Treatment.—Even slight and moderate bruises should be treated by rest of the injured part. A splint insures the rest of a limb (see treatment of Fractures, p. 80). One of the best modes of treatment is the snug application of a flannel bandage which secures a certain amount of rest of the part to which it is applied, and aids in preventing further swelling. Where bandaging is not feasible, as in certain parts of the body, or before bandaging in any kind of a bruise, the use of a cold compress is advisable. One layer of thin cotton or linen cloth should be wet in ice water, and should be put on the bruised part and continually changed for newly moistened pieces as soon as the first grows warm. Alcohol and water, of each equal parts, may be used in the same manner to advantage.

When cold is unavailable or unpleasant to the patient, several layers of cotton cloth may be wrung out in very hot water and applied to the part with frequent renewal. The value attributed to witch-hazel and arnica is mainly due to the alcohol contained in their preparations. Cataplasma Kaolini (U. S. P.) is an excellent remedy for simple bruises when spread thickly on the part and covered with a bandage. An ointment containing twenty-five per cent of ichthyol is also a useful application. Following severe bruises, the damaged parts should be kept warm by the use of hot-water bags, or by covering a limb with cotton wool and bandage, until such time as surgical advice may be obtained.

When the pain and swelling of bruises begin to subside, treatment should be pursued by rubbing with liniment of ammonia or chloroform, or vaseline if these are not obtainable. Moderate exercise of the part is desirable.

ABRASIONS.—When the surface skin is scraped off, as often happens to the shin, knee, or head, an ointment containing sixty grains of boric acid to the ounce of vaseline makes a good application, and this may be covered with a bandage. The same ointment is useful to apply to small 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 half an hour.

Rule 2.—Dry and strap with adhesive plaster, if you know how. If not, bandage snugly, beginning with tips of fingers or with toes, and make 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 or twist of a joint, producing a momentary displacement of the ends of the bones to such a degree that they are forced against the membrane and ligaments surrounding the joint, tearing one or both to a greater or less extent. The wrist and ankle are the joints more commonly sprained, and this injury is more likely to occur in persons with flabby muscles and relaxed ligaments, as in the so-called "weak-ankled." The damage to the parts holding the joint in place may be of any degree, from the tearing of a few fibers of the membrane enwrapping the joint to its complete rupture, together with that of the ligaments, so that the bones are no longer in place, the joint loses its natural shape and appearance, and we have a condition known as dislocation. In a sprain then, the twist of the joint produces only a temporary displacement of the bones forming the joint, sufficient to damage the soft structures around it, but not sufficient to cause lasting displacement of the bones or dislocation.

It will be seen that whether a sprain or dislocation results, depends upon the amount of injury sustained. Since it often happens that the bone entering into the joint is broken, it follows that whenever what appears to be a severe sprain occurs, with inability to move the joint and great swelling, it is important to secure surgical aid promptly. Since the discovery of the X-ray many injuries of the smaller bones of the wrist and ankle joint, formerly diagnosed as sprains by the most skillful surgeons, have, by its use, been discovered to be breaks of the bones which were impossible of detection by the older methods of examination.

Symptoms.—The symptoms of sprain are sudden, severe pain, often accompanied by faintness and nausea, swelling, tenderness, and heat of the injured parts. The sprained joint can be only moved with pain and difficulty. The swelling is due not so much to leaking of blood from broken blood vessels as to filling up of the joint with fluid caused by the inflammation, although in a few days after a severe sprain the skin a little distance below the injury becomes "black and blue" from escape of blood caused by the injury.

Treatment.—Since the treatment of severe sprains means first the discrimination between dislocation, a break of bone, and a rupture of muscle, ligament, or tendon, it follows that the methods herein described for treatment should only be employed in slight unmistakable sprains, or until a surgeon can be secured, or when one is unavailable. Nothing is better than immediate immersion of the sprained 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 about three and one-half inches wide should be snugly applied to the limb, beginning at the finger tips or at the toes and carrying the bandage some distance above the injured joint.

In bandaging a part there is always danger of applying the bandage too tightly, especially if the parts swell under the bandage. If this happens, there is increase of pain which may be followed by numbness of the limb and, what is still more significant, coldness and blueness of the extremities below the bandage, particularly of the fingers and toes. In such cases the bandage must be removed and reapplied with less force. If the ankle or knee be sprained the patient must go to bed 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 a sling. In the more serious cases the injured joint should be fixed in a splint before bandaging. An injured elbow joint is held at a right angle by a pasteboard splint, a bandage, and a sling, while the knee and wrist are treated with the limb in a straight line, as far as possible.

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 the forearm. Sheet wadding, which may be bought at any drygoods store, is torn into strips about two inches wide and sewed together forming a bandage ten or fifteen feet long, and this is first wound about the sprained joint. Then pieces of millboard or heavy pasteboard are soaked in water and applied while wet in long strips about three inches 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 the splint, reaching from the lower part of the calf to four inches above the knee. It should be from a quarter to half an inch thick, a little narrower than the leg, and be padded thickly with sheet wadding. It is held in place by strips of surgeon's adhesive plaster, about two inches wide, passed around the whole circumference of the limb above and below the knee joint, and covered with bandage.

In ordinary sprains of the ankle, uncomplicated by broken bone or ligament, it is possible for the patient, after resting in bed for a day, to go about on crutches, without bearing any weight on the foot until the third day after the accident. The treatment in the meanwhile consists in immersing the sprained ankle alternately, first in hot water for five minutes and then in cold water for five minutes, followed by rubbing of the parts about the injured joint with chloroform liniment for fifteen minutes, but not at the beginning touching the joint itself. The rubbing should be done by an assistant very gently the first day, with gradual increase in vigor as the days pass, not only kneading the ankle but moving the joint.

This treatment should be pursued once daily, and followed by bandaging with 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 moderate use 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 and movements of the joint by an assistant. Since sprains vary in severity it follows that some may need only the first day's preliminary treatment prescribed to effect a cure, while others may require fixation by a surgeon in a plaster-of-Paris splint for some time, with additional treatment which only his special knowledge can supply.



SYNOVITIS—Severe Injury.—Generally of ankle or knee from fall, or shoulder from blow.

First Aid Rule 1.—Provide large pitcher of hot water and large pitcher of cold water and basin. Hold joint over basin; pour hot water slowly over joint. Return this water to pitcher. Pour cold water over joint. Return water to pitcher. Repeat with hot water again, and follow with cold. Continue this alternation for half an hour.

Rule 2.—Put to bed, with hot-water bottles about joint, and wedge immovably with pillows.

Rule 3.—When tenderness and heat subside, strap with adhesive plaster in overlapping strips.

Conditions, Etc.—This condition, which may affect almost any freely movable joints, as the knee, elbow, ankle, and hip, is commonly caused by a wrench, blow, or fall. Occasionally it comes on without any apparent cause, in which case there is swelling and but slight pain or inflammation about the joint. We shall speak of synovitis of the knee ("water on the knee"), as that is the most common form, but these remarks will apply almost as well to the other joints. In severe cases there are considerable pain, redness and heat, and great swelling about the knee. The swelling is seen especially below the kneepan, on each 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, it will not be necessary for the patient to remain in bed, but when these symptoms are present a splint of some sort must be applied so that the leg is kept nearly straight, and the patient must keep to his bed until the heat, redness, and tenderness have subsided. In the meantime either an ice bag, hot poultice, cloths wrung out in hot water, or a hot-water bag should be kept constantly upon the knee.

A convenient splint consists of heavy pasteboard wet and covered with sheet wadding (or cotton batting) shaped and affixed to the back of the leg, from six inches below to four inches above the joint, by strips of adhesive plaster, as shown in the illustration, and then by bandage, leaving the knee uncovered for applications. A wooden splint well padded may be used instead.

In mild cases without much inflammation, and in others after the tenderness and heat have abated, the patient may go about if the knee is treated as follows: a pad of sheet wadding or cotton batting about two inches thick and five inches long and as wide as the limb is placed in the hollow behind the knee, and then the whole leg is encircled with sheet wadding from six inches below to four inches above the knee, covering the joint as well as the pad. Beginning now five inches below the joint, strips of surgeon's adhesive plaster, an inch wide and long enough to more than encircle the limb, are affixed about the leg firmly like garters so as to make considerable pressure. Each strip or garter overlaps the one below about one-third of an inch, and the whole limb is thus incased in plaster from five inches below the knee to a point about four inches above the joint.

An ordinary cotton bandage is then applied from below over the entire plaster bandage. When this arrangement loosens, the plaster should be taken off and new reapplied, or a few strips may be wound about the old plaster to reenforce it. The patient may walk about with this appliance without bending the knee.

