LIBRARY 
 
 OF THE 
 
 UNIVERSITY OF CALIFORNIA. 
 
 GIFT OF" 
 
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 Ctafe 
 
 " 
 

 
TREASURY DEPARTMENT. 
 Public Health and Marine-Hospital Service of the United States. 
 
 HANDBOOK 
 
 FOR THE 
 
 SHIP'S MEDICINE CHEST, 
 
 BY 
 
 GEORGE W. STONER, M. D., 
 
 Surgeon, U. S. Public Health and Marine-Hospital Service. 
 
 PREPARED BY DIRECTION 
 
 OK THK 
 
 SURGEON-GENERAL. 
 
 SECOND EDITION. 
 
 o 
 UNiV;-r.3ITY 
 
 'ON: 
 
 GOVERNMENT PRINTING OFFICE, 
 1904. 
 
SURGEON-GENERAL, 
 
 '"MBMMW^- 
 
 U. S. PUBLIC HEALTH AXD MARINE-HOSPITAL SEKVICE.. 
 Document No. 2389. 
 

 CONTENTS. 
 
 Page. 
 
 The medicine chest .' _ _ 7 
 
 1. Surgical instruments . . 7 
 
 2. Miscellaneous articles 7 
 
 3. Drugs and medicines . . . 8 
 
 4. Pills 8 
 
 5. Compressed tablets .. 8 
 
 6. Hard-filled capsules . . 8 
 
 7. Tablet triturates . . 8 
 
 8. Lozenges 8 
 
 9. Essences, elixirs, tinctures, etc 9 
 
 Important measures to be observed by the captain of the ship_ . 9 
 
 Requirements at sea . . 9 
 
 Yellow fever . 11 
 
 Malarial fever . . . 16 
 
 Smallpox . . 21 
 
 Cholera, epidemic, Asiatic _, : 24 
 
 The plague . . 26 
 
 Beriberi 29 
 
 Dysentery j 32 
 
 Sunstroke 34 
 
 Diarrhea ... 35 
 
 Cholera morbus . _ _ 36 
 
 Colic 37 
 
 Scurvy 38 
 
 Sore throat - . 39 
 
 Erysipelas 40 
 
 Rheumatism 41 
 
 Delirium tremens-- 44 
 
 Syphilis 45 
 
 Soft chancre (chancroids) 46 
 
 Gonorrhea - 48 
 
 Stricture urethra 50 
 
 Itch 52 
 
 Boils _ . 52 
 
 Piles 53 
 
 Injuries Hemorrhage (bleeding) 53 
 
 Wounds . 54 
 
 Burns and scalds 56 
 
 Effects of cold (frostbite) . . . 57 
 
 Scalp wounds 58 
 
 Wounds of the face . 58 
 
 3 
 
 129097 
 
Injuries to the chest 58 
 
 Injuries to the back 59 
 
 Broken bones (fractures) 59 
 
 Fracture of the lower jaw 60 
 
 Fracture of the thumb and fingers . 62 
 
 Fracture of the forearm 62 
 
 Fracture of the arm (between the elbow and shoulder) 63 
 
 Fracture of the thigh _ _ 65 
 
 Fracture of the kneecap 69 
 
 Fracture of the leg (below the knee) . . 70 
 
 Compound fractures 72 
 
 Dislocations 73 
 
 Dislocation of the fingers _ 74 
 
 Dislocation of the thumb . 74 
 
 Dislocation of the wrist 75 
 
 Dislocation of the elbow 75 
 
 Dislocation of the shoulder 77 
 
 Dislocation of the collar bone 78 
 
 Dislocation of the toes 78 
 
 Dislocation of the ankle 78 
 
 Dislocation of the knee. . 79 
 
 Dislocation of the hip . 79 
 
 Sprains 81 
 
 Nosebleed 81 
 
 Drowning: 
 
 Directions for restoring the apparently drowned 82 
 
 Instructions for saving drowning persons by swimming to their relief - 87 
 
 APPENDIX. 
 
 The U. S. Public Health and Marine-Hospital Service. . 89 
 
 Relief stations 89 
 
 Beneficiaries 90 
 
 Hospital relief 91 
 
 Out-patient relief 91 
 
 The Revenue-Cutter Service . 91 
 
 The Mississippi River Commission 92 
 
 The Engineer Corps, U. S. Army. . 92 
 
 The Life-Saving Service - . 92 
 
 The Light-House Service. 93 
 
 U. S. Army and Navy _ 93 
 
 Foreign seamen - - 93 
 
 Index . 95 
 
U. S. PUBLIC HEALTH AND MARINE-HOSPITAL SERVICE, 
 
 NEW YORK, N. Y. (IMMIGRATION DEPOT), 
 
 September 16, 1904. 
 To the SURGEON-GENERAL, 
 
 Public Health and Marine-Hospital Service, 
 
 Washington, D. 0. 
 
 SIR: In compliance with your directions, I have prepared and beg 
 leave to submit herewith a second edition of the Handbook for the 
 Ship's Medicine Chest. 
 
 The article on yellow fever has been revised, new articles on the 
 plague and on beriberi have been added, an extract from the United 
 States Quarantine Regulations has been inserted, and the order of 
 subjects of the handbook has been rearranged. 
 Respectfully submitted. 
 
 GEO. W. STONER, 
 Surgeon, Public Health and Marine-Hospital Service. 
 
HANDBOOK FOR THE SHIP'S MEDICINE CHEST. 
 
 THE MEDICINE CHEST. 
 
 SURGICAL INSTRUMENTS. 
 
 Catheters, rubber, assorted sizes, G. 
 
 Catheters, soft rubber, assorted sizes, 6. 
 
 Catheters, silver, 2. 
 
 Forceps, artery, 4. 
 
 Forceps, dissecting, 2. 
 
 Forceps, dressing, 2. 
 
 Knife, bistoury, straight, blunt point, 1. 
 
 Knife, bistoury, curved, sharp point, 1. 
 
 Knife, bistoury, straight, blunt point, 1. 
 
 Knives, sea pel, 2. 
 
 Needles, surgeon's, st might and curved, 
 
 assorted sizes, 12. 
 
 Pins, safety, assorted sizes, boxes, 4. 
 Probes, silver, 2. 
 
 Scissors, straight, sharp-pointed, 1. 
 Scissors, straight, blunt-pointed, 1. 
 Scissors, curved, blunt-pointed, 1. 
 Suturing materials : 
 Catgut, aseptic, assorted sizes, pa- 
 pers, 12. 
 
 Silk, assorted sizes, spools, 4. 
 Silkworm gut, box, 1. 
 Silver wire, 30 gm. 
 (The silk and catgut are also used 
 MS ligatures for tying blood ves- 
 sels. ) 
 
 Tongue depressor, 1. 
 Trocar and cannula, curved, 1. 
 
 MISCELLANEOUS ARTICLES. 
 
 Adhesive plaster. 
 
 Absorbent cotton. 
 
 Bandage, Esmarch's, 1. 
 
 Bandages, flannel, assorted sizes, 12. 
 
 Bandages, muslin, roller, assorted sizes, 
 
 48. 
 
 Bandages, rubber, 2. 
 Bedpan, 1. 
 
 Binder's board, sheets, 6. 
 Droppers, medicine, G. 
 Feeding cups, 2. 
 Flannel, 10 yards. 
 Footbath, 1. 
 Fracture box, 1. 
 Gauze, plain, aseptic, 10 yards. 
 Gauze, bichloride, 5 yards. 
 Gauze, iodoform, 5 yards. 
 Glasses, graduate, 2. 
 Glasses, medicine, 4. 
 
 Hot-water bags, 2. 
 
 Ice bags, or ice caps, 2. 
 
 Lint, 5 yards. 
 
 Muslin, 20 yards. 
 
 Oiled muslin, 5 yards. 
 
 Oiled silk, 5 yards. 
 
 Rubber sheets, 2. 
 
 Rubber tissue, 5 yards. 
 
 Rubber tubing, assorted sizes, 10 yard 
 
 Sand bags, 4. 
 
 Splint,- double inclined plane, 1. 
 
 Splints, molded, set, 1. 
 
 Suspensory bandages, 12. 
 
 Syringes, Davidson's, 2. 
 
 Syringe, fountain, 1. 
 
 Syringes, glass, 12. 
 
 Urinals, glass, 2. 
 
 Weight and pulley, 1. 
 
DRUGS AND MEDICINES. 
 
 Acid, carbolic. 
 
 Acid, nitric. 
 
 Argonin. 
 
 Beef extract. 
 
 Bismuth, subcarbonate. 
 
 Black wash. 
 
 Borax. 
 
 Blotting paper. 
 
 Calomel. 
 
 Carbolic soap. 
 
 Castor oil. 
 
 Collodion. 
 
 Epsom salts. 
 
 Ipecac powdered. 
 
 Linseed (flaxseed), ground. 
 
 Glycerin. 
 
 Linseed oil. 
 lodoform. 
 Mustard. 
 Olive oil. 
 
 Potassium citrate. 
 Rochelle salts. 
 Seidlitz powders. 
 Sulphur ointment. 
 Sulphur, roll. 
 Vaseline. 
 Vichy salts. 
 Zinc acetate. 
 Zinc oxide. 
 Zinc-oxide ointment. 
 Zinc sulphate. 
 
 PILLS. 
 
 Anti-constipation. 
 Blue mass, 5 grains (0.33 gm.). 
 Calomel, 2 grains (0.13 gin.). 
 Calomel, 5 grains (0.33 gm.). 
 Camphor and opium, 2 grains (0.12 
 
 gm.) camphor, 1 grain (0.06 gm.) 
 
 opium. 
 
 Cathartic, compound, U. S. P. 
 Copaiba mass, 3 grains (0.20 gm.). 
 Mercurous iodide, i grain (0.010 gm.). 
 
 Morphine sulphate,^ grain (0.01 gm.). 
 
 Opium, U. S. P., 1 grain (0.06 gm.). 
 
 Opium and lead acetate, i grain (0.03 
 gm.) opium, 14 grain (0.10 gm.) 
 lead acetate. 
 
 Quinine, iron, and strychnine phos- 
 phate. 
 
 Quinine sulphate, 2 grains (0.13 gm.). 
 
 Quinine sulphate, 5 grains (0.33 gm.). 
 
 COMPRESSED TABLETS. 
 
 Brown mixture and ammonium chlo- 
 ride. 
 
 Calomel and sodium bicarbonate, 1 
 grain (0.065 gm.) calomel, 1 grain 
 (0.065 gm.) sodium bicarbonate. 
 
 Cathartic, vegetable. 
 
 Cocaine. 
 
 Cough. 
 
 Diarrhea. 
 
 Dover's powder, 5 grains (0.33 gm.). 
 
 Gargle 
 
 Nausea. 
 
 Phenacetine, 5 grains (0.33 gm.). 
 
 Potassium bromide, 10 grains (0.66 
 gm. ) . 
 
 Potassium chlorate and borax, 2* 
 grains (0.16 gm.) potassium chlo- 
 rate, 2 grains (0.16 gm.) borax. 
 
 Potassium iodide, 5 grains (0.33 gm.). 
 
 HARD-FILLED CAPSULES. 
 
 Copaiba, 10 drops. Santal oil, 10 drops. 
 
 Copaiba and santal (5 drops copaiba, Santal oil, 5 drops. 
 5 drops santal). 
 
 TABLET TRITURATES. 
 
 Aconite, tincture, 1 drop. Morphine sulphate, f grain (0.01 gm.). 
 
 Mercurous iodide, % grain (0.03 gm.). Opium powder, grain (0.03 gm.). 
 
 LOZENGES. 
 
 Potassium chlorate, 2 grains (0.13 Potassium chlorate and ammonium 
 gm. ) . chloride. 
 
ESSENCES, ELIXIRS, TINCTURES, ETC. 
 
 Essence of peppermint Tincture of capsicum. 
 
 Elixir, aromatic. Tincture of chloride of iron. 
 
 Elixir of calisaya. Tincture of ginger. 
 
 Elixir calisaya, iron, quinine, and Tincture of iodine. 
 
 strychnia. Tincture of kino. 
 
 Paregoric. Tincture of myrrh. 
 
