tothe sides of the body, the assistant holding the tongue changinghands, if necessary, to let the arms pass. Just before the patient'shands reach the ground, the man astride the body will grasp the bodywith his hands, the ball of the thumb resting on either side of thepit of the stomach, the fingers falling into the grooves between theshort ribs. Now, using his knees as a pivot, he will at the moment thepatient's hands touch the ground throw (not too suddenly) all hisweight forward on his hands, and at the same time squeeze the waistbetween them, as if he wished to force something in the chest upwardout of the mouth; he will deepen the pressure while he slowly countsone, two, three, four (about five seconds), then suddenly lets go witha final push, which will send him back to his first position. Thiscompletes expiration. (A child or delicate person must be more gentlyhandled. )_ _At the instant of letting go, the man at the patient's head willagain draw the arms steadily upward to the sides of the patient'shead, as before (the assistant holding the tongue again changinghands to let the arms pass, if necessary), holding them there while heslowly counts one, two, three, four (about five seconds). _ _Repeat these movements deliberately and perseveringly twelve tofifteen times in every minute--thus imitating the natural motions ofbreathing. Continue the artificial respiration from one to four hours, or until the patient breathes; and for a while, after the appearanceof returning life, carefully aid the first short gasps until deepenedinto full breaths. _ _Keep body warm with hot-water bottles, hot bricks to limbs and feet, and blankets over exposed lower part of body. _ _Rule 5. --Treat burn, if any. If skin is not broken, cover burn withcloths wet with Carron oil (equal parts of limewater and linseed orolive oil). If skin is broken, or raw surface is exposed, spread overit paste of equal parts of boric acid and vaseline, and bandage overall. _ =Conditions, Etc. =--A shock produced by contact with an electriccurrent is not of rare occurrence. Lightning stroke is very uncommon;statistics show that in the United States each year there is one deathfrom this cause to each million of inhabitants. There are severalconditions which must be borne in mind when considering the accidentaleffect of an electric current. The pressure and strength of thecurrent (voltage and amperage) are often not nearly so important inregard to the effects on the body, as the area, duration, and locationof the points of contact with the current, and the resistance offeredby clothing and dry skin to the penetration of the electricity. When the heart lies in the course of the circuit, the danger isgreatest. A dog can be killed by a current of ten volts pressure whencontacts are made to the head and hind legs, because the current thenflows through the heart, while a current of eighty volts is requiredto kill a dog, under the same conditions, if contacts are made to headand fore leg. In a general way alternating currents of low frequencyare the most injurious to the body, and any current pressure higherthan two hundred volts is dangerous to life. On the other hand, acurrent of ninety-five volts has proved fatal to a human being. Inthis case the circumstances were particularly unfavorable to thevictim, as he was standing on an iron tank in boots wet with analkaline solution, and probably studded on the soles with nails, whenhe came in accidental contact with an industrial current. Moreover, hewas an habitual drunkard. In an instance of the contrary sort, a manreceived a current of 1, 700 volts (periodicity about 130) for fiftyseconds, in one of the early attempts at electro-execution, withoutbeing killed. The personal equation evidently enters into the matter. A strong physique here, as in other cases, is most favorable inresisting the effects of electric shock. High-pressure alternating currents (1, 300 to 2, 000 volts) are employedin electro-executions, and the contacts are carefully made, so thatthe current will enter the brain and pass through the heart to theleg. The two most vital parts are thus affected. In industrialaccidents such nice adjustments are fortunately almost impossible, andshocks received from high-pressure currents, even of 25, 000 volts, have not proved fatal because both the voltage and amperage have beengreatly lessened through poor contacts and great resistance ofclothing and dry skin, and also because the heart is not usuallyincluded in the circuit. Death is induced in one of three ways: 1. Currents of enormous voltageand amperage, as occur in lightning, actually destroy, burst and burnthe tissues through which the stroke passes. 2. Usually death followsaccidents from industrial currents, owing to contraction of the heart, the effect being the same as observed on other muscles. The heartinstantly ceases beating, and either remains absolutely quiet, orthere is a fine quivering of some of its fibers, as seen on openingthe chest in experiments upon animals. 3. A fatal issue may resultfrom the passage of the current through the head, so affecting thenerve centers that govern respiration that the breathing ceases. =Symptoms. =--These are generally muscular contractions, faintness, andunconsciousness (sometimes convulsions, if the current passes throughthe head), with failure of pulse and of breathing. For instance, aman who was removing a brush from a trolley car touched, with theother hand, a live rail. His muscles immediately contracted throwinghim back, and disconnecting him from contact with the current (500volts). He then fainted and became unconscious for a short time. Thepulse was rapid and feeble, and the breathing also at first, but itlater became slower than usual. On regaining sensibility the patientvomited and got on his feet, although feeling very weak for two hours. Unconsciousness commonly lasts only a few moments in nonfatal cases, but may continue for hours, its continuance being rather a favorablesign of ultimate recovery, if the heart and lungs are actingsufficiently. Bad after effects are rare. It is not uncommon for thepatient to declare that the accident had improved his generalfeelings. Occasionally there is temporary loss of muscular power, anda case has been reported of nervous symptoms following electric shocksimilar to those observed after any accidental violence. Burns ofvarying degrees of intensity occur at the point of entrance of thecurrent, from slight blisters to complete destruction of all thetissues. =Treatment. =--The treatment is completely outlined in the "first-aid"directions. Should contact be unbroken, an order to shut off theelectric current should at once be telephoned to the station. Protection of the rescuer with thick rubber gloves is of course theideal safeguard. In fatal cases the heart is instantaneously arrested, and nothing canbe done to start it into action. If the current passes through thebrain, by contact with the head or neck, then failure of breathing ismore apt to be the cause of death. Theoretically, it is in the latterevent only that treatment, i. E. , artificial respiration, will be ofavail. But as in any individual case the exact condition is always a matterof doubt, _artificial respiration_ is the most valuable remedialmeasure we possess; it should always be practiced for hours indoubtful cases. Two tablespoonfuls of brandy or whisky in a cup ofwarm water may be injected into the bowel, if a hypodermic syringe isnot available and the patient needs decided stimulation. CHAPTER III =Wounds, Sprains and Bruises= _Treatment of Wounds--Rules for Checking Hemorrhage--Lockjaw--Bandagesfor Sprains--Synovitis--Bunions and Felons--Foreign Bodies in the Eye, Ear and Nose. _ =WOUNDS. =--A wound is a condition produced by a forcible cutting, contusing, or tearing of the tissues of the body, and includes, in itslarger sense, bruises, sprains, dislocations, and breaks or fracturesof bones. As ordinarily used, a wound is an injury produced byforcible separation of the skin or mucous membrane, with more or lessinjury to the underlying parts. _The main object during the care of wounds should be to avoidcontamination with anything which is not surgically clean, from thebeginning to the end of the dressing; otherwise, every other step inthe whole process is rendered useless. _ Three essentials in the treatment of wounds are: 1. The arrest of bleeding. 2. Absolute cleanliness. 3. Rest of theinjured part. Dangerous bleeding demands immediate relief. Bleeding is of three kinds: 1. From a large artery. 2. From a vein. 3. General oozing. =BLEEDING FROM LARGE ARTERY IN SPURTS OF BRIGHT BLOOD. = _First Aid Rule 1. --Speed increases safety. Put patient down flat. Make pressure with hands between the wound and the heart till surgeonarrives, assistants taking turns. _ _Rule 2. --If arm or leg, tie rubber tubing or rubber suspenders tightabout limb between wound and heart, or tie strap or rope overhandkerchief or folded shirt wrapped about limb. If arm, put baseballin arm pit, and press arm against this. Or, for arm or leg, tie foldedcloth in loose noose around limb, put cane or umbrella through nooseand twist up the slack very tight, so as to compress the main arterywith knot. _ _Rule 3. --Keep limb and patient warm with hot-water bottles tillsurgeon arrives. _ This treatment is of course only a temporary expedient, as it isessential for a surgeon to tie the bleeding vessel itself; therefore amedical man should be summoned with all dispatch. =BLEEDING FROM VEIN; STEADY FLOW OF DARK BLOOD. = _First Aid Rule 1. --Make firm pressure with pad of cloth directly overwound, also with hands between wound and extremity, that is, on sideof cut away from the heart. _ _Rule 2. --Tie tight bandage about limb at this point, with rubbertubing or suspenders. _ _Rule 3. --Keep limb and patient warm with hot-water bottles tillsurgeon arrives. _ In the cases of bleeding from a vein, the flow of blood is continuous, and is of a dark, red hue, and does not spurt in jets, as from anartery. This kind of bleeding is not usually difficult to stop, and itis not necessary that the vein itself be tied--unless verylarge--provided that the wound be snugly bandaged after it is dressed. After the first half hour, release the limb and see if the bleedinghas stopped. If so, and the circulation is being interfered with, owing to the tightness of the bandage, reapply the bandage moreloosely. In the case of an injured artery of any considerable size, the amountof pressure required to stop the bleeding will arrest all circulationof blood in the limb, so that great damage, as well as pain, willensue if it be continued more than an hour or two, and during thistime the limb should be kept warm by thick covering and hot-waterbags, if they can be obtained. Bleeding _from a deep puncture_ may be stopped by plugging the cavitywith strips of muslin which have been boiled, or with absorbentcotton, similarly treated, keeping the plug in place by snugbandaging. =BLEEDING FROM PUNCTURED WOUND. = _First Aid Rule 1. --Extract pin, tack, nail, splinter, thorn, orbullet, IF YOU CAN SEE BULLET; do not probe. _ _Rule 2. --Pour warm water on wound and squeeze tissue to encouragebleeding. Send for small hard-rubber syringe. _ _Rule 3. --If deep, plug it with absorbent cotton, and put tightbandage over plug. If shallow, cover with absorbent cotton wet withboric-acid solution (one dram to one-half pint of water), orcarbolic-acid solution (one teaspoonful to the pint of hot water). _ _Rule 4. --When syringe comes, remove dressing, and clean wound byforcibly syringing carbolic solution directly into wound. Replacedressing. _ A small punctured wound should be squeezed in warm water to encouragebleeding and, if pain and swelling ensue, absorbent cotton soaked in aboric-acid solution (containing as much boric acid as the water willdissolve) or in carbolic-acid solution (one teaspoonful of pure acidto the pint of warm water) should be applied over the wound andcovered with oil silk or rubber or enamel cloth for a few days, oruntil the soreness has subsided. The dressing should be wet with thesolution as often as it becomes dry. Punctures by nails, especially ifdeep, should be washed out with a syringe, using one of the solutionsjust mentioned. A medicine dropper, minus the rubber part, attached toa fountain syringe, makes a good nozzle for this purpose. A moistdressing, like the one described, should then be applied, and the limbkept in perfect rest for a few days. When a surgeon's services are available, however, self-treatment isattended with too much danger, as a thorough opening up of such woundswith proper cleansing and drainage will afford a better prospect ofearly recovery, and avert the risk of serious inflammation andlockjaw, which sometimes follow punctured wounds of the hands andfeet. Foreign bodies, as splinters, may be removed with tweezers or aneedle, being careful not to break the splinter in the attempt. If apart remains in the flesh, or if the foreign body is a needle thatcannot be found or removed at once, the continuous application of ahot flaxseed or other poultice will lead to the formation of "matter, "with which the splinter or needle will often escape after a few days. Splinters finding their way under the nail may be removed by scrapingthe nail very thin over the splinter and splitting it with a sharpknife down to the point where the end of the splinter can be grasped. =BLEEDING IN FORM OF OOZING. = _First Aid Rule 1. --Apply water as hot as hand can bear. _ _Rule 2. --Elevate the part, and drench with carbolic solution (oneteaspoonful of carbolic acid to one pint of hot water). _ _Rule 3. --Bandage snugly while wet. _ _Rule 4. --Keep patient warm with hot-water bottles. _ =GENERAL OOZING= happens in the case of small wounds or from abradedsurfaces, and is caused by the breaking of numerous minute vesselswhich are not large enough to require the treatment recommended forlarge arteries or veins. It is rarely dangerous, and usually stopsspontaneously. When the loss of blood has been considerable, so thatthe patient is pale, faint, and generally relaxed, with cold skin, andperhaps nausea and vomiting, he should be stripped of all clothing andimmediately wrapped in a blanket wrung out of hot water, and thencovered with dry blankets. Heat should also be applied to the feet bymeans of hot-water bags or bottles, with great care not to burn asemiconscious patient's skin. The head should be kept low, and twotablespoonfuls of brandy, whisky, or other alcoholic liquor should begiven in a half cup of hot water by the mouth, if the patient canswallow. If much blood has been lost a quart of water, as hot as thehand can readily bear, and containing a teaspoonful of common salt, should be injected by means of a fountain syringe into the rectum. Somewhat the condition just described as due to loss of blood may becaused simply by shock to the nervous system following any severeaccident, and not attended by bleeding. The treatment of shock is, however, practically the same as that for hemorrhage, and improvementin either case is shown by return of color to the face and strength inthe pulse. Bleeding is apt to be much less in badly torn than inincised wounds, even if large vessels are severed, as when the legsare cut off in railroad accidents, for the lacerated ends of thevessels become entangled with blood and favor clotting. =LOCKJAW. =--In the lesser injuries, where bleeding is not an importantfeature, and in all wounds as well, after bleeding has been stopped, the main object in treatment consists in cleansing wounds of the germswhich cause "matter" or pus, general blood poisoning, and lockjaw. Thegerms of the latter live in the earth, and even the smallest woundswhich heal perfectly may later give rise to lockjaw if dirt has notbeen entirely removed from the wound at the time of accident. Injuriesto the hands caused by pistols, firecrackers, and kindred explosives, seem especially prone to produce lockjaw, and fatalities from thisdisorder are deplorably numerous after Fourth-of-July celebrations inthe United States. The wounds producing lockjaw usually occur in children who explodeblank cartridges in the palm of the hand. In this way the germs of thedisease are forced in with parts of the dirty skin and more or less ofthe wad from the shell. Since lockjaw is so frequent after theseaccidents, and so fatal, it is impossible to exert too much care intreatment. The wound should at once be thoroughly opened with a knifeto the very bottom, under ether, by a surgeon, and not only everyparticle of foreign matter removed, but all the surrounding tissueshould be cut out or cauterized. In addition, it is wise to use aninjection under the skin of tetanus-antitoxin, to prevent the disease. Proper restriction of the sale of explosives alone will put a stop tothis barbarous mode of exhibiting patriotism. =Treatment. =--It is not essential to use chemical agents orantiseptics to rid wounds of germs and so secure uninterruptedhealing. The person who is to dress the wound should prepare to do soat the earliest possible moment after giving first aid. He shouldproceed promptly to boil some pieces of absorbent cotton, as large asan egg, together with a nail brush in water. Some strips of cleancotton cloth may be used in the absence of absorbent cotton. Theboiling should be conducted for five minutes, when the basin or otherutensil in which the brush and cotton are boiled should be taken offthe fire and set aside to cool. Then the attendant should scrub hisown hands for five minutes in hot water with soap and brush. He next takes the brush, which has been boiled, out of the water andcleans the patient's skin for a considerable distance about the wound. When this is done, and the water and cotton which have been boiled aresufficiently cool, the wound should be bathed with the cotton andboiled water until all foreign matter has been removed from the wound;not only dirt which can be seen, but germs which cannot be seen. Someof the boiled cotton cloth or absorbent cotton, wet as it is, shouldbe placed over the wound and the whole covered by a bandage. Largegaping wounds are of course more properly closed by stitches, but verydeep wounds should be left partly open, so that the discharge maydrain away freely. Small, deep, punctured wounds are not to be closedat all, but should be sedulously kept open by pushing in strips ofboiled cotton cloth, in order to secure drainage. If the attendant has the requisite confidence, there is no reason whyhe should not attempt stitching a wound, providing the patient iswilling, and a surgeon cannot be obtained within twenty-four hours. Inthis case a rather stout, common sewing needle or needles are threadedwith black or white thread, preferably of silk, and, together with apair of scissors and a clean towel, are boiled in the same utensilwith the cotton and the nail brush. After the operator has scrubbedhis hands and cleansed the wound, he places the boiled towel about thewound so that the thread will fall on it during his manipulations andnot on the skin. The needle should be thrust into and through theskin, but no lower than this, and should enter and leave the skinabout a quarter of an inch from either edge of the wound. The stitchesare placed about one-half inch apart, and are drawn together and tiedtightly enough to join the two edges of the wound. The ends of thethread should be cut about one-half inch from the knot, being carefulwhile using the needle and scissors not to lay them down on anythingexcept the boiled towel. The wound is then covered with cotton, whichhas been boiled as described above, bandaged and left undisturbed fora week, if causing no pain. At the end of this time the stitches aretaken out after the attendant has washed his hands carefully, andboiled his scissors as before. Court plaster or plaster of any kind is a bad covering or dressing forwounds, as it may be itself contaminated with germs. It effectuallykeeps in any with which the wound is already infected, and preventsproper drainage. It is impossible in a work of this kind to describe the details of theafter treatment of wounds, as this can only be properly undertaken bya surgeon, owing to the varying conditions which may arise. In generalit may be stated that the same cleanliness and care should be followedduring the whole course of healing as has been outlined for the firstattempt at treatment. If the wound is small, and there is no discharge from it, it may bepainted with collodion or covered with boric-acid ointment (sixtygrains of boric acid to the ounce of vaseline) after the first day. Iflarge, it should be covered with cotton gauze or cloth which have beenboiled or specially prepared for surgical purposes. If pus ("matter")forms, the wound must be cleansed daily of discharge (more than onceif it is copious) with boiled water, or best with hydrogen dioxidesolution followed by a washing with a solution of carbolic acid (oneteaspoonful to the pint of hot water), or with a solution of mercurybichloride, dissolving one of the larger bichloride tablets, sold forsurgical uses, in a quart of water. It is a surgical maxim never to be neglected that wounds should not beallowed to close at the top before healing is completed at the bottom. As to close at the surface is the usual tendency in wounds that healslowly and discharge pus, it is necessary at times to enlarge theexternal opening by cutting or stretching with the blades of a pair ofscissors, or, and this is much more rational and comfortable for thepatient, by daily packing the outlet of the wound with gauze to keepit open. =BLEEDING FROM SCALP. = _First Aid Rule 1. --Cut hair off about wound, and clean thoroughlywith carbolic-acid solution (one teaspoonful to pint of hot water). _ _Rule 2. --Put pad of gauze or muslin directly over wet wound, and makepressure firmly with bandage. _ In case of wounds of the scalp, or other hairy parts, the hair shouldbe cut, or better shaved, over an area very much larger than thewounded surface, after which the cleansing should be done. To stopbleeding of the scalp, water is applied as hot as can be borne, andthen a wad of boiled cotton should be placed in the wound andbandaged down tightly into it for a time. Closing the wound withstitches will stop the bleeding much more effectively, however, and isnot very painful if done immediately after the accident. The stitchesshould be tied loosely, and not introduced nearer to each other thanhalf an inch, to allow drainage of discharge from the wound. =General Remarks. =--All wounds should be kept at rest after they aredressed. This is accomplished in the case of the lower limbs bykeeping the patient in bed with the leg raised on a pillow. The same kind of treatment applies in severe injuries of the hands. Inless serious cases a sling may be employed, and the patient may walkabout. When the injury is near a joint, as of the fingers, knee, wrist, or elbow, a splint made of thin board or tin (and covered withcotton wadding and bandaged) should be applied by means of surgeon'sadhesive plaster and bandage after the wound has been dressed. Ininjuries of the hand the splint should be applied to the palm side, and reach from the finger tips to above the wrist. Use a splint also. =NOSEBLEED. = _First Aid Rule 1. --Seat patient erect and apply ice to nape of neck. _ _Rule 2. --Put roll of brown paper under upper lip, and press lipfirmly against it. Press facial artery against lower jaw of bleedingside, till bleeding stops. This artery crosses lower edge of jawboneone inch in front of angle of jaw. _ _Rule 3. --Plug nostril with strip of thin cotton or muslin cloth. _ _Rule 4. --Do not wash away clots; encourage clotting to closenostril. _ =BLEEDING FROM LUNGS; BRIGHT BLOOD COUGHED UP. = =BLEEDING FROM STOMACH; DARK BLOOD VOMITED. = _First Aid Rule for both. Let patient lie flat and swallow smallpieces of ice, and also take one-quarter teaspoonful of table salt inhalf a glass of cold water. _ =BRUISE. = _First Aid Rule 1. --Bandage from tips of fingers, or from toes, makingsame pressure with bandage all the way up as you do over the injury. _ _Rule 2. --Apply heat through the bandage, over the injury, withhot-water bottles. _ =Cause, Etc. =--A bruise is a hidden wound; the skin is not broken. Itis an injury caused by a blunt body so that, while the tougher skinremains intact, the parts beneath are torn and crushed to a greater orlesser extent. The smaller blood vessels are torn and blood escapesunder the skin, giving the "black and blue" appearance so common inbruises of any severity. Sometimes, indeed, large collections ofblood form beneath the skin, causing a considerable swelling. Use of the bruised part is temporarily limited. Pain, faintness, andnausea follow severe bruises, and, in case of bad bruises of thebelly, death may even ensue from damage to the viscera or to thenerves. Dangerous bleeding from large blood vessels sometimes takesplace internally, and collections of blood may later break down intoabscesses. Furthermore, the bruise may be so great that the injury tomuscle and nerve may lead to permanent loss of use of the part. Forthese reasons a surgeon's advice should always be sought in cases ofbad bruises. Pain is present in bruises, owing to the tearing andstretching of the smaller nerve fibers, and to pressure on the nervescaused by swelling. The swelling is produced by escape of blood andfluid from the torn blood vessels. =Treatment. =--Even slight and moderate bruises should be treated byrest of the injured part. A splint insures the rest of a limb (seetreatment of Fractures, p. 80). One of the best modes of treatment isthe snug application of a flannel bandage which secures a certainamount of rest of the part to which it is applied, and aids inpreventing further swelling. Where bandaging is not feasible, as incertain parts of the body, or before bandaging in any kind of abruise, the use of a cold compress is advisable. One layer of thincotton or linen cloth should be wet in ice water, and should be put onthe bruised part and continually changed for newly moistened piecesas soon as the first grows warm. Alcohol and water, of each equalparts, may be used in the same manner to advantage. When cold is unavailable or unpleasant to the patient, several layersof cotton cloth may be wrung out in very hot water and applied to thepart with frequent renewal. The value attributed to witch-hazel andarnica is mainly due to the alcohol contained in their preparations. Cataplasma Kaolini (U. S. P. ) is an excellent remedy for simplebruises when spread thickly on the part and covered with a bandage. Anointment containing twenty-five per cent of ichthyol is also a usefulapplication. Following severe bruises, the damaged parts should bekept warm by the use of hot-water bags, or by covering a limb withcotton wool and bandage, until such time as surgical advice may beobtained. When the pain and swelling of bruises begin to subside, treatmentshould be pursued by rubbing with liniment of ammonia or chloroform, or vaseline if these are not obtainable. Moderate exercise of the partis desirable. =ABRASIONS. =--When the surface skin is scraped off, as often happensto the shin, knee, or head, an ointment containing sixty grains ofboric acid to the ounce of vaseline makes a good application, and thismay be covered with a bandage. The same ointment is useful to apply tosmall wounds and cuts after the first bandage is removed. =SPRAIN; NO DISPLACEMENT OF BONES. = _First Aid Rule 1. --Immerse in water, hot as hand can bear, for halfan hour. _ _Rule 2. --Dry and strap with adhesive plaster, if you know how. Ifnot, bandage snugly, beginning with tips of fingers or with toes, andmake same pressure all the way up that you do over injury. _ _Rule 3. --Rest. If ankle or knee is hurt, patient must go to bed. _ =Conditions, Etc. =--A sprain is an injury caused by a sudden wrench ortwist of a joint, producing a momentary displacement of the ends ofthe bones to such a degree that they are forced against the membraneand ligaments surrounding the joint, tearing one or both to a greateror less extent. The wrist and ankle are the joints more commonlysprained, and this injury is more likely to occur in persons withflabby muscles and relaxed ligaments, as in the so-called"weak-ankled. " The damage to the parts holding the joint in place maybe of any degree, from the tearing of a few fibers of the membraneenwrapping the joint to its complete rupture, together with that ofthe ligaments, so that the bones are no longer in place, the jointloses its natural shape and appearance, and we have a condition knownas dislocation. In a sprain then, the twist of the joint produces onlya temporary displacement of the bones forming the joint, sufficient todamage the soft structures around it, but not sufficient to causelasting displacement of the bones or dislocation. It will be seen that whether a sprain or dislocation results, dependsupon the amount of injury sustained. Since it often happens that thebone entering into the joint is broken, it follows that whenever whatappears to be a severe sprain occurs, with inability to move the jointand great swelling, it is important to secure surgical aid promptly. Since the discovery of the X-ray many injuries of the smaller bones ofthe wrist and ankle joint, formerly diagnosed as sprains by the mostskillful surgeons, have, by its use, been discovered to be breaks ofthe bones which were impossible of detection by the older methods ofexamination. =Symptoms. =--The symptoms of sprain are sudden, severe pain, oftenaccompanied by faintness and nausea, swelling, tenderness, and heat ofthe injured parts. The sprained joint can be only moved with pain anddifficulty. The swelling is due not so much to leaking of blood frombroken blood vessels as to filling up of the joint with fluid causedby the inflammation, although in a few days after a severe sprain theskin a little distance below the injury becomes "black and blue" fromescape of blood caused by the injury. =Treatment. =--Since the treatment of severe sprains means first thediscrimination between dislocation, a break of bone, and a rupture ofmuscle, ligament, or tendon, it follows that the methods hereindescribed for treatment should only be employed in slightunmistakable sprains, or until a surgeon can be secured, or when oneis unavailable. Nothing is better than immediate immersion of thesprained joint in as hot water as the hand can bear for half an hour. Following this, an elastic bandage of flannel cut on the bias aboutthree and one-half inches wide should be snugly applied to the limb, beginning at the finger tips or at the toes and carrying the bandagesome distance above the injured joint. In bandaging a part there is always danger of applying the bandage tootightly, especially if the parts swell under the bandage. If thishappens, there is increase of pain which may be followed by numbnessof the limb and, what is still more significant, coldness and bluenessof the extremities below the bandage, particularly of the fingers andtoes. In such cases the bandage must be removed and reapplied withless force. If the ankle or knee be sprained the patient must go tobed for at least twenty-four hours, and give the limb a complete rest. When the wrist or shoulder is sprained the arm should be confined in asling. In the more serious cases the injured joint should be fixed ina splint before bandaging. An injured elbow joint is held at a rightangle by a pasteboard splint, a bandage, and a sling, while the kneeand wrist are treated with the limb in a straight line, as far aspossible. In the case of the knee, the splint is applied to the back of the leg;in sprained wrist, to the palm of the hand and same side of theforearm. Sheet wadding, which may be bought at any drygoods store, istorn into strips about two inches wide and sewed together forming abandage ten or fifteen feet long, and this is first wound about thesprained joint. Then pieces of millboard or heavy pasteboard aresoaked in water and applied while wet in long strips about threeinches wide over the wadding, and the whole is covered with bandage. In the case of the knee it is better to use a strip of wood for thesplint, reaching from the lower part of the calf to four inches abovethe knee. It should be from a quarter to half an inch thick, a littlenarrower than the leg, and be padded thickly with sheet wadding. It isheld in place by strips of surgeon's adhesive plaster, about twoinches wide, passed around the whole circumference of the limb aboveand below the knee joint, and covered with bandage. In ordinary sprains of the ankle, uncomplicated by broken bone orligament, it is possible for the patient, after resting in bed for aday, to go about on crutches, without bearing any weight on the footuntil the third day after the accident. The treatment in the meanwhileconsists in immersing the sprained ankle alternately, first in hotwater for five minutes and then in cold water for five minutes, followed by rubbing of the parts about the injured joint withchloroform liniment for fifteen minutes, but not at the beginningtouching the joint itself. The rubbing should be done by an assistantvery gently the first day, with gradual increase in vigor as the dayspass, not only kneading the ankle but moving the joint. This treatment should be pursued once daily, and followed by bandagingwith a flannel bandage cut on the bias three and a half inches wide. With this method it is possible for the patient to regain the moderateuse of the ankle in about two or three weeks. The same general line of treatment applies to the other joints;partial rest and daily bathing in hot and cold water, rubbing andmovements of the joint by an assistant. Since sprains vary in severityit follows that some may need only the first day's preliminarytreatment prescribed to effect a cure, while others may requirefixation by a surgeon in a plaster-of-Paris splint for some time, withadditional treatment which only his special knowledge can supply. [Illustration: This picture shows an excellent method of fixing asprained joint, used by Prof. Virgil P. Gibney, M. D. , Surgeon-in-Chiefof the N. Y. Hospital for Ruptured and Crippled. It consists ofstrapping the joint by means of long, narrow strips of adhesiveplaster incasing it immovably in the normal position. This proceduremay be followed by anyone who has seen a surgeon practice it. ] =SYNOVITIS--Severe Injury. =--Generally of ankle or knee from fall, orshoulder from blow. _First Aid Rule 1. --Provide large pitcher of hot water and largepitcher of cold water and basin. Hold joint over basin; pour hotwater slowly over joint. Return this water to pitcher. Pour cold waterover joint. Return water to pitcher. Repeat with hot water again, andfollow with cold. Continue this alternation for half an hour. _ _Rule 2. --Put to bed, with hot-water bottles about joint, and wedgeimmovably with pillows. _ _Rule 3. --When tenderness and heat subside, strap with adhesiveplaster in overlapping strips. _ =Conditions, Etc. =--This condition, which may affect almost any freelymovable joints, as the knee, elbow, ankle, and hip, is commonly causedby a wrench, blow, or fall. Occasionally it comes on without anyapparent cause, in which case there is swelling and but slight pain orinflammation about the joint. We shall speak of synovitis of the knee("water on the knee"), as that is the most common form, but theseremarks will apply almost as well to the other joints. In severe casesthere are considerable pain, redness and heat, and great swellingabout the knee. The swelling is seen especially below the kneepan, oneach side of the front of the joint, and also often above the kneepan. Frequently the only signs of trouble are swelling with slight pain, unless the limb is moved. =Treatment. =--If the knee is not red, hot, or tender to the touch, itwill not be necessary for the patient to remain