When the swelling has nearly departed, the plaster may be removed and the knee rubbed twice daily about the joint and the joint itself moved to and fro gently by an attendant, and then bandaged with a flannel bandage. Painting the knee with tincture of iodine in spots as large as a silver dollar is also of service at this time. The knee should not be bent in walking until it can be moved by another person without producing 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 of the joint (p. 128). The ankle is treated as advised for sprain of that joint (p. 68). When a physician can be obtained no layman is justified in attempting to treat a case of water on the knee or similar affection of other joints.

BUNION AND HOUSEMAID'S KNEE.—Bunion is a swelling of the bursa, or cushion, 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 very painful. It is caused by pressure of a tight boot which also forces the great toe toward the little toe, and thus makes the great toe joint more prominent and so the more readily injured.

A somewhat similar swelling, often as large as an egg, is sometimes seen over the kneepan, more often in those who work upon their knees, hence the name housemaid's knee. The swelling may come on suddenly and be hot, tender, and painful, or it may be slow in appearing and give little pain.

Treatment.—The treatment for the painful variety of bunion and housemaid's knee is much the same: absolute rest with the foot kept raised, and application of cloths kept constantly wet with ice or cold water; or a thick covering of Cataplasma Kaolini (U. S. P.) may be applied until the inflammation has subsided. If the trouble is chronic, or the acute inflammation does not soon abate under the treatment advised, the case is one for the surgeon, and sometimes requires the knife for abscess formation. In the milder cases of bunion, wearing proper shoes whose inner border forms almost a straight line from heel to toe, so that the great toe is not pushed over toward the little toe, and painting the bunion every few days with tincture of iodine, until the skin begins to become sore, will often be sufficient to secure recovery.

RUN-AROUND; WHITLOW OR FELON.—"Run-around" consists in an inflammation of the soft parts about the finger nail. It is more common in the weak, but may occur in anyone, owing to the entrance of pus germs through a slight prick or abrasion which may pass unnoticed. The condition begins with redness, heat, tenderness, swelling, and pain of the flesh at the root of the nail, which extends all about the nail and may be slight and soon subside, or there may be great pain and increased swelling, with the formation of "matter" (pus), and result in the loss of the nail, particularly in the weak.

Whitlow or felon is a much more serious trouble. It begins generally as a painful swelling of one of the last joints of the fingers on the palm side. Among the causes are a blow, scratch, or puncture. Often there is no apparent cause, but in some manner the germs of inflammation gain entrance. The end of the finger becomes hot and tense, and throbs with sometimes almost unbearable pain. If the inflammation is chiefly of the surface there may be much redness, but if mainly of the deeper parts the skin may be but little reddened or the surface may be actually pale. There is usually some fever, and the pain is made worse by permitting the hand to hang down. If the felon is on the little finger or thumb the inflammation is likely to extend down into the palm of the hand, and from thence into the arm along the course of the tendons or sinews of the muscles. Death of the bone of the last finger joint necessitating removal of this part, stiffness, crippling, and distortion of the hand, or death from blood poisoning may ensue if prompt surgical treatment is not obtained.

Treatment.—At the very outset it may be possible to stop the progress of the felon by keeping the finger constantly wet by means of a bandage continually saturated with equal parts of alcohol and water, at night keeping it moist by covering with a piece of oil silk or rubber. Tincture of iodine painted all over the end of the finger is also useful, and the hand should be carried in a sling by day, and slung above the head to the headboard of the bed by night. If after twenty-four hours the pain increases, it is best to apply hot poultices to the finger, changing them as often as they cool. If the felon has not begun to abate by the end of forty-eight hours, the end of the finger must be cut lengthwise right down to the bone by a surgeon 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, if inflammation continues, by hot poulticing and incision with a knife; but poulticing is often sufficient. Attention to the general health by a physician will frequently be of service.

WEEPING SINEW; GANGLION.—This is a swelling as large as a large bean projecting from the back or front of the wrist with an elastic or hard feeling, and not painful or tender unless pressed on very hard. After certain movements of the hand, as in playing the piano or, for example, in playing tennis, some discomfort may be felt. Weeping sinew sometimes interferes with some of the finer movements of the hand. The swelling is not red or inflamed, but of the natural color of the skin. It does not continue to increase after reaching a moderate size, but usually persists indefinitely, although occasionally disappearing without treatment. The swelling contains a gelatinous substance which is held in a little sac in the sheath of the tendon or sinew, but the inside of the sac does not communicate with the interior of the sheath surrounding the tendon.

Treatment.—This consists in suddenly exerting great pressure on the swelling with the thumb, or in striking it a sharp blow with a book by which the sac is broken. Its contents escape under the skin, and in most cases become absorbed. If the swelling returns a very slight surgical operation will permanently cure the trouble.

CINDERS AND OTHER FOREIGN BODIES IN THE EYE.[4]—Foreign bodies are most frequently lodged on the under surface of the upper lid, although the surface of the eyeball and the inner aspect of the lower lid should also be carefully inspected. A drop of a two per cent solution of cocaine will render painless the manipulations. The patient should be directed to continue looking downward, and the lashes and edge of the lid are grasped by the forefinger and thumb of the right hand, while a very small pencil is gently pressed against the upper part of the lid, and the lower part is lifted outward and upward against the pencil so that it is turned inside out. The lid may be kept in this position by a little pressure on the lashes, while the cinder, or whatever foreign body it may be, is removed by gently sweeping it off the mucous membrane with a fold of a soft, clean handkerchief. (See Figs. 6 and 7.)



Hot cinders and pieces of metal may become so deeply lodged in the surface of the eye that they cannot be removed by the method recommended, or by using a narrow slip of clean white blotting-paper. All such cases should be very speedily referred to a physician, and the use of needles or other instruments should not be attempted by a layman, lest permanent damage be done to the cornea and opacity result. Such procedures are, of course, appropriate for an oculist, but when it is impossible to secure medical aid for days it can be attempted without much fear, if done carefully, as more harm will result if the offending body is left in place. It is surprising to see what a hole in the surface of the eye will fill up in a few days. If the foreign body has caused a good deal of irritation before its removal, it is best to drop into the eye a solution of boric acid (ten grains 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 ear by children, and insects sometimes find their way into the ear passage and create tremendous distress by their struggles. Smooth, nonirritating bodies, as buttons, pebbles, etc., do no particular harm for a long time, and may remain unnoticed for years. But the most serious damage not infrequently results from unskillful attempts at their removal by persons (even physicians unused to instrumental work on the ear) who are driven to immediate and violent action on the false supposition that instant interference is called for. Insects, it is true, should be killed without delay by dropping into the ear sweet oil, castor, linseed, or machine oil or glycerin, or even water, if the others are not at hand, and then the insect should be removed in half 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 the opening 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 of treatment then consist, first, in keeping cool; then in killing insects by dropping oil or water into the ear, and, if syringing proves ineffective, in using no instrumental methods in an attempt to remove the foreign body, but in awaiting such time as skilled medical services can be obtained. If beans or seeds are not washed out by syringing, the water may cause them to swell and produce pain. To obviate this, drop glycerin in the ear which absorbs water, and will thus shrivel the seed.

FOREIGN BODIES IN THE NOSE.—Children often put foreign bodies in their noses, as shoe buttons, beans, and pebbles. They may not tell of it, and the most conspicuous symptoms are the appearance of a thick discharge from one nostril, having a bad odor, and some obstruction to breathing on the same side. If the foreign body can be seen, the nostril on the unobstructed side should be closed and the child made to blow out of the other one. If blowing does not remove the body it is best to secure medical aid very speedily.

FOOTNOTES:

[4] The Editors have deemed it advisable to repeat here the following instructions, also occurring in Vol. II, Part I, for the removal of foreign bodies in the eye, ear, and nose, as properly coming under the head of "First Aid in Emergencies."



CHAPTER IV

Fractures

How to Tell a Broken Bone—A Simple Sling—Splints and Bandage,—A Broken Rib—Fractures of Arm, Shoulder, Hand, Hips Leg and Other Parts.

BROKEN BONE; FRACTURE.[5]

First Aid Rule 1.—Be sure bone is broken. If broken, patient can scarcely (if at all) move the part beyond the break, while attendant can move it freely in his hands. If broken, grating of rough edges of bone 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 for surgeon.

COMPOUND FRACTURE.

Important. If there is opening to the air from the break, because of tearing of tissues by end of bone, condition is very dangerous; first treatment may save life, by preventing infection. Before reducing fracture, and without stirring the patient much, after scrubbing your hands 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, very gently. Then wash most thoroughly again with clean water, previously boiled 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 hereafter directed, 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 about wound, between the splints, with cool carbolic-acid solution (one teaspoonful to a pint of hot water) before putting on the fresh cloths.