 Sirup, hypophosphites with iron. Tincture of opium (laudanum.). 
 
 Tincture of arnica. Turpentine. 
 Tincture of benzoin. 
 
 LIQUORS. 
 
 Brandy. rimmpagne. 
 
 Whisky. 
 
 MIXTURES. 
 
 Hot drops. Balsam copaiha mixture. 
 
 Sun cholera mixture. Lead and opium wash. 
 
 IMPORTANT MEASURES TO BE OBSERVED BY THE CAPTAIN OF THE SHIP. 
 
 The following is an extract from the Quarantine Regulations, 
 issued by the Secretary of the Treasury upon the recommendation 
 of the Surgeon-General of the Public Health and Marine-Hospital 
 Service of the United States : 
 
 REQUIREMENTS AT SEA. 
 
 The master of a vessel should observe the following measures on 
 board his vessel : 
 
 (a) The water-closets, forecastle, bilges, and similar portions of 
 the vessel liable to harbor infection should be disinfected and fre- 
 quently cleansed. 
 
 (fr) Free ventilation and rigorous cleanliness should be maintained 
 in all portions of the ship during the voyage and measures taken to 
 destroy rats, mice, fleas, flies, roaches, mosquitoes, and other vermin. 
 
 (c) A patient sick of a communicable disease should be isolated 
 and one member of the crew detailed for his care and comfort, who, 
 if practicable, should be immune to the disease. 
 
 (d) Communication between the patient or his nurse and other 
 persons on board should be reduced to a minimum. 
 
 (e) Used clothing, body linen, and bedding of the patient and 
 nurse should be immersed at once in boiling water or in a disinfecting 
 solution. 
 
 (/) The compartment from which the patient was removed should 
 be disinfected and thoroughly cleansed. Articles liable to convey 
 infection should remain in the compartments during the disinfection 
 when gaseous disinfection is used. 
 
 (g) Any person suffering from malaria or yellow fever should be 
 
10 
 
 kept under mosquito bars and the apartment in which he is confined 
 closely screened with mosquito netting. All mosquitoes on board 
 should be destroyed by burning Pyrethrum powder (Persian insect 
 powder) or by fumigation with sulphur. Mosquito larvae (wigglers 
 or wiggle tails) should be destroyed in water barrels, casks, and other 
 collections of water about the vessel by the use of petroleum (kero- 
 sene). Where this is not practicable, use mosquito netting to prevent 
 the exit of mosquitoes from such breeding places. 
 
 (h) In the case of plague special measures must be taken to de- 
 stroy rats, mice, fleas, flies, ants, and other vermin on board. 
 
 (i) In the case of cholera, typhoid feA^er, or dysentery the drink- 
 ing water should be boiled and the food thoroughly cooked. The 
 discharges from the patient should be immediately disinfected and 
 thrown overboard. 
 
 An inspection of the vessel, including the steerage, should be made 
 by the ship's physician once each day. 
 
 Should cholera, yellow fever, smallpox, typhus fever, plague, or 
 any other communicable disease appear on board a ship while at sea, 
 those who show symptoms of these diseases should be immediately 
 isolated in a proper place. The ship's physician should then immedi- 
 ately notify the captain, who should note same in his log, and all 
 of the effects liable to convey infection which have been exposed to 
 infection should be destroyed or disinfected. 
 
 The hospital should be disinfected as soon as it becomes vacant. 
 
 The dead should be enveloped in a sheet saturated with one of the 
 strong disinfecting solutions, without previous washing of the body, 
 and at once buried at sea or placed in a coffin hermetically sealed. 
 
 A complete clinical record should be kept by the ship's surgeon of 
 allcases of sickness on board and the record delivered to the quaran- 
 tine officer at the port of arrival. 
 
 The following disinfecting solutions are recommended for use 
 at sea : 
 
 Formulae for slront/ flixiitfc<iin</ solutions. 
 
 Bichloride of mercury (1 : 500) : Parts. 
 
 Bichloride of mercury 1 
 
 Sea water 500 
 
 Mix. 
 Carbolic acid (5 per cent) : 
 
 Alcohol 50 
 
 Carbolic acid, pure 50 
 
 Mix. 
 
 Then add fresh water 900 
 
 Formula' for weak solutions. 
 
 Bichloride of mercury (1 : 1,000) : 
 
 Bichloride of mercury 1 
 
 Sea water.. . 1,000 
 
11 
 
 Carbolic acid (2.5 per cent) : 
 
 Carbolic acid, pure 25 
 
 Fresh water 1, 000 
 
 Formalin (5 per cent) : 
 
 Formalin (or formol) 50 
 
 Water 950 
 
 It is suggested that a vessel should carry for every 100 passengers 
 bichloride of mercury, 5 pounds; carbolic acid, 10 pounds; alcohol, 
 10 pounds, and formalin, 10 pounds. 
 
 YELLOW FEVER. 
 
 Yellow fever is an acute infectious disease of the Tropics, charac- 
 terized by a febrile paroxysm, yellowness of the skin or conjunctiva 
 (jaundice), albuminuria, suppression of urine, and bloody or black 
 vomit. It is transmitted from one person to another through the bite 
 of a species of mosquito, the Stegomyia faciata. 
 
 The disease is endemic in the West Indies, on the Mexican coast 
 of the Gulf, in Central America, on the coast of Brazil, and West 
 coast of Africa. It has frequently been carried to southern ports 
 and to different places in the South Atlantic and Gulf States of this 
 country, and occasionally to certain ports in Europe ; but it has never 
 gained a firm foothold in the old country except on the west coast of 
 Africa, and is unknown in the Orient. 
 
 " Yellow fever is not endemic in Europe, nor does it naturally pre- 
 vail anywhere in. North America, yet it may be carried almost any- 
 where. Imported epidemics have occurred at ports of England, 
 France, Spain, and Portugal, and nearly all of the ports on the Atlan- 
 tic seaboard of the United States." (Wyman.) 
 
 The specific cause or germ of yellow fever has not yet been deter- 
 mined, but the disease is communicated from one person to another 
 through the bite of a species of mosquito, the Stegomyia faciata. 
 
 For the proof of this statement it is only necessary to refer to the 
 conclusion of the United States Army yellow- fever commission 
 of 1900-1901 (Doctors Reed, Carroll, Lazear, and Agramonte) as 
 reported by the head of said commission, the late Walter Reed, 
 major and surgeon, U. S. Army. To the brilliant work of this com- 
 mission we are indebted for the demonstration of the fact, previously 
 suggested by Doctor Finlay, of Habana, that 
 
 The mosquito (Stegomyia faciata) serves as the intermediate host of the para- 
 site of yellow fever. 
 
 Yellow fever is transmitted to the iiouimmnne individual by means of the bite 
 of a mosquito that has fed previously on the blood of those sick with this 
 disease. 
 
 Yellow fever is not conveyed by fomites, and hence disinfection of articles 
 of clothing, bedding, or merchandise supposedly contaminated by contact with 
 those sick with the disease is unnecessary. 
 
12 
 
 A house (or ship) may be said to be infected with yellow fever only when 
 there are present within its walls contaminated mosquitoes capable of convey- 
 ing the parasite of the disease. 
 
 The spread of yellow fever can most effectually be controlled by measures 
 directed to the destruction of the mosquitoes and protection of the sick against 
 the bites of these insects. 
 
 The commission showed also that the mosquito, to become infected, 
 must bite a yellow-fever patient during the first three or four days 
 of his illness, and that an interval of about twelve days or more after 
 this bite appears to be necessary before the mosquito is capable of 
 communicating the disease to a person. After this interval the mos- 
 quito is permanently infected and can cause the development of the 
 disease within five days after biting. 
 
 This conclusion as to the time elapsing from the infection of the 
 mosquito to the time it becomes capable of communicating the disease 
 to man is in accord with and fully confirms the extensive observations 
 previously made by Surg. Henry E. Carter, of the IT. S. Public 
 Health and Marine-Hospital Service. Before it was known that the 
 mosquito is the carrier of the disease Surgeon Carter proved " a 
 period of extrinsic incubation " corresponding to the cycle of devel- 
 opment of the disease in the mosquito. 
 
 In 1900 yellow fever raged throughout Cuba and was very severe 
 in Habana. During this year and in this city (Habana) the com- 
 mission made the scientific investigation and obtained the results 
 which have revolutionized all theories as to the prevention and spread 
 of yellow fever. Witness the fact reported January 9, 1902, by Maj. 
 W. C. Gorgas, chief sanitary officer of Cuba, that, with the aid of a 
 corps of men, working in accordance with the recommendations of 
 the commission, the disease has been completely eradicated from the 
 city of Habana. 
 
 The efficient maritime quarantine maintained by the U. S. Public 
 Health and Marine-Hospital Service must also be taken into consid- 
 eration, for while the disease was stamped out of the city by the 
 measures referred to, it was kept out by similar measures directed to 
 the cleansing of ships and to the isolation and protection of passen- 
 gers arriving from other infected ports. 
 
 Formerly the hotbed of yellow fever and for upward of a hundred 
 years the very center of infection, Habana is now free from the 
 disease, not a single case of yellow fever having occurred there during 
 the last three years; and all this as a result of the wholesale destruc- 
 tion of the mosquitoes and their breeding places, in the city and on 
 board of ships, and the protection of the sick by means of properly 
 constructed mosquito screens. 
 
 Yellow fever prevails chiefly in low countries along the coast, and 
 seldom extends to regions above an elevation of 1,000 feet. It is 
 
13 
 
 apt to be severe in the slums or badly drained sections of large cities. 
 Filthy, dark, and ill- ventilated rooms in a house (or ship) seem to 
 invite the disease. Heat and moisture or dampness favor its develop- 
 ment; frost arrests it. The mosquito is inactive during cold or 
 frosty weather. Or, quoting from Osier, " humidity and heat seem to 
 be the proper coefficients for the preservation of the poison. The 
 epidemics in the United States have always been in the summer and 
 autumn months, disappearing rapidly with the onset of cold 
 weather." 
 
 Strangers in yellow- fever districts are usually the first victims. 
 The negro is said to be less susceptible than the white. This appar- 
 ent immunity is probably due to the fact that the endemic regions 
 of yellow fever are populated chiefly by black or dark-skinned races, 
 who, as Guiteras has pointed out, have had the disease in childhood, 
 precisely as Koch has shown that natives of highly malarious coun- 
 tries are apparently free from malarial fever because of repeated and 
 persistent infection in early life. The immunity, then, of the negro 
 may be said to be the same as that of the white an acquired immunity. 
 Nonimmunes of either race are probably equally susceptible; or if 
 there be a difference it may apply to the relative thickness of the skin 
 rather than to the color, or, possibly, to the predilection of the mos- 
 quito. Stendel, according to Scheube, " is inclined to think that the 
 relative immunity of the negroes is to be attributed to the lively and 
 quite specific activity of their skin, distinctly evidenced by the odor." 
 
 In 1793 yellow fever prevailed extensively in Northern cities, par- 
 ticularly in Philadelphia, where out of a population of 40,000 (the 
 number of inhabitants of the city at that time) more than 4,000 died. 
 Epidemics occurred also in different parts of the United States during 
 the early part of the last century; but for many years past no 
 extensive outbreaks have occurred in this country except in the South- 
 ern States, where in 1853, 1867, 1873, 1878, 1897, 1898, and 1899 it 
 prevailed in different degrees of severity. The most extensive epi- 
 demic occurred throughout the South in 1878. It was unusually 
 severe in Alabama, Louisiana, and Mississippi, and caused about 
 16,000 deaths. The later epidemics were less severe. Localized out- 
 breaks occurred at different times in nearly all the Southern States, 
 but the disease was of milder type. 
 
 The disease is occasionally carried into northern latitudes by 
 infected ships, but it seldom reaches port, being usually stopped at 
 the quarantine station, where the sick are placed in hospital, the well 
 detained for observation, and the ship and everything disinfected. 
 