in bed, but when thesesymptoms are present a splint of some sort must be applied so that theleg is kept nearly straight, and the patient must keep to his beduntil the heat, redness, and tenderness have subsided. In the meantimeeither an ice bag, hot poultice, cloths wrung out in hot water, or ahot-water bag should be kept constantly upon the knee. A convenient splint consists of heavy pasteboard wet and covered withsheet wadding (or cotton batting) shaped and affixed to the back ofthe leg, from six inches below to four inches above the joint, bystrips of adhesive plaster, as shown in the illustration, and then bybandage, leaving the knee uncovered for applications. A wooden splintwell padded may be used instead. In mild cases without much inflammation, and in others after thetenderness and heat have abated, the patient may go about if the kneeis treated as follows: a pad of sheet wadding or cotton batting abouttwo inches thick and five inches long and as wide as the limb isplaced in the hollow behind the knee, and then the whole leg isencircled with sheet wadding from six inches below to four inchesabove the knee, covering the joint as well as the pad. Beginning nowfive inches below the joint, strips of surgeon's adhesive plaster, aninch wide and long enough to more than encircle the limb, are affixedabout the leg firmly like garters so as to make considerable pressure. Each strip or garter overlaps the one below about one-third of aninch, and the whole limb is thus incased in plaster from five inchesbelow the knee to a point about four inches above the joint. An ordinary cotton bandage is then applied from below over the entireplaster bandage. When this arrangement loosens, the plaster should betaken off and new reapplied, or a few strips may be wound about theold plaster to reënforce it. The patient may walk about with thisappliance without bending the knee. When the swelling has nearly departed, the plaster may be removed andthe knee rubbed twice daily about the joint and the joint itself movedto and fro gently by an attendant, and then bandaged with a flannelbandage. Painting the knee with tincture of iodine in spots as largeas a silver dollar is also of service at this time. The knee shouldnot be bent in walking until it can be moved by another person withoutproducing discomfort. Such treatment may be applied to the other joints in a general way. The elbow must be fixed by a splint as recommended for dislocation ofthe joint (p. 128). The ankle is treated as advised for sprain of thatjoint (p. 68). When a physician can be obtained no layman is justifiedin attempting to treat a case of water on the knee or similaraffection of other joints. =BUNION AND HOUSEMAID'S KNEE. =--Bunion is a swelling of the bursa, orcushion, at the first joint of the great toe where it joins the foot. It may not give much trouble, or it may be hot, red, tender, and verypainful. It is caused by pressure of a tight boot which also forcesthe great toe toward the little toe, and thus makes the great toejoint more prominent and so the more readily injured. A somewhat similar swelling, often as large as an egg, is sometimesseen over the kneepan, more often in those who work upon their knees, hence the name housemaid's knee. The swelling may come on suddenly andbe hot, tender, and painful, or it may be slow in appearing and givelittle pain. =Treatment. =--The treatment for the painful variety of bunion andhousemaid's knee is much the same: absolute rest with the foot keptraised, and application of cloths kept constantly wet with ice or coldwater; or a thick covering of Cataplasma Kaolini (U. S. P. ) may beapplied until the inflammation has subsided. If the trouble ischronic, or the acute inflammation does not soon abate under thetreatment advised, the case is one for the surgeon, and sometimesrequires the knife for abscess formation. In the milder cases ofbunion, wearing proper shoes whose inner border forms almost astraight line from heel to toe, so that the great toe is not pushedover toward the little toe, and painting the bunion every few dayswith tincture of iodine, until the skin begins to become sore, willoften be sufficient to secure recovery. =RUN-AROUND; WHITLOW OR FELON. =--"Run-around" consists in aninflammation of the soft parts about the finger nail. It is morecommon in the weak, but may occur in anyone, owing to the entrance ofpus germs through a slight prick or abrasion which may pass unnoticed. The condition begins with redness, heat, tenderness, swelling, andpain of the flesh at the root of the nail, which extends all about thenail and may be slight and soon subside, or there may be great painand increased swelling, with the formation of "matter" (pus), andresult in the loss of the nail, particularly in the weak. Whitlow or felon is a much more serious trouble. It begins generallyas a painful swelling of one of the last joints of the fingers on thepalm side. Among the causes are a blow, scratch, or puncture. Oftenthere is no apparent cause, but in some manner the germs ofinflammation gain entrance. The end of the finger becomes hot andtense, and throbs with sometimes almost unbearable pain. If theinflammation is chiefly of the surface there may be much redness, butif mainly of the deeper parts the skin may be but little reddened orthe surface may be actually pale. There is usually some fever, and thepain is made worse by permitting the hand to hang down. If the felonis on the little finger or thumb the inflammation is likely to extenddown into the palm of the hand, and from thence into the arm along thecourse of the tendons or sinews of the muscles. Death of the bone ofthe last finger joint necessitating removal of this part, stiffness, crippling, and distortion of the hand, or death from blood poisoningmay ensue if prompt surgical treatment is not obtained. =Treatment. =--At the very outset it may be possible to stop theprogress of the felon by keeping the finger constantly wet by means ofa bandage continually saturated with equal parts of alcohol and water, at night keeping it moist by covering with a piece of oil silk orrubber. Tincture of iodine painted all over the end of the finger isalso useful, and the hand should be carried in a sling by day, andslung above the head to the headboard of the bed by night. If aftertwenty-four hours the pain increases, it is best to apply hotpoultices to the finger, changing them as often as they cool. If thefelon has not begun to abate by the end of forty-eight hours, the endof the finger must be cut lengthwise right down to the bone by asurgeon to prevent death of the bone or extension of the inflammation. Poultices are then continued. "Run-around" is treated also by iodine, cold applications, and, ifinflammation continues, by hot poulticing and incision with a knife;but poulticing is often sufficient. Attention to the general health bya physician will frequently be of service. =WEEPING SINEW; GANGLION. =--This is a swelling as large as a largebean projecting from the back or front of the wrist with an elastic orhard feeling, and not painful or tender unless pressed on very hard. After certain movements of the hand, as in playing the piano or, forexample, in playing tennis, some discomfort may be felt. Weeping sinewsometimes interferes with some of the finer movements of the hand. The swelling is not red or inflamed, but of the natural color of theskin. It does not continue to increase after reaching a moderate size, but usually persists indefinitely, although occasionally disappearingwithout treatment. The swelling contains a gelatinous substance whichis held in a little sac in the sheath of the tendon or sinew, but theinside of the sac does not communicate with the interior of the sheathsurrounding the tendon. =Treatment. =--This consists in suddenly exerting great pressure on theswelling with the thumb, or in striking it a sharp blow with a book bywhich the sac is broken. Its contents escape under the skin, and inmost cases become absorbed. If the swelling returns a very slightsurgical operation will permanently cure the trouble. =CINDERS AND OTHER FOREIGN BODIES IN THE EYE. =[4]--Foreign bodies aremost frequently lodged on the under surface of the upper lid, althoughthe surface of the eyeball and the inner aspect of the lower lidshould also be carefully inspected. A drop of a two per cent solutionof cocaine will render painless the manipulations. The patient shouldbe directed to continue looking downward, and the lashes and edge ofthe lid are grasped by the forefinger and thumb of the right hand, while a very small pencil is gently pressed against the upper part ofthe lid, and the lower part is lifted outward and upward against thepencil so that it is turned inside out. The lid may be kept in thisposition by a little pressure on the lashes, while the cinder, orwhatever foreign body it may be, is removed by gently sweeping it offthe mucous membrane with a fold of a soft, clean handkerchief. (SeeFigs. 6 and 7. ) [Illustration: FIG. 6. FIG. 7. REMOVING A FOREIGN BODY FROM THE EYE. In Fig. 6 note how lashes and edge of lid are grasped by forefingerand thumb, also pencil placed against lid; in Fig. 7 lid is shownturned inside out over pencil. ] Hot cinders and pieces of metal may become so deeply lodged in thesurface of the eye that they cannot be removed by the methodrecommended, or by using a narrow slip of clean white blotting-paper. All such cases should be very speedily referred to a physician, andthe use of needles or other instruments should not be attempted by alayman, lest permanent damage be done to the cornea and opacityresult. Such procedures are, of course, appropriate for an oculist, but when it is impossible to secure medical aid for days it can beattempted without much fear, if done carefully, as more harm willresult if the offending body is left in place. It is surprising to seewhat a hole in the surface of the eye will fill up in a few days. Ifthe foreign body has caused a good deal of irritation before itsremoval, it is best to drop into the eye a solution of boric acid (tengrains to the ounce of water) four times daily. =FOREIGN BODIES IN THE EAR. =--Foreign bodies, as buttons, pebbles, beans, cherry stones, coffee, etc. , are frequently placed in the earby children, and insects sometimes find their way into the ear passageand create tremendous distress by their struggles. Smooth, nonirritating bodies, as buttons, pebbles, etc. , do no particular harmfor a long time, and may remain unnoticed for years. But the mostserious damage not infrequently results from unskillful attempts attheir removal by persons (even physicians unused to instrumental workon the ear) who are driven to immediate and violent action on thefalse supposition that instant interference is called for. Insects, itis true, should be killed without delay by dropping into the ear sweetoil, castor, linseed, or machine oil or glycerin, or even water, ifthe others are not at hand, and then the insect should be removed inhalf an hour by syringing as recommended for wax (Vol. II, p. 35). To remove solid bodies, turn the ear containing the body downward, pull it outward and backward, and rub the skin just in front of theopening into the ear with the other hand, and the object may fall out. Failing in this, syringing with warm water, as for removal of wax, while the patient is sitting, may prove successful. The essentials oftreatment then consist, first, in keeping cool; then in killinginsects by dropping oil or water into the ear, and, if syringingproves ineffective, in using no instrumental methods in an attempt toremove the foreign body, but in awaiting such time as skilled medicalservices can be obtained. If beans or seeds are not washed out bysyringing, the water may cause them to swell and produce pain. Toobviate this, drop glycerin in the ear which absorbs water, and willthus shrivel the seed. =FOREIGN BODIES IN THE NOSE. =--Children often put foreign bodies intheir noses, as shoe buttons, beans, and pebbles. They may not tell ofit, and the most conspicuous symptoms are the appearance of a thickdischarge from one nostril, having a bad odor, and some obstruction tobreathing on the same side. If the foreign body can be seen, thenostril on the unobstructed side should be closed and the child madeto blow out of the other one. If blowing does not remove the body itis best to secure medical aid very speedily. FOOTNOTES: [4] The Editors have deemed it advisable to repeat here the followinginstructions, also occurring in Vol. II, Part I, for the removal offoreign bodies in the eye, ear, and nose, as properly coming under thehead of "First Aid in Emergencies. " CHAPTER IV =Fractures= _How to Tell a Broken Bone--A Simple Sling--Splints and Bandage, --ABroken Rib--Fractures of Arm, Shoulder, Hand, Hips Leg and OtherParts. _ =BROKEN BONE; FRACTURE. =[5] _First Aid Rule 1. --Be sure bone is broken. If broken, patient canscarcely (if at all) move the part beyond the break, while attendantcan move it freely in his hands. If broken, grating of rough edges ofbone may be felt by attendant but should not be sought for. If broken, limb is generally shortened. _ _Rule 2. --Do not try to set bone permanently. Send at once forsurgeon. _ =COMPOUND FRACTURE. = _Important. If there is opening to the air from the break, because oftearing of tissues by end of bone, condition is very dangerous; firsttreatment may save life, by preventing infection. Before reducingfracture, and without stirring the patient much, after scrubbing yourhands very clean, note:_ _First Aid Rule 1. --If hairy, shave large spot about wound. _ _Rule 2. --Clean large area about wound with soap and water, verygently. Then wash most thoroughly again with clean water, previouslyboiled and cooled. Flood wound with cool boiled water. _ _Rule 3. --Cover wound with absorbent cotton (or pieces of muslin)which has been boiled. Then attend to broken bone, as hereafterdirected, in the case of each variety of fracture. _ _After the bone is set, according to directions, then note:_ _Rule 4. --Renew pieces of previously boiled muslin from time to time, when at all stained with discharges. Every day wash carefully aboutwound, between the splints, with cool carbolic-acid solution (oneteaspoonful to a pint of hot water) before putting on the freshcloths. _ =BROKEN BONES OR FRACTURES. =[6]--It frequently happens that the firsttreatment of fracture devolves upon the inexperienced layman. Immediate treatment is not essential, in so far as the repair of thefracture is directly concerned, for a broken bone does not unite forseveral weeks, and if a fracture were not seen by the surgeon for aweek after its occurrence, no harm would be done, provided that thelimb were kept quiet in fair position until that time. The object ofimmediate care of a broken bone is to prevent pain and avoid damagewhich would ensue if the sharp ends of the broken bone were allowed toinjure the soft tissues during movements of the broken limb. Fractures are partial or complete, the former when the bone is brokenonly part way through; simple, when the fracture is a mere break ofthe bone, and compound, when the end of one or both fragments pushthrough the skin, allowing the air with its germs to come in contactwith the wound, thus greatly increasing the danger. To be sure that abone is broken we must consider several points. The patient hasusually fallen or has received a severe blow upon the part. This isnot necessarily true, for old people often break the thigh bone at thehip joint by simply making a false step. Inability to use the limb and pain first call our attention to abroken bone. Then when we examine the seat of injury we usually noticesome deformity--the limb or bone is out of line, and there may be anunusual swelling. But to distinguish this condition from sprain orbruise, we must find that there is a new joint in the course of thebone where there ought not to be any; e. G. , if the leg were brokenmidway between the knee and ankle, we should feel that there wasapparently a new joint at this place, that there was increasedcapacity for movement in the middle of the leg, and perhaps the endsof the fragments of bones could be heard or felt grating together. These, then, are the absolute tests of a broken bone--unusual mobility(or capacity for movement) in the course of the bone, and grating ofthe broken fragments together. The last will not occur, of course, unless the fragments happen to lie so that they touch each other andshould not be sought for. In the case of limbs, sudden shortening ofthe broken member from overlapping of the fragments is a sure sign. =SPECIAL FRACTURES. = =BROKEN RIB. =--_First Aid Rule. --Patient puts hands on head whileattendant puts adhesive-plaster band, one foot wide, around injuredside from spine over breastbone to line of armpit of sound side. Thenput patient to bed. _ A rib is usually broken by direct violence. The symptoms are pain ontaking a deep breath, or on coughing, together with a small, verytender point. The deformity is not usually great, if, indeed, anyexists, so that nothing in the external appearance may call theattention to fracture. Grating between the fragments may be heard bythe patient or by the examiner, and the patient can often place hisfinger on the exact location of the break. When it is a matter of doubt whether a rib is broken or not thetreatment for broken rib should be followed for relief of pain. [Illustration: FIG. 8. METHOD OF BANDAGING BROKEN RIB (SCUDDER). Note manner of sticking one end of wide adhesive plaster alongbackbone; also assistant carrying strip around injured side. ] =Treatment= consists in applying a wide band of surgeon's adhesiveplaster, to be obtained at any drug shop. The band is made byoverlapping strips four or five inches wide, till a width of one footis obtained. This is then applied by sticking one end along the backbone and carrying it forward around the injured side of the chest overthe breastbone as far as a line below the armpit on the uninjured sideof the chest, i. E. , three-quarters way about the chest. These four-or five-inch strips of plaster may be cut the right length first andlaid together, overlapping about two inches, and put on as a whole, or, what is easier, each strip may be put on separately, beginning atthe spine, five inches below the fracture, and continuing to apply thestrips, overlapping each other about two inches, until the band ismade to extend to about five inches above the point of fracture, allthe strips ending in the line of the armpit of the uninjured side. (Fig. 8. ) If surgeon's plaster cannot be obtained, a strong unbleached cotton orflannel bandage, a foot wide, should be placed all around the chestand fastened as snugly as possible with safety pins, in order to limitthe motion of the chest wall. The patient will often be morecomfortable sitting up, and should take care not to be exposed to coldor wet for some weeks, as pleurisy or pneumonia may follow. Threeweeks are required for firm union to be established in broken ribs. =COLLAR-BONE FRACTURE. = _First Aid Rule. --Put patient flat on back, on level bed, with smallpillow between his shoulders; place forearm of injured side acrosschest, and retain it so with bandage about chest and arm. _ [Illustration: FIG. 9. A BROKEN COLLAR BONE (SCUDDER). Usual attitude of patient with a fracture of this kind; note loweringand narrowed appearance of left shoulder. ] Fracture of the collar bone is one of the commonest accidents. Thebone is usually broken in the middle third. A swelling often appearsat this point, and there is pain there, especially on lifting the armup and away from the body. It will be noticed that the shoulder, onthe side of the injury, seems narrower and also lower than its fellow. The head is often bent toward the injured side, and the arm of thesame side is grasped below the elbow by the other hand of the patientand supported as in a sling. (See Fig. 9. ) In examining an apparentlybroken bone _the utmost gentleness may be used_ or serious damage mayresult. =Treatment. =--The best treatment consists in rest in bed on a hardmattress; the patient lying flat on the back with a small pillowbetween the shoulders and the forearm of the injured side across thechest. This is a wearisome process, as it takes from two to threeweeks to secure repair of the break. On the other hand, if the forearmis carried in a sling, so as to raise and support the shoulder, whilethe patient walks about, a serviceable result is usually obtained; theonly drawback being that an unsightly swelling remains at the seat ofthe break. To make a sling, a piece of strong cotton cloth a yardsquare should be cut diagonally from corner to corner, making tworight-angled triangles. Each of these will make a properly shapedpiece for a sling. (See Figs. 10 and 11. ) Fracture of the collar bone happens very often in little children, and is commonly only a partial break or splitting of the bone, notextending wholly through the shaft so as to divide it into twofragments, but causing little more than bending of the bone (the"green-stick fracture"). [Illustration: FIG. 10. HOW TO MAKE A SLING (SCUDDER). In Fig. 10 note three-cornered bandage; No. 2 end is carried overright shoulder, No. 1 over left, then both fastened behind neck; No. 3brought over and pinned. ] [Illustration: FIG. 11. HOW TO MAKE A SLING (SCUDDER). The above illustration shows sling in position. It is made of cottoncloth a yard square cut diagonally from corner to corner. ] A fall from a chair or bed is sufficient to cause the accident. Achild generally cries out on movement of the arm of the injured side, or on being lifted by placing the hands under the armpits of thepatient. A tender swelling is seen at the point of the injury of thecollar bone. A broad cotton band, with straps over the shoulders tokeep it up, should encircle the body and upper arm of the injuredside, and the hand of the same side should be supported by a narrowsling fastened above behind the neck. =LOWER-JAW FRACTURE. = _First Aid Rule. --Put fragments into place with your fingers, securinggood line of his teeth. Support lower jaw by firmly bandaging itagainst upper jaw, mouth shut, using four-tailed bandage. (Fig. 12. )_ Fracture of the lower jaw is caused by a direct blow. It involves thepart of the jaw occupied by the lower teeth, and is more apt to occurin the middle line in front, or a short distance to one side of thispoint. The force causing the break usually not only breaks the bone, but also tears the gum through into the mouth, making a compoundfracture. There is immediate swelling of the gum at the point ofinjury, and bleeding. The mouth can be opened with difficulty. The condition of the teeth is the most important point to observe. Owing to displacement of the fragments there is a difference in thelevel of the teeth or line of the teeth, or both, at the place wherethe fracture occurs. Also one or more of the teeth are usuallyloosened at this point. In addition, unusual movement of thefragments may be detected as well as a grating sound on manipulation. =Treatment. =--The broken fragments should be pressed into place withthe fingers, and retained temporarily with a four-tailed bandage, asshown in the cut. Feeding is done through a glass tube, using milk, broths, and thin gruels. A mouth wash should be employed four timesdaily, to keep the mouth clean and assist in healing of the gum. Aconvenient preparation consists of menthol, one-half grain; thymol, one-half grain; boric acid, twenty grains; water, eight ounces. [Illustration: FIG. 12. BANDAGE FOR A BROKEN JAW (AMERICAN TEXT-BOOK). Above cut shows a four-tailed bandage; note method of tying; one stripsupports lower jaw; the other holds it in place against upper jaw. ] =SHOULDER-BLADE FRACTURE. = _First Aid Rule. --There is no displacement. Bandage fingers, forearm, and arm of affected side, and put this arm in sling. Fasten slung armto body with many turns of a bandage, which holds forearm againstchest and arm against side. _ Shoulder-blade fracture occasions pain, swelling, and tenderness onpressure over the point of injury. On manipulating the bone a gratingsound may be heard and unnatural motion detected. The treatmentconsists in bandaging the forearm and arm on the injured side frombelow upward, beginning at the wrist; slinging the forearm bent at aright angle across the front of the body, suspended by a narrow slingfrom the neck, and then encircling the body and arm of the injuredside from shoulder to elbow with a wide bandage applied under thesling, which holds the arm snugly against the side. This bandage isprevented from slipping down by straps attached to it and carried overeach shoulder. =ARM FRACTURE. = _First Aid Rule. --Pad two pieces of thin board nine by three incheswith handkerchiefs. Carefully pull fragments of bone apart, graspinglower fragment near elbow while assistant pulls gently on upperfragment near shoulder. Put padded boards (splints) one each side ofthe fracture, and wind bandage about their whole length, tightlyenough to keep bony fragments firm in position. Put forearm and handin sling. _ In fracture of the arm between the shoulder and elbow, swelling andshortening may give rise to deformity. Pain and abnormal motion aresymptoms, while a grating sound may be detected, but manipulation ofthe arm for this purpose should be avoided. The surface is apt soon tobecome black and blue, owing to rupture of the blood vessels beneaththe skin. The hand and forearm should be bandaged from below upward to theelbow. The bone is put in place by grasping the patient's elbow andpulling directly down in line with the arm, which is held slightlyaway from the side of the patient, while an assistant steadies andpulls up the shoulder. Then a wedge-shaped pad, long enough to reachfrom the patient's armpit to his elbow (made of cotton wadding orblanketing sewed in a cotton case) and about four inches wide andthree inches thick at one end, tapering up to a point at the other, isplaced against the patient's side with the tapering end uppermost inthe armpit and the thick end down. This pad is kept in place by astrip of surgeon's adhesive plaster, or bandage passing through thesmall end of the wedge, and brought up and fastened over the shoulder. [Illustration: FIG. 13. FIG. 14. BANDAGE FOR BROKEN ARM (SCUDDER). In Fig. 13 note splints secured by adhesive plaster; also pad inarmpit; in Fig. 14 see wide bandage around body; also sling. ] While the arm is pulled down from the shoulder, three strips ofwell-padded tin or thin board (such as picture-frame backing) twoinches wide and long enough to reach from shoulder to elbow, are laidagainst the front, outside, and back of the arm, and secured byencircling strips of surgeon's plaster or bandage. The arm is thenbrought into the pad lying against the side under the armpit, and isheld there firmly by a wide bandage surrounding the arm and entirechest, and reaching from the shoulder to elbow. It is prevented fromslipping by strips of cotton cloth, which are placed over theshoulders and pinned behind and before to the top of the bandage. Thewrist is then supported in a sling, not over two inches wide, with theforearm carried in a horizontal position across the front of the body. Firm union of the broken arm takes place usually in from four to sixweeks. (See Figs. 13 and 14. ) =FOREARM FRACTURE. = _First Aid Rule. --Set bones in proper place by pulling steadily onwrist while assistant holds back the upper part of the forearm. Ifunsuccessful, leave it for surgeon to reduce after "period ofinaction" comes, a few days later, when swelling subsides. Ifsuccessful, put padded splints (pieces of cigar box padded withhandkerchiefs) one on each side, front and back, and wind a bandageabout whole thing to hold it immovably. _ Two bones enter into the structure of the forearm. One or both ofthese may be broken. The fracture may be simple or compound, [7] whenthe soft parts are damaged and the break of the bone communicates withthe air, the ends of the bone even projecting through the skin. In fracture of both bones there is marked deformity, caused bydisplacement of the broken fragments, and unusual motion may bediscovered; a grating sound may also be detected but, as statedbefore, manipulation of the arm should be avoided. [Illustration: FIG. 15. SETTING A BROKEN FOREARM (SCUDDER). See manner of holding arm and applying adhesive plaster strips; onesplint is shown, another is placed back of hand and forearm. ] When only one bone is broken the signs are not so marked, but there isusually a very tender point at the seat of the fracture, and anirregularity of the surface of the bone may be felt at this point. Iffalse motion and a grating sound can also be elicited, the conditionis clear. The broken bones are put into their proper place by theoperator who pulls steadily on the wrist, while an assistant graspsthe upper part of the forearm and pulls the other way. The ends of thefragments are at the same time pressed into place by the other hand ofthe operator, so that the proper straight line of the limb isrestored. [Illustration: FIG. 16. FRACTURE OF BOTH BONES IN FOREARM (SCUDDER). This cut shows the position and length of the two padded splints; alsomethod of applying adhesive plaster. ] After the forearm is set, it should be held steadily in the followingposition while the splints are applied. The elbow is bent so that theforearm is held at right angles with the arm horizontally across thefront of the chest with the hand extended, open palm toward the bodyand thumb uppermost. The splints, two in number, are made of woodabout one-quarter inch thick, and one-quarter inch wider than theforearm. They should be long enough to reach from about two inchesbelow the elbow to the root of the fingers. They are covered smoothlywith cotton wadding, cotton wool, or other soft material, and thenwith a bandage. The splints are applied to the forearm in thepositions described, one to the back of the hand and forearm, and theother to the palm of the hand and front of the forearm. Usually there are spaces in the palm of the hand and front of thewrist requiring to be filled with extra padding in addition to that onthe splint. The splints are bound together and to the forearm by threestrips of surgeon's adhesive plaster or bandage, about two incheswide. One strip is wound about the upper ends of the splints, one iswrapped about them above the wrist, and the third surrounds the backof the hand and palm, binding the splints together below the thumb. The splints should be held firmly in place, but great care should beexercised to use no more force in applying the adhesive plaster orbandage than is necessary to accomplish this end, as it is easy tostop the circulation by pressure in this part. There should be somespring felt when the splints are pressed together after theirapplication. A bandage is to be applied over the splints and strips ofplaster, beginning at the wrist and covering the forearm to the elbow, using the same care not to put the bandage on too firmly. The forearmis then to be held in the same position by a wide sling, as shownabove. (See Figs. 15, 16, 17. ) [Illustration: FIG. 17. DRESSING FOR BROKEN FOREARM (SCUDDER). Proper position of arm in sling; note that hand is unsupported withpalm turned inward and thumb uppermost. ] Four weeks are required to secure firm union after this fracture. Whenthe fracture is compound the same treatment should be employed asdescribed under Compound Fracture of Leg, p. 116. =FRACTURE OF THE WRIST; COLLES'S FRACTURE. =--This is a break of thelower end of the bone on the thumb side of the wrist, and much thelarger bone in this part of the forearm. The accident happens when aperson falls and strikes on the palm of the hand; it is more common inelderly people. A peculiar deformity results. A hump or swellingappears on the back of the wrist, and a deep crease is seen just abovethe hand in front. The whole hand is also displaced at the wristtoward the thumb side. [Illustration: FIG. 18. A BROKEN WRIST (SCUDDER). Characteristic appearance of a "Colles's fracture"; note backwarddisplacement of hand at wrist; also fork-shaped deformity. ] It is not usual to be able to detect abnormal motion in the case ofthis fracture, or to hear any grating sound on manipulating the part, as the ends of the fragments are generally so jammed together thatit is necessary to secure a surgeon as soon as possible to pull themapart under ether, in order to remedy the existing "silver-fork"deformity. (See Figs. 18, 19, 20, 21, 22. ) =Treatment. =--Until medical aid can be obtained the same sort ofsplints should be applied, and in the same way as for the treatment offractured forearm. If the deformity is not relieved a stiff andpainful joint usually persists. It is sometimes impossible for themost skillful surgeon entirely to correct the existing deformity, andin elderly people some stiffness and pain in the wrist and fingers areoften unavoidable results. [Illustration: FIG. 19. FIG. 20. FIG. 21. FIG. 22. FRACTURE OF THE WRIST (SCUDDER). Above illustrations show deformities resulting from a broken wrist;Figs. 19 and 20 the crease at base of thumb; Fig. 21 hump on back ofwrist; Fig. 22 twisted appearance of hand. ] =FRACTURE OF BONE OF HAND, OR FINGER. = _First Aid Rule. --Set fragments of bone in place by pulling with onehand on finger, while pressing fragments into position with otherhand. Put on each side of bone a splint made of cigar box, padded withfolded handkerchiefs, and retain in place with bandage wound aboutsnugly. Put forearm and hand in sling. _ This accident more commonly happens to the bones corresponding to themiddle and ring finger, and occurs between the knuckle and the wrist, appearing as a swelling on the back of the hand. On looking at theclosed fist it will be seen that the knuckle corresponding to thebroken bone in the back of the hand has ceased to be prominent, andhas sunken down below the level of its fellows. The end of thefragment nearer the wrist can generally be felt sticking up in theback of the hand. [Illustration: FIG. 23. A BROKEN FINGER (SCUDDER). Note splint extending from wrist to tip of finger; also manner ofapplying adhesive plaster strips and pad in palm. ] If the finger corresponding to the broken bone in the back of the handbe pulled on forcibly, and the fragments be held between the thumb andforefinger of the other hand of the operator, pain and abnormalmotion may be detected, and the ends of the broken bone pressed intoplace. A thin wooden splint, as a piece of cigar box, about an inchwide at base and tapering to the width of the finger should be appliedto the palm of the hand extending from the wrist to a little beyondthe finger tip, secured by strips of adhesive plaster, as in the cut, and covered by a bandage. The splint should be well padded, and anadditional pad should be placed in the palm of the hand over the pointof fracture. Three weeks are required for firm union, and the handshould not be used for a month. It is usually easy to recognize a broken bone in a finger, unless thebreak is near a joint, when it may be mistaken for a dislocation. Pain, abnormal motion, and grating between the fragments are observed. If there is deformity, it may be corrected by pulling on the injuredfinger with one hand, while with the other the fragments are pressedinto line. A narrow, padded wooden or tin splint is applied, as in thecut (p. 102), reaching from the middle of the palm to the finger tip. Any existing displacement of the broken bone can be relieved by usingpressure with little pads of cotton held in place by narrow strips ofadhesive plaster where it is needed to keep the bone in line. Thesplint may be removed in two weeks and a strip of adhesive plasterwound about the finger to support it for a week or two more. In fracture of the thumb, the splint is applied along the back insteadof on the palm side. =HIP FRACTURE. = _First