BROKEN BONES OR FRACTURES.[6]—It frequently happens that the first treatment of fracture devolves upon the inexperienced layman. Immediate treatment is not essential, in so far as the repair of the fracture is directly concerned, for a broken bone does not unite for several weeks, and if a fracture were not seen by the surgeon for a week after its occurrence, no harm would be done, provided that the limb were kept quiet in fair position until that time. The object of immediate care of a broken bone is to prevent pain and avoid damage which would ensue if the sharp ends of the broken bone were allowed to injure the soft tissues during movements of the broken limb.

Fractures are partial or complete, the former when the bone is broken only part way through; simple, when the fracture is a mere break of the bone, and compound, when the end of one or both fragments push through the skin, allowing the air with its germs to come in contact with the wound, thus greatly increasing the danger. To be sure that a bone is broken we must consider several points. The patient has usually fallen or has received a severe blow upon the part. This is not necessarily true, for old people often break the thigh bone at the hip joint by simply making a false step.

Inability to use the limb and pain first call our attention to a broken bone. Then when we examine the seat of injury we usually notice some deformity—the limb or bone is out of line, and there may be an unusual swelling. But to distinguish this condition from sprain or bruise, we must find that there is a new joint in the course of the bone where there ought not to be any; e. g., if the leg were broken midway between the knee and ankle, we should feel that there was apparently a new joint at this place, that there was increased capacity for movement in the middle of the leg, and perhaps the ends of 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 of the broken fragments together. The last will not occur, of course, unless the fragments happen to lie so that they touch each other and should not be sought for. In the case of limbs, sudden shortening of the broken member from overlapping of the fragments is a sure sign.

SPECIAL FRACTURES.

BROKEN RIB.—First Aid Rule.—Patient puts hands on head while attendant puts adhesive-plaster band, one foot wide, around injured side from spine over breastbone to line of armpit of sound side. Then put patient to bed.

A rib is usually broken by direct violence. The symptoms are pain on taking a deep breath, or on coughing, together with a small, very tender point. The deformity is not usually great, if, indeed, any exists, so that nothing in the external appearance may call the attention to fracture. Grating between the fragments may be heard by the patient or by the examiner, and the patient can often place his finger on the exact location of the break.

When it is a matter of doubt whether a rib is broken or not the treatment for broken rib should be followed for relief of pain.



Treatment consists in applying a wide band of surgeon's adhesive plaster, to be obtained at any drug shop. The band is made by overlapping strips four or five inches wide, till a width of one foot is obtained. This is then applied by sticking one end along the back bone and carrying it forward around the injured side of the chest over the breastbone as far as a line below the armpit on the uninjured side of 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 and laid together, overlapping about two inches, and put on as a whole, or, what is easier, each strip may be put on separately, beginning at the spine, five inches below the fracture, and continuing to apply the strips, overlapping each other about two inches, until the band is made to extend to about five inches above the point of fracture, all the 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 or flannel bandage, a foot wide, should be placed all around the chest and fastened as snugly as possible with safety pins, in order to limit the motion of the chest wall. The patient will often be more comfortable sitting up, and should take care not to be exposed to cold or wet for some weeks, as pleurisy or pneumonia may follow. Three weeks 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 small pillow between his shoulders; place forearm of injured side across chest, and retain it so with bandage about chest and arm.



Fracture of the collar bone is one of the commonest accidents. The bone is usually broken in the middle third. A swelling often appears at this point, and there is pain there, especially on lifting the arm up and away from the body. It will be noticed that the shoulder, on the 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 the same side is grasped below the elbow by the other hand of the patient and supported as in a sling. (See Fig. 9.) In examining an apparently broken bone the utmost gentleness may be used or serious damage may result.

Treatment.—The best treatment consists in rest in bed on a hard mattress; the patient lying flat on the back with a small pillow between the shoulders and the forearm of the injured side across the chest. This is a wearisome process, as it takes from two to three weeks to secure repair of the break. On the other hand, if the forearm is carried in a sling, so as to raise and support the shoulder, while the patient walks about, a serviceable result is usually obtained; the only drawback being that an unsightly swelling remains at the seat of the break. To make a sling, a piece of strong cotton cloth a yard square should be cut diagonally from corner to corner, making two right-angled triangles. Each of these will make a properly shaped piece 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, not extending wholly through the shaft so as to divide it into two fragments, but causing little more than bending of the bone (the "green-stick fracture").



A fall from a chair or bed is sufficient to cause the accident. A child generally cries out on movement of the arm of the injured side, or on being lifted by placing the hands under the armpits of the patient. A tender swelling is seen at the point of the injury of the collar bone. A broad cotton band, with straps over the shoulders to keep it up, should encircle the body and upper arm of the injured side, and the hand of the same side should be supported by a narrow sling fastened above behind the neck.

LOWER-JAW FRACTURE.

First Aid Rule.—Put fragments into place with your fingers, securing good line of his teeth. Support lower jaw by firmly bandaging it against upper jaw, mouth shut, using four-tailed bandage. (Fig. 12.)

Fracture of the lower jaw is caused by a direct blow. It involves the part of the jaw occupied by the lower teeth, and is more apt to occur in the middle line in front, or a short distance to one side of this point. The force causing the break usually not only breaks the bone, but also tears the gum through into the mouth, making a compound fracture. There is immediate swelling of the gum at the point of injury, 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 the level of the teeth or line of the teeth, or both, at the place where the fracture occurs. Also one or more of the teeth are usually loosened at this point. In addition, unusual movement of the fragments may be detected as well as a grating sound on manipulation.

Treatment.—The broken fragments should be pressed into place with the fingers, and retained temporarily with a four-tailed bandage, as shown in the cut. Feeding is done through a glass tube, using milk, broths, and thin gruels. A mouth wash should be employed four times daily, to keep the mouth clean and assist in healing of the gum. A convenient preparation consists of menthol, one-half grain; thymol, one-half grain; boric acid, twenty grains; water, eight ounces.



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 arm to body with many turns of a bandage, which holds forearm against chest and arm against side.

Shoulder-blade fracture occasions pain, swelling, and tenderness on pressure over the point of injury. On manipulating the bone a grating sound may be heard and unnatural motion detected. The treatment consists in bandaging the forearm and arm on the injured side from below upward, beginning at the wrist; slinging the forearm bent at a right angle across the front of the body, suspended by a narrow sling from the neck, and then encircling the body and arm of the injured side from shoulder to elbow with a wide bandage applied under the sling, which holds the arm snugly against the side. This bandage is prevented from slipping down by straps attached to it and carried over each shoulder.

ARM FRACTURE.

First Aid Rule.—Pad two pieces of thin board nine by three inches with handkerchiefs. Carefully pull fragments of bone apart, grasping lower fragment near elbow while assistant pulls gently on upper fragment near shoulder. Put padded boards (splints) one each side of the fracture, and wind bandage about their whole length, tightly enough to keep bony fragments firm in position. Put forearm and hand in sling.

In fracture of the arm between the shoulder and elbow, swelling and shortening may give rise to deformity. Pain and abnormal motion are symptoms, while a grating sound may be detected, but manipulation of the arm for this purpose should be avoided. The surface is apt soon to become black and blue, owing to rupture of the blood vessels beneath the skin.

The hand and forearm should be bandaged from below upward to the elbow. The bone is put in place by grasping the patient's elbow and pulling directly down in line with the arm, which is held slightly away from the side of the patient, while an assistant steadies and pulls up the shoulder. Then a wedge-shaped pad, long enough to reach from the patient's armpit to his elbow (made of cotton wadding or blanketing sewed in a cotton case) and about four inches wide and three inches thick at one end, tapering up to a point at the other, is placed against the patient's side with the tapering end uppermost in the armpit and the thick end down. This pad is kept in place by a strip of surgeon's adhesive plaster, or bandage passing through the small end of the wedge, and brought up and fastened over the shoulder.



While the arm is pulled down from the shoulder, three strips of well-padded tin or thin board (such as picture-frame backing) two inches wide and long enough to reach from shoulder to elbow, are laid against the front, outside, and back of the arm, and secured by encircling strips of surgeon's plaster or bandage. The arm is then brought into the pad lying against the side under the armpit, and is held there firmly by a wide bandage surrounding the arm and entire chest, and reaching from the shoulder to elbow. It is prevented from slipping by strips of cotton cloth, which are placed over the shoulders and pinned behind and before to the top of the bandage. The wrist is then supported in a sling, not over two inches wide, with the forearm carried in a horizontal position across the front of the body. Firm union of the broken arm takes place usually in from four to six weeks. (See Figs. 13 and 14.)