 Symptoms. Yellow fever generally begins after an incubation 
 period of three or four days ; in 13 experimental cases it varied from 
 forty-one hours to five clays and seventeen hours. The onset is usually 
 sudden. It frequently comes on at night or in the early morning, and 
 
14 
 
 is generally, but not always, ushered in by a chill, which is followed by 
 moderate or high fever 101 to 105 F. (38.3 to 40.5 C.) ; hot skin, 
 quick pulse (100 to 1*20 per minute) ; flushed face, and watery, bril- 
 liantly reddened eyes. The tongue is usually moist and coated, but 
 soon becomes dry and pointed. Thirst is marked, the throat is sore, the 
 stomach is irritable, and in most cases there is nausea and vomiting 
 from the beginning. The bowels are constipated, the stools dark col- 
 ored. The urine is acid, scanty, and apt to be albuminous, especially 
 the evening urine. The presence of albumen on the first and second 
 days indicates a severe case (Guiteras). The fever may last from a 
 few hours to two or three days, but while the temperature keeps up 
 the pulse steadily fails. Death may take place in this early or first 
 stage of the disease. Usually this stage is followed by 
 
 . The second stage, or stage of calm, as it is called. During the stage 
 of calm the fever goes down, the temperature drops in some cases 
 below the normal, and the general symptoms subside. The skin may 
 or may not be tinged. There is usually some yellowness of the eyes. 
 In the milder cases this may be the beginning of convalescence. 
 
 In severe cases this stage of calm and apparent convalescence is 
 followed, in twelve or twenty-four hours, by 
 
 The third stage, or stage of febrile reaction, when the struggle for 
 life begins. The temperature now rises again, and the symptoms of 
 the first stage recur with increased severity, and other and more 
 serious symptoms are developed. The jaundice deepens, the pulse 
 drops in some cases to 40 or even to 30 per minute, vomiting increases ; 
 the vomited matter may be bile, blood, or altered blood (coffee-grounds 
 black). The patient complains of severe abdominal pain. The 
 stools are black and frequently of tarry consistence. The urine very 
 scanty and albuminous. Bleeding may occur from the nose and from 
 the mouth and gums. The strength rapidly fails, and the patient 
 dies from exhaustion. 
 
 In some cases even when black vomit occurs a change for the better 
 takes place and the patient gradually recovers, but if black vomit 
 sets in early in the disease it is nearly always fatal. In the " walking 
 cases " a man may be up and about, complaining of only slight ail- 
 ment, and be suddenly taken with black vomit and die. 
 
 Treatment. The milder and even the moderately severe cases may 
 easily be mistaken for other diseases; but if a man is seized with an 
 illness as above described, particularly if the ship is or has recently 
 been in a yellow-fever district or where } 7 ellow fever is likely to 
 prevail, he should be placed in a clean, well-ventilated room, as far 
 removed as possibly from the healthy members of the crew, and have 
 one good and constant attendant or nurse, who may, if convenient, 
 occupy an adjoining room when not in actual attendance at the bed- 
 side, but who must be given to understand that his whole duty con- 
 
15 
 
 sists in caring for the patient. The nurse should be supplied with 
 everything required for the care of the patient, but all unnecessary 
 articles should be removed from the room. Careful nursing in this 
 disease is more than " half the battle;'' but for the protection of the 
 nurse himself and for all members of the crew the one thing that 
 requires immediate attention is the screening of the patient's bed 
 and the doors and windows of his room, so as to prevent the mos- 
 quitos from biting the sick person and communicating the disease to 
 others. 
 
 Yellow fever is sometimes complicated with malarial fever, and 
 such complications may be very serious. When near the coasts where 
 these diseases prevail, it is a good plan to give each man on board a 
 daily allowance of quinine, say 10 grains (O.G5 gm.). The men 
 should also be careful to keep their bowels regular and to be regular 
 in their habits of eating and sleeping and avoid excitement, worry, 
 or excessive fatigue. They must not be allowed to go ashore. Their 
 beds and sleeping rooms should be properly screened with mosquito 
 netting. This will not only be a protection against a possible mala- 
 rial complication, but will place the body in the best condition to 
 battle against an attack of yellow fever, and may prevent an attack 
 of pernicious malaria, which in some of its forms is as serious and 
 dangerous as yellow fever itself. 
 
 As soon as the attack of yellow fever begins, place the patient at 
 rest in bed on a blanket, and immediately give him a hot footbath. 
 The foot tub should be half full of warm water, to which a pound of 
 mustard may be added. The patient's feet and legs are then placed 
 in the water, and a quantity of very hot water is added, so as to make 
 the bath as hot as he can stand it. The bath must be hot, and while 
 it is going on the entire body of the patient should be covered with 
 blankets, and he should drink hot tea. After the footbath is removed, 
 the patient should be allowed to perspire for ten minutes. His body 
 must then be quickly dried and wrapped in a fresh blanket. A 
 5-grain (0.33 gm.) dose of calomel should then be given, which may 
 be followed in six hours by a tablespoonful of Rochelle salts in a 
 glass of water, or in place of the calomel two compound cathartic 
 pills may be given. If vomiting occur, a large mustard plaster 
 should be placed over the region of the stomach and small pieces of 
 ice in the patient's mouth. 
 
 The diet in yellow fever is very important. For the first day or 
 two very little if anything is required. A little milk diluted with 
 vichy water may be allowed every three hours. Later a little broth 
 and very gradually, when the fever is reduced, other light and easily 
 digestible articles may be given in small quantities at regular 
 intervals. 
 
 If the fever continues high and the patient is restless, 5 grains (0.33 
 
16 
 
 gm.) of phenacetin may afford relief, and, if necessary, a second dose 
 may be given after an interval of three hours. Vichy or other alka- 
 line mineral water should be given in small quantities frequently 
 repeated. The bowels should then be kept open by means of rectal 
 injections of warm, soapy water. A long tube attached to the syringe 
 should be passed into the bowels as far as possible and at least a quart 
 injected once or twice a day. 
 
 If black vomit occur, give 15 or 20 drops of tincture of chloride of 
 iron in a little water every three hours. Apply mustard to the stom- 
 ach, and give cold champagne and 'viclty. or brandy and ice water. 
 
 Used clothing, body linen, and bedding of the patient and nurse 
 should be immersed at once in boiling water or in a disinfecting 
 solution. 
 
 * * * " All mosquitoes on board should be destroyed by burning 
 pyrethrum powder (Persian insect powder) or by fumigation with 
 sulphur. Mosquito larvae (wigglers, or wiggle tails) should be de- 
 stroyed in water barrels, casks, and other collections of water about 
 the vessel by the use of petroleum (kerosene) ; where this is not prac- 
 ticable use mosquito netting to prevent the exit of mosquitoes from 
 such breeding places." (U. S. Quarantine Regulations.) 
 
 The sick room, as soon as it is vacated, also the room occupied by 
 the nurse, should be thoroughly disinfected by burning sulphur, 2 
 pounds for every thousand cubic feet of air space, to destroy possibly 
 infected mosquitoes. 
 
 The sulphur is placed in an iron pot, the pot is then set on two 
 bricks in a tub containing a sufficient quantity of water to prevent the 
 burning sulphur from running on the floor and setting fire to the 
 ship. The windows and all crevices should be tightly closed. When 
 everything is ready the nurse should then light the sulphur, leave the 
 room and close the door. At the end of twelve hours the doors and 
 windows should be thrown open. The walls and ceiling and all 
 articles of furniture should then be washed down with a solution of 
 bichloride of mercury (1 to 1,000) and the ship should be taken to 
 the nearest quarantine station for thorough fumigation to destroy 
 mosquitoes in other parts of the vessel. 
 
 MALARIAL FEVER. 
 
 Malarial fever is an endemic infectious disease, caused by a para- 
 site of the blood. The disease is transmitted to man (inoculated) by 
 the bite of certain kinds of mosquitos, of the genus Anopheles. 
 
 The parasite in the blood of persons sick with malarial fever was 
 discovered in 1880 by Laveran, a French surgeon in Algiers. At 
 first repudiated, the discovery was later confirmed by other French 
 surgeons and by numerous Italian, British, German, and American 
 investigators. 
 
17 
 
 After the confirmation of the discovery of Laveran, the very 
 important questions arose as to the origin of the malarial parasites 
 and the means by which they enter the human body. The answers 
 were soon forthcoming. Mansori, Ross, and others demonstrated 
 conclusively that the disease is propagated and transmitted from one 
 person to another by a certain kind of mosquito. 
 
 " Doctor Manson took the advanced position that an intermediate 
 host in the shape of a certain gnat or mosquito was necessary in 
 transmitting the disease from man to man and was also an inevitable 
 portion of the cycle of development of the parasite. No subject has 
 been more carefully and elaborately worked out; in no research 
 known to modern science have fanciful or theoretical deductions been 
 the subject of more careful scrutiny; and to-day the 'mosquito 
 theory ' of the transmission of malaria is no longer a theory, but an 
 accepted fact." (Geddings.) 
 
 Malarial fever is a disease of warm and temperate regions; very 
 prevalent and of severe type in hot countries, especially along the 
 seacoast and basins of rivers, but gradually declining in extent and 
 virulence in proportion to the distance on either side from the 
 equator. In the Tropics the disease is constantly prevalent. In the 
 cooler, or temperate regions, as for example, along the coast of the 
 Central Atlantic States, it is active only during summer and 
 autumn. It is seldom developed at a lower temperature than 60 F. 
 (15.5 C.), and even in the hot climates malaria is probably never 
 contracted far away from land. The disease is said to be most fre- 
 quently contracted during the night, just after sunset and just before 
 sunrise being the most dangerous periods. It is therefore very 
 important in infected localities not to permit the men to go ashore, 
 nor to allow them to sleep on deck, if the vessel is lying near the land ; 
 or, if they must sleep on deck or other exposed places, to provide suit- 
 able protection by means of blankets and properly constructed mos- 
 quito bars. The protective measures already referred to under " yel- 
 low fever " are equally important in guarding against malaria. 
 
 There are different varieties and types of malarial intermittent 
 fever: (1) Quotidian, when the paroxysm occurs every day; (2) 
 tertian, when it occurs every other day; and (3) quartan, when it 
 occurs every fourth day. The disease is popularly known as " fever 
 and ague," " chills and fever," " the shakes,"' etc. It is character- 
 ized by recurring paroxysms, consisting as a rule of three distinct 
 stages: The cold, the hot, and the sweating stage. The attack may 
 be sudden or it may be preceded by a feeling of uneasiness, a 'desire to 
 stretch the limbs and yawn, headache, loss of appetite, and some- 
 times by vomiting. The chill may be of any degree of severity. 
 Patients sometimes complain only of chilliness, or of a creeping sen- 
 1325604 M 2 
 
18 
 
 sat ion of coldness over the back. More frequently the chill is well 
 marked; the feeling of cold spreads all over the body, the teeth 
 chatter, the patient shivers, and his whole body shakes. This cold 
 stage may last from a few minutes to an hour, or longer. 
 
 The hot stage gradually comes on as the cold stage subsides, and 
 soon there is a feeling of intense heat. The face becomes flushed, 
 the pulse full Or bounding, the headache continues, and the patient 
 is in high fever. This stage may last from half an hour to four or 
 five hours, when perspiration appears, first on the forehead and 
 gradually over the entire body, and the sweating stage is fully estab- 
 lished. With the appearance of perspiration the fever declines, the 
 distressing symptoms gradually cease, the patient experiences a feel- 
 ing of great relief, and soon falls into a refreshing sleep. The dura- 
 tion of the sweating stage varies from one to three hours. It may 
 be very profuse or very slight. At the end of the sweating stage the 
 patient may be greatly prostrated or may feel quite well, and able 
 to be up and about until the beginning of the cold stage of the next 
 fit, twenty-four, forty-eight, or seventy-two hours from the beginning 
 of the first. 
 
 Besides the three varieties of regularly intermittent malarial fever, 
 there are irregular forms of intermittent; also remittents, bilious 
 remittents, typhoid remittents or typho-malarial, and a very severe 
 type known as pernicious malarial fever. 
 
 In the irregular intermittent the paroxysms may be longer and 
 recur at irregular intervals, the cold stage may be absent, the fever 
 may come on gradually and decline to normal in the same manner. 
 
 When the attacks are prolonged, and when instead of declining to 
 normal there may be only a slight fall in the temperature and slight 
 sweating, the fever is called remittent fever. 
 