Aid Rule. --Put patient flat on back in bed, with limb wedgedbetween pillows till surgeon arrives. _ [Illustration: FIG. 24. TREATING A BROKEN HIP (SCUDDER). Note the manner of straightening leg and getting broken bone intoline; also assistant carefully steadying the thigh. ] A fracture of the hip is really a break of that portion of the thighbone which enters into the socket of the pelvic bone and forms the hipjoint. It occurs most commonly in aged people as a result of so slightan accident as tripping on a rug, or in falling on the floor from thestanding position, making a misstep, or while attempting to avoid afall. When the accident has occurred the patient is unable to rise orwalk, and suffers pain in the hip joint. When he has been helped tobed it will be seen that the foot of the injured side is turned out, and the leg is perhaps apparently shorter than its fellow. There ispain on movement of the limb, and the patient cannot raise his heel, on the injured side, from the bed. Shortening is an important sign. With the patient lying flat on the back and both legs together in astraight line with the body, measurements from each hip-bone are madewith a tape to the bony prominence on the inside of each ankle, inturn. One end of the tape is held at the navel and the other is swungfrom one ankle to the other, comparing the length of the two limbs. Shortening of less than half an inch is of no importance as a sign offracture. The fragments of broken bone are often jammed together(impacted) so that it is impossible to get any sound of gratingbetween them, and it is very unwise to manipulate the leg or hipjoint, except in the gentlest manner, in an attempt to get thisgrating. If the ends of the fragments become disengaged from eachother it often happens that union of the break never occurs. [Illustration: FIG. 25. TREATMENT FOR FRACTURED HIP (SCUDDER). Note method of holding splints in place with muslin strips; one aboveankle, one below and one above knee, one in middle and one aroundupper part of thigh. ] The treatment simply consists in keeping the patient quiet on a hardmattress, with a small pillow under the knee of the injured side andthe limb steadied on either side by pillows or cushions until asurgeon can be obtained. (See Thigh-bone Fracture. ) =THIGH-BONE FRACTURE. = _First Aid Rule. --Prepare long piece of thin board which will reachfrom armpit to ankle, and another piece long enough to reach fromcrotch to knee, and pad each with folded towels or blanket. _ _While one assistant holds body back, and another assistant pulls onankle of injured side, see that the fragments are separated andbrought into good line, and then apply the splints, assistants stillpulling steadily, and fasten the splints in place with bandage, or bytying several cloths across at three places above the knee and twoplaces below the knee. _ _Finally, pass a wide band of cloth about the body, from armpit tohips, inclosing the upper part of the well-padded splint, and fastenit snugly. The hollow between splint and waist must be filled withpadding before this wide cloth is applied. _ In fracture of the thigh bone (between the hip and knee), there isoften great swelling about the break. The limb is helpless anduseless. There is intense pain and abnormal position in the injuredpart, besides deformity produced by the swelling. The foot of theinjured limb is turned over to one side or the other, owing to arolling over of the portion of the limb below the break. With bothlower limbs in line with the body, and the patient lying on the back, measurements are made from each hip-bone to the prominence on theinside of either ankle joint. Shortening of the injured leg will befound, varying from one to over two inches, according to theoverlapping and displacement of the fragments. =Treatment. =--To set this fracture temporarily, a board about fiveinches wide and long enough to reach from the armpit to the footshould be padded well with towels, sheets, shawls, coats, blanket, orwhatever is at hand, and the padding can best be kept in place bysurgeon's adhesive plaster, bicycle tape, or strips of cloth. [8]Another splint should be provided as wide as the thigh and long enoughto reach along the back of the leg from the middle of the calf to thebuttock, and also padded in the same way. A third splint should beprepared in the same manner to go inside the leg, reaching from thecrotch to the inside of the foot. Still a fourth splint made of a thinboard as wide as the thigh, extending from the upper part of the thighto just above the knee, is padded for application to the front of thethigh. When these are made ready and at hand, the leg should be pulled onsteadily but carefully straight away from the body to relax themuscles, an assistant holding the upper part of the thigh and pullingin the opposite direction. Then, when the leg has been straightenedout and the thigh bone seems in fair line, the splints should beapplied; the first to the outside of the thigh and body, the secondunder the calf, knee, and thigh; the third to the inside of the wholelimb, and the fourth to the front of the thigh. Wide pads should be placed over the ribs under the outside splint tofill the space above the hips and under the armpit. Then all foursplints are drawn together and held in place by rubber-plaster strapsor strips of strong muslin applied as follows: one above the ankle;one below the knee; one above the knee; one in the middle of thethigh, and one around the upper part of the thigh. A wide band ofstrong muslin or sheeting should then be bound around the whole bodybetween the armpits and hips, inclosing the upper part of the outsidesplint. The patient can then be borne comfortably upon a stretchermade of boards and a mattress or some improvised cushion. (See Figs. 24 and 25. ) When the patient can be put immediately to bed after the injury, anddoes not have to be transported, it is only necessary to apply theouter, back, and front splints, omitting the inner splint. It isnecessary for the proper and permanent setting of a fractured thighthat a surgeon give an anæsthetic and apply the splints while themuscles are completely relaxed. It is also essential that the musclesbe kept from contracting thereafter by the application of a fifteen-or twenty-pound weight to the leg, after the splints are applied, butit is possible to outline here only the proper first-aid treatment. =KNEEPAN FRACTURE. = _First Aid Rule. --Pain is immediate and intense. Separated fragmentsmay be felt at first. Swelling prompt and enormous. Even if not sure, follow these directions for safety. _ _Prepare splint: thin board, four inches wide, and long enough toreach from upper part of thigh to just above ankle. Pad with foldedpiece of blanket or soft towels. Place it behind leg and thigh;carefully fill space behind knee with pad; fasten splint to limb withthree strips of broad adhesive plaster, one around upper end ofsplint, one around lower end, one just below knee. _ _Lay large flat, dry sponge over knee thus held, and bandage this inplace. Keep sponge and bandage wet with ice water. If no sponge isavailable, half fill rubber hot-water bottle with cracked ice, and laythis over knee joint. Put patient to bed. _ Fracture of kneepan is caused either by direct violence or muscularstrain. It more frequently occurs in young adults. Immediate pain isfelt in the knee and walking becomes impossible; in fact, often thepatient cannot rise from the ground after the accident. Swelling atfirst is slight, but increases enormously within a few hours. Immediately after the injury it may be possible to feel the separatebroken fragments of the kneepan and to recognize that they areseparated by a considerable space if the break is horizontally acrossthe bone. [Illustration: FIG. 26. A BROKEN KNEEPAN (SCUDDER). A padded splint, supporting knee, is shown reaching from ankle tothigh. Note number and location of adhesive plaster strips. ] Nothing can be done to set the fracture until the swelling about thejoint has been reduced, so that the first treatment consists insecuring immediate rest for the kneejoint, and immobility of thefragments. A splint made of board, about a quarter of an inch thickand about four inches wide for an adult, reaching from the upper partof the thigh above to a little above the ankle below, is applied tothe back of the limb and well padded, especially to fill the spacebehind the knee. The splint is attached to the limb by straps ofadhesive plaster two inches and a half wide; one around the lower endof the splint, one around the upper part, and the third placed justbelow the knee. To prevent and arrest the swelling and pain, pressureis then made on the knee by bandaging. One of the best methods (Scudder's) is to bind a large, flat, drysponge over the knee and then keep it wet with cold water; or to applyan ice bag directly to the swollen knee; a splint in either case beingthe first requisite. The patient should of course be put to bed assoon as possible after the accident, and should lie on the back withthe injured leg elevated on a pillow with a cradle to keep the clothesfrom pressing on the injured limb. (See cut, p. 110. ) =FRACTURE OF LEG BONES, BETWEEN KNEE AND ANKLE. = _First Aid Rule. --Handle very carefully; great danger of makingopening to surface. Special painful point, angle or new joint in bone, disability, and grating felt will decide existence of break. Letassistant pull on foot, to separate fragments, while you examine partof supposed break. If only one bone is broken, there may be nodisplacement. _ _Put patient on back. While two assistants pull, one on ankle and oneon thigh at knee, thus separating fragments, slide pillow lengthwiseunder knee, and, bringing its edges up about leg, pin them snuglyabove leg. _ _Prepare three pieces of thin wood, four inches wide and long enoughto reach from sole of foot to a point four inches above knee. Whileassistants pull on limb again, as before, put one splint each sideand third behind limb, and with bandage or strips of sticking plasterfasten these splints to the leg inclosed in its pillow as tight aspossible. _ In fracture of the leg between the knee and ankle we have pain, angular deformity or an apparent false joint in the leg, swelling andtenderness over the seat of fracture, together with inability to usethe injured leg. Two bones form the framework of the leg; the inner, or shinbone, the sharp edge of which can be felt in front throughoutmost of its course, being much the larger and stronger bone. When bothbones are broken, the displacement of the fragments, abnormal motionand consequent deformity, are commonly apparent, and a grating soundmay be heard, but should not be sought for. [Illustration: FIG. 27. FRACTURE OF BOTH LEG BONES (SCUDDER). This cut shows the peculiar deformity in breaks of this kind; seeposition of kneepan; also prominence of broken bone above ankle. ] An open wound often communicates with the break, making the fracturecompound, a much more serious condition. To avoid making the fracturea compound one, during examination of the leg, owing to the sharpends of the bony fragments, the utmost gentleness should be used. Under no circumstances attempt to move the fragments from side toside, or backward and forward, in an effort to detect the gratingsound often caused by the ends of broken bones. The greatest dangerlies in the desire to do too much. We again refer the reader to FirstAid Rule 1. [Illustration: FIG. 28. BANDAGE FOR BROKEN LEG (SCUDDER). Note the pillow brought up around leg and edges pinned together; alsolength and method of fastening splint with straps. ] When one bone is broken there may be only a point of tenderness andswelling about the vicinity of the break and no displacement orgrating sound. When in doubt as to the existence of a fracture alwaystreat the limb as if a fracture were present. "Black and blue"discoloration of the skin much more extensive than that followingsprain will become evident over the whole leg within twenty-fourhours. =Treatment. =--When a surgeon cannot be obtained, the followingtemporary pillowdressing, recommended by Scudder in his book onfractures, is one of the best. With the patient on his back, the leghaving been straightened and any deformity removed as far as possibleby grasping the foot and pulling directly away from the body while anassistant steadies the thigh, a large, soft pillow, inclosed in apillowcase, is placed under the leg. The sides of the pillow arebrought well up about the leg and the edges of the pillowcase arepinned together along the front of the leg. Then three strips of wood about four inches wide, three-sixteenths toa quarter of an inch thick, and long enough to reach from the sole ofthe foot to about four inches above the knee, are placed outside ofthe pillow along the inner and outer aspects of the leg and beneathit. The splints are held in place, with the pillow as padding beneath, by four straps of webbing (or if these cannot be obtained, by stripsof stout cloth, adhesive plaster, or even rope); but four pads made offolded towels should be put under the straps where they cross thefront of the leg where little but the pillowcase overlaps. Thesestraps are applied thus: one above the knee, one above the ankle, andthe other two between these two points, holding all firmly together. This dressing may be left undisturbed for a week or even ten days ifnecessary. (See Figs. 27 and 28. ) The leg should be kept elevated after the splints are applied, andsteadied by pillows placed either side of it. From one to two monthsare required to secure union in a broken leg in adults, and from threeto five months elapse before the limb is completely serviceable. Inchildren the time requisite for a cure is usually much shorter. =ANKLE-JOINT FRACTURE. = _First Aid Rule. --One or both bones of leg may be broken just aboveankle. Foot is generally pushed or bent outward. Prepare two pieces ofthin wood, four inches wide and long enough to go from sole of foot tojust below knee:--the splints. Pad them with folded towels or piecesof blanket. _ _While assistants pull bones apart gently, one pulling on knee, otherpulling on foot and turning it straight, apply the splints, one eachside of the leg. _ A fracture of the ankle joint is really a fracture of the lowerextremities of the bones of the leg. There are present pain and greatswelling, particularly on the inner side of the ankle at first, andthe whole foot is pushed and bent outward. The bony prominence on theinner side of the ankle is unduly marked. The foot besides being bentoutward is also displaced backward on the leg. This fracture might betaken for a dislocation or sprain of the ankle. Dislocation of theankle without fracture is very rare, and when the foot is returned toits proper position it will stay there, while in fracture the footdrops back to its former displaced state. In sprained ankle there arepain and swelling, but not the deformity caused by the displacement ofthe foot. This fracture may be treated temporarily by returning the foot to itsusual position and putting on side splints and a back splint, asdescribed for the treatment of fracture of the leg. =COMPOUND OR OPEN FRACTURE OF THE LEG. =--This condition may beproduced either by the violence which caused the fracture also leadingto destruction of the skin and soft parts beneath, or by the end of abony fragment piercing the muscles and skin from within. In eitherevent the result is much more serious than that of an ordinary simplefracture, for germs can gain entrance through the wound in the skinand cause inflammation with partial destruction or death of the part. =Treatment. =--Immediate treatment is here of the utmost value. It isapplicable to open or compound fracture in any part of the body. Thearea for a considerable distance about the wound, if covered withhair, should be shaved. It should then be washed with warm water andsoap by means of a clean piece of cotton cloth or absorbent cotton. Then some absorbent cotton or cotton cloth should be boiled in waterin a clean vessel for a few minutes, and, after the operator hasthoroughly washed his hands, the boiled water (when sufficiently cool)should be applied to the wounded area and surrounding parts with theboiled cotton, removing in the most painstaking way all visible andinvisible dirt. By allowing some of the water to flow over the woundfrom the height of a few feet this result is favored. Finally some ofthe boiled cotton, which has not been previously touched, is spreadover the wound wet, and covered with clean, dry cotton and bandaged. Splints are then applied as for simple fracture in the same locality(p. 113). If a fragment of bone projects through the wound it may bereplaced after the cleansing just described, by grasping the lowerpart of the limb and pulling in a straight line of the limb away fromthe body, while an assistant holds firmly the upper part of the limband pulls in the opposite direction. During the whole process neitherthe hands of the operator nor the boiled cotton should come in contactwith anything except the vessel containing the boiled water and thepatient. FOOTNOTES: [5] The engravings illustrating the chapters on "Fractures" and"Dislocations" are from Buck's "Reference Handbook of MedicalScience, " published by William Wood & Co. , New York; also, Scudder's"Treatment of Fractures" and "American Text-Book of Surgery, "published by W. B. Saunder's Company, Philadelphia. [6] It should be distinctly understood that the information aboutfractures is not supplied to enable anyone to avoid calling a surgeon, but is to be followed only until expert assistance can be obtainedand, like other advice in this book, is intended to furnish first-aidinformation or directions to those who are in places where physicianscannot be secured. [7] For treatment of compound fracture, see Compound Fracture of Leg(p. 116). [8] This method follows closely that recommended by Scudder, in hisbook "The Treatment of Fractures. " CHAPTER V =Dislocations= _How to Tell a Dislocation--Reducing a Dislocated Jaw--Stimson'sMethod of Treating a Dislocated Shoulder--Appearance of Elbow when Outof Joint--Hip Dislocations--Forms of Bandages. _ =DISLOCATIONS; BONES OUT OF JOINT. = =JAW. =--Rare. Mouth remains open, lower teeth advanced forward. _First Aid Rule 1. --Protect your thumbs. Put on thick leather gloves, or bind them with thick bandage. _ _Rule 2. --Assistant steadies patient from behind, with hands bothsides of his head, operator presses downward and backward with histhumbs on back teeth of patient, each side of patient's jaw, while thechin is grasped between forefingers and raised upward. Idea is tostretch the ligament at jaw joint, and swing jaw back while pulling onthis ligament. (Fig. 29. )_ _Rule 3. --Tie jaw with four-tailed bandage up against upper jaw for aweek. (Fig. 12, p. 90. )_ =SHOULDER. =--Common accident. No hurry. See p. 122. =ELBOW. =--Rare. No hurry. See p. 125. =HIP. =--No hurry. See p. 129. =KNEE. =--Rare. Easily reduced. Head of lower bone (tibia) is moved toone side; knee slightly bent. _First Aid Rule 1. --Put patient on back. _ _Rule 2. --Flex thigh on abdomen and hold it there. _ _Rule 3. --Grasp leg below knee and twist it back and forth, andstraighten knee. _ =DISLOCATIONS. =--A dislocation is an injury to a joint wherein theends of the bones forming a joint are forced out of place. Adislocation is commonly described as a condition in which a part (asthe shoulder) is "out of joint" or "out of place. " A dislocation mustbe distinguished from a sprain, and from a fracture near a joint. In asprain, as has been stated (p. 65), the bones entering into theformation of the joint are perhaps momentarily displaced, but returninto their proper place when the violence is removed. But, owing togreater injury, in dislocation the head of the bone slips out of thesocket which should hold it, breaks through the ligaments surroundingthe joint, and remains permanently out of place. For this reason thereis a peculiar deformity, produced by the head of the bone's lying inits new and unnatural situation, which is not seen in a sprain. Also, the dislocated joint cannot be moved by the patient or byanother person, except within narrow limits, while a sprained jointcan be moved, with the production of pain it is true, but without anymechanical obstacle. In the case of fracture near a joint there isusually increased movement in some new direction. When a dislocatedjoint is put in proper place it stays in place, whereas when afractured part is reduced there is nothing to keep it in place and, iflet alone, it quickly resumes its former faulty position. Only a few of the commoner dislocations will be considered here, asthe others are of rare occurrence and require more skill than can beimparted in a book intended for the laity. The following instructionsare not to be followed if skilled surgical attendance can be secured;they are intended solely for those not so fortunately situated. =DISLOCATION OF THE JAW. =--This condition is caused by a blow on thechin, or occurs in gaping or when the mouth is kept widely open duringprolonged dental operations. The joint surface at the upper part ofthe lower jaw, just in front of the entrance to the ear, is thrown outof its socket on one side of the face, or on both sides. If the jaw isput out of place on both sides at once, the chin will be foundprojecting so that lower front teeth jut out beyond the upper frontteeth, the mouth is open and cannot be closed, and the patient issuffering considerable pain. When the jaw is dislocated on one sideonly, the chin is pushed over toward the uninjured side of the face, which gives the face a twisted appearance; the mouth is partly openand fixed in that position. A depression is seen on the injured sidein front of the ear, while a corresponding prominence exists on theopposite side of the face, and the lower front teeth project beyondthe upper front teeth. [Illustration: FIG. 29. REDUCING DISLOCATION OF JAW (AMERICAN TEXT-BOOK). Thumbs placed upon last molar teeth on each side; note jaw graspedbetween fingers and thumbs to force it into place. ] =Treatment. =--A dislocation of one side of the jaw is treated in thesame manner as that of both sides. The dislocation may sometimes be reduced by placing a good-sized corkas far back as possible between the back teeth of the upper and lowerjaws (on one or both sides, according as the jaw is out of place onone or both sides), and getting the patient to bite down on the cork. This may pry the jaw back into place. The common method is for the operator to protect both thumbs bywrapping bandage about his thumbs, or wearing leather gloves, andthen, while an assistant steadies the head, the operator pressesdownward and backward on the back teeth of the patient on each side ofthe lower jaw with both thumbs in the patient's mouth, while the chinis grasped beneath by the forefingers of each hand and raised upward. When the jaw slips into place it should be maintained there by abandage placed around the head under the chin and retained there for aweek. During this time the patient should be fed on liquids through atube, so that it will not be necessary for him to open his mouth toany extent. (See Fig. 29. ) =DISLOCATION OF THE SHOULDER. =--This is by far the most common ofdislocations in adults, constituting over one-half of all suchaccidents affecting any of the joints. It is caused by a fall or blowon the upper arm or shoulder, or by falling upon the elbow oroutstretched hand. The upper part (or head) of the bone of the arm(humerus) slips downward out of the socket or, in some cases, inwardand forward. In either case the general appearance and treatment ofthe accident are much the same. The shoulder of the injured side losesits fullness and looks flatter in front and on the side. The arm isheld with the elbow a few inches away from the side, and the line ofthe arm is seen to slope inwardly toward the shoulder, as comparedwith the sound arm. The injured arm cannot be moved much by the patient, although it canbe lifted up and away from the side by another person, but cannot bemoved so that, with the elbow against the front of the chest, the handof the injured arm can be laid on the opposite shoulder. Neither canthe arm, with the elbow at a right angle, be made to touch the sidewith the elbow, without causing great pain. =Treatment. =--One of the simplest methods (Stimson's) of reducing thisdislocation consists in placing the patient on his injured side on acanvas cot, which should be raised high enough from the floor onchairs, and allowing the injured arm to hang directly downward towardthe floor through a hole cut in the cot, the hand not touching thefloor. Then a ten-pound weight is attached to the wrist. The gradualpull produced by this means generally brings the shoulder back intoplace without pain and within six minutes. (Fig. 30. ) [Illustration: FIG. 30. TREATING A DISLOCATED SHOULDER. (REFERENCE HANDBOOK. ) Patient lying on injured side; note arm hanging through hole in cotraised from floor on chairs; also weight attached to wrist. ] The more ordinary method consists in putting the patient on his backon the floor, the operator also sitting on the floor with hisstockinged foot against the patient's side under the armpit of theinjured shoulder and grasping the injured arm at the elbow, he pullsthe arm directly outward (i. E. , with the arm at right angles with thebody) and away from the trunk. An assistant may at the same time aidby lifting the head of the arm bone upward with his fingers in thepatient's armpit and his thumbs over the injured shoulder. If the arm does not go into place easily by one of these methods it isunwise to continue making further attempts. Also if the shoulder hasbeen dislocated several days, or if the patient is very muscular, itwill generally be necessary that a surgeon give ether in order toreduce the dislocation. It is entirely possible for a skillful surgeonto secure reduction of a dislocation of the shoulder several weeksafter its occurrence. After the dislocation has been relieved the arm, above the elbow, should be bandaged to the side of the chest and thehand of the injured side carried in a sling for ten days. =DISLOCATION OF THE ELBOW. =--This is more frequent in children, and isusually produced by a fall on the outstretched hand. The elbow isthrown out of joint, so that the forearm is displaced backward on thearm, in the more usual form of dislocation. The elbow joint is swollenand generally held slightly bent, but cannot be moved to any extentwithout great pain. The tip of the elbow projects at the back of thejoint more than usual, while at the front of the arm the distancebetween the wrist and the bend of the elbow is less than that of thesound arm. (See cut, p. 126. ) [Illustration: FIG. 31. Above cut shows characteristic appearance of a dislocated shoulder;note loss of fullness; also elbow held away from side and inwardsloping of arm. FIG. 32. DISLOCATED ELBOW AND SHOULDER. (AMERICAN TEXT-BOOK. ) Fig. 32 shows dislocation of elbow backward; note swollen condition ofleft elbow held slightly bent; also the projection of back of joint. ] For further proof that the elbow is out of joint we must compare therelations of three points in each elbow. These are the two bonyprominences on each side of the joint (belonging to the bone of thearm above the elbow) and the bony prominence that forms the tip of theelbow which belongs to the bone of the forearm. [Illustration: FIG. 33. TREATMENT OF DISLOCATED ELBOW (SCUDDER). Note padded right-angled tin splint; also three strips of surgeon'splaster on arm and forearm. ] In dislocation backward of the forearm, the tip of the elbow isobserved to be farther back, in relation to the two bony prominencesat the side of the joint, than is the case in the sound elbow. This isbest ascertained by touching the three points on the patient's elbowof each arm in turn with the thumb and middle finger on each of theprominences on the side of the joint, while the forefinger is placedon the tip of the elbow. The lower end of the bone of the upper armis often seen and felt very easily just above the bend of the elbow infront, as it is thrown forward (see Fig. 32, p. 126). Fracture of the lower part of the bone of the arm above the elbowjoint may present much the same appearance as the dislocation we aredescribing, but then the whole elbow is displaced backward, and therelation of the three points described above is the same in theinjured as in the uninjured arm. Moreover in fracture the deformity, when relieved, will immediately recur when the arm is released, asthere is nothing to hold the bones in place; but in dislocation, afterthe bones are replaced in their normal position, the deformity willnot reappear. =Treatment. =--The treatment for dislocation consists in bending theforearm backward to a straight line, or even a little more, and thenwhile an assistant holds firmly the arm above the elbow, the forearmshould be grasped below the elbow and pulled with great force awayfrom the assistant and, while exerting this traction, the elbow issuddenly bent forward to a right angle, when the bones should slipinto place. The after treatment is much the same as for most fractures of theelbow. The arm is retained in a well-padded right-angled tin splintwhich is applied with three strips of surgeon's plaster and bandage tothe front of the arm and forearm (see Fig. 33) for two or three weeks. The splint should be removed every few days, and the elbow jointshould be moved to and fro gently to prevent stiffness, and thesplint then reapplied. =DISLOCATION OF THE HIP. =--This occurs more commonly in males fromfifteen to forty-five years of age, and is due to external violence. In the more ordinary form of hip dislocation the patient stands on thesound leg with the body bent forward, the injured leg being greatlyshortened, with the toes turned inward so much that the foot of theinjured limb crosses over the instep of the sound foot. The injuredlimb cannot be moved outward and but slightly inward, yet may be bentforward. Walking is impossible. Pain and deformity of the hip jointare evident. The only condition with which this would be likely to be confused is afracture of bone in the region of the hip. Fracture of the hip iscommon in old people, but not in youth or middle adult life. Infracture there is usually not enough shortening to be perceived withthe eye; the toes are more often turned out, and the patient can oftenbear some weight on the limb and even walk. =Treatment. =--The simplest treatment is that recommended by Stimson, as follows: the patient is to be slung up in the air in a verticalposition by means of a sheet or belt of some sort placed around thebody under the armpits, so that the feet dangle a foot or so from thefloor, and then a weight of about ten or fifteen pounds, according tothe strength of the patient's muscles, is attached to the foot of theinjured leg (bricks, flatirons, or stones may be used), and thisweight will usually draw the bone down into its socket within ten orfifteen minutes. [Illustration: FIG. 34. REDUCING DISLOCATION OF HIP (REFERENCE HANDBOOK). Patient lying on table; uninjured leg held by assistant; leg ofdislocated side at right angles; note weight at bend of knee. ] Or the patient may assume the position shown in the accompanying cut, lying prone upon a table with the uninjured leg held horizontally byone person, while another, with the injured thigh held vertically andleg at right angles, grasps the patient's ankle and moves it gentlyfrom side to side after placing a five-to ten-pound sand bag, orsimilar weight of other substance, at the flexure of the knee. Whenthe dislocation has been overcome the patient should stay in bed for aweek or two and then go about gradually on crutches for two weekslonger. =SURGICAL DRESSINGS. =--Sterilized gauze is the chief surgical dressingof the present day. This material is simply cheese cloth, from whichgrease and dirt have been removed by boiling in some alkalinepreparation, usually washing soda, and rinsing in pure water. Thegauze is sterilized by subjecting it to moist or dry heat. Sterilizedgauze may be bought at shops dealing in surgeons' supplies andinstruments, and at most drug stores. Gauze or cheese cloth may besterilized (to destroy germs) by baking in a slow oven, in tin boxes, or wrapped in cotton cloth, until it begins to turn brown. It is wellto have a small piece of the gauze in a separate package, which may beinspected from time to time in order to see how the baking isprogressing, as the material to be employed for surgical purposesshould not be opened until just before it is to be used, any remainderbeing immediately covered again. Cut the gauze into pieces as large asthe hand, before it is sterilized, to avoid cutting and handlingafterwards. Gauze may also be sterilized by steaming in an Arnoldsterilizer, such as is used for milk, or by boiling, if it is to beapplied wet. Carbolized, borated, and corrosive-sublimate gauze havelittle special value. [Illustration: PLATE I. Fig. I. Fig. II. Fig. III. Fig. IV. APPLYING A ROLLER BANDAGE (REFERENCE HANDBOOK). Fig. I shows method of starting a spiral bandage; Fig. II, ready toreverse; Fig. III, the reverse completed; Fig. IV shows spica bandageapplied to groin. ] Absorbent cotton is also employed as a surgical dressing, and shouldalso be sterilized if it is to be used on raw surfaces. It is not souseful for dressing wounds as gauze, since it mats down closely, doesnot absorb secretions and discharges so well, and sticks to the parts. When torn into balls as large as an egg and boiled for fifteen minutesin water, it is useful as sponges for cleaning wounds. Sheet wadding, or cotton, is serviceable in covering splints before they are appliedto the skin. Wet antiseptic surgical dressings are valuable intreating wounds which are inflamed and not healing well. They are madeby soaking gauze in solutions of carbolic acid (half a teaspoonful ofthe acid to one pint of hot water), and, after application, coveringthe gauze with oil silk, rubber dam, or paraffin paper. Heavy brownwrapping paper, well oiled or greased, will answer the purpose whenbetter material is not at hand. =BANDAGES. =--Bandaging is an art that can only be acquired in anydegree of perfection by practical instruction and experience. Someuseful hints, however, may be given to the inexperienced. Cottoncloth, bleached or unbleached, is commonly employed for bandages; alsogauze, which does not make so effective a dressing, but is mucheasier of application, is softer and more comfortable, and is bestadapted to the use of the novice. A bandage cannot be put on properlyunless it is first rolled. A bandage for the limbs should be about twoand a half inches wide and eight yards long; for the fingers, three-quarters of an inch wide and three yards long. The bandage maybe rolled on itself till it is as large as the finger, and then rolleddown the front of the thigh, with the palm of the right hand, whilethe loose end is held taut in the left hand. [Illustration: PLATE II. Fig. I. Fig. II. Fig. III. Fig. IV. DIFFERENT FORMS OF BANDAGES. (AMERICAN TEXT-BOOK AND REFERENCE HANDBOOK. ) Fig. I shows application of figure-of-eight bandage; Fig. II, a spicabandage of thumb; Fig. III, a spica bandage of foot; Fig. IV, aT-bandage. ] Two forms of bandages are adapted to the limbs, the figure-of-eight, and the spiral reversed bandage. In applying a bandage always begin atthe lower extremity of the limb and approach the body. Make a fewcircular turns about the limb (see Fig. I, p. 132), then as the limbenlarges, draw the bandage up spirally, reversing it each time itencircles the limb, as shown in Fig. I, p. 134. In reversing, hold thebandage with the left thumb so that it will not slip, and thenallowing the free end to fall slack, turn down as in Fig. II, p. 132. The T-bandage is used to bandage the crotch