FOREARM FRACTURE.

First Aid Rule.—Set bones in proper place by pulling steadily on wrist while assistant holds back the upper part of the forearm. If unsuccessful, leave it for surgeon to reduce after "period of inaction" comes, a few days later, when swelling subsides. If successful, put padded splints (pieces of cigar box padded with handkerchiefs) one on each side, front and back, and wind a bandage about whole thing to hold it immovably.

Two bones enter into the structure of the forearm. One or both of these may be broken. The fracture may be simple or compound,[7] when the soft parts are damaged and the break of the bone communicates with the air, the ends of the bone even projecting through the skin.

In fracture of both bones there is marked deformity, caused by displacement of the broken fragments, and unusual motion may be discovered; a grating sound may also be detected but, as stated before, manipulation of the arm should be avoided.



When only one bone is broken the signs are not so marked, but there is usually a very tender point at the seat of the fracture, and an irregularity of the surface of the bone may be felt at this point. If false motion and a grating sound can also be elicited, the condition is clear. The broken bones are put into their proper place by the operator who pulls steadily on the wrist, while an assistant grasps the upper part of the forearm and pulls the other way. The ends of the fragments are at the same time pressed into place by the other hand of the operator, so that the proper straight line of the limb is restored.



After the forearm is set, it should be held steadily in the following position while the splints are applied. The elbow is bent so that the forearm is held at right angles with the arm horizontally across the front of the chest with the hand extended, open palm toward the body and thumb uppermost. The splints, two in number, are made of wood about one-quarter inch thick, and one-quarter inch wider than the forearm. They should be long enough to reach from about two inches below the elbow to the root of the fingers. They are covered smoothly with cotton wadding, cotton wool, or other soft material, and then with a bandage. The splints are applied to the forearm in the positions described, one to the back of the hand and forearm, and the other to the palm of the hand and front of the forearm.

Usually there are spaces in the palm of the hand and front of the wrist requiring to be filled with extra padding in addition to that on the splint. The splints are bound together and to the forearm by three strips of surgeon's adhesive plaster or bandage, about two inches wide. One strip is wound about the upper ends of the splints, one is wrapped about them above the wrist, and the third surrounds the back of the hand and palm, binding the splints together below the thumb. The splints should be held firmly in place, but great care should be exercised to use no more force in applying the adhesive plaster or bandage than is necessary to accomplish this end, as it is easy to stop the circulation by pressure in this part. There should be some spring felt when the splints are pressed together after their application. A bandage is to be applied over the splints and strips of plaster, beginning at the wrist and covering the forearm to the elbow, using the same care not to put the bandage on too firmly. The forearm is then to be held in the same position by a wide sling, as shown above. (See Figs. 15, 16, 17.)



Four weeks are required to secure firm union after this fracture. When the fracture is compound the same treatment should be employed as described under Compound Fracture of Leg, p. 116.

FRACTURE OF THE WRIST; COLLES'S FRACTURE.—This is a break of the lower end of the bone on the thumb side of the wrist, and much the larger bone in this part of the forearm. The accident happens when a person falls and strikes on the palm of the hand; it is more common in elderly people. A peculiar deformity results. A hump or swelling appears on the back of the wrist, and a deep crease is seen just above the hand in front. The whole hand is also displaced at the wrist toward the thumb side.



It is not usual to be able to detect abnormal motion in the case of this fracture, or to hear any grating sound on manipulating the part, as the ends of the fragments are generally so jammed together that it is necessary to secure a surgeon as soon as possible to pull them apart 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 of splints should be applied, and in the same way as for the treatment of fractured forearm. If the deformity is not relieved a stiff and painful joint usually persists. It is sometimes impossible for the most skillful surgeon entirely to correct the existing deformity, and in elderly people some stiffness and pain in the wrist and fingers are often unavoidable results.



FRACTURE OF BONE OF HAND, OR FINGER.

First Aid Rule.—Set fragments of bone in place by pulling with one hand on finger, while pressing fragments into position with other hand. Put on each side of bone a splint made of cigar box, padded with folded handkerchiefs, and retain in place with bandage wound about snugly. Put forearm and hand in sling.

This accident more commonly happens to the bones corresponding to the middle and ring finger, and occurs between the knuckle and the wrist, appearing as a swelling on the back of the hand. On looking at the closed fist it will be seen that the knuckle corresponding to the broken bone in the back of the hand has ceased to be prominent, and has sunken down below the level of its fellows. The end of the fragment nearer the wrist can generally be felt sticking up in the back of the hand.



If the finger corresponding to the broken bone in the back of the hand be pulled on forcibly, and the fragments be held between the thumb and forefinger of the other hand of the operator, pain and abnormal motion may be detected, and the ends of the broken bone pressed into place. A thin wooden splint, as a piece of cigar box, about an inch wide at base and tapering to the width of the finger should be applied to the palm of the hand extending from the wrist to a little beyond the finger tip, secured by strips of adhesive plaster, as in the cut, and covered by a bandage. The splint should be well padded, and an additional pad should be placed in the palm of the hand over the point of fracture. Three weeks are required for firm union, and the hand should not be used for a month.

It is usually easy to recognize a broken bone in a finger, unless the break 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 injured finger with one hand, while with the other the fragments are pressed into line. A narrow, padded wooden or tin splint is applied, as in the cut (p. 102), reaching from the middle of the palm to the finger tip. Any existing displacement of the broken bone can be relieved by using pressure with little pads of cotton held in place by narrow strips of adhesive plaster where it is needed to keep the bone in line. The splint may be removed in two weeks and a strip of adhesive plaster wound about the finger to support it for a week or two more.

In fracture of the thumb, the splint is applied along the back instead of on the palm side.

HIP FRACTURE.

First Aid Rule.—Put patient flat on back in bed, with limb wedged between pillows till surgeon arrives.



A fracture of the hip is really a break of that portion of the thigh bone which enters into the socket of the pelvic bone and forms the hip joint. It occurs most commonly in aged people as a result of so slight an accident as tripping on a rug, or in falling on the floor from the standing position, making a misstep, or while attempting to avoid a fall. When the accident has occurred the patient is unable to rise or walk, and suffers pain in the hip joint. When he has been helped to bed 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 is pain 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 a straight line with the body, measurements from each hip-bone are made with a tape to the bony prominence on the inside of each ankle, in turn. One end of the tape is held at the navel and the other is swung from 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 of fracture. The fragments of broken bone are often jammed together (impacted) so that it is impossible to get any sound of grating between them, and it is very unwise to manipulate the leg or hip joint, except in the gentlest manner, in an attempt to get this grating. If the ends of the fragments become disengaged from each other it often happens that union of the break never occurs.



The treatment simply consists in keeping the patient quiet on a hard mattress, with a small pillow under the knee of the injured side and the limb steadied on either side by pillows or cushions until a surgeon can be obtained. (See Thigh-bone Fracture.)

THIGH-BONE FRACTURE.

First Aid Rule.—Prepare long piece of thin board which will reach from armpit to ankle, and another piece long enough to reach from crotch to knee, and pad each with folded towels or blanket.

While one assistant holds body back, and another assistant pulls on ankle of injured side, see that the fragments are separated and brought into good line, and then apply the splints, assistants still pulling steadily, and fasten the splints in place with bandage, or by tying several cloths across at three places above the knee and two places below the knee.

Finally, pass a wide band of cloth about the body, from armpit to hips, inclosing the upper part of the well-padded splint, and fasten it snugly. The hollow between splint and waist must be filled with padding before this wide cloth is applied.

In fracture of the thigh bone (between the hip and knee), there is often great swelling about the break. The limb is helpless and useless. There is intense pain and abnormal position in the injured part, besides deformity produced by the swelling. The foot of the injured limb is turned over to one side or the other, owing to a rolling over of the portion of the limb below the break. With both lower limbs in line with the body, and the patient lying on the back, measurements are made from each hip-bone to the prominence on the inside of either ankle joint. Shortening of the injured leg will be found, varying from one to over two inches, according to the overlapping and displacement of the fragments.

Treatment.—To set this fracture temporarily, a board about five inches wide and long enough to reach from the armpit to the foot should be padded well with towels, sheets, shawls, coats, blanket, or whatever is at hand, and the padding can best be kept in place by surgeon's adhesive plaster, bicycle tape, or strips of cloth.[8] Another splint should be provided as wide as the thigh and long enough to reach along the back of the leg from the middle of the calf to the buttock, and also padded in the same way. A third splint should be prepared in the same manner to go inside the leg, reaching from the crotch to the inside of the foot. Still a fourth splint made of a thin board as wide as the thigh, extending from the upper part of the thigh to just above the knee, is padded for application to the front of the thigh.