 When a remittent fever is accompanied by recurring attacks of 
 bilious vomiting, constipation, or bilious diarrhea, and perhaps a 
 yellowish tint of the skin and eyes, it is said to be bilious remittent 
 fever. 
 
 When typhoid symptoms, such as dry tongue, low delirium, extreme 
 prostration, etc., appear in conjunction with the ordinary symptoms 
 of remittent or bilious remittent fever, the disease is called typhoid 
 remittent or typho-malarial fever. This is really the coexistence of 
 two diseases, typhoid fever and malarial fever. 
 
 Pernicious malarial fever, as the name indicates, is a very fatal 
 disease. It occurs chiefly in hot climates, but is occasionally met with 
 in temperate regions. It may be preceded by an apparently mild 
 attack ot intermittent fever, or the patient may be taken suddenly 
 with intense headache, high feA*er. wild or perhaps muttering de- 
 lirium, rapidly passing into unconsciousness, and death may occur 
 within a few hours from the beginning of the attack. 
 
19 
 
 In another form of the disease the attack begins with extreme cold- 
 ness of the surface of the body, with vomiting, or with severe diar- 
 rhea or dysentery, and the patient may die from collapse. 
 
 There is also a hemorrhagic form in which bleeding may occur 
 from the nose, mouth, or gums. The urine may be bloody or quite 
 dark in color, in some cases almost black. In tropical Africa and 
 other hot countries where the disease prevails it is known as " black- 
 water fever." 
 
 Hemorrhages, however, may occur in any severe or prolonged form 
 of malarial infection, and bloody urine (malarial hematuria) is not in- 
 frequently met with. 
 
 Treatment. Quinine is the remedy, and quinine also acts as a pre- 
 ventive. In going to a malarial region, treatment should be com- 
 menced several clays before arriving at port. To each man on board 
 should be given at least 10 grains (0.0 gm.) of quinine daily for a 
 period of one week. The allowance may then be reduced to 5 grains 
 (0.3 gm.) or even to 3 grains (0.2 gin.) a day. The bowels should 
 be kept freely open. 
 
 If a chill occur, the patient should at once be wrapped in blankets 
 and given hot drinks. During the hot stage, cold drinks, lemonade, 
 etc., may be given. As soon as the sweating stage begins, 10 or 15 
 grains (0.0 gm. to 1 gm.) of quinine should be given, and thereafter 5 
 grains (0.8 gm.) every six hours, for two or three days, and then con- 
 tinued in smaller doses, say 8 grains (0.2 gm.) three times daily, for 
 the next two weeks. 
 
 If the chill is severe, or if the surface of the body is very cold, hot- 
 water bottles or heated bricks or stones wrapped in cloth or in a 
 separate piece of blanket should be placed to the feet. Mustard 
 plasters may also be applied to the extremities and over the region 
 of the heart, and hot stimulating drinks should be given. 
 
 If vomiting occurs, a mustard plaster may also be placed over the 
 region of the stomach, above the navel, and cracked ice may be given 
 by the mouth. Headache may be relieved by cold applications. 
 
 If the hot stage is severe, a tepad bath may be given in a tub or by 
 means of a sponge. If the temperature is very high, 105 or 100 F. 
 (40.5 or 41.1 C.), a cold bath should be given. 
 
 For extreme pain or restlessness, a pill of morphine sulphate one- 
 sixth grain (0.01 gm.), or 12 drops of tincture of opium (laudanum), 
 or 10 grains (0.0 gm.) of Dover's powder may be given, and if neces- 
 sary repeated in three hours. 
 
 In bilious, remittant, and other severe types of malarial fever the 
 treatment should be more active. No time should be lost in giving 
 the quinine; 10 or 15 or 20 grains (0.6 gm. to 1.3 gm.) should be 
 given immediately, and along with this, if the bowels are not freely 
 open, 5 or 10 grains (0.3 gm. to 0.0 gm.) of calomel. After the 
 
20 
 
 bowels move, the quinine should be continued in 5-grain (0.3 gm.) 
 doses every four or five hours. 
 
 If there is much vomiting and if the medicine is not retained, an 
 emetic of lukewarm water or powdered ipecac should be given, and 
 after waiting a little while the quinine and, if necessary, the calomel 
 may be tried again. Mustard plaster to the region of the stomach, 
 cracked ice in the mouth, sips of very hot water, or a little cham- 
 pagne may have a good effect on the vomiting. If, notwithstanding 
 these measures, the A^omiting continues and the medicine is imme- 
 diately rejected, the rectum should be washed out with an injection of 
 warm water, and then at least 30 grains (2 gm.) of quinine in 2 or 3 
 ounces of water should be injected into the rectum. When the stom- 
 ach is settled 5-grain (0.3 gm.) doses of quinine may be given again 
 by the mouth. 
 
 The best method of giving quinine for rapid effect and perhaps the 
 be:st means of saving life in the severe pernicious forms of malarial 
 fever is to give the quinine hypodermically (injected under the skin 
 by means of a hypodermic syringe). But this method is out of the 
 question except in the hands of an experienced person, and even then 
 it is apt to produce abscesses. 
 
 The symptoms and signs of typical malarial intermittent fever are 
 so striking that they can hardly be mistaken for anything else. It 
 must not be forgotten, however, that there are typical and irregular 
 forms of malarial fever, and that they may be mistaken for other 
 diseases, such as tubercle (consumption) of the lungs, abscess of the 
 lungs or of the liver or any part of the body, or the result of the 
 passing of a catheter, all of which produce chills or chilliness and 
 fever. 
 
 Some forms of remittent or continued remittent malarial fever 
 may be difficult to distinguish from typhoid fever, and if the patient 
 is suffering from the poison of malarial fever and typhoid fever at 
 the same time he will have typho-malarial fever. The bilious remit- 
 tent type may be mistaken for yellow fever. 
 
 Quinine is the remedy for any form of malarial fever. If the 
 fever does not yield to full doses of quinine, it is probably not mala- 
 rial. At any rate this is the most practical method for determining 
 the question as to whether the fever is malarial or not. In the hos- 
 pital or laboratory the diagnosis is made by microscopical examina- 
 tion of the blood. 
 
 The diet in any form of acute fever should be light, liquid, and 
 nourishing, and if there is much prostration stimulants will be 
 required. Solid food should not be allowed. After the fever has 
 subsided a tonic should be given (a teaspoonful of elixir of iron, 
 quinine, and strychnia three times a day, or 10 drops of the tincture 
 of chloride of iron in a wineglassful of water three times daily). 
 
21 
 
 SMALLPOX. 
 
 Smallpox is an acute, contagious, self-limited disease, character- 
 ized by an initial fever and successive stages of eruption. It spreads 
 rapidly among persons unprotected by vaccination. It may be com- 
 municated by the breath, by exhalations from the skin, by clothing, 
 or by anything that has been in contact with a person suffering from 
 the disease. It is very contagious during the latter stage of eruption, 
 and especially during the period of convalescence when the dried pus 
 scales become detached from the skin and in the form of dry powder 
 or dust settle on everything about the room or compartment, and may 
 be conveyed not only to all parts of the ship, but to any part of the 
 world to which the ship is bound. 
 
 After a period of incubation of from eight to fourteen days, 
 occasionally longer, the disease begins suddenly, usually with a chill, 
 always with severe pain in the back and loins, intense headache, and 
 high fever. Vomiting occurs in many cases. The bowels may or 
 may not be constipated. 
 
 About the end of the third day or on the fourth day a papular 
 eruption appears on the forehead, and frequently on the lips and the 
 wrists, occasionally in the mouth and throat, and gradually extends 
 to other parts of the body. The eruption begins as a bright red dot 
 or spot slightly elevated above the surrounding skin, enlarging until 
 the second day, when it forms a papule. The papule is hard to the 
 touch, feels like shot under the skin. As soon as the eruption appears 
 the temperature begins to fall, and the distressing symptoms subside. 
 On the fifth or sixth day a small vesicle, with a depression of the cen- 
 ter, appears on the top of each papule. The vesicles gradually become 
 distended, the depressed centers rounded out, and about the eighth or 
 ninth day the change is completed and the vesicles become pustules. 
 They have a yellowish gray appearance and each pustule is sur- 
 rounded by a red border. The skin between them is swollen, the eyes 
 may be closed. During this change the temperature rises again, sec- 
 ondary fever sets in, the chief symptoms return, and a day or two later 
 another change begins. The pustules break, matter oozes out, crusts 
 form, first on the face and then over other parts of the body following 
 the order of the appearance of the eruption. The secondary fever 
 may be quite high in the beginning, but gradually declines as the 
 pustules change into crusts, and in favorable cases seldom lasts more 
 than two or three days. The crusts then rapidly dry and fall off, 
 leaving red spots on the skin, and here and there the characteristic 
 pockmarks or pits. The healing of the pustules is usually attended 
 by troublesome itching, 
 
 In some cases a diffuse redness of the skin or red spots appear on 
 the abdomen, or on the side of the chest, or on the inner surface of 
 
22 
 
 the thighs as early as the second day, but the distinctive papular 
 eruption makes its appearance as stated at the end of the third or 
 on the fourth day, and nearly always begins on the forehead. 
 
 In the confluent form of smallpox the eruption may appear a day 
 earlier and all the symptoms are more severe. The pustules run 
 together and form large brownish scabs, chiefly on the face and head, 
 but also on the hands and feet. The face and neck are greatly swol- 
 len, the eyes are closed, the features are distorted. The patient com- 
 plains of tension and burning of the skin ; there is much thirst. The 
 eruption may also appear in the mouth and throat. The secondary 
 fever is high. Delirium may be quite marked. In fatal cases the 
 pulse becomes rapid and feeble, and death occurs about the tenth or 
 eleventh day or later. 
 
 In favorable cases, about the eleventh or twelfth da} r the pustules 
 begin to break. The matter dries and forms crusts which slowly fall 
 off, leaving the skin quite red and in many cases dreadfully scarred 
 and pitted. 
 
 The crusts begin to drop off about the fourteenth day, but the proc- 
 ess of desquamation may not be completed until the end of the third 
 or fourth week, and the fever may persist during that period. In 
 some cases the entire skin of the hands is cast off like a glove, and the 
 
 O 
 
 skin of the feet and toes may be shed in a similar manner. There is a 
 milder form of smallpox called rarioloid, in which the symptoms are 
 usually milder and of shorter duration. Varioloid occurs in persons 
 who have been vaccinated. Sometimes the eruption begins on the 
 feet. In some cases it is confined to the feet and hands. Occasionally 
 the eruption is extensive and the symptoms arc severer 
 
 The most severe type of smallpox is the hemorrhagic (bloody). It 
 occurs in two forms. In one the case goes on in the usual way until 
 about the ninth or tenth day, w T hen blood makes its appearance in the 
 pock. This form is sometimes called black smallpox. In the other 
 form the eruption may be blood-colored from the second day, and 
 bleeding may take place from the nose or mouth or from the rectum. 
 The face is greatly swollen and the eyes are deeply bloodshot. Death 
 occurs during the first week, sometimes as early as the second day. 
 
 Before the characteristic eruption appears it is frequently very 
 difficult to determine the existence of smallpox. It is easily con- 
 founded with other eruptive diseases. The important points to 
 remember are the intense pain in the back, the high fever, and 
 bounding pulse, all of which precede the eruption, and that when 
 the eruption appears the fever and all the severe symptoms subside. 
 The temperature before the eruption may be up to 105 or 106 F. 
 (40.5 or 41.1 C.) When the eruption appears it begins to decline, 
 and within twenty-four or thirty-six hours is down to about 100 F. 
 
23 
 
 (37.7 C.) When the secondary fever sets in the temperature rises 
 again. 
 
 Treatment. The patient should be placed in a cool, well-ventilated 
 room, and strictly isolated; and every person on board should be 
 immediately vaccinated. No one should be allowed to come in con- 
 tact with him except the nurse or attendant, and the nurse or attend- 
 ant should not be allowed to come in contact with other members 
 of the crew. While in immediate attendance on the sick he should 
 wear overalls and jumper, and a head covering, to be removed 
 when he leaves the room, and immediately put on again when he 
 returns. Separate dishes and necessary utensils should be pro- 
 vided. The food should be placed at a convenient place near the 
 door of the sick room where the nurse can come and get it. Noth- 
 ing should be allowed in the room except the articles absolutely 
 necessary. The soiled clothing should be wrapped in a clean sheet 
 (or in a sheet that has been dipped in a 2 per cent solution of car- 
 bolic acid and wrung out), and the bundle placed in a kettle of water 
 and thoroughly boiled. If there is a sufficient supply of bedclothing 
 on board, the soiled articles should be destroyed by fire (burned). 
 The patient must be kept thoroughly clean. Good nursing is very 
 important. 
 