between the thighs, oraround the forehead and over the top of the skull. (See Fig. IV, p. 134. ) In the former case, the ends 1-1 are put about the body as abelt, and the end 2 is brought from behind, in the narrow part of theback, down forward between the thighs, over the crotch, and up to thebelt in the lower part of the belly. The figure-of-eight bandage isused on various parts, and is illustrated in the bandage called spicaof the groin, Fig. IV, p. 132. Beginning with a few circular turnsabout the body in the direction of 1, the bandage is brought down infront of the body and groin, as in 2, and then about the back of thethigh up around the front of the thigh, as in 3, across the back andonce around the body and down again as in 2. Other bandagesappropriate to various parts of the body are also illustrated that bytheir help the proper method of their application may be understood. See pages 132, 134, 136, 137. The triangular bandage (see p. 88) madefrom a large handkerchief or piece of muslin a yard square, cut orfolded diagonally from corner to corner, will be found invaluable inemergency cases. It is easily and quickly adjusted to almost any partof the body, and may be used for dressing wounds, or as a bandage forfractures, etc. [Illustration: PLATE III. Fig. I. Fig. II. BANDAGES FOR EXTREMITIES (AMERICAN TEXT-BOOK). Fig. I shows a spiral reversed bandage of arm and hand, requiringroller 2-1/2 inches wide and 7 yards long; Fig. II shows a spiralreversed bandage of leg and foot, requiring roller 2-1/2 inches wideand 14 yards long. ] [Illustration: PLATE IV. Fig. I. Fig. II. Fig. III. Fig. IV. BANDAGES FOR HEAD AND HAND. (AMERICAN TEXT-BOOK. ) Fig. I shows a gauntlet bandage; Fig. II, a circular bandage for thejaw; Fig. III, a circular bandage for the head; Fig. IV, afigure-of-eight bandage for both eyes. ] CHAPTER VI =Ordinary Poisons= _Unknown Poisons--Antidotes for Poisoning by Acids and Alkalies--TheStomach Pump--Emetics--Symptoms and Treatment of Metal Poisoning--Narcotics. _ _First Aid Rule 1. --Send at once for physician. _ _Rule 2. --Empty stomach with emetic. _ _Rule 3. --Give antidote. _ In most cases of poisoning emetics and purgatives do the most good. =UNKNOWN POISONS. =--Act at once before making inquiry orinvestigation. _First Aid Rule. --Give two teaspoonfuls of chalk (or whiting, orwhitewash scraped from the wall or a fence) mixed with a wineglass ofwater. Beat four eggs in a glass of milk, add a tablespoonful ofwhisky, and give at once. _ Meanwhile, turn to p. 186, and be prepared to follow Rule 2 underSuffocation, in case artificial respiration may be necessary, in spiteof the stimulant and antidotes. After having taken the first steps, try to ascertain the exact poison used, but waste no time at thestart. If you can find out just what poison was swallowed, give thetreatment advised under that poison, excepting what you may alreadyhave given. =ACIDS. =--Symptoms: Corrosion or bleeding of the parts with which theycome in contact, followed by intense pain, and then prostration fromshock. Nitric acid stains face yellow; sulphuric blackens; carbolicwhitens the mucous membrane, and also causes nausea and stupor. =Treatment. =--_Carbolic:_ Give a tablespoonful of alcohol or wineglassof whisky or brandy at once; or one tablespoonful of castor oil, alsoa half pint of sweet oil, also a pint of milk. Put to bed, and applyhot-water bottles. _Nitric and Oxalic:_ Chalk, lime off walls, whitewash scraped offfence or wall, one teaspoonful mixed with a quarter of a glass ofwater. Give one tablespoonful castor oil, and half a pint of sweetoil. Inject into the rectum one tablespoonful of whisky in two ofwater. _Sulphuric:_ Soapsuds, half a glass; a pint of milk. _Other Acids:_ Limewater, or two teaspoonfuls of aromatic spirit ofammonia diluted with a glass of water. One tablespoonful of castoroil. =ALKALIES. =--Symptoms: Burning and destruction of the mucous membraneof mouth, severe pain, vomiting and purging of bloody matter, rapiddeath by shock. _Ammonia; Potash; Lye; Caustic Soda; Washing Soda:_ Give half a glassof vinegar mixed with half a glass of water; also juice of four lemonsin two glasses of water. One teaspoonful of castor oil in half a glassof olive oil. If prostrated, give tablespoonful of whisky in a quarterof a glass of hot water. =METALS. =--Symptoms: Great irritation, cramps and purging, suppressionof urine, delirium or stupor, collapse, and generally death. _Arsenic; Paris Green; Fowler's Solution; "Rough on Rats":_ Intensepain, thirst, griping in bowels, vomiting and bloody purging, shock, delirium. Patient picks at the nose. Send to druggist's for two ounceshydrated sesquioxide of iron, the best antidote, and givetablespoonful every quarter hour in half a glass of water. Meanwhile, or if antidote is not to be had, give a glass or two of limewater, followed by a teaspoonful of mustard dissolved in a glass of water, followed by warm water in any quantity. _Copper; Blue Vitriol; Verdigris:_ Give one tablespoonful of mustardin a glass of warm water. After vomiting, give whites of three eggs, one pint of milk. _Mercury; Corrosive Sublimate; Bug Poison; White Precipitate;Bichloride of Mercury:_ Give whites of four eggs for every grain ofmercury suspected; cause vomiting by giving a tablespoonful of mustardmixed with a glass of warm water, or thirty grains of powdered ipecacmixed with half a glass of water. _Silver Nitrate:_ Give two teaspoonfuls of table salt dissolved intwo glasses of hot water. After half an hour give a tablespoonful ofcastor oil. _Phosphorous; Matches:_ Give teaspoonful of mustard mixed in a glassof water. After vomiting has occurred, give a tablespoonful of gumarabic dissolved in a tumblerful of hot water. An hour later givetablespoonful of Epsom salts dissolved in a glass of water. GIVE NOOIL. _Antimony; Tartar Emetic:_ Symptoms as stated for metals. Give thirtygrains of powdered ipecac stirred in wineglass of water, even ifvomiting has occurred. Give three cups of strong tea, or hot infusionof oak bark, and two teaspoonfuls of whisky in wineglass of hot water. Use hot-water bottles to keep patient warm. =NARCOTICS. =--_Aconite; Belladonna; Camphor; Digitalis; Ergot;Hellebore; Lobelia:_ These all cause nausea, numbness, stupor, rapidity of the heart followed by weakness of heart, delirium orconvulsions, coma, and death. There is often an acid taste in mouth, with dryness of throat and mouth, fever, vomiting and diarrhea, withsevere pain in the bowels. Pupils are dilated. In either case use the stomach pump at once. If no pump is at hand, siphon out stomach with rubber tube and funnel. If tube is notavailable, give thirty grains of powdered ipecac stirred in awineglass of water, followed by two glasses of warm water. As thepatient vomits, give more warm water. When vomiting ceases, give twocups of strong hot coffee, and then a tablespoonful of castor oil. Keep patient awake by rubbing; do not exhaust him by walking himabout. He must lie flat. If prostration follows, give two teaspoonfulsof whisky in wineglass of hot water from time to time, if repetitionis necessary. _Alcohol; Liquors Containing It:_ Symptoms of drunkenness, stupor, drowsiness, irritability of temper, rapid, weak heart, sleep, coma. Breath testifies. If possible, use stomach pump early, or tube and funnel. Or givethirty grains of powdered ipecac stirred in a wineglass of water, andwhen vomiting ceases give thirty drops of aromatic spirit of ammoniain a wineglass of water every half hour till pulse has become full andrapid. Then apply cold to the head and heat to the extremities. _Chloral; Patent Sleeping Medicines; "Knock-out Drops. "_ Symptoms:Nausea, coldness and numbness, stupidity, prostration, often vomitingand purging, sleep, coma. Heart very weak, with pulse at wrist veryfeeble. Constriction of the mouth and throat, with dryness. Pain inbowels is marked before stupor appears. Use stomach pump if possible, or empty stomach with rubber tube andfunnel, siphoning fluids out. Or give thirty grains of powdered ipecacstirred in a wineglass of water. When vomiting ceases, give twoteaspoonfuls of whisky in half a glass of hot water. Give hypodermicinjection of sulphate of strychnine, one-twentieth of a grain everytwo or three hours, till patient is roused and weakness is past. Rubbing of the surface, application of hot-water bottles to the bodyand legs. If breathing ceases, follow Rule 2 under Suffocation (p. 186) tillbreathing is well established again. _Opium; Morphine; Laudanum; Paregoric; Soothing Syrups. _ Symptoms:Drowsiness, sleep, stupor when roused, pupils very small--"pin point"unless patient is used to the drug--constipation, cold skin. Use stomach pump, if at hand. Or give emetic of thirty grains ofpowdered ipecac stirred in a wineglass of water, followed by twoglasses of warm water, as vomiting proceeds. Let the patient inhaleammonia or smelling salts. Give him half a grain of permanganate ofpotash dissolved in a wineglass of water, every half hour. Inject twoounces of black coffee, at blood heat, into the rectum. Rub the lower part of the body and legs briskly toward the heart, while artificial respiration is being carried out. See Rule 2 underSuffocation (p. 186). Thirty drops of tincture of belladonna to anadult, every hour, will assist the breathing. Do not exhaust thepatient by walking him around, slapping him with wet towels, orstriking him on the calves; keep him awake by rubbing. _Tobacco when Swallowed:_ Nausea and vomiting occur, with severe painand great prostration; delirium or convulsions may follow. The heart, at first rapid and full, becomes weak and compressible. Give emetic at once: thirty grains of powdered ipecac stirred inwineglass of water, followed by two glasses of warm water, by degrees. Give whisky, two teaspoonfuls in wineglass of hot water. Keep patientwarm. _Nux Vomica; Strychnine. _ Symptoms: Excitement, rapid heart action, restlessness, panic of apprehension, twitching of forearms and hands, possibly convulsions, during consciousness. Use stomach pump, if possible, or give thirty grains of powderedipecac stirred in a wineglass of water. Then, when vomiting hasceased, give twenty grains of chloral, together with thirty grains ofbromide of sodium in half a glass of water, at blood heat, injectedinto the rectum. Give twenty grains of bromide of sodium in awineglass of water, every hour, by the mouth. If convulsions, put chloroform before nose and mouth, as follows: pourtwenty drops of chloroform on a handkerchief and hold it close to themouth, letting air pass freely under it. Stop when patient relaxes. Resume if he becomes rigid again. _Cocaine. _ Symptoms: General nervousness, irritability of temper, wakefulness, followed quickly by great pallor, dilatation of thepupils, unconsciousness, and convulsions. Give the patient two teaspoonfuls of whisky in a wineglass of waterevery hour. Give, if possible, a hypodermic of a thirtieth of a grainof strychnine, every two hours, or as he may require it, to keep thepulse full and strong. Use hot-water bottles to feet and legs. _Phenacetin; Acetanilid; Headache Powders:_ Give two teaspoonfuls ofwhisky in a wineglass of hot water. If the heart flags, give tinctureof digitalis, five minims in tablespoonful of water, every two hours, or till three doses are given. It is better to use digitalin, oneone-hundredth of a grain hypodermically, if possible. CHAPTER VII =Food Poisoning= _Food Containing Bacterial Poisons Resulting from Putrefaction; FoodInfected with Disease Germs; Food Containing Parasites--Tapeworm--Trichiniasis--Potato Poisoning. _ =FOOD POISONING. =--Much the same symptoms from all meats, fish, shellfish, milk, cheese, ice cream, and vegetables; namely, vomiting, cramps, diarrhea, headache, prostration, weak pulse, cold hands andfeet, possibly an eruption. _First Aid Rule 1. --Rid patient of poison. Cause repeated vomiting bygiving three or four glasses of warm water, each containing half alevel teaspoonful of mustard. Put finger down throat to assist. Emptybowels by giving warm injection of soapsuds and water by fountainsyringe. _ _Rule 2. --Support heart and rally nerve force. Give teaspoonful ofwhisky in tablespoonful of hot water every half hour, as needed. Puthot-water bottles at feet and about body. _ =Conditions, Etc. =--Bacterial poisons, constituting irritants of thestomach and bowels, are found in certain mussels, oysters fromartificial beds, eels out of stagnant ditches--as well as the uncookedblood of the common river eel--certain fish at all times, certain fishwhen spawning, putrefied fish, fermented canned fish, sausages ofwhich the ingredients have putrefied, putrefied meat, imperfectlycured bacon, putrefied cheese, milk improperly handled and not cooledbefore being transported, ice cream which fermented before freezing, or ice cream containing putrid gelatin, and mouldy corn meal and thebread made from it. These poisons are called toxins, or toxalbumins, or bacterialproteids. They are no longer called ptomaines, because many ptomainesare not poisonous. They are formed within the cells of the bacteria, and result from the combination of certain constituents of the foodmaterial that nourishes the bacteria, in some way not quiteunderstood. Some decomposition must have taken place in the foodbefore it can furnish to the bacteria the nourishment it needs. Ifthis has happened, the bacteria multiply rapidly, and the toxins thatare formed are taken up by the lymphatics and carried away from thetissues as fast as possible. But so great is their virulence that theyact on several vital organs before they can be antagonized by thenatural elements of the blood. =Symptoms. =--The symptoms are much the same in all the cases ofbacterial poisoning mentioned. Sudden and violent vomiting anddiarrhea appear a few hours after eating the spoiled food, or may bedelayed. There may be headache, colic, and cramps in the muscles. Marked prostration and weak pulse with cold hands and feet arecharacteristic. The appearance of skin eruptions is not uncommon. Theoccurrence of such symptoms in several persons, some hours afterpartaking of the same food, is sufficient to warrant one inpronouncing the trouble food poisoning. =Treatment. =--The objects of treatment are to rid the patient of thepoison, and to stimulate the heart and general circulation, and drawon the reserve nerve force. It is best to procure medical aid to washout the stomach, but when this is impossible, the patient should beencouraged to swallow plenty of tepid water and then vomit it. Ifthere is no natural inclination to do so, vomiting may be broughtabout by putting the finger in the back of the throat. The sameprocess should be repeated a number of times, and the result will bealmost as good as though a physician had used a stomach tube. Ateaspoonful of salt or tablespoonful of mustard in the water willhasten its rejection. Then the bowels should likewise be emptied. Ifvomiting continues this will not be possible by means of drugs givenby the mouth, although calomel may be retained given in half-graintablets hourly to an adult, until the bowels begin to move, or tilleight to ten tablets are taken. When vomiting is excessive, emptyingof the bowels may be brought about quickly by giving warm injectionsof soapsuds into the bowel with a fountain syringe. Brandy or whiskyin teaspoonful doses given in a tablespoonful of hot water athalf-hour intervals should follow the emptying of the stomach andbowels, and the patient must be kept quiet. He must also be kept warmby means of hot-water bags and blankets. =INFECTED FOOD. =--A frequent source of illness is infection by diseasegerms transmitted in food. The meat of animals slaughtered when sickwith abscess, pneumonia, kidney disease, diarrhea, or anthrax(malignant pustule) carries disease germs and causes serious illness;so does the meat of animals killed after recent birth of their young, and probably having fever. Oysters may be contaminated with excrementfrom typhoid patients, and may then transmit the disease to those whoeat them. Milk from diseased animals, or contaminated with germs of typhoidfever, scarlet fever, tuberculosis, diphtheria, etc. , is apt to causethe same disease in the human being who drinks it. If such infected food is eaten raw, the diseases with which it iscontaminated may be transmitted. If subjected to cooking at atemperature of at least the boiling point, comparative safety issecured; but the toxins accompanying the disease germs in the infectedfood are not as a rule rendered harmless. Treatment must be directedto each disease thus transmitted. Poisoning resulting from eating canned meats has sometimes beenattributed to supposed traces of tin, zinc, or solder, which havebecome dissolved in the fluids of the meat, but in the vast majorityof cases such poisoning is due to toxins accompanying the germs ofputrefaction, the meats having been unfit for canning at the outset. In such cases the symptoms are the same as in other food poisoning, and the treatment must be such as is elsewhere directed (see pp. 147and 149). While human breast milk is germ free, the cows' milk sold in cities isa very common source of disease. Scrupulous care of the cows, of theclothing and hands of the milkers, of the stables at which the herdsare quartered, and of the cans, pails, and pans used, reduces to aminimum the amount of filth and impurity otherwise mixed with milk. Inthe household, as well as during transportation, milk should be keptcool, with ice if necessary. It should also never be left uncovered, for it readily absorbs gases, effluvia, and contaminating substancesin the air, and affords an excellent medium for the growth andpropagation of germs. When partially or entirely soured, it should notbe used, except in the preparation of articles of food by cooking, asdirected in cook books. It should never be used if there is any doubtabout its purity. Unless all doubt has been removed, it is best tosubject milk intended for children's consumption to a temperature of160° F. For ten minutes, and then put it on the ice, especially duringhot weather. Germs are thus rendered harmless, and the nourishingqualities of the milk remain unimpaired. Summer diarrhea of children, also called cholera infantum, occurs asan epidemic in almost all large cities during the hottest days ofsummer. The disease is largely fatal, especially during the first hotmonth, because the most susceptible and tender children are the firstaffected. It is due to the absorption into the systems of thesechildren of the toxins formed during the putrefying of milk in thestomachs and bowels of the little sufferers. Clean, pure sweet milk, free from bacteria should be used to prevent the occurrence of thisdisease. Its treatment is outlined in Vol. III. Exactly what bacteriacause the disease is not decided. Possibly the milk is infected, butprobably the poisonous results come from toxins. =FOOD CONTAINING PARASITES. =--The parasites found in food in thiscountry are echinococcus, guineaworm, hookworm, trichina, andtapeworm. Echinococcus cannot be understood or diagnosed by thelayman. Guineaworm is excessively rare in the United States; it gainsaccess into the body through drinking water which contains theindividuals. Hookworm is the cause of "miners' anæmia, " and isextremely rare in this country. The entrance of living food parasites can be absolutely prevented bythorough cooking of meats, especially pork and beef. Heat destroys the"measles" and the trichina worms. =TAPEWORM. =--This is developed in man after eating "measly" beef orpork. "Measles" are embryo tapeworms called, from their appearance, "bladder worms. " In from six to ten weeks after being received intothe intestine of a man, these bladder worms become full grown, andmeasure from ten to thirty feet in length--the tapeworms. =Symptoms. =--Vertigo, impairment of sight and of hearing, itching ofthe nose, salivation, loss of appetite, dyspepsia, emaciation, colic, palpitation of the heart, and sometimes fainting accompany thepresence of the tapeworm. Generally the condition becomes knownthrough the passage in the excrement of small sections of the worm. These sections resemble flat portions of macaroni. =Treatment. =--This, to be successful, must be directed by a physician. When no physician can be procured, the patient may attempt his ownrelief. After fasting for twenty-four hours, pumpkin seed, from whichthe outer coverings have been removed by crushing, are soakedovernight in water and taken on an empty stomach in the morning; achild takes one or two ounces thoroughly mashed and mixed with sirupor honey, and an adult four ounces (see Vol. III, p. 245). =TRICHINIASIS. =--This is a dangerous disease caused by the presence inthe muscles and other tissues of the trichinæ, little worms which areswallowed in raw or partly cooked pork, ham, or bacon. Nausea, vomiting, colic, and diarrhea appear early, generally on the secondday after eating the infected meat. Later, stiffness of the musclesoccurs, with great tenderness, swelling of the face and of theextremities, sweating, hoarseness, difficult breathing, inability tosleep, bronchitis, and pneumonia. There is no treatment for the disease. Many cases which are not fatalare probably considered to be obscure rheumatism. Many cases ofpneumonia are caused by the worm. =POTATO POISONING. =--There remains one variety of food poisoning whichneeds mention, since it occurs when least expected, and when properfood has been subjected to natural growth. As the potato belongs tothe botanical family containing the dangerous belladonna, tobacco, hyoscyamus, and stramonium, it is not surprising that is should alsocontain a powerful poisonous alkaloid, namely, solanine. Solanine isdeveloped in potatoes, especially during their sprouting stage. Violent vomiting and diarrhea and inflammation of the stomach andbowels are caused by it. Careful peeling of sprouting potatoes, andremoval of their eyes, will lessen, if not wholly obviate, the dangerfrom eating them. This form of food poisoning is rare. CHAPTER VIII =Bites and Stings= _Several Kinds of Mosquitoes--Cause of Yellow Fever--Bee, Wasp, andHornet Stings--Wood Ticks, Lice, and Fleas--Scorpions andCentipedes--Poisonous Snakes--Dog and Cat Bites. _ =MOSQUITOES. =--The female mosquito is the offender. During or aftersucking blood she injects a poison into the body which causes itching, swelling, and, in some susceptible persons, considerable inflammationof the skin. The bites of the mosquitoes living on the shores of theArctic Ocean and in the tropics are the most virulent. The mostimportant relation of mosquitoes to man was only recently discovered. They are probably the sole cause of malaria and yellow fever in thehuman being. The malarial parasite which lives in the blood of man, when he is suffering from malaria, first inhabits the body of acertain kind of mosquito. The mosquito acquires the undevelopedparasite by biting the human malarial patient, and then acts as amedium of infection by transmitting the active parasite to somehealthy man, through the bite. The more common house mosquito, the Culex, does not carry the parasiteof malaria, and it is important to be able to distinguish theAnopheles which is the source of malaria. The Anopheles is more commonin the country, while the Culex is a city pest. The Culex has veryshort palpi, the name given to the projections parallel to theproboscis; while those of Anopheles are so large that it appears tohave three probosces. There are no markings on the wings of theordinary species of Culex, while the wings of Anopheles are distinctlymottled. The Culex, sitting on a wall or ceiling, holds its hind legsabove its back and its body nearly parallel to the wall or ceiling, but the Anopheles carries its hind legs either against the wall orhanging down (rarely above the back), and its body, instead of lyingparallel to the wall or ceiling, hangs away at an angle of aboutforty-five degrees from it. The Culex lays her eggs in sinks, tanks, cisterns, and water abouthouses, but the Anopheles deposits her ova in shallow pools andsluggish streams, especially those on which is a growth of green scumor algæ. Such are the main distinguishing features of themalaria-carrying mosquito, the Anopheles, and the commoner housevariety, the Culex. To prevent malaria, mosquito bites must be prevented by nettings inhouses, especially for the protection of sleepers. Pools, ponds, andmarshy districts must be drained in order to destroy the breedingplaces of Anopheles, and in the malarial season, petroleum (kerosene)must be poured on the surface of such waters to arrest the developmentof the immature insects (larvæ). The mosquito is believed to be the sole cause of yellow fever, beingcapable of communicating the germ of the disease to man by its bitetwo weeks after it has itself been contaminated with the germ infeeding on the blood of a yellow-fever patient. This invaluablediscovery was made by Dr. Walter Reed, U. S. A. , in 1901, as a resultof his labors and those of other members of the yellow-fevercommission of the U. S. Army in Cuba, involving the death of one ofthe members of the commission (Dr. Lazear), and utilizing the heroismof a number of our young soldiers who voluntarily offered themselvesto be bitten by mosquitoes that had previously bitten yellow-feverpatients, and who experimentally occupied premises containing allsorts of articles infected by yellow-fever patients. The result oftheir research proves that yellow fever is not contagious at all, inthe usual sense, but is communicated only through the medium ofmosquitoes. This shows the fallacy of many quarantine rules regardingyellow-fever patients, and of the fear of nursing the sick, and willresult in controlling the disease. In the case of malaria or yellow fever, there is a vicious circle intowhich man and the mosquito enter; malaria and yellow-fever patientscontaminate the mosquitoes which bite them, and the mosquitoes intheir turn infect man with these diseases. A patient with malariacoming into a nonmalarial place, and being bitten by mosquitoes, maylead to an epidemic of the disorder which becomes endemic. Toterminate this condition, it is necessary to prevent the contact ofman with mosquitoes and to kill these insects. Both malaria andyellow fever will doubtless be practically eradicated before longthrough the result of these scientific discoveries. =Treatment of Mosquito Bites. =--To prevent mosquitoes, fleas, lice, horseflies, etc. , from biting, it is necessary merely to dip the cleanhands into a pail of water in which, while hot, one ounce of purecarbolic acid was dissolved, and while they are thus wet rub thesolution over all the exposed skin and allow it to dry naturally. Amixture of kerosene (petroleum) and water used in the same way willalso afford protection. All poisons introduced into the body byinsects are of an acid nature, and to this quality are due the painand irritation which it is our object to overcome. The best remedy, naturally, is an alkali of some sort. Water of ammonia, diluted, or astrong solution of saleratus or baking soda in water, are the two mostsuccessful remedies to apply, either through bathing, or on clothssaturated in one of the solutions. Clean clay, mixed with water tomake a mud poultice, is a useful application in emergencies. =BEE, WASP, AND HORNET STINGS. =--The pain and swelling are produced bythe poison of the insect which leaves the poison bag at the base ofthe barb at the instant that the person is stung. The bee stings butonce, as the sting being barbed is broken off, and is retained in theflesh of the victim. The sting of the wasp and hornet is merelypointed, and is not lost during the stinging process so that they canrepeat the act. Bee keepers, after being stung a number of times, usually become immune, i. E. , they are no longer poisoned by bites ofthese insects. It is well to extract the sting of bees before all of the poison hascome away. A fine pair of forceps is useful for this purpose; or, bypressing the hollow tube of a small key directly down over thepuncture made by the sting, it may be squeezed out. Ammonia water, as recommended for mosquitoes, is the best remedy torelieve the pain. =WOOD TICKS. =--Ticks inhabit the woods and bushes throughout thetemperate zone, and at certain periods during the summer season attackpassing men and animals. The common tick is nearly circular in shape, very flat, with a dark, brown, horny body about one-sixteenth to one-eighth inch in diameter. Each of its eight legs possesses two claws, and the proboscis inclosesfeelers which are similarly armed. The beetle plunges its barbedproboscis into the flesh of man or animals, and holds on very firmlywith its other members till it is gorged with blood, growing as largeas a good-sized bean, when it drops off. The bite is painless, and itis not until the insect is engorged with blood that it is perceptible;if, however, attempts are made to remove the tick before it is readyto let go, the proboscis may be torn off and left in the skin, whenpainful local suppuration will follow. =Treatment. =--As the presence of tick is far from agreeable, theinsect may often be removed by painting it with turpentine, whicheither kills it or causes the claws to be relaxed; in either case thetick loosens its hold and drops to the ground. A tropical variety, carapato, buries the whole head in the flesh of its host before it isperceived, and if turpentine does not loosen its hold, the head mustbe dug out with a clean needle or knife blade. =LICE= (_Pediculi_). --Head lice are most common. They are gray withblack margins, about one-twenty-fifth to one-twelfth inch long, andwingless. The color changes with the host, as the lice are black onthe negro, and white in the case of the Eskimos. The female lays fiftyto sixty eggs ("nits"), seen as minute, white specks glued to the sideof a hair; usually not more than one or two on a single hair. The eggshatch in six days. The irritation produced by the presence of the parasites on the headleads to general itching, more particularly on the lower part of theback of the head. The constant scratching starts an inflammation ofthe skin with the formation of pimples, weeping spots, and crusts, from the dried discharge, possessing a bad odor. The denuded spotsbecoming infected, the neighboring glands enlarge and are felt astender lumps beneath the skin at the back of the neck, under the jaw, or at either side of the neck. Whenever there are persistent itchingand irritation of the scalp, particularly at the back of the head, lice or "nits" should be sought for. Sometimes it is more easy to findthem on a fine-tooth comb passed through the hair. Lice are verycommon in dirty households, and are occasionally seen on the mostfastidious persons, who accidentally acquire them in public places orconveyances. =Treatment. =--The hair should be cut short when permissible. Anycrusts on the head should be softened by the application of sweet oil, and then removed by washing in soap and warm water. Petroleum orkerosene is a good remedy. It must be rubbed on the head twosuccessive nights, the head being covered by a cap, and washed offeach morning with hot water and soap. The patient must be cautionednot to approach an open flame after kerosene has been put on his head. The eggs or "nits" are next to be attacked with vinegar, which issponged on the hair and the fine-tooth comb plied daily for a week. The remaining irritation of the scalp can be cured by washing the headdaily and applying sweet oil. A simpler plan consists of drenching hair and scalp twice with coldinfusion of (poisonous) larkspur seed, made by steeping for an hour anounce of the seed in six ounces of hot water. This treatment will destroy both insects and eggs. After twenty-fourhours the hair and scalp must be shampooed with warm water thoroughly. =CLOTHES LICE. =--These insects are a trifle larger than the head lice, being one-twelfth to one-eighth inch long, of a dirty, yellowish-graycolor, and only infesting the most filthy people. The lice aregenerally only seen on the clothes, where they live, coming out on thebody only to feed. The visible signs on the body are varying degreesof irritation from redness to ulceration, due to scratching. Thetreatment is simply cleanliness of the body and clothes. =CRAB LICE. =--The crab louse or "crab" inhabits the skin covered byhair about and above the sexual organs most frequently, and fromthence spreads to the hairy region on the abdomen, chest, armpits, beard, and eye lashes. Itching and scratching first call attention tothe presence of the parasites, which are even more troublesome thanthe other species. Application of kerosene to the part is sufficient to kill the lice, but this treatment must be repeated several times at intervals of aweek, in order to kill the parasites subsequently hatched. =FLEA. =--Flea bites are recognized by the itching caused by the poisonintroduced by the insect, and by points of dried blood surrounded fora little while by a red zone. In the case of children and people withdelicate skins, red or white lumps appear resembling nettlerash. Generally the skin is simply covered with minute, red points, perhapsraised a little by swelling above the surface, and when very numerousmay remotely resemble the rash of measles. Fleas, unlike lice, do notbreed on the body, but as soon as they are satiated leave their host. Their eggs are laid in cracks in floors, on dirty clothes and similarspots, and it is only the mature flea which preys upon man. The humanflea may infest the dog and return to man, but the dog flea is adistinct species, and never remains permanently on the human host. Forthese reasons it is not difficult to get rid of fleas after they haveattacked the body, unless continually surrounded by them. =JIGGER OR SAND FLEA. =--Also called chique, chigo, and nigua. It iscommon in Cuba, Porto Rico, and Brazil. About one-half the size of theordinary flea, it is of a brownish-red color with a white spot on theback. The female lives in the sand and attacks man, on whom she lives, boring into the skin about the toe nail, usually, and laying her eggsunder the skin, which gives rise to itching at first and then violentpain. The insect sucks blood and grows as it gorges itself, producinga white swelling of the skin in the center of which is seen a blackspot, the front part of the flea. The flea after expelling its eggsdrops off and dies. People with habitually sweaty feet are exempt fromattacks of the pest. Unless the flea is unattached, one must either wait until the insectcomes away of its own free will, or remove it with a red-hot needle inorder to destroy the eggs. The negroes peel the skin from the swellingwith a needle and squeeze out the eggs. Ordinarily the bites do nopermanent injury, but occasionally if numerous, or if the insect ispressed into the skin in the efforts to remove it, or if soresresulting from bites are neglected, then violent inflammation, greatpain, and even death of the part may result. Sound shoes and a nightand morning inspection of the feet will protect against the inroads ofthe sand fleas. =FLIES. =--The common housefly does not bite, but is constantlyinimical to human health by conveying disease germs of typhoid fever, cholera, and other disorders from bowel discharges of patientssuffering from these diseases to articles of food on which the insectslight. Flies have been a fruitful source of sickness in militarycamps, as evidenced in the recent Spanish-American and Anglo-Africancampaigns. The bites of the sandfly, gadfly, and horsefly may be bothrelieved and prevented by the same means recommended in the case ofmosquitoes for these purposes. =SCORPION OR CENTIPEDE STING. = _First Aid Rule. --Squeeze lemon juice on wound. _ =SPIDER OR TARANTULA BITE. = _First Aid Rule. --Pour water of ammonia on bite. If patient isdepressed, give strong coffee. _ =SCORPIONS AND CENTIPEDES. =--These