When these are made ready and at hand, the leg should be pulled on steadily but carefully straight away from the body to relax the muscles, an assistant holding the upper part of the thigh and pulling in the opposite direction. Then, when the leg has been straightened out and the thigh bone seems in fair line, the splints should be applied; the first to the outside of the thigh and body, the second under the calf, knee, and thigh; the third to the inside of the whole limb, and the fourth to the front of the thigh.

Wide pads should be placed over the ribs under the outside splint to fill the space above the hips and under the armpit. Then all four splints are drawn together and held in place by rubber-plaster straps or strips of strong muslin applied as follows: one above the ankle; one below the knee; one above the knee; one in the middle of the thigh, and one around the upper part of the thigh. A wide band of strong muslin or sheeting should then be bound around the whole body between the armpits and hips, inclosing the upper part of the outside splint. The patient can then be borne comfortably upon a stretcher made 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, and does not have to be transported, it is only necessary to apply the outer, back, and front splints, omitting the inner splint. It is necessary for the proper and permanent setting of a fractured thigh that a surgeon give an anaesthetic and apply the splints while the muscles are completely relaxed. It is also essential that the muscles be kept from contracting thereafter by the application of a fifteen- or twenty-pound weight to the leg, after the splints are applied, but it is possible to outline here only the proper first-aid treatment.

KNEEPAN FRACTURE.

First Aid Rule.—Pain is immediate and intense. Separated fragments may 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 to reach from upper part of thigh to just above ankle. Pad with folded piece of blanket or soft towels. Place it behind leg and thigh; carefully fill space behind knee with pad; fasten splint to limb with three strips of broad adhesive plaster, one around upper end of splint, one around lower end, one just below knee.

Lay large flat, dry sponge over knee thus held, and bandage this in place. Keep sponge and bandage wet with ice water. If no sponge is available, half fill rubber hot-water bottle with cracked ice, and lay this over knee joint. Put patient to bed.

Fracture of kneepan is caused either by direct violence or muscular strain. It more frequently occurs in young adults. Immediate pain is felt in the knee and walking becomes impossible; in fact, often the patient cannot rise from the ground after the accident. Swelling at first is slight, but increases enormously within a few hours. Immediately after the injury it may be possible to feel the separate broken fragments of the kneepan and to recognize that they are separated by a considerable space if the break is horizontally across the bone.



Nothing can be done to set the fracture until the swelling about the joint has been reduced, so that the first treatment consists in securing immediate rest for the kneejoint, and immobility of the fragments. A splint made of board, about a quarter of an inch thick and about four inches wide for an adult, reaching from the upper part of the thigh above to a little above the ankle below, is applied to the back of the limb and well padded, especially to fill the space behind the knee. The splint is attached to the limb by straps of adhesive plaster two inches and a half wide; one around the lower end of the splint, one around the upper part, and the third placed just below the knee. To prevent and arrest the swelling and pain, pressure is then made on the knee by bandaging.

One of the best methods (Scudder's) is to bind a large, flat, dry sponge over the knee and then keep it wet with cold water; or to apply an ice bag directly to the swollen knee; a splint in either case being the first requisite. The patient should of course be put to bed as soon as possible after the accident, and should lie on the back with the injured leg elevated on a pillow with a cradle to keep the clothes from 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 making opening to surface. Special painful point, angle or new joint in bone, disability, and grating felt will decide existence of break. Let assistant pull on foot, to separate fragments, while you examine part of supposed break. If only one bone is broken, there may be no displacement.

Put patient on back. While two assistants pull, one on ankle and one on thigh at knee, thus separating fragments, slide pillow lengthwise under knee, and, bringing its edges up about leg, pin them snugly above leg.

Prepare three pieces of thin wood, four inches wide and long enough to reach from sole of foot to a point four inches above knee. While assistants pull on limb again, as before, put one splint each side and third behind limb, and with bandage or strips of sticking plaster fasten these splints to the leg inclosed in its pillow as tight as possible.

In fracture of the leg between the knee and ankle we have pain, angular deformity or an apparent false joint in the leg, swelling and tenderness over the seat of fracture, together with inability to use the injured leg. Two bones form the framework of the leg; the inner, or shinbone, the sharp edge of which can be felt in front throughout most of its course, being much the larger and stronger bone. When both bones are broken, the displacement of the fragments, abnormal motion and consequent deformity, are commonly apparent, and a grating sound may be heard, but should not be sought for.



An open wound often communicates with the break, making the fracture compound, a much more serious condition. To avoid making the fracture a compound one, during examination of the leg, owing to the sharp ends of the bony fragments, the utmost gentleness should be used. Under no circumstances attempt to move the fragments from side to side, or backward and forward, in an effort to detect the grating sound often caused by the ends of broken bones. The greatest danger lies in the desire to do too much. We again refer the reader to First Aid Rule 1.



When one bone is broken there may be only a point of tenderness and swelling about the vicinity of the break and no displacement or grating sound. When in doubt as to the existence of a fracture always treat the limb as if a fracture were present. "Black and blue" discoloration of the skin much more extensive than that following sprain will become evident over the whole leg within twenty-four hours.

Treatment.—When a surgeon cannot be obtained, the following temporary pillowdressing, recommended by Scudder in his book on fractures, is one of the best. With the patient on his back, the leg having been straightened and any deformity removed as far as possible by grasping the foot and pulling directly away from the body while an assistant steadies the thigh, a large, soft pillow, inclosed in a pillowcase, is placed under the leg. The sides of the pillow are brought well up about the leg and the edges of the pillowcase are pinned together along the front of the leg.

Then three strips of wood about four inches wide, three-sixteenths to a quarter of an inch thick, and long enough to reach from the sole of the foot to about four inches above the knee, are placed outside of the pillow along the inner and outer aspects of the leg and beneath it. The splints are held in place, with the pillow as padding beneath, by four straps of webbing (or if these cannot be obtained, by strips of stout cloth, adhesive plaster, or even rope); but four pads made of folded towels should be put under the straps where they cross the front of the leg where little but the pillowcase overlaps. These straps are applied thus: one above the knee, one above the ankle, and the other two between these two points, holding all firmly together. This dressing may be left undisturbed for a week or even ten days if necessary. (See Figs. 27 and 28.)

The leg should be kept elevated after the splints are applied, and steadied by pillows placed either side of it. From one to two months are required to secure union in a broken leg in adults, and from three to five months elapse before the limb is completely serviceable. In children 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 above ankle. Foot is generally pushed or bent outward. Prepare two pieces of thin wood, four inches wide and long enough to go from sole of foot to just below knee:—the splints. Pad them with folded towels or pieces of blanket.

While assistants pull bones apart gently, one pulling on knee, other pulling on foot and turning it straight, apply the splints, one each side of the leg.

A fracture of the ankle joint is really a fracture of the lower extremities of the bones of the leg. There are present pain and great swelling, particularly on the inner side of the ankle at first, and the whole foot is pushed and bent outward. The bony prominence on the inner side of the ankle is unduly marked. The foot besides being bent outward is also displaced backward on the leg. This fracture might be taken for a dislocation or sprain of the ankle. Dislocation of the ankle without fracture is very rare, and when the foot is returned to its proper position it will stay there, while in fracture the foot drops back to its former displaced state. In sprained ankle there are pain and swelling, but not the deformity caused by the displacement of the foot.

This fracture may be treated temporarily by returning the foot to its usual position and putting on side splints and a back splint, as described for the treatment of fracture of the leg.

COMPOUND OR OPEN FRACTURE OF THE LEG.—This condition may be produced either by the violence which caused the fracture also leading to destruction of the skin and soft parts beneath, or by the end of a bony fragment piercing the muscles and skin from within. In either event the result is much more serious than that of an ordinary simple fracture, for germs can gain entrance through the wound in the skin and cause inflammation with partial destruction or death of the part.

Treatment.—Immediate treatment is here of the utmost value. It is applicable to open or compound fracture in any part of the body. The area for a considerable distance about the wound, if covered with hair, should be shaved. It should then be washed with warm water and soap by means of a clean piece of cotton cloth or absorbent cotton. Then some absorbent cotton or cotton cloth should be boiled in water in a clean vessel for a few minutes, and, after the operator has thoroughly washed his hands, the boiled water (when sufficiently cool) should be applied to the wounded area and surrounding parts with the boiled cotton, removing in the most painstaking way all visible and invisible dirt. By allowing some of the water to flow over the wound from the height of a few feet this result is favored. Finally some of the boiled cotton, which has not been previously touched, is spread over 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 be replaced after the cleansing just described, by grasping the lower part of the limb and pulling in a straight line of the limb away from the body, while an assistant holds firmly the upper part of the limb and pulls in the opposite direction. During the whole process neither the hands of the operator nor the boiled cotton should come in contact with anything except the vessel containing the boiled water and the patient.