 In the early stage, when the fever is high, place the patient in a 
 cold bath, or give him a cold sponge bath, note the temperature of 
 the body, and repeat the bath every three hours if the thermometer 
 registers above 103 F. (39.4 C.). If the bowels are constipated, 
 give small doses of Epsom or Rochelle salts every two or three hours. 
 If diarrhea is troublesome, give teaspoonful doses of paregoric 
 every two or three hours until it is checked. 
 
 For the severe pain in the back a tablet of morphine, \ grain 
 (0.01 gm.), may be given, and, if necessary, repeated in two hours. 
 The food should be soft and nourishing and given at regular intervals. 
 Cold drinks, lemonade, barley water, etc., may be freely given. 
 
 The pain and tension in the skin may be relieved by cold applica- 
 tions. A piece of lint, wet with a cold 2 per cent solution of carbolic 
 acid, may be applied to the face and frequently renewed. Holes 
 should be cut into the lint corresponding to the eyes, nose, and mouth, 
 and oiled silk may be placed on top. When the pustules begin to 
 form it is a good plan to touch each one with tincture of iodine (a 
 camel's hair brush may be used for the purpose), and a day later to 
 puncture them with the point of a needle. The needle should first 
 be boiled, and the point should then be dipped in tincture of iodine 
 before making the puncture. When crusts begin to form, olive oil or 
 glycerin should be applied. If the hair is long it should be cut short 
 early in the disease before the pustular stage begins. The eyes must 
 be carefully cleansed several times a day, else blindness may follow. 
 
24 
 
 A solution of borax, 5 grains to a fluid ounce of water (0.33 gm. to 
 30 c. c.), is a good eyewash. The mouth, throat, and nose also re- 
 quire attention. A saturated solution of chlorate of potassium may 
 be used as a mouth wash and gargle. 
 
 When the crusts and scabs drop off they should be carefully gath- 
 ered up and burned. The patient should then have a daily bath with 
 carbolic soap and water. When the case is ended the room and all 
 exposed articles must be disinfected by burning sulphur (4 pounds 
 to every 1,000 cubic feet of air space) . 
 
 If near port when the disease breaks out the ship should be taken 
 direct to the quarantine station, where the patient may be taken care 
 of and the ship disinfected. 
 
 CHOLERA (EPIDEMIC CHOLERA, ASIATIC CHOLERA). 
 
 Cholera is an infectious disease, caused by a specific organism, dis- 
 covered in 1884 by Koch, of Berlin, Germany, and named Comma 
 bacillus, because its shape, as seen under the microscope, is not unlike 
 that of a comma. 
 
 Cholera is not endemic in any part of the world except Asia. Its 
 home is in India, where in certain localities it has been endemic prob- 
 ably for centuries. 
 
 The first widespread epidemic is said to have occurred in that coun- 
 try in the year 1817. During the years 1830 and 1832 extensive epi- 
 demics occurred in different parts of Europe and there were recur- 
 rences of smaller epidemics up to 1838. In the j^ear 1832 the disease 
 was brought to the United States in emigrant ships from Great 
 Britain via Quebec; also by ships entering at New York. In 1835-36 
 it again appeared in the United States; in 1846 there was another 
 widespread epidemic in Europe. In 1848 it entered the United 
 States through the port of New Orleans and overspread the Missis- 
 sippi Valley and extended across the continent to California. In 
 1854 it Avas again introduced into the United States through the port 
 of New York and a widespread epidemic was the result. In 1866 
 the disease was again epidemic in Europe, also in Arabia and Egypt, 
 and during the same year and the year following, and again in 1873, 
 smaller epidemics occurred in the United States. In 1883-84 an 
 extensive epidemic prevailed in Europe, particularly in France and 
 Italy. The last serious epidemic occurred in Europe in 1892 and 
 1893, chiefly in Hamburg, where it attacked nearly 18,000 persons, 
 and more than 7,000 died within a period of three months. In 1892 
 a few cases were brought to New York Harbor, but there was no 
 spread of the disease. 
 
 Every epidemic of cholera is probably due to a spread of the dis- 
 ease directly or indirectly from its home in India. It is apt to be 
 
25 
 
 developed in the wake of moving masses of human beings. It fol- 
 lows the great lines of travel to different parts of the world. It is 
 spread probably through the agency of the dejections from cholera 
 patients, which contain the comma bacilli. These find their way 
 into the water supply, or become attached to different articles of 
 food and are then, in turn, introduced through the mouth into the 
 systems of health} 7 persons. They may be conveyed in clothing, or 
 in merchandise of different kinds. An infected ship may carry the 
 disease from one end of the world to the other. 
 
 An attack of cholera may be of any degree of severity. The symp- 
 toms usually begin after a period of incubation of from two to five 
 days. The mildest forms are called choleraic diarrhea. The stools 
 are watery, rather large, and of yellowish color, and, in the absence of 
 other symptoms of true cholera, may be mistaken for ordinary diar- 
 rhea, or the attack may begin with colicky pains, purging and vomit- 
 ing as in cholera morbus. 
 
 All such symptoms occurring in persons who have been ashore at 
 infected ports, or who have drunk water taken at such ports, should 
 be regarded as extremely suspicious. Under ordinary circumstances 
 it is difficult to distinguish between severe cases of cholera morbus 
 and genuine cholera. Cholera morbus is usually due to indigestible 
 food or other irritating exciting cause, and while true cholera may 
 not be ascribed to such a cause, persons with weak or irritable stom- 
 achs are more apt to be attacked by cholera than are healthy persons. 
 
 The majority of cases of cholera begin with looseness of the bowels, 
 or an apparently simple diarrhea. After a day or two, or within an 
 hour or two, the diarrhea may become very violent. The evacuations 
 soon lose their yellowish color and assume the grayish-white appear- 
 ance known as " rice-water stools." Severe cramps occur in the feet 
 and calves of the legs, and sometimes in the hands and arms. Vomit- 
 ing soon follows. There is a burning sensation in the stomach and 
 the thirst is unquenchable. The urine is suppressed. Large quan- 
 tities of fluid may gush from the mouth as well as from the rectum, 
 the patient sinks into a condition of collapse. The skin becomes cold 
 and covered with a clammy sweat. The tongue is coated and cold to 
 the touch, the voice becomes very faint and husky, the breath icy. 
 The whole body shrinks. The temperature in the mouth may fall 
 from 5 to 10 below normal, while in the rectum it may rise several 
 degrees above normal. The intellect usually remains clear until near 
 the end. 
 
 In the very serious forms of cholera the patient may fall into col- 
 lapse and die within an hour from the beginning of the attack. 
 
 In the milder forms, or if the patient survive the collapse of the 
 severe forms, the symptoms gradually subside, the skin becomes 
 warm, the pulse stronger, the urine is again passed, the stools become 
 
26 
 
 more natural, and the patient recovers. But there may be a relapse 
 or the reaction may be too severe and a low type of fever, called 
 cholera-typhoid, may be developed and prove fatal within a few days. 
 
 Treatrnent. During the prevalence of an epidemic of cholera, or 
 while in the vicinity of ports on the Indian coast, where the disease is 
 endemic, every case of mildest diarrhea, looseness of the bowels, or 
 irritable stomach should receive the most careful attention, for the 
 reason that, as already stated, cholera usually begins with such symp- 
 toms; and if the infection is brought on board, the men with bowel or 
 stomach trouble of any kind are usually the first victims to the dread 
 disease. Kest in bed, good ventilation, simple diet, and clean sur-* 
 rouridings must be insisted upon from the very start. The drinking 
 water must be boiled. The patient should be carefully isolated and 
 everything brought into contact with him or contaminated by his 
 excretions must be disinfected. The stools should be passed into a 
 chamber containing a 5 per cent solution of carbolic acid, or a 10 per 
 cent solution of chloride of lime. The linen and bedclothes should be 
 disinfected by dry heat, or by steam, 212 F. (100 C.) or by boiling. 
 The spoons, knives, plates, and utensils of any kind should be boiled 
 immediately after they are used. 
 
 The medicinal treatment in the first stages of true cholera is about 
 the same as for cholera morbus, already described. Opium (lauda- 
 num), or morphine, or " Hot Drops" are the remedies chiefly to be 
 relied upon, but none of these medicines should be given during the 
 stage of collapse. 
 
 Brandy and water, in small quantities at a time, hot coffee, and tea 
 are valuable in this stage. Brandy and warm water, or coffee or tea 
 should be injected into the rectum. Warm water should also be 
 injected into the rectum through a long soft-rubber tube or large 
 catheter attached to a Davidson or, preferably, a fountain syringe. 
 A 1 or 2 per cent solution of tannic acid (tannin) is also* recom- 
 mended. One or two quarts may be slowly introduced. The patient 
 should be wrapped in warm blankets and have hot-water bags, hot 
 'bottles, or hot bricks placed to his extremities and alongside his body 
 (careful of course not to have them too hot, lest great harm be done 
 by burning the skin). 
 
 A ship with cholera on board should go to the nearest quarantine 
 station for treatment, not only for treatment of the sick, but also for 
 the well, and above all for the treatment of the ship, so as to prevent 
 further spread of the disease. 
 
 THE PLAGUE. 
 
 Plague, the most dangerous of all infectious diseases, is caused by 
 a specific micro-organism (the bacillus pestis bubonica) discovered 
 in 1894 by Kitasato, a Japanese physician. 
 
27 
 
 " Plague was known to the ancients, and at different times since 
 the beginning of the Christian era hundreds of thousands of people 
 of the Old World have been carried off by its ravages. It has 
 probably always existed in the Orient, more especially in India, 
 where it is now raging in terrible epidemic form. 
 
 " Plague is a disease of hot countries, but it may occur in any coun- 
 try or be carried to any country in any season of the year. The most 
 widespread and disastrous epidemics occurred in Europe during the 
 sixth, fourteenth, seventeenth, and eighteenth centuries, and since 
 then epidemics of varying degrees of severity have occurred in dif- 
 ferent parts of the Old World in Europe, Africa, and Asia. Of late 
 years the disease has also appeared in South America and Mexico. 
 It has never gained a foothold in the United States, except the local- 
 ized epidemic in the Chinese quarter of San Francisco." 
 
 The disease is commonly called buhontc /^n/iic for the reason that 
 in the large majority of cases buboes (inflamed and enlarged lym- 
 phatic glands) form in the groins. But there is another and more 
 fatal form of the disease, known as Kepti<--in'tr i>In</ne, in which 
 buboes are not apparent. Cases of this form run such a rapid course 
 that the patient dies of septicaemia (blood poisoning) before the 
 buboes appear. 
 
 There is also a very dangerous and fatal form of the disease recog- 
 nized as pneumonic plague. This form begins not unlike that of a 
 pneumonia; the sputum is very bloody, and contains multitudes of 
 the bacilli. 
 
 Buboes occur in about 75 per cent of all cases, chiefly in the groin, 
 but also in the armpit and neck and occasionally about the elbow and 
 the knee joint. They are usually developed by the third or fourth 
 day, sometimes within the first twenty-four hours ; occasionally as late 
 as the second week. They vary in size from a marble to a goose egg, 
 and as a rule are very painful. Sometimes, after attaining a con- 
 siderable size, the buboes are absorbed; more frequently they sup- 
 purate and break. Small boils or abscesses may form on different 
 parts of the body. In some cases dark-colored spots (petechia) from 
 slight hemorrhages form in or beneath the skin. Hemorrhages may 
 also occur from the nose or mouth or from any mucous membrane. 
 