both inhabit the tropics andsemitropical regions, and lurk in dark corners and out-of-the-wayplaces, crawling into the boots and clothing during the night. Scorpions sting with their tails, which are brought over the head andback for the purpose, while holding on to the victim with theirlobsterlike claws. The poisonous centipede has a flattenedbrownish-yellow body, with a single pair of short legs for each bodysegment, and long, many-jointed antennæ. The wounds made by either of these pests are rarely dangerous, exceptin young children and those in feeble health. The stings are usuallyrelieved by bathing with a two per cent solution of carbolic acid, with rum, or with lemon juice. =SPIDERS. =--Many of the tropical spiders bite the human being. Trapdoor spiders are among the commonest of these pests. Their bodiesgrow to great size, two to two and a half inches long, and are coveredwith hair giving them a horrid appearance. They live in holes bored inthe ground, and provided with a trapdoor contrivance which is closedwhen the insect is at home. The trapdoor spider resembles the tarantula, by which name it isusually known in Cuba and Jamaica, but is somewhat smaller andcommoner. Neither the stings of the trapdoor spider nor true tarantulaare usually dangerous although the wounds caused by the bites may healslowly. Application of water of ammonia and of the other remedies recommendedfor mosquito bites (p. 158) are indicated here, and if the patient isgenerally depressed by the poison, strong coffee forms a goodantidote. =SNAKE BITE. = _First Aid Rule 1. --Make the wound bleed. Cut slit through the wound, lengthwise of limb, two inches long and half an inch deep. Squeezetissues. _ DO NOT SUCK THE WOUND. _Rule 2. --Keep poison out of general circulation. Tie large cord orbandage tightly about part between wound and heart. Loosen in fifteenminutes. _ _Rule 3. --Use antidote. Wash wound and cut with fresh solution ofchloride of lime (one part to sixty parts of water). Injectanti-venene with hypodermic syringe, ten cubic centimeters, as onlabel. Or, inject with hypodermic syringe thirty minims of solution ofpermanganate of potash (five grains to two ounces of water), threetimes in different places. If no syringe at hand, pour permanganatesolution into wound. _ _Rule 4. --Support heart if weak. Inject with hypodermic syringeone-thirtieth grain of sulphate of strychnine into leg. Repeat asneeded every thirty minutes with caution. _ _Rule 5. --Give no whisky or other liquor. Do not burn the wound. _ =SNAKE BITE. =--There are many different species of poisonous snakes inthe United States. The more common are the rattlesnake, the moccasin, the copperhead, and the common viper. All the venomous snakes have certain characteristics by which they maybe distinguished from their harmless brethren. The head is generallybroad and flat and of a triangular shape, the wide, heavy jawstapering to a point at the lips. There is a depression or pit betweenthe nostril and eye on the upper lip, hence the name "pit vipers"given to poisonous snakes. The pupil of the eye is long and vertical, of an oval or elliptical shape. Venomous snakes are thicker in proportion to their length thanharmless snakes, the surface of their bodies is rougher, and theirtails are blunt or club-shaped. Conversely, harmless snakes possesslong narrow heads, the pupils of their eyes are round, not verticalslits, and their bodies are not thick for their length, but long andslim with pointed tails. The bite of vipers of all kinds is much morepoisonous in tropical regions, and in the North fatal snake bite is arare occurrence. If there is a doubt whether a snake is poisonous, the neck may bepressed down against the ground between the jaws of a forked stick, and the poison fangs looked for without danger. These hang directlydown from the front part of the upper jaw, or are thrust horizontallyforward just in front of the upper lip, and may drip saliva and venom. In Cuba and Porto Rico there is a viper called Juba, or Boaquira, which is a counterpart of the Northern rattlesnake, and the mostpoisonous of the many species in that region. Among venomous speciesof the Philippines are two boas and also a viper from nine to ten feetlong, which exceptionally pursues and attacks man. This snake iseasily killed by a blow on the neck. Another small viper with aclub-shaped tail, inhabiting these islands, is nocturnal in itshabits, and may get into boots at night. Boots, therefore, shouldalways be inspected before one puts them on in the morning. Usually it is only the young, old, and weak who succumb to snake bite. =Symptoms. =--The symptoms of snake bite of all poisonous species aresimilar. At first there is some pain in the wound, which rapidlyincreases together with swelling and discoloration until death of thepart may ensue. The vital centers in the brain controlling the heartand breathing apparatus, are paralyzed by the poison. There is oftendrowsiness and stupor, and the breathing is labored and the pulse weakand irregular, with faintness and cold sweats. =Treatment. =--The treatment consists first in keeping the poison outof the general blood stream. With this purpose in view a handkerchief, piece of cotton clothing, string, or strap should be immediately woundabout the bitten limb above the wound, between it and the heart. Thiswill retard absorption of the poison only for a time; it is saidtwenty-five minutes. The knife is the most effective means of removingthe poison by making an oval cut on each side of the wound so that thetwo incisions meet and remove all the flesh below and around thewound. Bleeding should be encouraged to drain out the poison. The skincontaining the wound may be lifted up, and the whole wound cut out byone snip of the scissors where this is practicable. Some advocate burning out the wound with a red-hot wire, or darningneedle, instead of cutting, but the treatment is less effective andmore painful. Rambaud forbids burning. As to the general condition: ifstupor is a prominent symptom the patient must be made to move aboutand exercise to keep alive his nerve centers. Otherwise onetablespoonful of whisky may be given in half a cup of hot waterhourly, to sustain the weakened heart and respiration until recoveryensues. The most effective treatment, according to Dr. George Rambaud, Director of the Pasteur Institute of New York City, is thoroughwashing of the wound (after it has been opened with the knife) withfreshly prepared solution of chloride of lime, in the proportion ofone part of lime to sixty of water. The burning of a wound is badpractice. If necessary, chloride-of-lime solution should be injectedinto the tissues around the wound. One about to go into a place wherethe most venomous snakes are found should inject into himself a doseof Calmette's antivenomous serum every two or three weeks as a meansof prevention. If the serum is used, whisky should not be given in thetreatment of one who has been bitten, for the anti-venene is apowerful cell stimulator. Calmette, the Director of the Pasteur Institute in Lille, France, several years ago discovered antivenomous serum. That serum isefficient for the bites of most of the venomous snakes of differentcountries, including the rattlesnake, cobra, python, etc. It is prepared in the dry form so that it can be carried easily, andwill keep almost indefinitely. The proper course to be followed bypersons going into countries infested by venomous snakes is always tohave on hand a few doses of it. Its value has been positivelydemonstrated within the last few years in India, where it is used inthe British Army, as well as in other countries. In the fluid form it should be used hypodermically, a dose of tencubic centimeters being injected within eighty or ninety minutes ofthe reception of the poison. =DOG BITE OR CAT BITE. = (See Hydrophobia, Vol. V, p. 264. ) _First Aid Rule 1. --Make sure animal is mad. Send patient to Pasteurinstitute if one is within reach. _ _Rule 2. --Remove poison from wound. Encourage bleeding by squeezingtissue about wound. Suck wound, if you have no cracks in lips, andspit out fluid. Pour hot carbolic solution into wound (a third of ateaspoonful of carbolic acid to a pint of hot water). _ _Rule 3. --Cauterize. Dip wooden meat skewer, or lead pencil, into purenitric acid, and rub into wound. Or, use red-hot poker, or red-hotnail grasped by tongs or pincers, or red coal from fire. _ _Rule 4. --Do not kill the animal. If he is alive and well at the endof a week, he was not mad. _ CHAPTER IX =Burns, Scalds, Frostbites, Etc. = _Classes of Burns--Treatment--Burns Caused by Acids andAlkalies--First Aid Rules for Frostbites--Real Freezing--Ingrowing ToeNail--Fainting--Suffocation--Fits. _ =BURNS AND SCALDS. =--If slight, skin very red, unbroken. _First Aid Rule. --Cover with cloths wet in strong solution of bakingsoda in cold water. Dry gently, and spread with white of egg, thick. _ If deeper, blisters, skin broken, thick swelling; there may be somebleeding. _First Aid Rule 1. --Stop pain quickly. Cut away clothing very gently. Break no blisters. Cover with Carron oil (equal parts of limewater andlinseed or olive oil) and light bandage. Give fifteen drops oflaudanum[9] every half hour in tablespoonful of water, till relievedin part or three doses are taken. _ _Rule 2. --Combat shock. If patient is cold, pulse weak, head confused, give tablespoonful of whisky in a quarter of a glass of hot water. Puthot-water bottles at feet. _ _Rule 3. --Quench thirst with pieces of ice held in mouth or a swallowof cold milk. _ See page 174 for subsequent treatment. A burn is produced by dry heat, a scald by moist heat; the effect andtreatment of both are practically identical. Burns are commonlydivided into three classes, according to the amount of damageinflicted upon the body. _First Class. _--There is redness, pain, and some swelling of the skin, followed, in a few days, by peeling of the surface layer (epidermis)and recovery. Sunburn and burns caused by slight exposures to gasesand vapors fall into this category. =Treatment. =--The immediate immersion of the part in cold water isfollowed by relief, or the application of cloths wet with a saturatedsolution of saleratus or baking powder is useful. Anything whichprotects the burned skin from the irritating effect of the air isefficacious, and in emergencies any one of the following may beapplied: starch, flour, molasses, white paint, or a mixture of whiteof egg and sweet oil, equal parts. Usually after the first pain hasbeen relieved by bathing with soda and water, or its application oncloths, the employment of a simple ointment suffices, as cold cream orvaseline. _Second Class. _--In this class of cases the inflammation is moresevere and the deeper layers of the skin are involved. In addition tothe redness and swelling of the skin there are present blisters whichappear at once or within a few hours. The general condition isaffected according to the size of the burn. If half of the body isonly reddened, death usually results, and a burn of a third of thebody is often fatal. The shock is so great at times that pain may notbe at once intense. Shock is evidenced by general depression, withweakness, apathy, cold feet and hands, and failure of the pulse. Ifthe patient rallies from this condition, then fever and pain becomeprominent. If steam has been inhaled, there may be sudden death fromswelling of the interior of the throat, or inflammation of the lungsmay follow inhalation of smoke and hot air. _Third Class. _--In this class are included burns of so severe a naturethat destruction and death of the tissues follows; not only of theskin but of the flesh and bones in the worst cases. It is impossibleto tell by the appearance of the skin what the extent of thedestruction may be until the dead parts slough away after a week orten days. The skin is of a uniform white color in some cases, or maybe of a yellow, brown, gray, or black hue, and is comparativelyinsensitive at first. Pus ("matter") begins to form around the deadpart in a few days, and the dead tissue comes away later, to befollowed by a long course of suppuration, pain, excessive granulations("proud flesh"), and, unless skillfully treated, by contraction of thesurrounding area, leaving ugly scars and interfering with theappearance and usefulness of the parts. The treatment of such casesafter the first care becomes that to be pursued in wounds generally(p. 50), and belongs within the domain of the surgeon. =Treatment of the More Severe Burns. =--If the patient is sufferingfrom shock he should receive some hot alcoholic drink, as hot waterand whisky, and be put to bed under warm coverings with hot-water bagsor bottles at his feet. The clothing must be cut away from the burned parts with the greatestcare, and only a portion of the body should be uncovered at a time andin a warm room. Pain may be subdued by laudanum[10]; fifteen drops maybe given to an adult, and the drug may be repeated at hour intervalsin doses of ten drops until the suffering has been allayed. Lumps ofice held in the mouth will quench thirst, and the diet should beliquid, as milk, soups, gruels, white of egg, and water. The bowelsshould be moved daily by rectal injections of soap and warm water. Asa matter of local treatment, the surface layer of the skin should bekept intact if possible. Blisters are not to be disturbed unless theyare large and tense; if so, their bases may be pricked with a needlesufficiently to let out the fluid contents. Carron oil (equal parts of olive oil and limewater) has been thecommon remedy for burns, and it is an efficient, though very dirty, dressing, useful if the skin is generally unbroken. It should beapplied on clean, soft linen or cotton cloth, which is soaked in theoil, laid over the burned area, and covered with a thick layer ofcotton batting and a bandage. When the skin is denuded, leaving a rawsurface exposed, the burn must be treated on the same plan as wounds, and should be kept as clean and free from germs as possible. Anointment made of equal parts of boric acid and vaseline, spreadthickly on clean cloth, is a good antiseptic preparation in caseswhere the skin is broken. It is best not to change the dressingoftener than once in two or three days, unless the discharge or odorare considerable. Fresh dressing is very painful and often harmful. When the dressing is removed, warm saline solution (one teaspoonful ofcommon salt in a quart of water) is allowed to flow over the burnuntil all discharge is washed off. Then the raw surface is dusted overwith pure boric acid or aristol, and the boric-acid ointment appliedas before. The cloth upon which the ointment is spread should be madefree from germs by boiling in water, and then drying it in an oven andkeeping it well wrapped in a clean towel except when wanted. The same care is requisite as that described under wounds (p. 50) inregard to cleanliness. Very extensive burns are most satisfactorily treated by completeimmersion of the burned limbs or entire body in salt solution (samestrength as above), which is kept at a temperature of from 94° to104° F. , according to the feelings of the patient. The patient lies ina bath tub on horsehair, or better, rubber mattress and rubberpillows; completely covered with water except the head. The urine andbowel discharges must be passed in the water, which is then changed, and the temperature is kept at an even mark by allowing warm water tocontinually run into the tub to displace that which runs out. Thelatter can be arranged by siphonage with a rubber tube. While thismethod requires more care, and running hot and cold water, it is themost comfortable treatment for these cases, usually attended by awfulsuffering, and at the same time it is most favorable to healing. It is beyond the scope of this work to describe the variouscomplications and the details of the after treatment in severe burns, including skin grafting, which may tax all the ingenuity of theskilled surgeon. It is hoped that the foregoing may give a clear ideaof the treatment to be pursued in emergencies and may prove of someuse to those who may unfortunately be compelled to care for burnsduring a considerable time without the aid of a physician. =BURN BY STRONG ACID. = _First Aid Rule 1. --Neutralize the acid. Scatter baking soda thicklyover burn, or pour limewater over it. _ _Rule 2. --Control pain. Wash off soda with stream of water. ApplyCarron oil (equal parts of limewater and linseed oil or olive oil). Bandage lightly. _ =BURN BY STRONG ALKALI. =--As ammonia, quicklime, lye. _First Aid Rule 1. --Neutralize the alkali. Pour vinegar over theburn. _ _Rule 2. --Control pain. Wash off vinegar with stream of water. Drygently. Apply vaseline or cold cream. _ =BURNS CAUSED BY STRONG MINERAL ACIDS OR BY ALKALIES. =--If acids arethe cause, the skin should not be washed at first, but either chalk, whiting, or some mild alkali, as baking soda, should be strewn overthe burn, and then after the effect of the acid is neutralized, washoff the soda with stream of warm water. Dry gently with gauze. ApplyCarron oil or paste of boric acid and vaseline, equal parts. If strongalkalies have been spilled on the skin, as ammonia, potash, orquicklime, then vinegar is the proper substance to employ, followed bywashing. Then dry gently. Vaseline or cold cream is usually sufficientas after treatment. Limewater is useful in counteracting the effect ofacids spattered in the eye. In the case of alkalies in the eye, thevinegar used should be diluted with three parts of water. Albolene orliquid vaseline is the best agent to drop in the eye after eitheraccident, in order to relieve the irritation and pain, and thepatient should stay in a dark room. =FROSTBITE, REAL FREEZING. =--Nose, ears, fingers, toes; insensible totouch, stiff, pale or blue. Person may be unconscious. _First Aid Rule 1. --Restore circulation. Rub gently, then vigorously, with snow. _ _Rule 2. --Restore heat very gradually. Sudden heat is fatal. Keep incold room, and rub with cloth wet with very cold water tillcirculation is established. Then rub with equal parts of alcohol andwater and expose gradually to heat of living room. _ _Rule 3. --If person ceases to breathe, resuscitate as if drowned. Openhis mouth, grasp his tongue, and pull it forward and keep it there. Let another assistant grasp the arms just below the elbows and drawthem steadily upward by the sides of the patient's head to the ground, the hands nearly meeting (which enlarges the capacity of the chest andinduces inspiration. ) (See pp. 30 and 31. ) While this is being done, let a third assistant take position astride the patient's hips withhis elbows resting on his own knees, his hands extended ready foraction. Next, let the assistant standing at the head turn down thepatient's arms to the sides of the body, the assistant holding thetongue changing hands if necessary to let the arms pass. Just beforethe patient's hands reach the ground the man astride the body willgrasp the body with his hands, the ball of the thumb resting oneither side of the pit of the stomach, the fingers falling into thegrooves between the short ribs. Now, using his knees as a pivot, hewill at the moment the patient's hands touch the ground throw (not toosuddenly) his whole weight forward on his hands, and at the same timesqueeze the waist between them, as if he wished to force something inthe chest upward out of the mouth; he will deepen the pressure whilehe slowly counts one, two, three, four (about five seconds), thensuddenly lets go with a final push, which will send him back to hisfirst position. This completes expiration. (A child or a delicateperson must be more gently handled. )_ _At the instant of letting go, the man at the head of the patient willagain draw the arms steadily upward to the sides of the patient's headas before (the assistant holding the tongue again changing hands tolet the arms pass, if necessary), holding them there while he slowlycounts one, two, three, four (about five seconds). _ _Repeat these movements deliberately and perseveringly twelve orfifteen times in every minute--thus imitating the natural motions ofbreathing. Continue the artificial respiration from one to four hours, or until the patient breathes; and for a while after the appearance ofreturning life carefully aid the first short gasps until deepened intofull breaths. _ _Keep body warm after this with warm-water bottles. _ =FROSTBITE. =--The nose, chin, ears, fingers, and toes are the partsusually frozen, although severe results ending in death of the frozenpart occur more often owing to low vitality of the patient than to thecold itself. In the milder degree of frostbite there is stiffness, numbness, and tingling of the frozen member; the skin is of a pale, bluish hue and somewhat shrunken. Recovery ensues with burning pain, tingling, redness, swelling and peeling of the epidermis, as afterslight burns. The skin is icy cold, white, and insensitive in severeforms of frostbite, and, if not skillfully treated, becomes, later, either swollen and discolored, or shriveled, dry, and black. In eithercase the frozen part dies and is separated from the living tissueafter the establishment of a sharp line of inflammation which resultsin ulceration and formation of pus, and thus the dead part sloughsoff. It is, however, possible for a part thoroughly frozen to regainits vitality. =Treatment. =--The essential element in the treatment is to secure avery gradual return of blood to the frozen tissues, and so avoidviolent inflammation. To obtain this result the patient should becared for in a cold room, the frozen parts are rubbed gently withsnow, or cloth wet with ice water, until they resume their usualwarmth. Then it is well to rub them with a mixture of alcohol andwater, equal parts, for a time and expose them to the usualtemperature of a dwelling room. Warm drinks are now administered tothe patient. The frozen member, if hand or foot, is raised high inthe air on pillows and covered well with absorbent cotton and bandage. If much redness, swelling, and pain result this dressing is removedand the part is wrapped in a single thickness of cotton cloth keptcontinually wet with alcohol and water. Subsequent treatment consists in keeping the damaged parts coveredwith vaseline or cold cream, absorbent cotton, and bandage. Ifblisters and sores result, the care is similar to that described forlike conditions under burns. If death of the frozen part becomesinevitable, the hand or foot should be suspended in a nearly verticalposition to keep the blood out, and the part bathed twice daily with asolution of corrosive sublimate (one 7. 7 gr. Tablet to pint of water), dusted well with aristol, and dressed with absorbent cotton andbandage until the dead tissue separates and comes away. If the frozenpart is large it may be necessary to remove it with a knife, but thisis not essential when the tips of the fingers or toes are frozen. =General Effect of Cold. =--Sudden exposure to severe cold causessleep, stupor, and death. Persons found apparently frozen to deathshould be brought into a cold room, which should be gradually heated, and the body rubbed with snow or ice water, and artificial respirationemployed, as just directed. Attempts at resuscitation ought to bepersistent, as recoveries have been reported after several hours ofunconsciousness and apparent death from freezing. =CHILBLAINS AND MILD FROSTBITES. =--The effects of severe cold on thebody are very similar to those of intense heat, though they are verymuch slower in making their appearance. After a person has frozen afinger or toe he may not notice much inconvenience for days, whensuddenly violent inflammation may set in. The fingers, ears, nose, andtoes are the members which suffer most frequently from the effects ofcold. Similar symptoms of inflammation, described under burns, alsoresult from cold, that is, redness and swelling of the skin, blisterswith more severe and deeper inflammatory involvement, or, in case theparts are thoroughly frozen, local death and destruction of thetissues. But it is not essential that the body be exposed to thefreezing temperature or be frozen at all, in order that some harm mayresult, for chilblains often follow when the temperature has not beenlower than 40° F. , or thereabouts. The effect of cold is to contract the blood vessels, with theproduction of numbness, pallor, and tingling of the skin. When thecold no longer acts then the blood vessels dilate to more than theirusual and normal state, and more or less inflammation results. Themore sudden the return to warmth the greater the inflammatory sequel. Chilblains represent the mildest morbid effect of cold on the body. They exist as bluish-red swellings of the skin, usually on the feet orhands, but may attack the nose or ears, and are attended by burning, itching, and smarting. This condition is caused by dilatation of thevessels following exposure to cold. It is more apt to happen in young, anæmic women. Chilblains usually disappear during warm weather. Scratching, friction, or the severity of the attack may lead to theappearance of blisters and sores. In severe cases the fingers and toespresent a sausage-like appearance, owing to swelling. =Treatment. =--Susceptible persons should wear thick, warm (not rough)stockings and warm gloves. The chilled members must never be suddenlywarmed. Regular exercise and cold shower baths are good to strengthenthe circulation, but the feet and hands must be washed in warm wateronly, and thoroughly dried. If sweating of these parts is a commonoccurrence, starch or zinc oxide should be dusted on freely night andmorning. Cod-liver oil is an efficacious remedy in these cases; oneteaspoonful of Peter Möller's pure oil three times daily after meals. The affected parts are bathed twice daily in a solution of zincacetate (one dram to one pint of water), and followed by theapplication, on soft linen or cotton, of zinc-oxide ointmentcontaining two per cent of carbolic acid. If this is not curative, iodine ointment mixed with an equal quantity of lard may be tried. Exposure to cold will immediately bring on a recurrence of thetrouble. If the affection of the feet is severe the patient must restin bed. If the parts become blistered and open sores appear, then thesame treatment as for burns is indicated. Wash with a weak solutionof corrosive sublimate (one tablet for surgical purposes in two quartsof warm water) and apply an ointment of boric acid and vaseline, equalparts, spread on soft, clean cotton or linen. Rest of the part andexistence in a warm atmosphere will complete the cure. =INGROWING TOE NAIL. =--This is a condition in which the flesh alongthe edges of the great toe nail becomes inflamed, owing either toovergrowth of the nail or to pressure of the soft parts against it. Improper footgear is the most common cause, as shoes which are toonarrow across the toes, or not long enough, or those with high heelswhich throw the toes forward so that they are compressed by the toe ofthe boot, especially in walking downhill. A faulty mode of cutting the toe nails in a healthy foot may favoringrowing toe nails. Toe nails should be cut straight across, and nottrimmed away at the corners to follow the outline of the toes--as thenthe flesh crowds in at the corners of the nails, and when the nailpushes forward in its growth it presses into the flesh. Nails whichhave a very rounded surface are more apt to produce trouble, becausethen the edges are likely to grow down into the flesh. Inflammation iningrowing toe nail usually arises along the outer edge of the nail. The flesh here becomes red, tender, painful, and swollen so that itoverlaps the nail. After a time "matter" or pus forms and finds itsway under the nail, and the parts about it ulcerate, and "proudflesh" or excessive granulation tissue springs up and imbeds the edgeof the nail. Wearing a shoe, or walking, becomes impossible. Thecondition may last for months, or even years, if not rightly treated. =Treatment. =--Properly fitting footgear must be worn--broad at thetoes with low heels and of sufficient length. If pus ("matter") forms, the cut edge should be raised up by pushing in a little absorbentcotton under the nail every day. Hot poultices of flaxseed meal, orother material will relieve any special pain and inflammation. Soakingthe foot frequently in hot water, and observing especial cleanliness, will aid recovery. Tannic acid, or some antiseptic powder likenosophen, should be dusted along the edge of the nail, and the fleshcrowded away from the nail by pushing in a little cotton with sometannic acid upon it. If there is a raw surface about the border of the nail, powdered leadnitrate may be dusted upon it each morning for four or five days, tillthe ulcerated tissue shrinks away and the edge of the nail becomesvisible. The toe should be covered with absorbent cotton and abandage. As soon as the toe is really inflamed the case becomessurgical, and as such demands the care of a surgeon when one can beobtained. =FAINTING. = _First Aid Rule 1. --Remove impediments to respiration. Remove collar, loosen all waist bands and cords, unhook corset or cut the laces atperson's back. _ _Rule 2. --Assist heart and brain with blood pressure. Put cushionunder buttocks, wind skirt close about legs, and raise feet in air. Wait ten seconds. _ _Rule 3. --Aid respiration. Put mild smelling salts under nose. Spattercold water in face. _ =SUFFOCATION FROM GAS IN WELLS, CISTERNS, OR MINES, OR FROMILLUMINATING GAS. = _First Aid Rule 1. --Remove quickly into pure air. _ _Rule 2. --Resuscitate as if drowned. Open his mouth, grasp his tongue, pull it forward and keep it there. Let another assistant grasp thearms just below the elbows, and draw them steadily upward by the sidesof the patient's head to the ground, the hands nearly meeting, whichenlarges the capacity of the chest and induces inspiration. (See pp. 30 and 31. ) While this is being done, let a third assistant takeposition astride the patient's hips with his elbows resting on his ownknees, his hands extended ready for action. Next, let the assistantstanding at the head turn down the patient's arms to the sides of hisbody, the assistant holding the tongue, changing hands if necessary tolet the arms pass. _ _Just before the patient's hands reach the ground, the man astride thebody will grasp the body with his hands, the ball of the thumb restingon either side of the pit of the stomach, the fingers falling intothe grooves between the short ribs. Now, using his knees as a pivot, he will, at the moment the patient's hands touch the ground, throw(not too suddenly) his whole weight forward on his hands, and at thesame time squeeze the waist between them, as if he wished to forcesomething in the chest upward out of the mouth; he will deepen thepressure while he slowly counts one, two, three, four (about fiveseconds), then suddenly lets go with a final push, which will send himback to his first position. This completes expiration. A child or adelicate person must be more gently handled. _ _At the instant of letting go, the man at the head of the patient willagain draw the arms steadily upward, to the sides of the patient'shead, as before (the assistant holding the tongue again, changinghands if necessary to let the arms pass, holding them there while heslowly counts one, two, three, four (about five seconds)). _ _Repeat these movements deliberately and perseveringly twelve orfifteen times in every minute, thus imitating the natural motions ofbreathing. Continue the artificial respiration from one to four hours, or until the patient breathes; and for a while after the appearance ofreturning life, carefully aid the first short gasps until deepenedinto full breaths. _ _Keep the body warm with hot-water bottles and blanket. _ _Rule 3. --Give oxygen to breathe from a cylinder, for two days, atshort intervals, in the case of illuminating gas. _ =FIT; CONVULSION. = _First Aid Rule 1. --Aid breathing. Loosen collar, waist bands, andunhook corset, or cut the laces behind. _ _Rule 2. --Protect from injury. Gently restrain from falling or rollingagainst furniture; lay flat on bed. _ _Rule 3. --Protect tongue from being bitten. Open jaws and put betweenteeth rubber eraser tied to stout string, or rubber stopper tied tostout string. _ _Rule 4. --Crush pearl of amyl nitrite in handkerchief, and hold closeto patient's nose and mouth, till face is red and patient relaxes. _ _Rule 5. --Let patient sleep after fit without rousing. _ FOOTNOTES: [9] Caution. Dangerous. Use only on physician's order. [10] Caution. Dangerous. Use only on physician's order. Part II GERM DISEASES BY KENELM WINSLOW CHAPTER I =Contagious Diseases= _Scarlet Fever--Symptoms and Treatment--PrecautionsNecessary--Measles--Communicating theDisease--Smallpox--Vaccination--How to Diagnose Chickenpox. _ =ERUPTIVE CONTAGIOUS FEVERS= (_including Scarlet Fever, Measles, German Measles, Smallpox, and Chickenpox_). --These, with the exceptionof smallpox, attack children more commonly than adults. As they allbegin with fever, and the characteristic rash does not appear for fromone to four days after the beginning of the sickness, the diagnosis ofthese diseases must always be at the onset a matter of doubt. For thisreason it is wise to keep any child with a fever isolated, even if thetrouble seems to be due to "a cold" or to digestive disturbance, toavoid possible communication of the disorder to other children. Whilecolds and indigestion are among the most frequent ailments ofchildren, they must not be neglected, for measles begins as a badcold, smallpox like the _grippe_, and scarlet fever with a sore throator tonsilitis, and vomiting. By isolation is meant that the sick child should stay in a room byhimself, and the doors should be kept closed and no children shouldenter, nor should any objects in the room be removed to other parts ofthe house after the beginning of its occupation by the patient. The services of a physician are particularly desirable in all thesediseases, in order that an early diagnosis be made and measures betaken to protect the family, neighbors, and community from contagion. The failure of parents or guardians to secure medical aid for childrenis regarded by the law as criminal neglect, and is subject topunishment. Boards of health require the reporting of all contagiousdiseases as soon as their presence is known, and failure to complywith their rules also renders the offender liable to fine orimprisonment in most places. =SCARLET FEVER= (_Scarlatina_). --There is no difference betweenscarlet fever and scarlatina. It is a popular mistake that the latteris a mild type of scarlet fever. Fever, sore throat, and a bright-redrash are the characteristics of this disease. It occurs mostfrequently in children between the ages of two and six years. It ispractically unknown under one year of age. Prof. H. M. Biggs, of theNew York Department of Health, has seen but two undoubted cases ininfants under twelve months. It is rare in adults, and one attackusually protects the patient from another. Second attacks haveoccurred, but many such are more apparent than real, since an error indiagnosis is not uncommon. The disease is communicated chiefly bymeans of the scales of skin which escape during the peeling process, but may also be acquired at any time from the onset of the attack fromthe breath, urine, and discharges from the body; or from substanceswhich have come in contact with these emanations. Scarlet fever isprobably a germ disease, and the germs may live for weeks in toys, books, letters, clothing, wall paper, etc. Close contact with thepatient, or with objects which have come in close touch with thepatient, is apparently necessary for contagion. =Period of Development. =--After exposure to the germs of scarletfever, usually from two to five days elapse before the disease showsitself. Occasionally the outbreak of the disease occurs withintwenty-four