FOOTNOTES:

[5] The engravings illustrating the chapters on "Fractures" and "Dislocations" are from Buck's "Reference Handbook of Medical Science," 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 about fractures is not supplied to enable anyone to avoid calling a surgeon, but is to be followed only until expert assistance can be obtained and, like other advice in this book, is intended to furnish first-aid information or directions to those who are in places where physicians cannot 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 his book "The Treatment of Fractures."



CHAPTER V

Dislocations

How to Tell a Dislocation—Reducing a Dislocated Jaw—Stimson's Method of Treating a Dislocated Shoulder—Appearance of Elbow when Out of 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 both sides of his head, operator presses downward and backward with his thumbs on back teeth of patient, each side of patient's jaw, while the chin is grasped between forefingers and raised upward. Idea is to stretch the ligament at jaw joint, and swing jaw back while pulling on this ligament. (Fig. 29.)

Rule 3.—Tie jaw with four-tailed bandage up against upper jaw for a week. (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 to one 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, and straighten knee.

DISLOCATIONS.—A dislocation is an injury to a joint wherein the ends of the bones forming a joint are forced out of place. A dislocation is commonly described as a condition in which a part (as the shoulder) is "out of joint" or "out of place." A dislocation must be distinguished from a sprain, and from a fracture near a joint. In a sprain, as has been stated (p. 65), the bones entering into the formation of the joint are perhaps momentarily displaced, but return into their proper place when the violence is removed. But, owing to greater injury, in dislocation the head of the bone slips out of the socket which should hold it, breaks through the ligaments surrounding the joint, and remains permanently out of place. For this reason there is a peculiar deformity, produced by the head of the bone's lying in its new and unnatural situation, which is not seen in a sprain.

Also, the dislocated joint cannot be moved by the patient or by another person, except within narrow limits, while a sprained joint can be moved, with the production of pain it is true, but without any mechanical obstacle. In the case of fracture near a joint there is usually increased movement in some new direction. When a dislocated joint is put in proper place it stays in place, whereas when a fractured part is reduced there is nothing to keep it in place and, if let alone, it quickly resumes its former faulty position.

Only a few of the commoner dislocations will be considered here, as the others are of rare occurrence and require more skill than can be imparted in a book intended for the laity. The following instructions are 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 the chin, or occurs in gaping or when the mouth is kept widely open during prolonged dental operations. The joint surface at the upper part of the lower jaw, just in front of the entrance to the ear, is thrown out of its socket on one side of the face, or on both sides. If the jaw is put out of place on both sides at once, the chin will be found projecting so that lower front teeth jut out beyond the upper front teeth, the mouth is open and cannot be closed, and the patient is suffering considerable pain. When the jaw is dislocated on one side only, the chin is pushed over toward the uninjured side of the face, which gives the face a twisted appearance; the mouth is partly open and fixed in that position. A depression is seen on the injured side in front of the ear, while a corresponding prominence exists on the opposite side of the face, and the lower front teeth project beyond the upper front teeth.



Treatment.—A dislocation of one side of the jaw is treated in the same manner as that of both sides.

The dislocation may sometimes be reduced by placing a good-sized cork as far back as possible between the back teeth of the upper and lower jaws (on one or both sides, according as the jaw is out of place on one 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 by wrapping bandage about his thumbs, or wearing leather gloves, and then, while an assistant steadies the head, the operator presses downward and backward on the back teeth of the patient on each side of the lower jaw with both thumbs in the patient's mouth, while the chin is grasped beneath by the forefingers of each hand and raised upward. When the jaw slips into place it should be maintained there by a bandage placed around the head under the chin and retained there for a week. During this time the patient should be fed on liquids through a tube, so that it will not be necessary for him to open his mouth to any extent. (See Fig. 29.)

DISLOCATION OF THE SHOULDER.—This is by far the most common of dislocations in adults, constituting over one-half of all such accidents affecting any of the joints. It is caused by a fall or blow on the upper arm or shoulder, or by falling upon the elbow or outstretched hand. The upper part (or head) of the bone of the arm (humerus) slips downward out of the socket or, in some cases, inward and forward. In either case the general appearance and treatment of the accident are much the same. The shoulder of the injured side loses its fullness and looks flatter in front and on the side. The arm is held with the elbow a few inches away from the side, and the line of the arm is seen to slope inwardly toward the shoulder, as compared with the sound arm.

The injured arm cannot be moved much by the patient, although it can be lifted up and away from the side by another person, but cannot be moved so that, with the elbow against the front of the chest, the hand of the injured arm can be laid on the opposite shoulder. Neither can the arm, with the elbow at a right angle, be made to touch the side with the elbow, without causing great pain.

Treatment.—One of the simplest methods (Stimson's) of reducing this dislocation consists in placing the patient on his injured side on a canvas cot, which should be raised high enough from the floor on chairs, and allowing the injured arm to hang directly downward toward the floor through a hole cut in the cot, the hand not touching the floor. Then a ten-pound weight is attached to the wrist. The gradual pull produced by this means generally brings the shoulder back into place without pain and within six minutes. (Fig. 30.)



The more ordinary method consists in putting the patient on his back on the floor, the operator also sitting on the floor with his stockinged foot against the patient's side under the armpit of the injured shoulder and grasping the injured arm at the elbow, he pulls the arm directly outward (i. e., with the arm at right angles with the body) and away from the trunk. An assistant may at the same time aid by lifting the head of the arm bone upward with his fingers in the patient's armpit and his thumbs over the injured shoulder.

If the arm does not go into place easily by one of these methods it is unwise to continue making further attempts. Also if the shoulder has been dislocated several days, or if the patient is very muscular, it will generally be necessary that a surgeon give ether in order to reduce the dislocation. It is entirely possible for a skillful surgeon to secure reduction of a dislocation of the shoulder several weeks after its occurrence. After the dislocation has been relieved the arm, above the elbow, should be bandaged to the side of the chest and the hand of the injured side carried in a sling for ten days.

DISLOCATION OF THE ELBOW.—This is more frequent in children, and is usually produced by a fall on the outstretched hand. The elbow is thrown out of joint, so that the forearm is displaced backward on the arm, in the more usual form of dislocation. The elbow joint is swollen and generally held slightly bent, but cannot be moved to any extent without great pain. The tip of the elbow projects at the back of the joint more than usual, while at the front of the arm the distance between the wrist and the bend of the elbow is less than that of the sound arm. (See cut, p. 126.)



For further proof that the elbow is out of joint we must compare the relations of three points in each elbow. These are the two bony prominences on each side of the joint (belonging to the bone of the arm above the elbow) and the bony prominence that forms the tip of the elbow which belongs to the bone of the forearm.



In dislocation backward of the forearm, the tip of the elbow is observed to be farther back, in relation to the two bony prominences at the side of the joint, than is the case in the sound elbow. This is best ascertained by touching the three points on the patient's elbow of each arm in turn with the thumb and middle finger on each of the prominences on the side of the joint, while the forefinger is placed on the tip of the elbow. The lower end of the bone of the upper arm is often seen and felt very easily just above the bend of the elbow in front, as it is thrown forward (see Fig. 32, p. 126).

Fracture of the lower part of the bone of the arm above the elbow joint may present much the same appearance as the dislocation we are describing, but then the whole elbow is displaced backward, and the relation of the three points described above is the same in the injured as in the uninjured arm. Moreover in fracture the deformity, when relieved, will immediately recur when the arm is released, as there is nothing to hold the bones in place; but in dislocation, after the bones are replaced in their normal position, the deformity will not reappear.

Treatment.—The treatment for dislocation consists in bending the forearm backward to a straight line, or even a little more, and then while an assistant holds firmly the arm above the elbow, the forearm should be grasped below the elbow and pulled with great force away from the assistant and, while exerting this traction, the elbow is suddenly bent forward to a right angle, when the bones should slip into place.

The after treatment is much the same as for most fractures of the elbow. The arm is retained in a well-padded right-angled tin splint which is applied with three strips of surgeon's plaster and bandage to the 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 joint should be moved to and fro gently to prevent stiffness, and the splint then reapplied.