 The bacilli are found in the buboes, blood, and internal organs. 
 They enter the body through the respiratory and digestive tracts, or 
 by way of abrasions or small injuries of the skin. Many of the lower 
 animals suffer equally with man. Rats are the chief carriers of the 
 disease from house to house or from dock to ship. Most epidemics 
 of human plague are preceded by wholesale deaths among the rats. 
 The infection may be spread by fleas, flies, mosquitoes, and other 
 insects, or by means of infected articles of clothing, bedding, .etc., or 
 by the food and drinking water taken at infected ports. 
 
28 
 
 Symptoms. The incubation period of the plague varies from two 
 to ten days. Occasionally the onset of the actual disease is preceded 
 by prodromal symptoms lasting from twelve to thirty-six hours, char- 
 acterized by chilliness, headache, nausea, congestion of the eyes, nose- 
 bleed, giddiness, an anxious and painful expression of the face, mental 
 depression, and sometimes dull pain in the groin and armpits. 
 
 In most cases, however, bubonic plague begins suddenly with fever, 
 which may or maA 7 not be preceded by a chill. The temperature rises 
 rapidly and reaches its highest point, 105 or 106 F. (40.5 to 
 41.1 C.) on the second or third day. The pulse, at first full, rapidly 
 becomes small and weak, and the beats vary from one hundred to a 
 hundred and fifty or more per minute. The tongue, at first moist 
 and red or white coated, soon becomes dry and brown, and dark- 
 colored crusts (sordes) may form on the teeth, lips, and nostrils. 
 Delirium or coma is apt to set in. Prostration is extreme, and the 
 patient may die in this early stage before the bubo attains any con- 
 siderable size, or, as in the septicsemic form of the disease, without 
 the appearance of the bubo at all. 
 
 In some cases on the third or fourth day the temperature drops a 
 degree or two, but generally rises again until about the fifth or sixth 
 day, when it suddenly drops to normal or subnormal. Death may 
 or may not take place in this stage. More frequently there is a sud- 
 den rise in the temperature immediately preceding death, and in 
 favorable cases the temperature falls to the normal gradually. 
 
 About 70 per cent of all cases die within the first six days. Sur- 
 vival of the sixth day may therefore be regarded as a hopeful sign. 
 In cases which tend to recovery the symptoms improve gradually. 
 Convalescence is slow, and at the seat of the bubo an indolent sore 
 may be left, which is very slow to heal. 
 
 Treatment. Plague is a filth disease. A clean ship and personal 
 cleanliness are therefore of the greatest importance. 
 
 If the disease breaks out the patient should be immediately isolated 
 in a clean and well-ventilated compartment, and the ship should be 
 thoroughly disinfected. All articles in the forecastle or elsewhere 
 on board and not absolutely necessary for use should be destroyed. 
 Articles of clothing or bedding soiled by the discharges of the patient 
 or which have been in close contact with 'the body should be burned 
 or thrown overboard and sunk; other articles of clothing should be 
 disinfected by steam 212 F. (100 C.) or by boiling, and always 
 dried in the sunshine and open air. All rats and vermin of every 
 kind should be destroyed. The discharges from the patient urine, 
 feces, vomit, or sputum should be passed into bowls or pots contain- 
 ing a 5 per cent solution of carbolic acid or 10 per cent solution of 
 chloride of lime or ordinary milk of lime. 
 
 The person detailed to wait on the patient should be free from 
 
29 
 
 sores or scratches of any kind, and should exercise the most scru- 
 pulous care of his hands, and all articles brought into contact with the 
 patient should be disinfected. 
 
 Medicinal treatment. Constipation should be relieved by calomel, 
 5 grains (0.3 gm.), followed in five hours by a dose of Rochelle or 
 Epsom salts. Stimulants should be given from the beginning; the 
 food should be concentrated and nourishing. If diarrhea is per- 
 sistent it may be relieved by salol in 5-grain (0.3 gm.) doses, given 
 every three hours. 
 
 Ice or cold water should be applied to the aching head and the hot 
 body sponged with cold or tepid water. In the earlier stage of the 
 buboes the local application of ice is useful. Later on, if softened, 
 they should be incised and dressed with iodoform gauze! Pain and 
 restlessness may be relieved by morphine, \ grain (0.01 gm.), repeated 
 in two hours if necessary. 
 
 The ship should be taken to the nearest quarantine for necessary 
 treatment, and especially to give the survivors the best chance for life. 
 
 KKRiKKRi (THE KAKKE OF .IAPAX). 
 
 Beriberi is a form of multiple-neuritis (inflammation of nerves), 
 characterized by numbness^ tenderness, and <rdenm (dropsical swell- 
 ing) of the legs and other parts of the body; by irritability of the 
 heart, extreme weakness, and paralysis. 
 
 It occurs in epidemic form or as an endemic in most tropical and 
 subtropical climates, and is not infrequently carried into temperate 
 latitudes. It is not contagions in the ordinary sense of the term, 
 but may be communicated from one person to another. Like other 
 forms of infectious or epidemic disease, beriberi is apt to break out 
 in overcrowded places, as, for example, in jails and asylums. 
 
 For the purpose of this article, however, beriberi is to be regarded 
 as a ship disease, or rather as a disease developed in ship from germs 
 taken on board at a tropical or subtropical port or elsewhere, through 
 the medium of persons coming from infected or endemic districts, and 
 cultivated by the artificial conditions of the forecastle. 
 
 Eleven cases, occurring among foreign seamen, were admitted to 
 the Long Island College Hospital at this port (New York) during 
 the year 1903, and the records of the U. S. Public Health and Marine- 
 Hospital Service for the last ten or fifteen years show that sailors 
 suffering from beriberi have been admitted to marine hospitals at 
 different points on the Atlantic and Pacific coasts of the United 
 States from vessels arriving from tropical or hot countries. The 
 disease is frequently carried to the seaports of Great Britain by vessels 
 trading to India, or is developed en route because of the peculiarly 
 dirty and insanitary condition of the forecastle and its occupants 
 the lascars. 
 
30 
 
 " They feel the cold of the English climate so much that on enter- 
 ing British seas they try to keep their quarters warm by lighting 
 fires and stopping up all ventilators. By these means they create a 
 hot, steamy, atmosphere and a sodden state of the place they live and 
 sleep in, which is a very good imitation of the tropical conditions the 
 germ of beriberi requires for its development. In other words, those 
 lascar sailors create an incubator on a large scale, which, should it 
 chance to contain a beriberi germ, quickly becomes extensively in- 
 fected and lethal." (Manson.) 
 
 Four forms of the disease are recognized 
 
 (1) The mild or rudimentary form usually begins with a feeling 
 of weakness and numbness of the extremities, with oedema of the 
 shins and tenderness of the muscles, especially of the calves, uneasi- 
 ness in the belly, shortness of breath, and palpitation of the heart. 
 These symptoms may last only a few days or several weeks and then 
 disappear, but recurrences are common. 
 
 (2) In the dry or atrophic form there is no oedema, but the other 
 symptoms are marked and more rapidly developed. Instead of 
 oedema and puffiness there is atrophy of the parts. The tendon re- 
 flexes are lost. The legs and arms and sometimes the face are paral- 
 yzed and painful. All the muscles of the body waste away. The 
 patient presents a pitiful, shrunken appearance, suffers intense pain, 
 is sensitive to the slightest touch, and may die from general exhaus- 
 tion or. after lingering many months, gradually improve and get 
 well. 
 
 (3) The wet or dropsical form begins with symptoms similar to 
 those of the mild form, but the (edema soon extends over the entire 
 body, watery effusions into the serous sacs take place; there is marked 
 shortness of breath, frequently nausea and vomiting, and always 
 weakness of the heart. Death may occur from heart failure or from 
 paralysis of respiration. On the other hand, the dropsy may grad- 
 ually or rapidly disappear and leave the patient in essentially the 
 same condition as that described under the head of the dry or atrophic 
 form. 
 
 (4) The most serious or dangerous form of beriberi is called the 
 acute pernicious cardiac form. In this the general symptoms of the 
 disease may be only slightly developed, but the cardiac (heart) 
 symptoms are marked. The disease in this form usually lasts several 
 days or weeks, but death may occur from heart failure within twenty- 
 four hours from the onset. 
 
 The mortality in different epidemics varies from 3 to 60 per cent. 
 
 Diagnosis. In tropical regions typical cases of beriberi are easily 
 recognized, but as the incubation period varies from several weeks 
 to as many months the first symptoms of the disease may not appear 
 until the ship is far away from the tropical country, and then the 
 
31 
 
 diagnosis may be somewhat difficult for the reason that some of the 
 symptoms may be absent or those present so slightly developed as to 
 be easily overlooked until the man suddenly becomes helpless or dies 
 from paralysis of the heart. Careful examination of other members 
 of the crew will then probably show symptoms of the disease, and the 
 captain will be reminded that ship beriberi can be developed only in 
 a damp, filthy, ill-ventilated or overcrowded forecastle, into which 
 the seed (germ) was introduced weeks or months before. Pain and 
 numbness of the legs and palpitation of the heart occurring in men 
 of or from the Tropics should suggest the possibility of the presence 
 of beriberi, and also the necessity for prompt action on the part of 
 the captain. 
 
 Treatment. "The first and most important thing to be attended 
 to in the treatment of a case of beriberi is the removal of the patient 
 from the building, camp, or ship in which the disease was contracted." 
 (Manson.) 
 
 If the disease breaks out during the voyage all the men must be 
 removed from the forecastle and made to sleep on deck, with their 
 bodies properly clothed and. if necessary, protected by an awning. 
 
 All articles of clothing and bedding should be boiled, thoroughly 
 washed, and dried in the open air. The forecastle should be disin- 
 fected by burning sulphur (see description of method, p. 1(3), 
 thoroughly cleaned, and dried. All rotten planking and bilge water 
 should be removed, and all woodwork should -be scraped and painted. 
 No one should be allowed to sleep in the forecastle until it is thor- 
 oughly dried and aired; overcrowding must he avoided. If the men 
 have been eating rice in any quantity it should be stopped. (In 
 Japan the cause of the disease is attributed to the excessive use of 
 rice or bad rice and raw or spoiled fish.) Wheat flour and oatmeal 
 should be used instead ; also beans and fat meat, fresh meat, milk and 
 eggs, and red wine all in liberal quantities. The best thing the 
 captain can do for the sick man himself (bearing in mind the possi- 
 bility of heart failure and sudden death), is to relieve him from duty 
 and allow him to rest in bed; or if not too sick, move about slowly in 
 fresh air and sunshine. 
 
 In the beginning of the disease, especially if the muscles are pain- 
 ful, salicylate of soda, 1 gram (15 grains) three or four times a day 
 is considered good treatment. For palpitation or irritability of the 
 heart, tincture of strophanthus, 5 drops every four hours. If there 
 are marked signs of heart failure inhalation of nitrite of amyl may 
 be given 3 or 1 drops on a handkerchief and applied to the nostrils. 
 
 In dropsical cases the bowels should be kept open by the use of 
 Epsom or Rochelle salts, a tablespoon fid in a glass of water two or 
 three times a day. 
 
32 
 
 In the atrophic cases, after the subsidence of the pain, rubbing the 
 muscles (massage) is of service. 
 
 For a tonic the elixir of iron, quinine, and strychnine may be used 
 to advantage. One or 2 teaspoonfuls three times a day. 
 
 DYSENTERY. 
 
 Dysentery, or bloody flux, as it is sometimes called, is an affection 
 an inflammation and ulceratioii of the mucous membrane of the 
 large bowel. It occurs in different degrees of severity. It may be 
 acute or chronic. There are different varieties. Its severest form 
 is met with in tropical countries where it frequently occurs in wide- 
 spread epidemics. Epidemics also occur in temperate regions. Spo- 
 radic cases ma 3^ be found almost everywhere. The disease prevails 
 in summer and autumn. It may attack an entire ship's crew. 
 
 Bad food, unripe fruit, impure drinking water, exposure to cold 
 and dampness, while probably not in themselves the direct cause of 
 dysentery, doubtless favor the operation of other causes. 
 
 /Symptoms. The onset may be sudden or gradual. There may, 
 or may not, be chills or chilliness. There is usually some feverish- 
 ness. The tongue is furred and moist, but soon becomes red and dry, 
 or brownish and glazed. 
 