hours of exposure, and rarely is delayed for a week or tendays. =Symptoms. =--The onset is usually sudden. It begins with vomiting (invery young children sometimes convulsions), sore throat, fever, chilliness, and headache. The tongue is furred. The patient is oftenstupid; or may be restless and delirious. Within twenty-four hours orso the rash appears--first on the neck, chest, or lower part ofback--and rapidly spreads over the trunk, and by the end offorty-eight hours covers the legs and entire body excepting the face, which may be simply flushed. The rash appears as fine, scarlet pinpoints scattered over a background of flushed skin. At its fullestdevelopment, at the end of the second or third day, the whole body maypresent the color of a boiled lobster. After this time the rashgenerally fades away and disappears within five to seven days. It islikely to vary much in intensity while it lasts. As the rash fades, scaling of the skin begins in large flakes and continues from ten daysto as many weeks, usually terminating by the end of the sixth toeighth week. One of the notable features is the appearance of thetongue, at first showing red points through a white coating, and afterthis has cleared away, in presenting a raspberry-like aspect. Thethroat is generally deep red, and the tonsils may be dotted over withwhite spots (see Tonsilitis) or covered with a whitish or graymembrane suggesting diphtheria, which occasionally complicates scarletfever. The fever usually is high (103° to 107° F), and the pulseranges from 120 to 150; both declining after the rash is fullydeveloped, generally by the fourth day. The urine is scanty and dark. There is, however, great variation in the symptoms as to theirpresence or absence, intensity, and time of occurrence anddisappearance. =Complications and Sequels. =--These are frequent and make scarletfever the most dreaded of the eruptive diseases, except smallpox. Enlarged glands under the jaw and at the sides of the neck are common, and appear as lumps in these sites. Usually not serious, they mayenlarge and threaten life. Pain and swelling in the joints, especiallyof the elbows and knees, are not rare, and may be the precursors ofserious inflammation of these parts. One of the most frequent andserious complications of scarlet fever is inflammation of the kidneys, occurring more often toward the end of the second week of the disease. Examination of the urine by the attending physician at frequentintervals throughout the course of the disorder is essential, althoughpuffiness of the eyelids and face, and of the feet, ankles, and hands, together with lessened secretion of urine--which often becomes of adark and smoky hue--may denote the onset of this complication. Thedisease of the kidneys usually results in recovery, but occasionallyin death or in chronic Bright's disease of these organs. Inflammationof the middle ear with abscess, discharge of matter from the earexternally, and--as the final outcome--deafness, is not uncommon. Thiscomplication may be prevented to a considerable extent by spraying thenose and throat frequently and by the patient's use of a nightcap withearlaps, if the room is not sufficiently warm. Inflammation of theeyelids is an occasional complication. The heart is sometimes attackedby the toxins of the disease, and permanent damage to the organ, inthe form of valvular trouble, may result. Blindness and nervousdisorders are among the rarer sequels including paralyses and St. Vitus's dance. =Determination of Scarlet Fever. =--When beginning with vomiting, headache, high fever, and sore throat, and followed in twenty-fourhours with a general scarlet rash, this is not difficult; butoccasionally other diseases present rashes, as indigestion, _grippe_, and German measles, which puzzle the most acute physicians. Measlesmay be distinguished from scarlet fever in that measles appears firston the face, the rash is patchy or blotchy, and does not show forthree to four days after the beginning of the sickness. The patientseems to have a bad cold, with cough, running at the nose, and soreeyes. German measles is mild, and while the rash may look somethinglike that of scarlet fever, the patient does not seem generally ill, is hardly affected at all, though rarely troubled with slight catarrhof the nose. In no sickness are the services of a physician morenecessary than in scarlet fever; first, to determine the existence ofthe disease, and then to prevent or combat the complications whichoften approach insidiously. =Outlook. =--The average death rate of scarlet fever is about ten percent. It is very fatal in children about a year old, and most of thedeaths occur in those under the age of six. But the mortality variesgreatly at different times and in different epidemics. In 1904-5, inmany parts of the United States, the disease was very prevalent andcorrespondingly mild, and deaths were rare. =Duration of Contagion. =--The disease is commonly consideredcontagious only so long as peeling of the skin lasts. But it seemsprobable that any catarrhal secretion from the nose, throat, or ear iscapable of communicating the germs from a patient to another personfor many days after other evidences of the disease are past. Scarletfever patients should always be isolated for as long a period as sixweeks--and better eight weeks--without regard to any shorter durationof peeling, and if peeling continues longer, so should the isolation. =Treatment. =--In case a physician is unobtainable the patient must beput to bed in the most airy, sunshiny room, which should be heated to70° F. , and from which all the unnecessary movables should be takenout before the entrance of the patient. A flannel nightgown and lightbed clothing are desirable. The fever is best overcome by coldsponging, which at the same time diminishes the nervous symptoms, suchas restlessness and delirium. The body is sponged--part at atime--with water at the temperature of about 70° F. , after placing asingle thickness of old cotton or linen wet with ice or cold water(better an ice cap) over the forehead. The part is thoroughly dried assoon as sponged, and the process is repeated whenever the temperatureis over 103° F. There need be no fear that the patient may catch coldif only a portion of the body is exposed at any one time. If there isany chilliness following sponging, a bag or bottle containing hotwater may be placed at the feet. It is well that a rubber bagcontaining ice, or failing this a cold cloth, be kept continually onthe head while fever lasts. The throat should be sprayed hourly with asolution of hydrogen peroxide (full strength) and the nose with thesame, diluted with an equal amount of water, three times a day. Theoutside of the throat it is wise to surround with an ice bag, orlacking this, a cold cloth frequently wet and covered with a piece ofoil silk (or rubber) and flannel. The diet should consist of milk, broths, or thin gruels, and plenty ofwater should be allowed. Sweet oil or carbolized vaseline should berubbed over the whole body night and morning during the entiresickness and convalescence. The bowels must be kept regular byinjections or mild cathartics, and, after the fever subsides, vegetables, fruit, cereals, and milk may be permitted, together withmeat or eggs once daily. It is imperative for the nurse and also themother to wear a gown and cap over the outside clothes, to be slippedoff in the hall at the door of the sick room when leaving the latter. =MEASLES. =--Measles is a contagious disease, characterized by apreliminary stage of fever and catarrh of the eyes, nose, and throat, and followed by a general eruption on the skin. One attack practicallyprotects a person from another, yet, on the other hand, second attacksoccur with extreme rarity. It is more contagious than scarlet fever, and isolation of a patient in a house is of less service in preventingcommunication to other inmates, whereas in scarlet fever half thenumber of susceptible children may escape the disease through thisprecaution. The germs which cause measles perish rapidly, so thatinfected clothes or other objects merely require a thorough airing tobe rendered safe, whereas in scarlet fever the danger of transmissionof the contagion may lurk in infected clothing and other substancesfor weeks, unless they are subjected to proper disinfection. A patientwith measles is capable of communicating the disorder from its onset, before the appearance of the rash, through the breath, discharges fromthe nose and eyes, tears and saliva and all the secretions. At the endof the third week of the disease the patient is usually incapable ofgiving the disease to others. Close contact with a patient is commonlynecessary for one to acquire the disease, but it is frequently claimedthat it is carried by a third person in the clothes, as by a nurse. Itis infrequent in infants under six months, and most frequent betweenthe second and sixth year. Adults are attacked by measles more oftenthan by scarlet fever. =Development. =--A period of from seven to sixteen days after exposureto measles elapses before the disease becomes apparent. =Symptoms. =--The disease begins like a severe nasal catarrh withfever. The eyes are red and watery, the nose runs, and the throat isirritable, red, and sore, and there is some cough, with chilliness andmuscular soreness. The fever, higher at night, varies from 102° to104° F. , and the pulse ranges from 100 to 120. There is often markeddrowsiness for a day or two before the rash appears. Coated tongue, loss of appetite, occasional vomiting, and thirst are present duringthis period. The appearance of minute, whitish spots, surrounded by ared zone, may often be seen in the inside of the mouth opposite theback teeth for some days before the eruption occurs. The preliminary period, when the patient seems to be suffering with abad cold, lasts for four days usually, and on the evening of thefourth day the rash breaks out. It first appears on the face and thenspreads to the chest, trunk, and limbs. Two days are generallyrequired for the complete development of the rash; it remains thus infull bloom for about two days more, then begins to subside, fadingcompletely in another two days--six days in all. The rash appears as bright-red, slightly raised blotches on the face, which is generally somewhat swollen. The same rash extends to theabdomen, back, and limbs. Between the mottled, red rash may be seenthe natural color of the skin. At this time the cough may be hoarseand incessant, and the eyes extremely sensitive to light. The feverand other symptoms abate when the rash subsides, and well-markedscaling of the skin occurs. =Complications and Sequels. =--Severe bronchitis, pneumonia, croup, laryngitis, sore eyes, ear abscess and deafness, violent diarrhea, convulsions, and, as a late result, consumption sometimes accompany orfollow measles. For the consideration of these disorders, see specialarticles in other parts of this work. =Outlook. =--The vast majority of healthy patients over two years oldrecover from measles completely. Younger children, or those sufferingfrom other diseases, may die through some of the complicationsaffecting the lungs. The disease is peculiarly fatal in some epidemicsoccurring among those living in unhygienic surroundings, and incommunities unaccustomed to the ravages of measles. Thus, in anepidemic attacking the Fiji Islanders, over one-quarter of the wholepopulation (150, 000) died of measles in 1875. Measles is more severein adults than in children. =Diagnosis. =--For one not familiar with the characteristic rash awritten description of it will not suffice for the certain recognitionof the disease, but if the long preliminary period of catarrh andfever, and the appearance of the eruption on the fourth day, be takeninto account--together with the existence of sore eyes and hoarse, hard cough--the determination of the presence of measles will not bedifficult in most cases. =Treatment. =--The patient should be put to bed in a darkened, well-ventilated room at a temperature of 68° to 70° F. While byisolation of the patient we may often fail to prevent the occurrenceof measles in other susceptible persons in the same house, because ofthe very infectious character of the disease, and because it isprobable that they have already been exposed during the early stageswhen measles was not suspected, yet all possible precautions should beadopted promptly. For this reason other children in the house shouldbe kept from school and away from their companions, and they oughtnot to be sent away from home to spread the disease elsewhere. Thebowels should be kept regular by soapsuds injections or by mildcathartics, as a Seidlitz powder. If the fever is over 103° F. And isaccompanied by much distress and restlessness, children may be spongedwith tepid water, and adults with water at 80° F. , every two hours orso as directed under scarlet fever. When cough is incessant or therash does not come out well, there is nothing better than the hotpack. The patient is stripped and wrapped from feet to neck in a blanketwrung out of hot water containing two teaspoonfuls of mustard stirredinto a gallon of water. This is then covered with two dry blankets andthe patient allowed to remain in the blankets for two or three hours, when the application may be repeated. It is well to keep a cold clothon the head during the process. Cough is also relieved by a mixturecontaining syrup of ipecac, twenty drops; paregoric, one teaspoonful, for an adult (or one-third the dose for a child of six), which shouldbe given in one-quarter glass of water and may be repeated every twohours. If there is hoarseness, the neck should be rubbed with amixture of sweet oil, two parts; and oil of turpentine, one part, andcovered with a flannel bandage. The cough mixture will tend to relievethis condition also. A solution of boric acid (ten grains of boricacid to the ounce of water) is to be dropped in both eyes every twohours with a medicine dropper. Although usually mild, the eye symptomsmay be very severe and require special treatment, and considerablyimpaired vision may be the ultimate result. Severe diarrhea iscombated with bismuth subnitrate, one-quarter teaspoonful, every threehours. For adults, the diet consists of milk, broths, gruels, and raweggs. Young children living on milk mixtures should receive themixture to which they are accustomed, diluted one-half with barleywater. Nourishment must be given every two hours except during sleep. The patient should be ten days in bed, and should remain three days inhis room after getting up (or three weeks in all, if there are otherswho may contract measles in the house), and after leaving his roomshould stay in the house a week longer. The principal danger after anattack of measles is of lung trouble--pneumonia or tuberculosis(consumption)--and the greatest care should be exercised to avoidexposure to the wet or to cold draughts. =GERMAN MEASLES= (_Rötheln_). --German measles is related neither tomeasles nor scarlet fever, but resembles them both to a certainextent--more closely the former in most cases. It is a distinctdisease, and persons who have had both measles and scarlet fever arestill susceptible to German measles. One attack of German measlesusually protects the patient from another. Adults, who have not beenpreviously attacked, are almost as liable to German measles aschildren, but it is rare that infants acquire the disease. It is avery contagious disorder--but not so much so as true measles--andoften occurs in widespread epidemics. The breath and emanations fromthe skin transmit the _contagium_ from the appearance of the firstsymptom to the disappearance of the eruption. =Development. =--The period elapsing after exposure to German measlesand before the appearance of the symptoms varies greatly--usuallyabout two weeks; it may vary from five to eighteen days. =Symptoms. =--The rash may be the first sign of the disease and morefrequently is so in children. In others, for a day or two precedingthe eruption, there may be headache, soreness, and redness of thethroat, the appearance of red spots on the upper surface of the backof the mouth, chilliness, soreness in the muscles, loss of appetite, watering of the eyes. Catarrhal symptoms are most generally absent, animportant point in diagnosis. When present, they are always mild. These preliminary symptoms, if present, are much milder and of shorterduration than in measles, where they last for four days before therash appears; and the hard, persistent cough of measles is absent inGerman measles. Also, while there is sore throat in the latter, thereis not the severe form with swollen tonsils covered with white spotsso often seen in scarlet fever. Fever is sometimes absent in Germanmeasles; usually it ranges about 100° F. , rarely over 102° F. Thus, German measles differs markedly from both scarlet fever and measlesproper. The rash usually appears first on the face, then on the chest, and finally covers the whole body, in the space of a fewhours--twenty-four hours at most. The eruption takes the form ofrose-red, round or oval, slightly raised spots--from the size of a pinhead to that of a pea--sometimes running together into uniformredness, as in scarlet fever. The rash remains fully developed forabout two days, and often changes into a coppery hue as it graduallyfades away. There are often lumps--enlarged glands--to be felt underthe jaw, on the sides and back of the neck, which occur more commonlyin German than in true measles. The glands at the back of the neck arethe most characteristic. They are enlarged in about two-thirds of thecases. =Determination. =--The diagnosis or determination of the existence ofmeasles must be made, in the absence of a physician, on the generalsymptoms rather than on the rash, which requires experience for itsrecognition and is subject to great variations in appearance, at onetime simulating measles, at another scarlet fever. German measles differs from true measles in the following points: thepreliminary period--before the rash--is mild, short, or absent; feveris mild or absent; the cold in the nose and eyes and cough are slightor may be absent, as contrasted with these symptoms in measles, whilethe enlarged glands in the neck are more pronounced than in measles. The onset of German measles is not so sudden as in scarlet fever andnot accompanied with vomiting as in the latter, while the sore throatand fever are much milder in German measles. The peeling, which is soprominent in scarlet fever with the disappearance of the rash, is notinfrequently present. It may be absent. Its presence or absence seemsto depend upon the severity of the eruption. The desquamation whenpresent is finer than in either measles or scarlet fever. =Outlook. =--Recovery from German measles is the invariable rule, andwithout complications or delay. =Treatment. =--Little or no treatment is required. The patient shouldremain in bed in a darkened room on a liquid diet while fever lasts, and be isolated from others indoors until all signs of the eruptionare passed. The eyes should be treated with boric acid as in measles;the diet, during the fever, consisting of milk, broths, thin cereals, beef juice, raw eggs or eggnog, for adults and older children; whileinfants should have their milk mixture diluted one-half with barleywater. A bath and fresh clothing for the patient, and thoroughcleansing and airing of the sick room and clothing are usuallysufficient after the passing of the disease without chemicaldisinfection. =SMALLPOX. =--Smallpox is one of the most contagious diseases known. Itis extremely rare for anyone exposed to the disease to escape itsonslaught unless previously protected by vaccination or by a formerattack of the disease. One is absolutely safe from acquiring smallpoxif recently and successfully vaccinated, and thus has one of the mostfrightful and fatal scourges to which mankind has ever been subjectbeen robbed of its dangers. The _contagium_ is probably derivedentirely from the scales and particles of skin escaping from smallpoxpatients, and in the year 1905-6 the true germ of the disease wasdiscovered by Councilman, of Boston. It is not necessary to come indirect contact with a patient to contract the disease, as the_contagium_ may be transmitted some little distance through the air, possibly even outside of the sick room. One attack almost invariablyprotects against another. All ages are liable to smallpox; it isparticularly fatal in young children, and during certain epidemics hasproved more so in colored than in white people. =Development. =--A period of ten or twelve days usually elapses afterexposure to smallpox before the appearance of the first symptoms ofthe disease. This period may vary, however, from nine to fifteen days. =Symptoms. =--There is a preliminary period of from twenty-four toforty-eight hours after the beginning of the disease before aneruption occurs. The onset is ushered in by a set of symptomssimulating those seen in severe _grippe_, for which smallpox is oftenmistaken at this time. The patient is suddenly seized with a chill, severe pains in the head, back, and limbs, loss of appetite andvomiting, dizziness on sitting up, and fever--103° to 105° F. In youngchildren convulsions often take the place of the chill seen inadults. On the second day a rash often appears on the lower part ofthe belly, thighs, and armpits, which may resemble that characteristicof measles or scarlet fever, but does not last for over a day or two. It is very evanescent and, consequently, rarely seen. Diarrhea oftenoccurs, as well as vomiting, particularly in children. On the eveningof the fourth day the true eruption usually appears; first on theforehead or face, and then on the arms, hands, and legs, palms, andsoles. The eruption takes successively four forms: first, red, feelinglike hard pimples or like shot; then, on the second or third day ofthe eruption, these pimples become tipped with little blisters withdepressed centers, and surrounded by a red blush. Two or three dayslater the blisters are filled with "matter" or pus and present ayellowish appearance and are rounded on top. Finally, on about thetenth day of the eruption, the pustules dry up and the matter exudes, forming large, yellowish or brownish crusts, which, after a while, drop off and leave red marks and, in severe cases, pitting. The feverpreceding the eruption often disappears upon the appearance of thelatter and in mild cases does not reappear, but in severe forms thetemperature remains about 100° F. , and when the eruption is at itsheight again mounts to 103° to 105° F. , and gradually falls withconvalescence. The eruption is most marked on the face, hands, andforearms, and occurs less thickly on the body. It appears also in themouth and throat and when fully developed on the face gives rise topain and considerable swelling and distortion of the features, so thatthe eyes are closed and the patient becomes frightfully disfigured andwell-nigh unrecognizable. Delirium is common at this time, andpatients need constant watching to prevent their escape from bed. Inthe severe forms the separate eruptive points run together so that theface and hands present one distorted mass of soreness, swelling, andcrusting. In these, pitting invariably follows, while in those caseswhere the eruption remains distinct, pitting is not certain to occur. A still worse form is that styled "black smallpox, " in which the skinbecomes of a dark-purplish hue, from the fact that each pustule is asmall blood blister, and bleeding occurs from the nose, mouth, etc. These cases are almost, without exception, fatal in five to six days. The patient may say that the eruption was the first symptom heobserved. This was particularly noticed in negroes, many of whom hadnever been vaccinated. The eruption may exhibit but a dozen or sopoints, especially about the forehead, wrists, palms, and soles. Afterthe first four days the fever and all the disagreeable symptoms maysubside, and the patient may feel absolutely well. The eruption, however, passes through the stages mentioned, although but half thetime may be occupied by the changes; five or six days instead of tento twelve for crusts to form. In such cases the death rate has beenexceedingly low, although it is perfectly possible for a person tocontract the most severe smallpox from one of these mild (and oftenunrecognized) cases, as has unfortunately happened. Smallpox occurringafter successful vaccination resembles, in its characteristics, thecases just described, and unless vaccination had been done many yearspreviously, the results are almost always favorable as regards lifeand absence of pitting. =Detection. =--Smallpox is often mistaken for chickenpox, or some ofthe skin diseases, in its mild forms. The reader is referred to thearticle on chickenpox for a consideration of this matter. The mildtype should be treated just as rigidly as severe cases with regard toisolation and quarantine, being more dangerous to the communitybecause lightly judged and not stimulating to the adoption ofnecessary precautions. The preliminary fever and other symptomspeculiar to smallpox will generally serve to determine the true natureof the disease, since these do not occur in simple eruptions on theskin. The general symptoms and course of smallpox must guide thelayman rather than the appearance of the eruption, which requireseducated skill and experience to recognize. Chickenpox in an adult isless common than in children. Smallpox is very rare in one who hassuffered from a previous attack of the disease or in one who has beensuccessfully vaccinated within a few years. =Outlook. =--The death rate of smallpox in those who have beenpreviously vaccinated at a comparatively recent date, or invarioloid, as it is called when thus modified by vaccination, is only1. 2 per cent. There are, however, severe cases following vaccinationsdone many years previous to the attack of smallpox. While these cannotbe called varioloid, yet the death rate is much lower than in smallpoxoccurring in the unvaccinated. Thus, before the mild epidemic of 1894the death rate in the vaccinated was sixteen per cent; since 1894 ithas been only seven per cent; while in the unvaccinated before 1894 itwas fifty-eight per cent; and since that date it has been butseventeen per cent, as reported by Welch from the statistics of 5, 000cases in the Philadelphia Municipal Hospital. =Complications. =--While a variety of disorders may follow in thecourse of smallpox, complications are not very frequent in even severecases. Inflammation of the eyelids is very common, however, and alsoboils in the later stages. Delirium and convulsions in children arealso frequent, as well as diarrhea; but these may almost be regardedas natural accompaniments of the disease. Among the less commoncomplications are: laryngitis, pneumonia, diseases of the heart, insanity, paralysis, various skin eruptions, inflammation of thejoints and of the eyes and ears, and baldness. =Treatment. =--Prevention is of greatest importance. Vaccination standsalone as the most effective preventive measure in smallpox, and assuch has no rival in the whole domain of medicine. The modern methodincludes the inoculation of a human being with matter taken from oneof the eruptive points on the body of a calf suffering with cowpox. Whether cowpox is a modified form of smallpox or a distinct disease isunknown. The period of protection afforded by a successful vaccination isuncertain, because it varies with different individuals. In a generalway immunity for about four or five years is thus secured; ten ortwelve years after vaccination the protection is certainly lost andsmallpox may be then acquired. Every individual should be vaccinatedbetween the second and third month after birth, and between the agesof ten and twelve, and at other times whenever an epidemic threatens. An unvaccinated person should be vaccinated and revaccinated, untilthe result is successful, as immunity to vaccination in anunvaccinated person is practically unknown. When unsuccessful, thevaccine matter or the technique is faulty. A person continuouslyexposed to smallpox should be vaccinated every few weeks--ifunsuccessful, no harm or suffering follow; if successful, it provesliability to smallpox. A person previously vaccinated successfully may"take" again at any time after four or five years, and, in event ofpossible exposure to smallpox, should be revaccinated several timeswithin a few weeks--if the vaccination does not "take"--before theattempt is given up. An unvaccinated person, who has been exposed tosmallpox, can often escape the disease if successfully vaccinatedwithin three days from the date of the exposure, but is not sure todo so. Diseases are not introduced with vaccination now that the vaccinematter is taken from calves and not from the human being, as formerly. Most of the trouble and inflammation of the vaccinated part followingvaccination may be avoided by cleanliness and proper care invaccinating. In the absence of a physician, vaccination may be properly done by anyintelligent person when the circumstances demand it. Vaccination isusually performed upon the outside of the arm, a few inches below theshoulder, in the depression situated in that region. If done on theleg, the vaccination is apt to be much more troublesome and mayconfine the patient to bed. The arm should be thoroughly washed insoap and warm water, from shoulder to elbow, and then in alcoholdiluted one-third with water. When this has evaporated (withoutrubbing), the dry arm is scratched lightly with a cold needle whichhas previously been held in a flame and its point heated red hot. Thepoint must thereafter not be touched with anything until the skin isscratched with it. The object is not to draw blood, but to remove theouter layer of skin, over an area about one-fourth of an inch square, so that it appears red and moist but not bleeding. This isaccomplished by very light scratching in various directions. Anotherspot, about an inch or two below, may be similarly treated. Thenvaccine matter, if liquid, is squirted on the raw spots, or, if driedon points, the ivory point is dipped in water which has been boiledand cooled, and rubbed thoroughly over the raw places. The arm mustremain bare and the vaccination mark untouched until the surface ofthe raw spot is perfectly dry, which may take half an hour. A piece ofsterilized surgical gauze, reaching halfway about the arm and kept inplace with strips of adhesive plaster (or an absolutely cleanhandkerchief bound about the arm, and held by sewing or safety pins), ought to cover the vaccination for three days. After this time thesore must only come in contact with soft and clean old cotton orlinen, which may be daily pinned in the sleeve of the under garment. If the scab is knocked off and an open sore results it should betreated like any wound. If the vaccination "takes, " it passes through several stages. On thethird day following vaccination a red pimple forms at the point ofintroduction of the matter, which is surrounded by a circle ofredness. Some little fever may occur. On the fifth day a blister orpimple containing clear fluid with a depressed center is seen, and acertain amount of hard swelling, itchiness, and pain is present aboutthe vaccination. A sore lump (gland) is often felt under the arm. Thefull development is reached by the eighth day, when the pimple is fulland rounded and contains "matter, " and is surrounded by a large areaof redness. From the eleventh day the vaccination sore dries, and abrown scab forms over it about the end of the fourteenth day, and theredness and swelling gradually depart. At the end of about three weeksthe scab drops off, leaving a pitted scar or mark. Not infrequentlythe vaccination results in a very slight pimple and redness, whichpasses through the various stages described, in a week or ten days, inwhich case the vaccination should be repeated. Unless the vaccinationfollows very closely the course described, it cannot be regarded assuccessful, although after the first one or two vaccinations theresult is often not so severe, and the time of completion of thevarious stages somewhat shortened. Rarely an eruption, resembling that at the vaccination site, appearson the vaccinated limb and even becomes general upon the body, due tourticaria or to inoculation, through scratching. The special treatment of an attack of smallpox is largely a matter ofcareful nursing. A physician or nurse can scarcely lay claim to anygreat degree of heroism in caring for smallpox patients, as there isno danger of contracting the disease providing a successfulvaccination has been recently performed upon them. The patient shouldbe quarantined in an isolated building, and all unnecessary articlesshould be removed from the sick room, in the way of carpets and otherfurnishings. It is well that the room be darkened to save irritationof the eyes. The diet should be liquid: milk, broths, and gruels. Laudanum, fifteen drops, or paregoric, one tablespoonful in water, may be given to adults, once in three hours, to relieve pain duringthe first few days. Sponging throughout the course of the disease isessential; first, with cool water, as directed for scarlet fever, withthe use of cold on the head to relieve the itching, fever, anddelirium. The cold pack is still more efficient. To give this, thepatient is wrapped in a sheet wrung out in water at a temperaturebetween 68° and 75° F. The sheet surrounds the naked body from feet toneck, and is tucked between the legs and between the body and arms;the whole is then covered with a dry blanket, and a cold, wet cloth orice cap is placed upon the head. The patient may be permitted toremain in the pack for an hour, when it may be renewed, if necessary, to allay fever and restlessness; otherwise it may be discontinued. Thecold sponging or cold pack are indicated when the temperature is over102. 