DISLOCATION OF THE HIP.—This occurs more commonly in males from fifteen to forty-five years of age, and is due to external violence. In the more ordinary form of hip dislocation the patient stands on the sound leg with the body bent forward, the injured leg being greatly shortened, with the toes turned inward so much that the foot of the injured limb crosses over the instep of the sound foot. The injured limb cannot be moved outward and but slightly inward, yet may be bent forward. Walking is impossible. Pain and deformity of the hip joint are evident.

The only condition with which this would be likely to be confused is a fracture of bone in the region of the hip. Fracture of the hip is common in old people, but not in youth or middle adult life. In fracture there is usually not enough shortening to be perceived with the eye; the toes are more often turned out, and the patient can often bear 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 vertical position by means of a sheet or belt of some sort placed around the body under the armpits, so that the feet dangle a foot or so from the floor, and then a weight of about ten or fifteen pounds, according to the strength of the patient's muscles, is attached to the foot of the injured leg (bricks, flatirons, or stones may be used), and this weight will usually draw the bone down into its socket within ten or fifteen minutes.



Or the patient may assume the position shown in the accompanying cut, lying prone upon a table with the uninjured leg held horizontally by one person, while another, with the injured thigh held vertically and leg at right angles, grasps the patient's ankle and moves it gently from side to side after placing a five-to ten-pound sand bag, or similar weight of other substance, at the flexure of the knee. When the dislocation has been overcome the patient should stay in bed for a week or two and then go about gradually on crutches for two weeks longer.

SURGICAL DRESSINGS.—Sterilized gauze is the chief surgical dressing of the present day. This material is simply cheese cloth, from which grease and dirt have been removed by boiling in some alkaline preparation, usually washing soda, and rinsing in pure water. The gauze is sterilized by subjecting it to moist or dry heat. Sterilized gauze may be bought at shops dealing in surgeons' supplies and instruments, and at most drug stores. Gauze or cheese cloth may be sterilized (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 well to have a small piece of the gauze in a separate package, which may be inspected from time to time in order to see how the baking is progressing, as the material to be employed for surgical purposes should not be opened until just before it is to be used, any remainder being immediately covered again. Cut the gauze into pieces as large as the hand, before it is sterilized, to avoid cutting and handling afterwards. Gauze may also be sterilized by steaming in an Arnold sterilizer, such as is used for milk, or by boiling, if it is to be applied wet. Carbolized, borated, and corrosive-sublimate gauze have little special value.



Absorbent cotton is also employed as a surgical dressing, and should also be sterilized if it is to be used on raw surfaces. It is not so useful for dressing wounds as gauze, since it mats down closely, does not absorb secretions and discharges so well, and sticks to the parts. When torn into balls as large as an egg and boiled for fifteen minutes in water, it is useful as sponges for cleaning wounds. Sheet wadding, or cotton, is serviceable in covering splints before they are applied to the skin. Wet antiseptic surgical dressings are valuable in treating wounds which are inflamed and not healing well. They are made by soaking gauze in solutions of carbolic acid (half a teaspoonful of the acid to one pint of hot water), and, after application, covering the gauze with oil silk, rubber dam, or paraffin paper. Heavy brown wrapping paper, well oiled or greased, will answer the purpose when better material is not at hand.

BANDAGES.—Bandaging is an art that can only be acquired in any degree of perfection by practical instruction and experience. Some useful hints, however, may be given to the inexperienced. Cotton cloth, bleached or unbleached, is commonly employed for bandages; also gauze, which does not make so effective a dressing, but is much easier of application, is softer and more comfortable, and is best adapted to the use of the novice. A bandage cannot be put on properly unless it is first rolled. A bandage for the limbs should be about two and a half inches wide and eight yards long; for the fingers, three-quarters of an inch wide and three yards long. The bandage may be rolled on itself till it is as large as the finger, and then rolled down the front of the thigh, with the palm of the right hand, while the loose end is held taut in the left hand.



Two forms of bandages are adapted to the limbs, the figure-of-eight, and the spiral reversed bandage. In applying a bandage always begin at the lower extremity of the limb and approach the body. Make a few circular turns about the limb (see Fig. I, p. 132), then as the limb enlarges, draw the bandage up spirally, reversing it each time it encircles the limb, as shown in Fig. I, p. 134. In reversing, hold the bandage with the left thumb so that it will not slip, and then allowing 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, or around 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 a belt, and the end 2 is brought from behind, in the narrow part of the back, down forward between the thighs, over the crotch, and up to the belt in the lower part of the belly. The figure-of-eight bandage is used on various parts, and is illustrated in the bandage called spica of the groin, Fig. IV, p. 132. Beginning with a few circular turns about the body in the direction of 1, the bandage is brought down in front of the body and groin, as in 2, and then about the back of the thigh up around the front of the thigh, as in 3, across the back and once around the body and down again as in 2. Other bandages appropriate to various parts of the body are also illustrated that by their help the proper method of their application may be understood. See pages 132, 134, 136, 137. The triangular bandage (see p. 88) made from a large handkerchief or piece of muslin a yard square, cut or folded diagonally from corner to corner, will be found invaluable in emergency cases. It is easily and quickly adjusted to almost any part of the body, and may be used for dressing wounds, or as a bandage for fractures, etc.



CHAPTER VI

Ordinary Poisons

Unknown Poisons—Antidotes for Poisoning by Acids and Alkalies—The Stomach 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 or investigation.

First Aid Rule.—Give two teaspoonfuls of chalk (or whiting, or whitewash scraped from the wall or a fence) mixed with a wineglass of water. Beat four eggs in a glass of milk, add a tablespoonful of whisky, and give at once.

Meanwhile, turn to p. 186, and be prepared to follow Rule 2 under Suffocation, in case artificial respiration may be necessary, in spite of the stimulant and antidotes. After having taken the first steps, try to ascertain the exact poison used, but waste no time at the start. If you can find out just what poison was swallowed, give the treatment advised under that poison, excepting what you may already have given.

ACIDS.—Symptoms: Corrosion or bleeding of the parts with which they come in contact, followed by intense pain, and then prostration from shock. Nitric acid stains face yellow; sulphuric blackens; carbolic whitens the mucous membrane, and also causes nausea and stupor.

Treatment.—Carbolic: Give a tablespoonful of alcohol or wineglass of whisky or brandy at once; or one tablespoonful of castor oil, also a half pint of sweet oil, also a pint of milk. Put to bed, and apply hot-water bottles.

Nitric and Oxalic: Chalk, lime off walls, whitewash scraped off fence or wall, one teaspoonful mixed with a quarter of a glass of water. Give one tablespoonful castor oil, and half a pint of sweet oil. Inject into the rectum one tablespoonful of whisky in two of water.

Sulphuric: Soapsuds, half a glass; a pint of milk.

Other Acids: Limewater, or two teaspoonfuls of aromatic spirit of ammonia diluted with a glass of water. One tablespoonful of castor oil.

ALKALIES.—Symptoms: Burning and destruction of the mucous membrane of mouth, severe pain, vomiting and purging of bloody matter, rapid death by shock.

Ammonia; Potash; Lye; Caustic Soda; Washing Soda: Give half a glass of vinegar mixed with half a glass of water; also juice of four lemons in two glasses of water. One teaspoonful of castor oil in half a glass of olive oil. If prostrated, give tablespoonful of whisky in a quarter of a glass of hot water.

METALS.—Symptoms: Great irritation, cramps and purging, suppression of urine, delirium or stupor, collapse, and generally death.

Arsenic; Paris Green; Fowler's Solution; "Rough on Rats": Intense pain, thirst, griping in bowels, vomiting and bloody purging, shock, delirium. Patient picks at the nose. Send to druggist's for two ounces hydrated sesquioxide of iron, the best antidote, and give tablespoonful 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 mustard in 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 of mercury suspected; cause vomiting by giving a tablespoonful of mustard mixed with a glass of warm water, or thirty grains of powdered ipecac mixed with half a glass of water.

Silver Nitrate: Give two teaspoonfuls of table salt dissolved in two glasses of hot water. After half an hour give a tablespoonful of castor oil.

Phosphorous; Matches: Give teaspoonful of mustard mixed in a glass of water. After vomiting has occurred, give a tablespoonful of gum arabic dissolved in a tumblerful of hot water. An hour later give tablespoonful of Epsom salts dissolved in a glass of water. GIVE NO OIL.

Antimony; Tartar Emetic: Symptoms as stated for metals. Give thirty grains of powdered ipecac stirred in wineglass of water, even if vomiting has occurred. Give three cups of strong tea, or hot infusion of 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 or convulsions, coma, and death. There is often an acid taste in mouth, with dryness of throat and mouth, fever, vomiting and diarrhea, with severe 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 not available, give thirty grains of powdered ipecac stirred in a wineglass of water, followed by two glasses of warm water. As the patient vomits, give more warm water. When vomiting ceases, give two cups of strong hot coffee, and then a tablespoonful of castor oil.