 The first stools may l>e like those of an ordinary diarrhea. After 
 jv day or two, or maybe within a few hours, these are replaced by 
 Miiall mucous stools frequently mixed with blood and small particles 
 of fecal matter. Soon the evacuations consist of mucus alone, or of 
 blood and mucus, or of a jelly-like matter and small white clumps 
 of mucus. Later they may be shreddy, and brownish or greenish in 
 color. Patient complains of cramps and "colicky" pains in his 
 belly; a burning sensation in the rectum, with a feeling as if some- 
 thing must be expelled, and of a constant desire to go to stool. The 
 evacuations may number from ten to twenty, or forty to fifty, or 
 even a hundred or more a day, according to the severity of the case. 
 The quantity of each may not exceed a teaspoonful. 
 
 In mild cases there is a gradual change to normal and patient may 
 recover after a period of a week or ten days. Severer cases continue 
 for several weeks or longer, and then recover, or become chronic and 
 incurable, or death may occur from general weakness. 
 
 Tropical dysentery, the variety which occurs most frequently and 
 in epidemic form in tropical or subtropical regions, but also occa- 
 sionally in temperate climates, is said to be produced by a micro- 
 organism w T hich enters the system in drinking water. 
 
 The symptoms in this form of dysentery are similar to those 
 already described. The burning sensation and bearing-down pain, 
 however, are less marked. The stools are less frequent, t>ut they 
 
33 
 
 are larger and more watery; at times more like diarrhea than 
 typical dysentery. The disease in favorable cases runs a course of 
 from six to twelve weeks. Recovery is always slow. Death may 
 occur from exhaustion, or from abscess of the liver, which is a 
 common complication. In the most fatal epidemics the course of 
 the disease is very rapid. Death sometimes occurs within a few 
 hours. 
 
 Treatment. Rest in bed. If possible, the patient should use the 
 bedpan instead of the commode or closet, so as to insure the greatest 
 amount of rest, which is very important. Stop all solid food. Give 
 2 tablespoon fuls (30 c. c.) of castor oil and 15 drops of laudanum 
 in one dose, and if necessary repeat the dose in six hours, or give 
 smaller doses at intervals of four hours. After the bowels have 
 been thoroughly cleared out, a pill of opium (or opium and camphor), 
 or opium and acetate of lead, should be given every three hours. 
 Hot applications should be placed on the abdomen. The bearing- 
 down pain and the burning sensation may be relieved by washing 
 out the rectum with a pint of warm water and by injecting 2 ounces 
 of thin starch containing 25 or 30 drops of laudanum. 
 
 In place of the castor oil, sulphate of magnesium (Epsom salts) 
 may be given in tablespoonful doses, repeated every two hours until 
 a free and large action of the bowels results, and then the pill of 
 opium, or opium and camphor, or opium and acetate of lead given 
 every three hours. Or, instead of the opium pills, subnitrate or 
 subcarbonate of bismuth may be given in 30 or 40 grain (2 gm. or 
 2.6 gm.) doses. 
 
 After two or three days, if the disease continues, the castor oil 
 or the Epsom salts may be repeated, and after its effect is pro- 
 duced, the same line of treatment continued. 
 
 Or, in place of the oil and salts, 5 grains (0.33 gm.) of calomel 
 may be given, and repeated, if necessary, in six hours. 
 
 The diet should be limited to the lightest articles, such as thin 
 porridge, milk, and broths. And even in the lightest cases the patient 
 should be kept warm in bed. 
 
 In tropical countries, or in the treatment of tropical dysentery, 
 the remedy chiefly relied on is powdered ipecac. The patient is 
 not allowed any food for three or four hours, then he is given 15 
 drops of laudanum, and this is followed in twenty minutes by a 
 dose of from 20 to 60 grains (1.33 gm. to 4 gm.) of ipecac. To pre- 
 vent vomiting the patient is placed flat on his back and kept very 
 quiet for three or four hours. If vomiting occurs within an hour, 
 the dose is repeated. 
 
 The best means of protection or prevention is to keep the body 
 in sound condition. If the disease occurs among the ship's crew, 
 
 1325604 M 3 
 
34 
 
 the healthy men should be very careful not to catch cold, and to 
 avoid errors in eating and drinking. Sudden changes of tempera- 
 ture should be guarded against by a proper supply of clothing. 
 The drinking water should be boiled. 
 
 SUNSTROKE. 
 
 The term sunstroke denotes a sudden attack of illness from expos- 
 ure or prolonged exposure to the rays of the sun; but the same 
 condition may be produced in hot weather by exposure to high 
 temperature not in the direct rays of the sun, particularly if the 
 person is engaged at hard work in close quarters. Stokers on 
 steamships are sometimes affected by the heat of the furnace. Men 
 
 debilitated from or addicted to the excessive use of stimulants are 
 
 - 
 
 more apt to suffer than those of temperate habits. 
 
 Sunstroke occurs in two forms : Heat stroke (heat fever) , in which 
 the temperature of the body is very high, and heat prostration or 
 heat exhaustion, in which the surface of the body is cool, sometimes 
 considerably below normal. The difference is very important because 
 of the different treatment required. 
 
 In severe cases of heat stroke, the patient may be stricken down 
 in a state of unconsciousness and die instantly or within an hour or 
 two. In other cases there may be intense headache, dizziness, marked 
 restlessness, nausea and vomiting and hot " burning " skin. The 
 thermometer may register 110 F. (43.3 C.). Pulse is full and may 
 be slow or fast. Breathing is labored, may be sighing or rattling. 
 Patient soon becomes unconscious, the stupor deepens and death 
 may occur within twenty-four hours; or the temperature may drop, 
 consciousness may return and the patient get well. 
 
 In heat prostration, as already stated, the surface of the body is 
 cool, the pulse rapid and feeble, and there is a feeling of general 
 weakness. There may be only slight f aintness and nausea, and under 
 prompt treatment patient may rapidly recover, or, on the other hand, 
 there may be complete loss of consciousness and a rapid and fatal 
 termination from exhaustion and heart failure. 
 
 Treatment. In heat stroke (heat fever) the temperature of the 
 body should be reduced as rapidly as possible. Remove the patient 
 to the coolest and best ventilated part of the ship. Place him in a 
 cold-water bath, add ice, rub the body with the blocks of ice, apply 
 iced water with ice cap to his head ; and keep up the treatment 
 until the temperature, as shown by the thermometer in the rectum 
 is reduced to 100 F. (37.7 C.). If the temperature rise again, 
 repeat the treatment. If symptoms of exhaustion follow the reduc- 
 tion of the temperature, stimulants should be given whisky or 
 brandy and water in small quantities. 
 
 In heat prostration, with cool skin, weak and rapid pulse, stimu.- 
 
35 
 
 hints and friction are required. Give brandy or whisky, rub the 
 surface of the body and the extremities, place hot water bottles to 
 the feet, and cover the body with blankets. If the head is hot, 
 apply cold water to the forehead. If vomiting occur, inject the 
 stimulants into the rectum. Apply mustard over the region of the 
 stomach. Mustard may also be applied to the feet. 
 
 DIARRHEA. 
 
 Acute diarrhea is caused by acute inflammation or by irritation of 
 the intestines. It may occur as a complication in many different 
 diseases. It is usually one of the symptoms of typhoid fever. It is 
 not infrequently met with in severe cases of malaria. It is called 
 functional or simple diarrhea when it occurs independently of any 
 other appreciable disease. It may be caused by exposure to cold or 
 by errors in diet. Diarrhea, or looseness of the bowels, is sometimes 
 produced by the receipt of unexpected and exciting news, by a sudden 
 fright, or by any strong mental emotion; intestinal digestion is 
 arrested and diarrhea is the result. 
 
 In simple diarrhea there may or may not be griping and colicky 
 pains. In the more severe forms the tongue is coated and there is 
 some fever. Thirst is marked in proportion to the size and frequency 
 of the thin or watery discharges. If the rectum is affected, there is a 
 constant desire to go to stool, and a burning sensation and bearing- 
 down pain, as in dysentery. 
 
 Diarrhea may last from a few hours to as many days, or longer. It 
 may become chronic. 
 
 Treatment. In all cases, rest and light diet. In the milder forms 
 nothing further may be required. In the more severe forms it is 
 a good plan to begin with a dose of 1 or 2 tablespoonfuls of castor oil, 
 to which 10 or 12 drops of laudanum may be added, or in place of the 
 oil and laudanum Epsom salts or Rochelle salts may be given. The 
 diet should be limited to light articles, such as cornstarch, gruel, weak 
 broths, soft-boiled eggs, milk, and thoroughly toasted bread. As a 
 rule, in very acute cases, the less food and drink taken the better. 
 The patient should rest in bed and keep his body warm. 
 
 After the bowels have been freely moved by the oil or salts, if the 
 diarrhea or pain continue, give 2 tea spoonfuls of equal parts of pare- 
 goric and tincture of catechu, and, if necessary, repeat the dose after 
 an interval of three or four hours. If nausea and vomiting occur, 
 apply mustard to the region of the stomach, and give tablespoonful 
 doses of equal parts of milk and lime water, or a little champagne and 
 carbonated water. 
 
 In chronic diarrhea careful attention to diet is of the greatest im- 
 portance. The treatment is about the same as for chronic dysentery. 
 
36 
 
 CHOLERA MORBUS (SPORADIC CHOLERA). 
 
 Cholera niorbus is an affection of the stomach and intestines, 
 attended by vomiting, purging, and cramps. It comes on suddenly, 
 and may begin by vomiting or purging. It is usually met with dur- 
 ing the hot months of summer. It is frequently caused by eating 
 unripe and indigestible fruits and vegetables or decomposed or 
 improperly cooked fish or shell fish, or salad mixtures. Drinking 
 large quantities^ of iced water and sudden checking of the perspira- 
 tion, or irritants of any kind, may set up the trouble. The disease 
 usually begins suddenly, often at night, with vomiting, or after a 
 feeling of uneasiness or nausea or a severe cramp. The contents of 
 the stomach are first thrown up, then a slimy bilious matter, and later 
 the vomited matter seems to be pure water. The stools are at first 
 solid or semisolid, but they soon become more watery, lose their color, 
 and sometimes appear not unlike the rice-water stools of genuine 
 Asiatic cholera. The patient soon has a wasted look. His thirst 
 is unquenchable. His skin may become cold and clammy and the 
 pulse very weak. Cramps may occur in the feet and in the calves 
 of the legs. The disease runs a rapid course. The acute symptoms 
 may subside in a few hours. The attack seldom lasts more than 
 twelve hours. Recovery is the rule, but treatment should be promptly 
 applied. 
 
 Treatment. Apply a large mustard plaster to the abdomen. Give 
 15 drops of tincture of opium (laudanum). If the dose is rejected 
 (immediately vomited), try it again. If rejected a second time, 
 then a morphine pill or tablet ^ grain (0.01 gin.) should be given 
 If the morqhine pill is quickly rejected, it may be tried a second time 
 by crushing or rubbing it into a powder and placing it on the back 
 of the patient's tongue immediately after an act of vomiting. If 
 the laudanum or morphia are not retained, then try a teaspoonful of 
 " hot drops," or a teaspoonful of " Sun Cholera Mixture." If vom- 
 iting quickly occur, then inject into the rectum by means of a glass 
 or rubber syringe about 40 drops of laudanum mixed with a little 
 thin starch or a little water. The rectal injection should be given 
 immediately after an evacuation, and the patient should be instructed 
 to hold it as long as possible. In whatever way the remedy is given 
 the dose should be repeated in about one hour if the vomiting and 
 purging continue. 
 
 It must not be forgotten, however, that all these remedies contain 
 opium and that if the patient is inclined to sleep or shows other con- 
 stitutional effect of the drug the dose must not be repeated. 
 
 The nausea and thirst may be controlled by cracked ice placed in 
 the mouth. Small quantities of carbonated water, or of iced cham- 
 pagne, may be allowed. If the thirst is very urgent, a tablespoonful 
 
37 
 
 of iced water may be given at short intervals. Large quantities of 
 water must not be allowed. If there is marked prostration, a little 
 brandy and water or whisky and water should be given. 
 
 COLIC. 
 