5° F. , and when with fever there are restlessness and delirium. Great cleanliness is important throughout the disease; the bedclothesshould be changed daily and the patient sponged two or three timesdaily with warm water, unless fever is high. Cloths wet with coldcarbolic-acid solution (one-half teaspoonful to the pint of hot water)should be kept continuously on the face and hands. Holes are cut inthe face mask for the eyes, nose, and mouth, and the whole coveredwith a similar piece of oil silk to keep in the moisture. Suchapplications give much relief, and to some extent prevent pitting. The hair must be cut short, and crusts on the scalp treated withfrequent sponging and applications of carbolized vaseline, to softenthem and hasten their falling. The boric-acid solution should bedropped into the eyes as recommended for measles, and the throatsprayed every few hours with Dobell's solution. Diarrhea in adults maybe checked with teaspoonful doses of paregoric given hourly in water. Vaseline and cloths used on a patient must not be employed on another, as boils are thus readily propagated. All clothing, dishes, etc. , coming in contact with a patient must be boiled, or soaked in atwo-per cent carbolic-acid solution for twenty-four hours, or burned. When the patient is entirely free from scabs, after bathing andputting on disinfected or new clothes outside of the sick room, he isfit to reënter the world. =CHICKENPOX. =--Chickenpox is a contagious disease, chiefly attackingchildren. While it resembles smallpox in some respects, at timessimulating the latter so closely as to puzzle physicians, it is adistinct disease and is in no way related to smallpox. This is shownby the fact that chickenpox sometimes attacks a patient sufferingwith, or recovering from, smallpox. Neither do vaccination nor aprevious attack of smallpox protect an individual from chickenpox. Chickenpox is not common in adults, and its apparent presence in agrown person should awaken the liveliest suspicion lest the case beone of smallpox, since this mistake has been frequently made, andwith disastrous results, during an epidemic of mild smallpox. Oneattack of chickenpox usually protects against another, but two orthree attacks in the same individual are not unknown. The disease maybe transmitted from the patient to another person from the time of thefirst symptom until the disappearance of the eruption. The diseaseordinarily occurs in epidemics, but occasionally in isolated cases. =Development. =--A period of two weeks commonly elapses after exposureto the disease before the appearance of the first symptom ofchickenpox, but this period may vary from thirteen to twenty-one days. =Symptoms. =--The characteristic eruption is often the first warning ofchickenpox, but in some cases there may be a preliminary period ofdiscomfort, lasting for a few hours, before the appearance of therash; particularly in adults, in whom the premonitory symptoms may bequite severe. Thus, there may be chilliness, nausea, and evenvomiting, rarely convulsions in infants, pain in the head and limbs, and slight fever (99° to 102° F. ) at this time. The eruption showsfirst on the body, in most cases, especially the back. It consists ofsmall red pimples, which rapidly develop into pearly looking blistersabout as large as a pea to that of the finger nail, and are sometimessurrounded by a red blush on the skin. These blisters vary in number, from a dozen or so to two hundred. They do not run together, and inthree to four days dry up, become shriveled and puckered, and coveredwith a dark-brown or blackish crust, and drop off, leaving onlytemporary red spots in most cases. The fever usually continues duringthe eruption. During the first few days successive fresh crops offresh pimples and blisters appear, so that while the first crop isdrying the next may be in full development. This forms one of itsdistinguishing features when chickenpox is compared with smallpox. Inchickenpox the eruption is seen on the unexposed skin chiefly, but mayoccur on the scalp and forehead, and even on the palms, soles, forearms, and face. In many cases the eruption is found in the mouth, on its roof, and the inside of the cheeks. The blisters rarely contain"matter" or pus, as in smallpox, unless they are scratched. Scratchingmay lead to the formation of ugly scars and should be prevented, especially when the eruption is on the face. Pitting rarely occurs. =Determination. =--The discrimination between chickenpox and smallpoxis sometimes extremely puzzling and demands the skill of anexperienced physician. When one is unavailable, the following pointsmay serve to distinguish the two disorders: smallpox usually beginslike a severe attack of _grippe_, with pain in the back and head, general pains and nausea or vomiting, with high fever (103° to 104°F. ) These last two or three days, and may completely subside when therash appears. In chickenpox preliminary discomfort is absent, or lastsbut a few hours before the eruption. The eruption of smallpox usuallyoccurs first on the forehead, near the hair, or on the palms of thehands, soles of the feet, the arms and legs, but is usually sparse onthe body. The eruption appears about the same time in smallpox and notin successive crops, as in chickenpox. Chickenpox is more commonly adisease of childhood; smallpox attacks all ages. The crusts inchickenpox are thin, and appear in four or five days, while those ofsmallpox are large and yellow, and occur after ten or twelve days. =Outlook. =--Chickenpox almost invariably results in a rapid and speedyrecovery without complications or sequels. The young patients oftenfeel well throughout the attack, which lasts from eight to twelvedays. =Treatment. =--Children should be kept in bed during the eruptive stageuntil the blisters have dried. To prevent scratching, the calaminelotion may be used (Vol. II, p. 145), or carbolized vaseline, orbathing with a solution of baking soda, one teaspoonful to the pint oftepid water. The diet should be that recommended for German measles. Patients should be kept in the house and isolated until all signs ofthe eruption are passed, and then receive a good bath and freshclothing before mingling with others. The sick room should bethoroughly cleaned and aired; thorough chemical disinfection is notessential. The services of a physician are always desirable in order that it maybe positively determined that the disease is not a mild form ofsmallpox. CHAPTER II =Infectious Diseases= _Typhoid Fever--How it is Contracted--Complications and Sequels--Rest, Diet, and Bathing the Requisites--Mumps--Whooping Cough--Erysipelas. _ =TYPHOID FEVER (ENTERIC FEVER). =--Through ignorance which prevailedbefore the discovery of the germ of typhoid fever and exact methodsfor determining the presence of the same, the term was loosely appliedand is to this day. Thus mild forms of typhoid are called gastricfever, slow fever, malarial fever, nervous fever, etc. , all truetyphoid in most cases; while typhoid fever, common to certainlocalities and differing in some respects from the typical form, isoften named after the locality in which it occurs, as the "mountainfever" common to the elevated regions of the western United States. This want of information is apt to prevail in regions remote frommedical centers, and leads to neglect of the necessary strict measuresfor the protection of neighboring communities, for the excretion ofone typhoid patient has led to thousands of cases and hundreds ofdeaths. Typhoid fever is a communicable disease caused by a germ which attacksthe intestines chiefly, but also invades the blood, and at times allthe other parts of the body, and is characterized by continued fever, an eruption, tenderness and distention of the bowels, and generallydiarrhea. It is common to all parts of the earth in the temperatezones, and occurs more frequently from July to December in the northtemperate zone, from February to July in the south temperate zone. Itis most prevalent in the late summer and autumn months and after ahot, dry summer. Individuals between the ages of fifteen and thirtyare more prone to typhoid fever, but no age is exempt. The sexes arealmost equally liable to the disease, although it is said that forevery four female cases there are five male cases. The robust succumbas readily as the weak. =Cause and Modes of Communication. =--While the typhoid germ is alwaysthe immediate cause, yet it is brought in contact with the body invarious ways. Contamination of water supply through bad drainage isthe principal source of epidemics of typhoid. Before carefullyprotected public water supplies were in vogue in Massachusetts, therewere ninety-two deaths from typhoid fever in 100, 000 inhabitants, while thirty-five years after town water supplies became the rule, there were only nineteen deaths for the same population. Whenevertyphoid is prevalent, the water used for drinking and all otherhousehold purposes should be boiled, and uncooked food should beavoided. Flies are carriers of typhoid germs by lighting on the nose, the mouth, and the discharges of typhoid patients, and then conveyingthe germs to food, green vegetables, and milk. Cooking the food, preventing contact of flies with the patients, and keeping flies outof human habitations becomes imperative. Milk is a source of contagionthrough contaminated water used to wash cans, or to adulterate it, orthrough handling of it by patients or those who have come in contactwith patients. Oysters growing in the mouths of rivers and near theoutlets of drains and sewers are carriers of typhoid germs, and, ifeaten raw, sometimes communicate typhoid fever. Dust is an occasionalmedium of communication of the germ. It is probable, however, that thegerm always enters the body by being swallowed with food or drink, anddoes not enter through the lungs. There is little doubt on this point. Ice may harbor the germ for many months, for freezing does not killit, and epidemics have been traced to this source. Clothing, wood, utensils, door handles, etc. , which have been contaminated by contactwith discharges from patients, may also prove mediums of communicationof the typhoid germ to healthy individuals. Typhoid germs escape frompatients sick with the disease chiefly in the bowel discharges andurine, sometimes in the sweat, saliva, and vomited matter. Sewer gas and emanations from sewage and filth will not communicatetyphoid fever directly, but the latter afford nutriment for the growthof the germ, and after becoming infected, may eventually come incontact with drinking water or food, and so prove dangerous. Impropercare of discharges of excrement and urine--with the assistance offlies--are responsible for the enormous typhoid epidemics in militarycamps, so that in the late Spanish-American War one-fifth of all oursoldiers in camp contracted the disease. In the upper layers of thesoil typhoid germs may live for six months through frosts and thaws. The disease is preventable, and will probably be stamped out in time. In some of the most thickly populated cities in the world, as inVienna, its occurrence is most infrequent, owing to intelligentsanitary control and pure water supply, while in the most salubriouscountry districts its inroads are the most serious and fatal throughignorance and carelessness. =Development. =--From eight to twenty-three days elapse from the timeof entrance of typhoid germs into the body before the patient is takensick. One attack usually protects one against another, but two orthree attacks are not unheard of in the same person. =Symptoms. =--Typhoid fever is subject to infinite variations, and itwill here be possible only to outline what may be called a typicalcase. In a work of this kind the preliminary symptoms are of mostimportance in warning one of the probability of an attack, so that theprospective patient can govern himself accordingly, as in no otherdisease is rest in bed of more value. Patients who persist in walkingabout with typhoid fever for the first week or so are most likely todie of the disease. The average duration of the disease is about one month. During thefirst week the onset is gradual, the temperature mounting a littlehigher each day--as 99. 5° F. The first evening, 101° the second, 102°the fourth, 104° the fifth, 105° the sixth, and 105. 5° the seventh. Inthe morning of each day the temperature is usually about a degree ormore lower than that of the previous night. From the end of the firstweek to the beginning of the third the temperature remains at itshighest point, being about the same each evening and falling one ortwo degrees in the morning. During the third week the temperaturegradually falls, the highest point each evening being a degree or solower than the previous day, while in the fourth week the temperaturemay be below normal in the morning and a degree or so above normal atnight. So much for this symptom. After the entrance of typhoid germsinto the bowels and before the recognized onset of the disease, theremay be lassitude and disinclination for exertion. The disease beginswith headache, backache, loss of appetite, sometimes a chill in adultsor a convulsion in children, soreness in the muscles, pains in thebelly, nosebleed, occasional vomiting, diarrhea, coated tongue, oftensome cough, flushed face, pulse 100, gradually increasing asdescribed. These symptoms are, to a considerable extent, characteristic of thebeginning of many acute diseases, but the gradual onset with constantfever, nosebleed, and looseness of the bowels are the most suggestivefeatures. Then, if at the end of the first week or ten days pink-redspots, about as large as a pin head, appear on the chest and belly tothe number of two or three to a dozen, of very numerously, anddisappear on pressure (only to return immediately), the existence oftyphoid fever is pretty certain. Headache is now intense. These rosespots--as they are called--often appear in crops during the second andthird weeks, lasting for a few days, then departing. During the second week there is often delirium and wandering at night;the headache goes, but the patient is stupid and has a dusky, flushedface. The tongue becomes brownish in color, and its coat is cracked, and the teeth are covered with a brownish matter. The skin isgenerally red and the belly distended and tender. Diarrhea is oftenpresent with three to ten discharges daily of a light-yellow, pea-soupnature, with a very offensive odor. Constipation throughout thedisease is, however, not uncommon in the more serious cases. The pulseranges from 80 to 120 a minute. During the third week, in cases of moderate severity, the generalcondition begins to improve with lowering of the temperature, clearingof the tongue, and less frequent bowel movements. But in severe casesthe patient becomes weaker, with rapid, feeble pulse, ranging from 120to 140; stupor and muttering delirium; twitching of the wrists andpicking at the bedclothes, with general trembling of the muscles inmoving; slow, hesitating speech, and emaciation; while the urine andfæces may be passed unconsciously in bed. Occasionally the patientwith delirium may require watching to prevent him from getting out ofbed and injuring himself. He may appear insane. During the fourth week, in favorable cases, the temperature falls tonormal in the morning, the pulse is reduced to 80 or 100, the diarrheaceases, and natural sleep returns. Among the many and frequent variations from the type described, theremay be a fever prolonged for five or six weeks, with a good recovery. Chills are not uncommon during the disease, sometimes owing tocomplications. Relapse, or a return of the fever and other symptomsall over again, occurs in about ten per cent of the cases. This mayhappen more than once, and as many as five relapses have been recordedin one patient. A slight return of the fever for a day or two is oftenseen, owing to error in diet, excitement, or other imprudence afterapparent recovery. Death may occur at any time from the first week, owing to complications or the action of the poison of the disease. Pneumonia, perforation of and bleeding from the bowels are the mostfrequent dangerous complications. Unfavorable symptoms are continuedhigh fever (105° to 106° F. ), marked delirium, and trembling of themuscles in early stages, and bleeding from the bowels; also intenseand sudden pain with vomiting, indicating perforation of theintestines. The result is more apt to prove unfavorable in very fatpatients, and especially so in persons who have walked about until thefever has become pronounced. Bleeding from the bowels occurs in fourto six per cent of all cases and is responsible for fifteen per centof the deaths; perforation of the bowels happens in one to two percent of all cases and occasions ten per cent of the deaths. =Detection. =--It is impossible for the layman to determine theexistence of typhoid fever in any given patient absolutely, but whenthe symptoms follow the general course indicated above, a probabilitybecomes established. Unusual types are among the most difficult andpuzzling cases which a physician has to diagnose, and he can rarely beabsolutely sure of the nature of any case before the end of the firstweek or ten days, when examination of the blood offers an exactmethod of determining the presence of typhoid fever. Typhoidfever--especially where there are chills--is often thought to bemalaria, when occurring in malarial regions, and may be improperlycalled "typhoid malaria. " There is no such disease. Rarely typhoidfever and malaria coexist in the same person, and while this was notuncommon in the soldiers returning from Cuba and Porto Rico, it is anextremely unusual occurrence in the United States. Examination of theblood will determine the presence or absence of both of thesediseases. =Complications and Sequels. =--These are very numerous. Among theformer are diarrhea, delirium, mental and nervous diseases, bronchitis, pleurisy, pneumonia, ear abscess, perforation of andhemorrhage from the bowels, inflammation of the gall bladder, diseaseof heart, kidney, and bladder, and many rarer conditions, dependingupon the organ which the germ invades. Among sequels are boils, baldness, bone disease, painful spine, and, less commonly, insanityand consumption. While convalescence requires weeks and months, thepatient often gains greatly in flesh and feels made over anew, as infact he has been to a great extent, through the destruction and repairof his organs. =Outlook. =--The death rate varies greatly in different epidemics andunder different conditions. During the Spanish-American War in theenormous number of cases--over 20, 000--the death rate was only aboutseven per cent, which represents that in the best hospitals of thiscountry and in private practice. Osler states that the mortalityranges from five to twelve per cent in private practice, and fromseven to twenty per cent in hospital practice, because hospital casesare usually advanced before admission. The chances of recovery aremuch greater in patients under fifteen years, and are also morefavorable between the twenty-second and fortieth years. =Treatment. =--There is perhaps no disease in which the services of aphysician are more desirable or useful than in typhoid fever, onaccount of its prolonged course and the number of complications andincidents which may occur during its existence. It is the duty of thephysician to report cases of typhoid to the health authorities, andthus act as a guardian of the public health. If, however, in anycircumstances one should have the misfortune to have the care of atyphoid patient remote from medical aid, it is a consolation to knowthat the outlook is not greatly altered by medicine or specialtreatment of any sort. There have been epidemics in remote parts ofthis country where numbers of persons have suffered with typhoidwithout any professional care, and yet with surprisingly good results. Thus, in an epidemic occurring in a small community in Canada, twenty-four persons sickened with typhoid and received no medical careor treatment whatever, and yet there was but one death. The essentialsof treatment are comprised in _Rest, Diet, and Bathing_. Rest to theextent of absolute quiet in the horizontal position, at the firstsuspicion of typhoid, is requisite in order to avoid the dangers ofbleeding and perforation of the bowels resulting from ulceration ofstructures weakened by the disease. The patient should be assisted toturn in bed, must make no effort to rise during the sickness, andshould pass urine and bowel discharges into a bedpan or urinal undercover. In case of bleeding from the bowels, the bedpan should not beused, but the discharges may be received for a time in cloths, withoutstirring the patient. =Diet. =--This should consist chiefly of liquids until a week afterthe fever's complete disappearance. A cup of liquid should be givenevery two hours except during a portion of the sleeping hours. Milk, diluted with an equal amount of water, forms the chief food in mostcases unless it disagrees, is refused, or is unobtainable. In addition to milk, albumen water--white of raw egg, strained anddiluted with an equal amount of water, and flavored with a few dropsof lemon juice or with brandy--is valuable; also juice squeezed fromraw beef--in doses of four tablespoonfuls--coffee, cocoa, and strainedbarley, rice, or oatmeal gruel, broths, unless diarrhea is marked andincreased by the same. Soft custard, jellies, ice cream, milk-and-flour porridge, and eggnog may be used to increase thevariety. Finely scraped raw or rare beef, very soft toast, andsoft-boiled or poached eggs are allowable after the first week ofnormal temperature, at the end of the third or fourth week of thedisease, and during the course of the disease under circumstanceswhere the fluids are not obtainable or not well borne. An abundance ofwater should be supplied to the patient throughout the disease. =Bathing. =--The importance of cold, through the medium of water, intyphoid fever accomplishes much, both in reducing the temperature andin stimulating the nervous system and relieving restlessness anddelirium. Bathing is usually applied when the temperature rises above102. 5° F. , and may be repeated every two or three hours ifrestlessness, delirium, and high temperature require it. The immersion of patients in tubs of cold water, as practiced withbenefit in hospitals, is out of the question for use by inexperiencedlaymen. The patient should have a woven-wire spring bed and soft hairmattress, over which is laid a folded blanket covered by a rubbersheet. Sponging the naked body with ice water will suffice in somecases; in others, when the temperature is over 102-1/2° F. , envelopingthe whole body in a sheet wet in water at 65°, and either rubbing thesurface with ice or cloths wet in ice-cold water, for ten or fifteenminutes, is advisable. Rubbing of the skin of the chest and sides isnecessary during the application of cold to prevent shock. The use ofa cold cloth on the head and hot-water bottle at the feet, during thesponging, will also prove beneficial. In children and others objectingto these cold applications, the vapor bath is effective. For this apiece of cheese cloth (single thickness) is wet with warm water--100°to 105°--and is wrapped about the naked body from shoulders to feet, and is continually wet by sprinkling with water at the temperature of98°. The evaporation of the water will usually, in fifteen to twentyminutes, cool the body sufficiently if the patient is fannedcontinuously by two attendants. In warm weather the patient shouldonly be covered with a sheet for a while after the bath, which shouldreduce the temperature to 3°. Hot water at the feet, and a littlebrandy or whisky given before the sponging if the pulse be feeble, will generally prevent a chill. Patients should be gently dried afterthe bath and covered with dry bedclothing. The utmost care should betaken not to agitate a feeble patient during sponging. The long period of lying in bed favors the occurrence of bedsores. These are apt to appear about the lower part of the spine, and beginwith redness of the skin, underneath which a lump may be felt. Constant cleanliness and bathing with alcohol, diluted with an equalamount of water, will tend to prevent this trouble, while moving thepatient so as to take the pressure off this region and avoiding anyrumpling of the bedding under his body are also serviceable, as wellas the ring air cushion. Medicine is not required, except for specialsymptoms, and has no influence either in lessening the severity of orin shortening the disease. Brandy or whisky diluted with water arevaluable in severe cases, with muttering delirium, dry tongue, andfeeble pulse; it is not usually called for before the end of thesecond week, and not in mild cases at any time. A tablespoonful ofeither, once in two to four hours, is commonly sufficient. Pain anddistention of the belly are relieved by applying a pad over the wholefront of the belly--consisting of two layers of flannel wrung out of alittle very hot water containing a teaspoonful of turpentine--andcovered by a dry flannel bandage wrapped about the body. Also the useof white of egg and water, and beef juice, instead of milk, willbenefit this condition. Diarrhea--if there are more than four discharges daily--may be checkedby one-quarter level teaspoonful doses of bismuth subnitrate, orteaspoonful doses of paregoric, once in three hours. Constipation isrelieved by injections of warm soapsuds, once in two days. Bleedingfrom the bowels must be treated by securing perfect quiet on thepatient's part, and by giving lumps of ice by the mouth, and cuttingdown the nourishment for six hours. Fifteen drops of laudanum shouldbe given to adults, if there is restlessness, and some whisky, if thepulse becomes feeble, but it is better to reserve this until thebleeding has stopped. Patients may be permitted to sit up after a weekof normal temperature, but solid food must not be resumed until two orthree weeks after departure of fever, and then very gradually, avoiding all coarse and uncooked vegetables and fruit. The greatest care must be exercised by attendants to escapecontracting the disease and to prevent its communication to others. The bowel discharges must be submerged in milk of lime (one part ofslaked lime to four parts of water), and remain in it one hour beforebeing emptied. The urine should be mixed with an equal amount of thesame, or solution of carbolic acid (one part in twenty parts of hotwater), and the mixture should stand an hour before being thrown intoprivy or sewer. Clothing and linen in contact with the patient mustbe soaked in the carbolic solution for two hours. The patient'sexpectoration is to be received on old muslin pieces, which must beburned. The bedpan and eating utensils must be frequently scalded inboiling water. The attendant should wash his hands always aftertouching the patient, or objects which have come in contact withpatient or his discharges, and thus will avoid contagion. If farm ordairy workers come in contact with the patient, the latter precautionis especially important. If there is no water-closet in the house, thedisinfected discharges may be buried at least 100 feet from any wellor stream. Typhoid fever is only derived from the germs escaping inthe urine, and in the bowel, nose, or mouth discharges of typhoidpatients. =MUMPS. =--Mumps is a contagious disease characterized by inflammationof the parotid glands, situated below and in front of the ears, andsometimes of the other salivary glands below the jaw, and rarely ofthe testicles in males and the breasts in females. Swelling and inflammation of the parotid gland also occur from injury;and as a complication of other diseases, as scarlet fever, typhoidfever, etc. ; but such conditions are wholly distinct from the diseaseunder discussion. Mumps is more or less constantly prevalent in mostlarge cities, more often in the spring and fall, and is oftenepidemic, attacking ninety per cent of young persons who have notpreviously had the disease. It is more common in males, affectingchildren and youths, but rarely infants or those past middle age. Oneattack usually protects against another. =Development. =--A period of from one to three weeks elapses, afterexposure to the disease, before the first signs develop. The germ hasnot yet been discovered, and the means of communication are unknown. The breath has been thought to spread the germs of the disease, andmumps can be conveyed from the sick to the well, by nurses and otherswho themselves escape. =Symptoms. =--Sometimes there is some preliminary discomfort before theapparent onset. Thus, in children, restlessness, peevishness, languor, nausea, loss of appetite, chilliness, fever, and convulsions may usherin an attack. Mumps begins with pain and swelling below the ear on oneside. Within forty-eight hours a large, firm, sensitive lump formsunder the ear and extends forward on the face, and downward andbackward in the neck. The swelling is not generally very painful, butgives a feeling of tightness and disfigures the patient. It makesspeaking and swallowing difficult; the patient refuses food, and talksin a husky voice; chewing causes severe pain. After a period of two tofour days the other gland usually becomes similarly inflamed, butoccasionally only one gland is attacked. There is always fever fromthe beginning. At first the temperature is about 101° F. , rarely muchhigher than 103° or 104°. The fever continues four or five days andthen gradually declines. The swelling reaches its height in from twoto five days, and then after forty-eight hours slowly subsides, anddisappears entirely within ten to fourteen days. The patient maycommunicate the disease for ten days after the fever is past, andneeds to be isolated for that period. Earache and noises in the earfrequently accompany mumps, and rarely abscess of the ear and deafnessresult. The most common complication occurs in males past puberty, when, during recovery or a week or ten days later, one or bothtesticles become painful and swollen, and this continues for as long atime as the original mumps. Less often the breasts and sexual organsof females are similarly affected. =Complications and Sequels. =--Recovery without mishap is the usualresult in mumps, with the exception of involvement of the testicles. Rarely there are high fever, delirium, and great prostration. Sometimes after inflammation of both testicles in the young the organscease to develop, and remain so, but sexual vigor is usually retained. Sometimes abscess and gangrene of the inflamed parotid gland occur. Recurring swelling and inflammation of the gland may occur, andpermanent swelling and hardness remain. Meningitis, nervous and jointcomplications are among the rarer sequels. =Treatment. =--The patient should remain in bed while the fever lasts. A liquid diet is advisable during this time. Fever may be allayed byfrequent sponging of the naked body with tepid water. High fever anddelirium demand the constant use, on the head, of the ice cap (arubber bag, made to fit the head, containing ice). The relief of painin the swollen gland is secured by the frequent application of a thicklayer of sheet cotton, large enough to cover the whole side of theneck, wrung out of hot water and covered with oil-silk or rubbersheeting, with a bandage to retain it in place. Paregoric may be given for the same purpose--a tablespoonful foradults; a teaspoonful for a child of eight to ten, well diluted withwater, and not repeated inside of two hours, and not then unless thepain continues unabated. Inflammation of the testicles demands rest inbed, elevation of the testicle on a pillow after wrapping it in athick layer of absorbent cotton, or applying hot compresses, asrecommended for the neck. After the first few days of this treatment, adjust a suspensory bandage, which can be procured at any apothecaryshop, and apply daily the following ointment: guiacol, sixty grains;lard, one-half ounce, over the swollen testicle. =WHOOPING COUGH. =--A contagious disease characterized by fits ofcoughing, during which a whooping or crowing sound is made following along-drawn breath. Whooping cough is generally taken through directcontact with the sick, rarely through exposure to the sick room, or topersons or clothing used by the sick. The germ which causes thedisease is probably in the mucus of the nose and throat. Whoopingcough is usually more or less prevalent in all thickly settledcivilized communities, at times is epidemic, and often followsepidemics of measles. It occurs chiefly in children from six months tosix years of age. Girls and all weak and delicate subjects areslightly more susceptible to the disease. Some children are naturallyimmune to whooping cough. One attack usually protects against another. =Development. =--A variable period elapses between the time of exposureto whooping cough and the appearance of the first symptoms. This maybe from two days to two weeks; usually seven to ten days. =Symptoms. =--Whooping cough begins like an ordinary cold in the head, with cough, worse at night, which persists. The coughing fits increaseand the child gets red in the face, has difficulty in getting itsbreath during them, and sometimes vomits when the attack is over. After a variable period, from a few days to two weeks from thebeginning of the cough, the peculiar feature of the disease appears. The child gives fifteen or twenty short coughs without drawing breath, the face swells and grows blue, the eyeballs protrude, the veins standout, and the patient appears to be suffocating, when at last he drawsin a long breath with a crowing or whooping sound, which gives rise tothe name of the disease. Several such fits of coughing may follow oneanother and are often succeeded by vomiting and the expulsion of alarge amount of phlegm or mucus, which is sometimes streaked withblood. In mild cases there may be six to twelve attacks in twenty-fourhours; in severe cases from forty to eighty. The attacks last from afew seconds to one or two minutes. Occasionally the whoop comes beforethe coughing fit, and sometimes there may be no whooping at all, onlyfits of coughing with vomiting. Between the attacks, puffiness of theface and eyes and blueness of the tongue persist. The coughing fitsand whooping last usually from three to six weeks, but the duration ofthe disease is very variable. Occasionally it lasts many months, especially when it occurs in winter. The contagiousness of whoopingcough continues about two months, or ceases before that time with thecessation of the cough. Oftentimes there may be occasional whoopingfor months; or, after ceasing altogether for some days, it may beginagain. In neither of these conditions is the disease considered stillcontagious after two months. When an attack of whooping is coming on, the child often seems to have some warning, as he seems terrified andsuddenly sits up in bed, or, if playing, grasps hold of something, orruns to his mother or nurse. Coughing fits are favored by emotion orexcitement, by crying, singing, eating, drinking, sudden change oftemperature, and by bad air. =Complications and Sequels. =--These are many and make whooping cough acritical disease for very young children. Bronchitis and pneumoniaoften complicate whooping cough in winter, and diarrhea frequentlyoccurs with it in summer. Convulsions not infrequently follow thecoughing fits in infants, and, owing to the amount of blood forced tothe head during the attacks, nosebleed and dark spots on the foreheadand surface of the eyes appear from breaking of small blood vessels inthese places. Severe vomiting and diarrhea occasionally aggravate thecase, and pleurisy and consumption may occur. The violent coughing maypermanently damage the heart. Rupture of the lung tissue happens fromthe same cause, and paralysis sometimes follows breaking of a bloodvessel in the brain. But in the vast majority of cases in childrenover two years old no dangerous sequel need be feared. =Outlook. =--Owing to the numerous complications, whooping cough mustbe looked upon as a very serious disease, especially in infants undertwo years, and in weak, delicate children. It causes one-fourth of alldeaths among children, the death rate varying from three to fifteenper cent in different times and under different circumstances. Forthis reason a physician's services should always be secured whenpossible. =Treatment. =--A host of remedies is used for whooping cough, but nosingle one is always the best. It is often necessary to try differentmedicines till we find one which excels. Fresh air is of greatestimportance. Patients should be strictly isolated in rooms bythemselves, and it is wise to send away children who have not beenexposed. Morally, parents are criminally negligent who allow theirchildren with whooping cough to associate with healthy children. Ifthe coughing fits are severe or there is fever, children should bekept in bed. Usually there is not much fever; perhaps an elevation ofa degree or two at first, and at times during the disease. Otherwise, children may be outdoors in warm weather, and in winter on warm, quietdays. Sea air is especially good for them. It is best that the sickshould have two rooms, going from one to the other, so that thewindows in the room last occupied may be opened and well ventilated. Fresh air at night is especially needful, and the patient should sleepin a room which has been freshly aired. The temperature should be keptat an even 70° F. , and the child should not be exposed to draughts. Vaporizing antiseptics in the sick room has proved beneficial. A twoper cent solution of carbolic acid in water is useful for thispurpose, or a substance called vapo-cresoline, with which is sold avaporizing lamp and directions for use. A one per cent solution ofresorcin, or of hydrogen dioxide, diluted with four parts of water, used in an atomizer for spraying the throat, every two hours, hasgiven good