Keep patient awake by rubbing; do not exhaust him by walking him about. He must lie flat. If prostration follows, give two teaspoonfuls of whisky in wineglass of hot water from time to time, if repetition is 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 give thirty grains of powdered ipecac stirred in a wineglass of water, and when vomiting ceases give thirty drops of aromatic spirit of ammonia in a wineglass of water every half hour till pulse has become full and rapid. 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 vomiting and purging, sleep, coma. Heart very weak, with pulse at wrist very feeble. Constriction of the mouth and throat, with dryness. Pain in bowels is marked before stupor appears.

Use stomach pump if possible, or empty stomach with rubber tube and funnel, siphoning fluids out. Or give thirty grains of powdered ipecac stirred in a wineglass of water. When vomiting ceases, give two teaspoonfuls of whisky in half a glass of hot water. Give hypodermic injection of sulphate of strychnine, one-twentieth of a grain every two or three hours, till patient is roused and weakness is past. Rubbing of the surface, application of hot-water bottles to the body and legs.

If breathing ceases, follow Rule 2 under Suffocation (p. 186) till breathing 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 of powdered ipecac stirred in a wineglass of water, followed by two glasses of warm water, as vomiting proceeds. Let the patient inhale ammonia or smelling salts. Give him half a grain of permanganate of potash dissolved in a wineglass of water, every half hour. Inject two ounces 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 under Suffocation (p. 186). Thirty drops of tincture of belladonna to an adult, every hour, will assist the breathing. Do not exhaust the patient by walking him around, slapping him with wet towels, or striking him on the calves; keep him awake by rubbing.

Tobacco when Swallowed: Nausea and vomiting occur, with severe pain and 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 in wineglass of water, followed by two glasses of warm water, by degrees. Give whisky, two teaspoonfuls in wineglass of hot water. Keep patient warm.

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 powdered ipecac stirred in a wineglass of water. Then, when vomiting has ceased, give twenty grains of chloral, together with thirty grains of bromide of sodium in half a glass of water, at blood heat, injected into the rectum. Give twenty grains of bromide of sodium in a wineglass of water, every hour, by the mouth.

If convulsions, put chloroform before nose and mouth, as follows: pour twenty drops of chloroform on a handkerchief and hold it close to the mouth, 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 the pupils, unconsciousness, and convulsions.

Give the patient two teaspoonfuls of whisky in a wineglass of water every hour. Give, if possible, a hypodermic of a thirtieth of a grain of strychnine, every two hours, or as he may require it, to keep the pulse full and strong. Use hot-water bottles to feet and legs.

Phenacetin; Acetanilid; Headache Powders: Give two teaspoonfuls of whisky in a wineglass of hot water. If the heart flags, give tincture of digitalis, five minims in tablespoonful of water, every two hours, or till three doses are given. It is better to use digitalin, one one-hundredth of a grain hypodermically, if possible.



CHAPTER VII

Food Poisoning

Food Containing Bacterial Poisons Resulting from Putrefaction; Food Infected 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 and feet, possibly an eruption.

First Aid Rule 1.—Rid patient of poison. Cause repeated vomiting by giving three or four glasses of warm water, each containing half a level teaspoonful of mustard. Put finger down throat to assist. Empty bowels by giving warm injection of soapsuds and water by fountain syringe.

Rule 2.—Support heart and rally nerve force. Give teaspoonful of whisky in tablespoonful of hot water every half hour, as needed. Put hot-water bottles at feet and about body.

Conditions, Etc.—Bacterial poisons, constituting irritants of the stomach and bowels, are found in certain mussels, oysters from artificial beds, eels out of stagnant ditches—as well as the uncooked blood of the common river eel—certain fish at all times, certain fish when spawning, putrefied fish, fermented canned fish, sausages of which the ingredients have putrefied, putrefied meat, imperfectly cured bacon, putrefied cheese, milk improperly handled and not cooled before being transported, ice cream which fermented before freezing, or ice cream containing putrid gelatin, and mouldy corn meal and the bread made from it.

These poisons are called toxins, or toxalbumins, or bacterial proteids. They are no longer called ptomaines, because many ptomaines are not poisonous. They are formed within the cells of the bacteria, and result from the combination of certain constituents of the food material that nourishes the bacteria, in some way not quite understood. Some decomposition must have taken place in the food before it can furnish to the bacteria the nourishment it needs. If this has happened, the bacteria multiply rapidly, and the toxins that are formed are taken up by the lymphatics and carried away from the tissues as fast as possible. But so great is their virulence that they act on several vital organs before they can be antagonized by the natural elements of the blood.

Symptoms.—The symptoms are much the same in all the cases of bacterial poisoning mentioned. Sudden and violent vomiting and diarrhea appear a few hours after eating the spoiled food, or may be delayed. There may be headache, colic, and cramps in the muscles. Marked prostration and weak pulse with cold hands and feet are characteristic. The appearance of skin eruptions is not uncommon. The occurrence of such symptoms in several persons, some hours after partaking of the same food, is sufficient to warrant one in pronouncing the trouble food poisoning.

Treatment.—The objects of treatment are to rid the patient of the poison, and to stimulate the heart and general circulation, and draw on the reserve nerve force. It is best to procure medical aid to wash out the stomach, but when this is impossible, the patient should be encouraged to swallow plenty of tepid water and then vomit it. If there is no natural inclination to do so, vomiting may be brought about by putting the finger in the back of the throat. The same process should be repeated a number of times, and the result will be almost as good as though a physician had used a stomach tube. A teaspoonful of salt or tablespoonful of mustard in the water will hasten its rejection. Then the bowels should likewise be emptied. If vomiting continues this will not be possible by means of drugs given by the mouth, although calomel may be retained given in half-grain tablets hourly to an adult, until the bowels begin to move, or till eight to ten tablets are taken. When vomiting is excessive, emptying of the bowels may be brought about quickly by giving warm injections of soapsuds into the bowel with a fountain syringe. Brandy or whisky in teaspoonful doses given in a tablespoonful of hot water at half-hour intervals should follow the emptying of the stomach and bowels, and the patient must be kept quiet. He must also be kept warm by means of hot-water bags and blankets.

INFECTED FOOD.—A frequent source of illness is infection by disease germs transmitted in food. The meat of animals slaughtered when sick with 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 excrement from typhoid patients, and may then transmit the disease to those who eat them.

Milk from diseased animals, or contaminated with germs of typhoid fever, scarlet fever, tuberculosis, diphtheria, etc., is apt to cause the same disease in the human being who drinks it.

If such infected food is eaten raw, the diseases with which it is contaminated may be transmitted. If subjected to cooking at a temperature of at least the boiling point, comparative safety is secured; but the toxins accompanying the disease germs in the infected food are not as a rule rendered harmless. Treatment must be directed to each disease thus transmitted.

Poisoning resulting from eating canned meats has sometimes been attributed to supposed traces of tin, zinc, or solder, which have become dissolved in the fluids of the meat, but in the vast majority of cases such poisoning is due to toxins accompanying the germs of putrefaction, 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. 147 and 149).

While human breast milk is germ free, the cows' milk sold in cities is a very common source of disease. Scrupulous care of the cows, of the clothing and hands of the milkers, of the stables at which the herds are quartered, and of the cans, pails, and pans used, reduces to a minimum the amount of filth and impurity otherwise mixed with milk. In the household, as well as during transportation, milk should be kept cool, with ice if necessary. It should also never be left uncovered, for it readily absorbs gases, effluvia, and contaminating substances in the air, and affords an excellent medium for the growth and propagation of germs. When partially or entirely soured, it should not be used, except in the preparation of articles of food by cooking, as directed in cook books. It should never be used if there is any doubt about its purity. Unless all doubt has been removed, it is best to subject milk intended for children's consumption to a temperature of 160 deg. F. for ten minutes, and then put it on the ice, especially during hot weather. Germs are thus rendered harmless, and the nourishing qualities of the milk remain unimpaired.

Summer diarrhea of children, also called cholera infantum, occurs as an epidemic in almost all large cities during the hottest days of summer. The disease is largely fatal, especially during the first hot month, because the most susceptible and tender children are the first affected. It is due to the absorption into the systems of these children of the toxins formed during the putrefying of milk in the stomachs and bowels of the little sufferers. Clean, pure sweet milk, free from bacteria should be used to prevent the occurrence of this disease. Its treatment is outlined in Vol. III. Exactly what bacteria cause the disease is not decided. Possibly the milk is infected, but probably the poisonous results come from toxins.