results. In the beginning of the disease, before thewhooping has begun, a mixture of paregoric and syrup of ipecac willrelieve the cough, ten drops of the former with five of the latter, for a child of two years, given together in water every three hours. The bromide of sodium, five grains in water, every three hours duringthe day, for a child of two, is serviceable in relieving the fits ofcoughing in the day; while at night, two grains of chloral, notrepeated, may be given in water at bedtime to secure sleep, in a childof two. The tincture of belladonna, in doses of two drops in water, three times daily, for a child of two, is also often efficacious. Quinine, given in the dose of one-sixth grain for each month of thechild's age under a year; or in one and one-half grain doses for eachyear of age under five, is one of the older and more valuableremedies. It should be given three times daily in pill with jelly, orsolution in water. Bromoform in doses of two drops for a child of two, and increasing to five drops for a child of six, may be given in syrupthree times daily with benefit. Most of these drugs should be employedonly with a doctor's advice, when this is possible. To sum up, use thevapo-cresoline every day. When no physician is available, begin withbelladonna during the day, using bromide of sodium at night. If thisfails to modify the whooping after five days' trial, use bromide andchloral. In severe cases use bromoform. During a fit of coughing andwhooping, it is well to support the child's head, and if he ceases tobreathe, he should be slapped over the face and chest with a towel wetwith cold water. Interference with sleep caused by coughing, and lossof proper nourishment through vomiting, lead to wasting and debility. Teaspoonful doses of emulsion of cod-liver oil three times daily, after eating, are often useful in convalescence, and great care mustbe taken at this time to prevent exposure and pneumonia. Change of airand place will frequently hasten recovery remarkably in the laterstages of the disease. =ERYSIPELAS. =--Erysipelas is a disease caused by germs which gainentrance through some wound or abrasion in the skin or mucousmembranes. Even where no wound is evident it may be taken for grantedthat there has been some slight abrasion of the surface, althoughinvisible. Erysipelas cannot be communicated any distance through theair, but it is contagious in that the germs which cause it may becarried from the sick to the well by nurses, furniture, bedding, dressings, clothing, and other objects. Thus, patients with wounds, women in childbirth, and the newborn may become affected, but modernmethods of surgical cleanliness have largely eliminated these forms oferysipelas, especially in hospitals, where it used to be common. Erysipelas attacks people of all ages, some persons being verysusceptible and suffering frequent recurrences. The form which ariseswithout any visible wound is seen usually on the face, and occurs mostfrequently in the spring. The period of development, from the time thegerms enter the body until the appearance of the disease, lasts fromthree to seven days. Erysipelas begins with usually a severe chill (or convulsion in ababy) and fever. Vomiting, headache, and general lassitude are oftenpresent. A patch of red appears on the cheeks, bridge of nose, orabout the eye or nostril, and spreads over the face. The margins ofthe eruption are sharply defined. Within twenty-four hours the diseaseis fully developed; the skin is tense, smooth, and shiny, scarlet andswollen, and feels hot, and is often covered with small blisters. Thepain is more or less intense, burning or itching occurs, and there isa sensation of great tightness or tension. On the face the swellingcloses the eye and may interfere with breathing through the nose. Thelips, ears, and scalp are swollen, and the person may becomeunrecognizable in a couple of days. Erysipelas tends to spread like adrop of oil, and the borders of the inflammatory patch are wellmarked. It rarely spreads from the face to the chest and body, and butoccasionally attacks the throat. During the height of the inflammationthe temperature reaches 104° F, or over. After four or five days, inmost cases, erysipelas begins to subside, together with the pain andtemperature, and recovery occurs with some scaling of the skin. Thedeath rate is said to average about ten per cent in hospitals, fourper cent in private practice. Headache, delirium, and stupor arecommon when erysipelas attacks the scalp. The appearance of thedisease in other locations is similar to that described. Relapses arenot uncommon, but are not so severe as the original attack. Spreadingmay extend over a large area, and the deeper parts may becomeaffected, with the formation of deep abscesses and great destructionof tissue. Certain internal organs, heart, lungs, spleen, and kidneys, are occasionally involved with serious consequences. The old, thediseased, and the alcoholic are more apt to succumb, also the newborn. It is a curious fact that cure of malignant growths (sarcoma), chronicskin diseases, and old ulcers sometimes follows attacks of erysipelas. =Treatment. =--The duration of erysipelas is usually from a few days toabout two weeks, according to its extent. It tends to run a definitecourse and to recovery in most cases without treatment. The patientmust be isolated in a room with good ventilation and sunlight. Dressings and objects coming in contact with him must be burned orboiled. The diet should be liquid, such as milk, beef tea, soups, andgruels. The use of cloths wet constantly with cold water, or with acold solution of one-half teaspoonful of pure carbolic acid to thepint of hot water, or with a poisonous solution of sugar of lead, fourgrains to the pint, should be kept over small inflamed areas. Fever isreduced by sponging the whole naked body with cold water at frequentintervals. A tablespoonful of whisky or brandy in water may be givenevery two hours to adults if the pulse is weak. Painting the bordersof the inflamed patch with contractile collodion may prevent itsspreading. The patient must be quarantined until all scaling ceases, usually for two weeks. CHAPTER III =Malaria and Yellow Fever= _The Malarial Parasite--Mosquitoes the Means of Infection--DifferentForms of Malaria--Symptoms and Treatment--No Specific for YellowFever. _ =MALARIA; CHILLS AND FEVER; AGUE; FEVER AND AGUE; SWAMP OR MARSHFEVER; INTERMITTENT OR REMITTENT FEVER; BILIOUS FEVER. =--Malaria is acommunicable disease characterized by attacks of fever occurring atcertain intervals, and due to a minute animal parasite which inhabitsthe body of the mosquito, and is communicated to the blood of man bythe bites of this insect. In accordance with this definition malaria is not a contagious diseasein the sense that it is acquired by contact with the sick, which isnot the case, but it is derived from contact with certain kinds ofmosquitoes, and can be contracted in no other way, despite the manypopular notions to the contrary. Mosquitoes, in their turn, acquirethe malarial parasite by biting human beings suffering from malaria. It thus becomes possible for one malarial patient, coming to a regionhitherto free from the disease, to infect the whole district withmalaria through the medium of mosquitoes. =Causes. =--While the parasite infesting mosquitoes is the only directcause of malaria, yet certain circumstances are requisite for the lifeand growth of the mosquitoes. These are moisture and propertemperature, which should average not less than 60° F. Damp soil, marshes, or bodies of water have always been recognized as favoringmalaria. Malaria is common in temperate climates--in the summer and autumnmonths particularly, less often in spring, and very rarely in winter, while it is prevalent in the tropics and subtropics all the yearround, but more commonly in the spring and fall of these regions. Theolder ideas, that malaria was caused by something arising in vaporsfrom wet grounds or water, or by contamination of the drinking water, or by night air, or was due to sleeping outdoors or on the groundfloors of dwellings, are only true in so far as these favor the growthof the peculiar kind of mosquitoes infected by the malarial parasites. Two essentials are requisite for the existence of malaria in a region:the presence of the particular mosquito, and the actual infection ofthe mosquito with the malarial parasite. The kind of mosquito actingas host to the malarial parasite is the genus _Anopheles_, of whichthere are several species. The more common house mosquito of theUnited States is the _Culex_. The _Anopheles_ can usually bedistinguished from the latter by its mottled wings, and, when on awall or ceiling, it sits with the body protruding at an angle of 45°from the surface, with its hind legs hanging down or drawn against thewall. In the case of the _Culex_, the body is held parallel with thewall, the wings are usually not mottled, and the hind legs are carriedup over the back. When a mosquito infected with the malarial parasite bites man, theparasite enters his blood along with the saliva that anoints thelancet of the mosquito. The parasite is one of the simplest forms ofanimal life, consisting of a microscopical mass of living, motilematter which enters the red-blood cell of man, and there grows, undergoes changes, and, after a variable time, multiplies by dividinginto a number of still smaller bodies which represent a new generationof young parasites. This completes the whole period of theirexistence. It is at that stage in the development of the parasite inthe human body when it multiplies by dividing that the chills andfever in malaria appear. What causes the malarial attack at this pointis unknown, unless it be that the parasites give rise to a poison atthe time of their division. Between the attacks of chills and fever inmalaria there is usually an interval of freedom of a few hours, whichcorresponds to the period intervening in the life of the parasite inthe human body, between the birth of the young parasites and theirgrowth and final division, in turn, into new individuals. Thisinterval varies with the kind of parasite. The common form of malariais caused by a parasite requiring forty-eight hours for itsdevelopment. The malarial attacks caused by this parasite then occurevery other day, when the parasite undergoes reproduction by division. However, an attack may occur every day when there are two separategroups of these parasites in the blood, the time of birth of one setof parasites, with an accompanying malarial attack, happening one day;that of the other group coming on the next, so that between the twothere is a daily birth of parasites and a daily attack of malaria. Incases of malaria caused by one group of parasites the attacks appearat about the same time of day, but when the attacks are caused bydifferent groups of parasites the times of attack may vary ondifferent days. In the worst types of malaria the parasites do not allgo through the same stages of development at the same time, as iscommonly the case in the milder forms prevalent in temperate regions, so that the fever--corresponding to the stage of reproduction of theparasites--occurs at irregular intervals. In a not uncommon type of malaria the attacks occur every third day, with two days of intermission or freedom from fever. Different groupsof parasites causing this form of malaria, and having different timesof reproduction, may inhabit the same patient and give rise tovariation in the times of attack. Thus, an attack may occur on twosuccessive days with a day of intermission. The reproduction of the parasite in the human blood is not a sexualreproduction; that takes place in the body of the mosquito. When a healthy mosquito bites a malarial patient, the parasite entersthe body of the mosquito with the blood of the patient bitten. Itenters its stomach, where certain differing forms of the parasite, taking the part of male and female individuals, unite and form a newparasite, which, entering the stomach wall of the mosquito, givesbirth in the course of a week to innumerable small bodies as theirprogeny. These find their way into the salivary glands which secretethe poison of the mosquito bite, and escape, when the mosquito bites ahuman being, into the blood of the latter and give him malaria. =Distribution. =--Malaria is very widely distributed, and is much moresevere in tropical countries and the warmer parts of temperateregions. In the United States malaria is prevalent in some parts ofNew England, as in the Connecticut Valley, and in the course of theCharles River, in the country near Boston. It is common in thevicinity of the cities of Philadelphia, New York, and Baltimore, buthere is less frequent than formerly, and is of a comparatively mildtype. More severe forms prevail along the Gulf of Mexico and theshores of the Mississippi and its branches, especially in Mississippi, Texas, Louisiana, and Arkansas, but even here it is less fatal andwidespread than formerly. In Alaska, the Northwest, and on the PacificCoast of the United States malaria is almost unknown, while it is butslightly prevalent in the region of the Great Lakes, as about LakesErie and St. Clair. =Development. =--Usually a week or two elapses after the entrance ofthe malarial parasite into the blood before symptoms occur; rarelythis period is as short as twenty-four hours, and occasionally mayextend to several months. It often happens that the parasite remainsquiescent in the system without being completely exterminated afterrecovery from an attack, only to grow and occasion a fresh attack, amonth or two after the first, unless treatment has been thoroughlyprosecuted for a sufficient time. =Symptoms. =--Certain symptoms give warning of an attack, as headache, lassitude, yawning, restlessness, discomfort in the region of thestomach, and nausea or vomiting. The attack begins with a chillinessor creeping feeling, and there may be so severe a chill that thepatient is violently shaken from head to foot and the teeth chatter. Chills are not generally seen in children under six, but an attackbegins with uneasiness, the face is pinched, the eyes sunken, the lipsand tips of the fingers and toes are blue, and there is dullness andoften nausea and vomiting. Then, instead of a chill, the eyelids andlimbs begin to twitch, and the child goes into a convulsion. While thesurface of the skin is cold and blue during a chill, yet thetemperature, taken with the thermometer in the mouth or bowel, reaches102°, 105°, or 106° F. , often. The chill lasts from a few minutes toan hour, and as it passes away the face becomes flushed and the skinhot. There is often a throbbing headache, thirst, and sometimes milddelirium. The temperature at this time, when the patient feelsintensely feverish, is very little higher than during the chill. Thefever lasts during three or four hours, in most cases, and graduallydeclines, as well as the headache and general distressing symptomswith the onset of sweating, to disappear in an hour or two, when thepatient often sinks into a refreshing sleep. Such attacks morecommonly occur every day, every other day, or after intermissions oftwo days. Rarely do attacks come on with intervals of four, five, six, or more days. The attacks are apt to recur at the same time of day asin the first attack. In severe cases the intervals may grow shorter, in mild cases, longer. In the interval between the attacks the patientusually feels well unless the disease is of exceptional severity. There is also entire freedom from fever in the intervals except in thegrave types common to hot climates. Frequently the chill is absent, and after a preliminary stage of dullness there is fever followed bysweating. This variety is known as "dumb ague. " =Irregular and Severe Form--Chronic Malaria. =--This occurs in thosewho have lived long in malarial regions and have suffered repeatedattacks of fever, or in those who have not received proper treatment. It is characterized by a generally enfeebled state, the patient havinga sallow complexion, cold hands and feet, and temperature belownormal, except occasionally, when there may be slight fever. When thecondition is marked, there are breathlessness on slight exertion, swelling of the feet and ankles, and "ague cake, " that is, enlargementof the spleen, shown by a lump felt in the abdomen extending downwardfrom beneath the ribs on the left side. Among unusual forms of malaria are: periodic attacks of drowsinesswithout chills, but accompanied by slight fever (100° to 101° F. );periodic attacks of neuralgia, as of the face, chest, or in the formof sciatica; periodic "sick headaches. " These may take the place ofordinary malarial attacks in malarial regions, and are cured byordinary malarial treatment. =Remittent Form (unfortunately termed "bilious"). =--This severe typeof malaria occurs sometimes in late summer and autumn, in temperateclimates, but is seen much more commonly in the Southern United Statesand in the tropics. It begins often with lassitude, headache, loss ofappetite and pains in the limbs and back, a bad taste, and nausea fora day or two, followed by a chill, and fever ranging from 101° to 103°F. , or more. The chill is not usually repeated, but the fever iscontinuous, often suggesting typhoid fever. With the fever, there areflushed face, occasional delirium, and vomiting of bile, but moreoften a drowsy state. After twelve to forty-eight hours the feverabates, but the temperature does not usually fall below 100° F. , andthe patient feels better, but not entirely well, as in the ordinaryform of malaria, where the fever disappears entirely between theattacks. After an interval varying from three to thirty-six hours thetemperature rises again and the more severe symptoms reappear, and sothe disease continues, there never being complete freedom from fever, the temperature sometimes rising as high as 105° or 106° F. In somecases there are nosebleed, cracked tongue, and brownish deposit on theteeth, and a delirious or stupid state, as in typhoid fever, but thedistention of the belly, diarrhea, and rose spots are absent. The skinand whites of the eyes often take on the yellowish hue of jaundice. This fever has been called typhomalarial fever, under the suppositionthat it was a hybrid of the two. This is not the case, although it ispossible that the two diseases may occur in the same individual at thesame time. This, indeed, frequently happened as stated, in oursoldiers coming from the West Indies during the Spanish-AmericanWar--but is an extremely uncommon event in the United States. =Pernicious Malaria. =--This is a very grave form of the disease. Itrarely is seen in temperate regions, but often occurs in the tropicsand subtropics. It may follow an ordinary attack of chills and fever, or come on very suddenly. After a chill the hot stage appears, and thepatient falls into a deep stupor or unconscious state, with flushedface, noisy breathing, and high fever (104° to 105° F. ). Wild deliriumor convulsions afflict the patient in some cases. The attack may lastfor six to twenty-four hours, from which the patient may recover, onlyto suffer another like seizure, or he may die in the first. In anotherform of this pernicious malaria the symptoms resemble true cholera, and is peculiar to the tropics. In this there are violent vomiting, watery diarrhea, cramps in the legs, cold hands and feet, andcollapse. Sometimes the attack begins with a chill, but fever, if any, is slight, although the patient complains of great thirst and inwardheat. The pulse is feeble and the breathing shallow, but the intellectremains clear. Death often occurs in this, as in the former type of perniciousmalaria, yet vigorous treatment with quinine, iron, and nitre willfrequently prove curative in either form. =Black Water Fever. =--Rarely in temperate climates, but frequently inthe Southern United States and in the tropics, especially Africa;after a few days of fever, or after chilliness and slight fever, theurine becomes very dark, owing to blood escaping in it. This sometimesappears only periodically, and is often relieved by quinine. It isapparently a malarial fever with an added infection from anothercause. =Chagres Fever. =--A severe form of malarial fever acquired on theIsthmus of Panama, apparently a hemorrhagic form of the perniciousvariety, and so treated. =Detection. =--To the well-educated physician is now open an exactmethod of determining the existence of malaria, and of distinguishingit from all similar diseases, by the examination of the patient'sblood for the malarial parasite--its presence or absence deciding thepresence or absence of the disease. For the layman the followingpoints are offered: intermittency of chills and fever, or of feveralone, should suggest malaria, particularly in a patient living in orcoming from a malarial region, or in a previous sufferer from thedisease. In such a case treatment with quinine will solve the doubt inmost cases, and will do no harm even if the disease be not malaria. Malaria is one of the few diseases which can be cured with certaintyby a drug; failure to stop the symptoms by proper amounts of quininemeans, in the vast majority of cases, that they are not due tomalaria. There are many other diseases in which chills, fever, andsweating occur at intervals, as in poisoning from the presence ofsuppuration or formation of pus anywhere in the body, but the layman'signorance will not permit him to recognize these in many instances. The quinine test is the best for him. =Prevention. =--Since the French surgeon, Laveran, discovered theparasite of malaria in 1880, and Manson, in 1896, emphasized the factthat the mosquito is the medium of its communication to man, the wayfor the extermination of the disease has been plain. "Mosquitoengineering" has attained a recognized place. This consists indestroying the abodes of mosquitoes (marshes, ponds, and pools) bydrainage and filling, also in the application of petroleum on theirsurface to destroy the immature mosquitoes. Such work has already ledto wonderful results. [11] Open water barrels and water tanks prove afruitful breeding place for these insects, and should be abolished. The protection of the person from mosquito bites is obtained by properscreening of habitations and the avoidance of unscreened open air, ator after nightfall, when the pests are most in evidence. Dwellings onhigh grounds are less liable to mosquitoes. Persons entering amalarial region should take from two to three grains of quinine threetimes a day to kill any malarial parasites which may invade theirblood, and should screen doors and windows. Patients after recoveryfrom malaria must prolong the treatment as advised, and renew it eachspring and fall for several years thereafter. A malarial patient is adirect menace to his entire neighborhood, if mosquitoes enter. =Treatment. =--The treatment of malaria practically means the use ofquinine given in the proper way and in the proper form and dose. Despite popular prejudices against it, quinine is capable of littleharm, unless used in large doses for months, and no other remedy hasyet succeeded in rivaling it in any way. Quinine is frequently uselessfrom adulteration; this may be avoided by getting it of a reliabledrug house and paying a fair price for the best to be had. Neitherpills nor tablets of quinine are suitable, as they sometimes passthrough the bowels undissolved. The drug should be taken dissolved inwater, or, more pleasantly, in starch wafers or gelatin capsules. Whenthe drug is vomited it may be given (in double the dose) dissolved inhalf a pint of water, as an injection into the bowels, three timesdaily. Infants of a few months may be treated by rubbing an ointment(containing thirty grains of quinine sulphate mixed with an ounce anda half of lard) well into the skin of the armpits and groins, nightand morning. Children under the age of two can be best treated byquinine made into suppositories--little conical bodies of cocoa buttercontaining two grains each--one being introduced into the bowel, nightand morning. During an attack of malaria the discomfort of the chill and fever maybe relieved to considerable extent by thirty grains of sodium bromide(adult dose) in water. Hot drinks and hot-water bottles with warmcovering may be used during the chill, while cold sponging of thewhole naked body will afford comfort during the hot stage. In thepernicious form, attended with unconsciousness, sponging with verycold water, or the use of the cold bath with vigorous friction of thewhole body and cold to the head are valuable. The effect of quinine isgreatest during the time of birth of a new generation of youngparasites in the blood, which corresponds with the time of themalarial attack. But in order that the quinine shall have time topermeate the blood, it must be given two to four hours before theexpected chill, and then will probably prevent the next attack butone. A dose of ten grains of quinine sulphate taken three times dailyfor the first three days of treatment; then a dose of three grains, three times daily for two weeks; and finally two grains, three timesdaily for the rest of the month of treatment will, in many cases, complete a cure. If the quinine cause much ringing in the ears anddeafness, it will be found that sodium bromide taken with the quinine(in twice the dose) dissolved in water, will correct this trouble. Ifthe patient is constipated and the bowel discharges are light colored, a few one-quarter grain doses of calomel may be taken every two hours, and followed in twelve hours by a dose of Epsom salts, on the firstday of treatment, with quinine. It is no use to take quinine by themouth later than two hours before an attack, and if the patient cannotsecure treatment before this time, he should take a single dose oftwenty grains of quinine. To children may be given a daily amount of quinine equal to one grainfor each year of their age. In the severe forms of remittent andpernicious types of malaria it may be necessary for the patient totake as much as thirty grains of quinine every three days or so to cutshort the attack. But, unfortunately, the digestion may be so poorthat absorption of the drug does not occur, and in such an event theuse of quinine in the form of the bisulphate in thirty-grain doses, with five grains of tartaric acid, will in some cases prove effective. Chronic malaria is best treated with small doses of quinine, togetherwith arsenic and iron. A capsule containing two grains of quininesulphate, one-thirtieth grain of arsenious acid, and two grains ofreduced iron should be taken three times daily for several weeks. =YELLOW FEVER. =--This is a disease of tropical and subtropicalcountries characterized by fever, jaundice, and vomiting (in severecases vomiting of blood), caused by a special germ or parasite whichis communicated to man solely through the agency of the bites of aspecial mosquito, _Stegomyia fasciata_. =Distribution. =--Yellow fever has always been present in Havana, Rio, Vera Cruz, and other Spanish-American seaports; also on the west coastof Africa. It is frequently epidemic in the tropical ports of theAtlantic in America and Africa, and there have been numerous epidemicsin the southern and occasional ones in the northern seacoast cities ofthe United States. The last epidemic occurred in the South in 1899. Rarely has the disease been introduced into Europe, and it has neverspread there except in Spanish ports. The disease is one requiringwarm weather, for a temperature under 75° F. Is unsuitable to thegrowth of the special mosquito harboring the yellow-fever parasite. Itspreads in the crowded and unsanitary parts of seacoast cities, towhich it is brought on vessels by contaminated mosquitoes oryellow-fever patients from the tropics. Havana has heretofore been thesource of infection for the United States, but since the disease hasbeen eradicated by the American army of occupation, that danger hasbeen removed. Yellow fever is not at all contagious in the sense thata healthy person can contract the disease by contact with ayellow-fever patient, or with his discharges from the stomach, bowels, or elsewhere, and is probably only communicated to man by the bite ofa particular kind of mosquito harboring the yellow-fever organism inits body. Both these facts have been incontestably proved, [12] in partby brave volunteers from the United States Army who submitted to sleepfor twenty-one days on clothes soiled with discharges from patientsdying of yellow fever, and escaped the disease; and by others livingin uncontaminated surroundings who permitted themselves to be bittenby infected mosquitoes and promptly developed yellow fever. =Development. =--After a person has been bitten by an infectedmosquito, from fourteen hours to five days and seventeen hours elapsebefore the development of the first symptoms--usually this periodlasts from three to four days. With the appearance of a single case ina region, a period of two weeks must elapse before the development ofanother case arising from the first one. This follows because amosquito, after biting a patient, cannot communicate the germ toanother person for twelve days, and two days more must elapse beforethe disease appears in the latter. =Symptoms. =--During the night or morning the patient has a chill (orfeels chilly) and experiences discomfort in the stomach, withsometimes nausea and vomiting. There is pain through the forehead andeyes, in the back and thighs, and often in the calves. The face isflushed and slightly swollen--particularly the upper lip--and the eyesare bloodshot, and gradually, in the course of thirty-six hours, thewhites become yellowish. This is one of the most distinguishingfeatures of the fever, but is often absent in children. The tongue iscoated, there are loss of appetite, lassitude, sore throat, andconstipation. In the beginning the temperature ranges from 101° to103° F. , or in severe cases as high as 105° or 106° F. , and the pulsefrom 110 to 120 beats a minute. The fever continues for severaldays--except in mild cases--but the pulse usually falls before thetemperature does. For example, the temperature may rise a degreeduring the third day to 103° F. , while the pulse falls ten or morebeats at the same time and may not be over 70 or 80, while thetemperature is still elevated. This is another peculiar feature of thedisease. Vomiting often increases on the second or third day, and thedreaded "black vomit" may then occur. This presents the appearance ofcoffee grounds or tarry matter and, while a dangerous symptom, doesnot by any means presage a fatal ending. The black color is due toaltered blood from the stomach, and bleeding sometimes takes placefrom the nose, throat, gums, and bowels, with black discharges fromthe latter. The action of the kidneys is usually interfered with, causing diminution in the amount of urine. It is extremely importantto pay regard to this feature, because failure of the patient to passa proper amount of urine calls for prompt action to avert fatalpoisoning from retained waste matters in the blood. The normal amountof urine passed in twenty-four hours in health is over three pints, and while not more than two-thirds of this amount could be expected tobe passed by a fever patient, yet in yellow fever the passage of urinemay be almost or wholly suppressed. The course of the disease variesgreatly. In children--especially of the Creoles--it is frequently somild as to pass unnoticed. In adults the fever may only last a fewhours, or two or three days, with gradual recovery from the varioussymptoms, and yellowness of the skin lasting for some time. This isnot seen readily during the stage of fever when the surface isreddened, but at that time may be detected by pressure on the skin fora minute, when the skin will present a yellow hue on removing thefinger before the blood returns to the pressure spot. With fall offever, and abatement of symptoms after two or three days, the patient, instead of going on to recovery may, after a few hours or a day ortwo, again become very feverish and have vomiting--perhaps of blood orblack vomit--yellow skin, feeble pulse, failure of kidney action withsuppression of urine, delirium, convulsions, stupor, and death; or maybegin to again recover after a few days. Mild fever, slight jaundice, and absence of bleeding are favorable signs; black vomit, high fever, and passage of little urine are unfavorable signs. The death rate isvery variable in different epidemics and among different classes;anywhere from fifteen to eighty-five per cent. Among the betterclasses it is often not greater than ten per cent in private practice. Heavy drinkers and those living in unfavorable surroundings are apt tosuccumb. =Prevention. =--Yellow fever, like malaria, is a preventable disease, and will one day be only a matter of historic interest. Dr. W. C. Gorgas, U. S. A. , during 1901, by ridding Havana of the mosquitocarrying the yellow-fever organism through screening barrels andreceptacles holding water, and by treating drains, cesspools, etc. , with kerosene, succeeded in also eradicating yellow fever from thatcity, so that in the following year there was not one death from thisdisease; whereas, before this time, the average yearly mortality hadbeen 751 deaths in Havana. Spread of the disease is controlled bypreventing access of mosquitoes to the bodies of living or deadyellow-fever patients; while personal freedom from yellow fever may besecured by avoiding mosquito bites, through protection by screensindoors, and covering exposed parts of the face, hands, and ankleswith oil of pennyroyal or spirit of camphor, while outdoors. =Treatment. =--There is unfortunately no special cure known for yellowfever such as we possess in malaria. The patient should be wellcovered and surrounded with hot-water bags during chill. It isadvisable to give a couple of compound cathartic pills or atablespoonful of castor oil at the start. Two, or at most three, ten-grain doses of phenacetin at three hours intervals will relievethe pain during the early stage. Cracked ice given frequently by themouth and the application of a mustard paper or paste (one partmustard, three parts flour, mixed with warm water and applied betweentwo layers of thin cotton) over the stomach will serve to allayvomiting. Cold sponging (see Typhoid Fever, p. 232) is the besttreatment for fever. The black vomit may be arrested by one-quarterteaspoonful doses of tincture of the chloride of iron, given in fourtablespoonfuls of water, every hour after vomiting. The bowels shouldbe moved daily by injection of warm soapsuds. The patient should notrise from his bed, but should use a bedpan or other receptacle. Inaddition, a pint of warm water, containing one-half teaspoonful ofsalt, should be injected into the bowel night and morning and, ifpossible, retained by the patient. The object of the latter is by itsabsorption to stimulate the action of the kidneys. The diet shouldconsist of milk, diluted with an equal amount of water, broths, gruels, etc. , and only soft food should be given for ten days afterrecovery. Iced champagne in tablespoonful doses at frequent intervals, or two teaspoonful doses of whisky in a little ice water, given everyhalf hour, relieves vomiting and supports the strength. FOOTNOTES: [11] See Volume V, p. 76, for detailed methods. --EDITOR. [12] See Frontispiece, Vol. V. +--------------------------------------------------------------------+| TRANSCRIBER'S NOTE. || =================== || || The following change was made: || || Part II, Chapter II, Typhoid Fever, Symptoms (p. 225) || || Original text: || || "... Flushed face, pulse 100°, gradually increasing as || described. " || || Changed to: || || "... Flushed face, pulse 100, gradually increasing as || described. " || || "Pulse 100" was preferred over "temperature 100°". || |+--------------------------------------------------------------------+