 Intestinal or spasmodic colic. These terms are applied to abdom- 
 inal pain occurring in paroxysms of different degrees of severity. 
 The pain is usually referred to the region of the navel or middle 
 of the belly. It may be due to indigestible food, cold or acid drinks, 
 poisons, gases, or any irritating substance. It is often preceded by 
 obstinate constipation. Vomiting frequently occurs, and in malarious 
 districts it is apt to be " bilious." 
 
 Foods and drinks taken in excessive quantity are frequently the 
 cause of indigestion. 
 
 Another variety of colic, called lead colic or painters colic, is 
 caused by lead poisoning. It is not .uncommon in painters or work- 
 ers in lead. It may be caused by drinking water taken from leaden 
 pipes. An attack may be mild or exceedingly severe. It is usually 
 attended by obstinate constipation and by contraction of the abdo- 
 men. 
 
 The severe paroxysmal pain attending the passage of a gallstone 
 from the gall bladder to the intestine is called biliary colic. In 
 biliary colic the pain is usually most marked in the region above the 
 navel or about the stomach (epigastric region). The paroxysms 
 begin and end suddenly. Severe nausea and vomiting occur. The 
 skin and eyes may become yellow or of a yellowish hue (jaundiced), 
 the same as in bilious colic. Gallstones may occasionally be found 
 in the stools if carefully looked for. Some cases, however, are 
 difficult to distinguish from ordinary intestinal colic. 
 
 The severe excruciating pain caused by the passage of a small 
 rough stone or calculus or* particles of sandy substance from the 
 kidney through the ureter to the urinary bladder is called nephritic 
 colic, kidney colic, or an attack of " the gravel." The pain usually 
 begins with a one-sided boring backache. Suddenly it increases in 
 intensity and shoots down the loin to the hip and thigh, and the 
 patient writhes in agony until the " stone " or particle, sometimes 
 not larger than the head of a medium-sized pin, reaches the bladder, 
 when the pain suddenly ceases. The paroxysm may last from half 
 an hour to a number of hours, or one or two days. It may not recur 
 for months or years; on the other hand there may be two or more 
 paroxysms at comparatively short intervals. 
 
 Colicky pains are present in many different diseases. Appendicitis 
 frequently begins with pain not unlike that of intestinal colic. 
 
 Treatment. If the colic is due to indigestible food, or too much 
 food of any kind, an emetic should be given. 
 
38 
 
 After the stomach is emptied give a little spirit (brandy or whisky) 
 with 10 or 15 drops of tincture or essence of ginger or essence of pep- 
 permint, diluted with hot water. Apply a large mustard plaster or a 
 hot poultice or cloths wrung out of hot water, or heat of any kind to 
 the abdomen. (Local applications of hot water usually afford some 
 relief in any variety of colic or wherever pain exists.) If the colicky 
 pains persist, 10 or 12 drops of laudanum should be given by the 
 mouth or a pill of morphine, grain (0.01 gm.) , and repeated, if neces- 
 sary, in two hours ; or 30 or 40 drops of laudanum in a little water or 
 starch may be injected into the rectum. 
 
 If the bowels were constipated when the attack began, an injection 
 of soap and warm water should be given by the rectum, or small doses 
 of Epsom salts or castor oil may be given by the mouth. The diet 
 for a day or two should be light articles in small quantities at a time. 
 The treatment for lead colic is about the same, except that the consti- 
 pation should be relieved at once by full doses of Epsom salts or castor 
 oil. Apply heat to the abdomen or place the patient in a warm bath. 
 Pressure applied to the abdomen affords some relief. Remove the 
 cause or remove the patient from the cause of the disease. 
 
 In biliary colic, the bowels should be freely moved, patient should 
 be placed in a hot bath, and laudanum or morphia given to relieve 
 pain. 
 
 In nephritic or kidney colic, hot baths and morphia are the reme- 
 dies. A morphine pill, J grain (0.01 gm.), should be given, and 
 repeated in one hour if the pain is not relieved, and the bath should 
 be as hot as the patient can stand it. The best method of giving 
 morphia in all cases of severe pain is by hypodermic injection (injec- 
 tion under the skin), and in many cases where the stomach is irritable 
 and vomiting occurs this is the only way to obtain the desired effect. 
 But hypodermic medication by inexperienced persons is not to be 
 recommended. 
 
 SCURVY. 
 
 Scurvy is a disease produced by improper or unsuitable food. 
 Many years ago it was of frequent occurrence among seafaring men 
 on long voyages. Now it is a comparatively rare disease, thanks to 
 better provisions and better methods in issuing food supplies. Occa- 
 sionally, however, a ship comes in with scurvy on board. Two years 
 ago twelve cases were admitted to the U. S. Marine Hospital at New 
 York from one vessel. 
 
 Symptoms. Swelling, sponginess, and bleeding of the gums. The 
 teeth become loose and frequently drop out. The breath is foul, the 
 tongue swollen. The skin becomes dry and scaly. Hemorrhages 
 (small dark red spots) dccur under the skin, first on the legs and then 
 on the arms and other parts of the body. Bleeding frflm the nose 
 
39 
 
 frequently occurs. Swelling about the ankles is common. The skin 
 of the legs is frequently discolored in large blotches, and there is often 
 a peculiar hardness or induration of the muscles of the calf of the 
 leg. The complexion is frequently of greenish or dirty-yellow hue. 
 The pulse is rapid and weak. There may or may not be slight 
 fever. The bowels may be constipated or there may be a troublesome 
 diarrhea. 
 
 In severe cases debility and emaciation are quite marked. The 
 mind wanders, and occasionally there is wild delirium. 
 
 Treatment. This consists almost wholly in a change of diet. Give 
 fresh vegetables, fresh milk, fresh beef, oranges, lemons, limes, or 
 lime juice. Begin with small quantities at short intervals, and 
 increase the allowance as rapidly as the stomach can take care of it. 
 Pickles, onions, sauerkraut, raw potatoes, and raw cabbage are valu- 
 able articles in the make-up of a varied diet. 
 
 Chlorate of potassium dissolved in water should be used as a mouth 
 wash, and the gums should be frequently painted with tincture of 
 myrrh. The skin should be kept in good condition by frequent bath- 
 ing. The sleeping quarters should be clean and well ventilated. 
 
 SORE THROAT (TONSILITIS, QUINSY). 
 
 Sore throat is a common disease. It is usually the result of expos- 
 ure to wet and cold. Talking, laughing, or shouting in a damp, 
 cold atmosphere is sometimes the cause of it. It frequently occurs 
 in persons predisposed to rheumatism. It may accompany or be 
 an extension from an ordinary " cold in the head." Sometimes 
 the inflammation is limited to the mucous membrane of the pharynx 
 and soft palate; it is then known as pharyngitis or acute catarrhal 
 sore throat. More frequently the tonsils are affected, and the inflam- 
 mation is then called tonsilitis. When the inflammation is more 
 deeply seated in the tonsil and tends to suppurate or form an 
 abscess the term quinsy is applied. An attack of sore throat may 
 last from two to ten days, or longer. 
 
 Symptoms of acute sore throat are chilliness and feverishness, 
 pain or soreness on swallowing, dryness, or a tickling or scratching 
 sensation in the throat. 
 
 There is apt to be a stiffness and some tenderness along the side of 
 the neck. If one or both tonsils are involved, as they usually are 
 to a greater or less extent, the symptoms are more severe. In marked 
 cases examination shows redness and swelling of the parts affected- 
 swollen tonsils (tonsilitis) and white or cream-colored spots may be 
 seen on the surface of one or both tonsils. (This form of the disease 
 is frequently mistaken for diphtheria.) There may be high fever and 
 great prostration. 
 
 In the severest form of tonsilitis (quinsy) the tonsils are hard 
 
40 
 
 and swollen to twice or three times their natural size, and the patient 
 is unable to swallow or to open his mouth beyond a fraction of an 
 inch. The saliva dribbles away; if suppuration occur the tonsil 
 gradually softens until the abscess breaks. With the discharge of 
 the pus the severe pain is relieved and the patient rapidly recovers. 
 If the abscess is large, and if the pus is discharged in a backward 
 direction, there is danger from suffocation, particularly if the abscess 
 breaks during sleep. Fortunately the abscess usually points toward 
 the mouth, and the pus runs out. 
 
 Treatment. Persons who are subject to attacks of sore throat 
 should keep their feet clean and dry and be very careful not to catch 
 cold. If a case develop, give a gargle of salt water or chlorate of 
 potassium and water (saturated solution) or borax and water, or dry 
 borax may be applied to the tonsil. Dry bicarbonate of sodium (bak- 
 ing soda) is highly recommended as a local application, a small quan- 
 tity to be applied every hour. Apply cold water or a light ice bag to 
 the neck, or a thick piece of flannel saturated w 7 ith ice water may be 
 placed around the neck and covered with oiled silk or oiled muslin. 
 Small pieces of ice placed in the mouth are usually agreeable. The 
 bowels should be kept open by means of Epsom or Rochelle salts. 
 If the fever is high and the pulse full, give one drop of tincture of 
 aconite in a teaspoonf ul of water every hour. Give a Dover's powder 
 at night. 
 
 If the cold applications to the neck do not give relief, or if they are 
 not agreeable to the patient, apply hot water or poultices and give 
 hot gargles, or let the patient gargle with hot tea. If the swelling 
 is very great, he can not gargle. If near port, send for a surgeon. 
 
 When the swelling and acute symptoms begin to subside give 5 
 drops of the tincture of chloride of iron with 20 drops of glycerine in 
 a teaspoonful of water every two hours. The diet should be liquid 
 or soft, and nourishing. 
 
 ERYSIPELAS (ST. ANTHONY'S FIRE). 
 
 Erysipelas is an inflammation of the skin. It usually begins with 
 a chill, followed by a high fever. It is a frequent complication of 
 wounds, but is more frequently developed without any apparent 
 injury. A large majority of cases begin on the face, usually on 
 the nose, first as a small red spot, which is soon elevated above the 
 surrounding skin, and gradually or rapidly spreads over the face 
 and ears, and not infrequently over the entire hairy scalp; some- 
 times over the neck and chest, and occasionally down the back and 
 to other parts of the body. The skin is painful, red, hot, and swollen, 
 and blisters frequently form. The swelling is most marked about 
 the eyes and ears, the eyes are closed, and the patient's features are 
 changed and distorted to such a degree that the appearance once sean 
 
41 
 
 will not soon be forgotten. The disease limited to the face and scalp 
 usually runs its course in a few days or a week, but sometimes before 
 the face is healed red spots appear on other parts of the body, and the 
 case may be prolonged. Abscesses beneath the skin are not uncommon. 
 
 Besides the symptoms already mentioned there are headache, loss 
 of appetite, coated tongue, frequently vomiting, and in some cases 
 delirium and marked depression. 
 
 The outcome is usually favorable, but in drunkards or in persons 
 debilitated from previous diseases death is sometimes the result. 
 
 Treatment. Erysipelas is only slightly contagious, under ordinary 
 circumstances; but persons suffering from wounds or scratches of 
 the skin are very apt to be attacked. The patient should therefore be 
 isolated placed in a room by himself and his attendant should be a 
 healthy man and free from any skin injury. 
 
 Erysipelas being a self-limited disease, it is a common saying 
 among physicians that the majority of ordinary or moderately severe 
 cases would get well without any treatment. But this is probably 
 true of many other diseases, and while it may be difficult, perhaps 
 impossible, to limit the spread of the eruption or shorten the course 
 of the disease in a given case of erysipelas, something may be done to 
 relieve distressing symptoms and, particularly in feeble persons, to 
 fortify the system against the attack. " Treat the patient rather 
 than the disease " is good advice in more troubles than one. 
 
 The oldest and one of the best local applications for erysipelas is 
 cold water, and if the fever is very high cold sponging of the entire 
 body or a cold bath may afford considerable relief. Subnitrate or 
 subcarbonate of bismuth may be dusted over, or vaseline may be 
 applied to the skin. In feeble persons stimulants are required, and 
 for the restlessness or sleeplessness a pill of morphine sulphate, J 
 grain (0.01 gm.) , or 12 drops of laudanum may be given and repeated, 
 if necessary, in two hours. * The tincture of the chloride of iron has 
 been a popular remedy for a long time, and if given in moderate doses 
 of 10 or 12 drops in water every three hours may do a great deal of 
 good. Epsom or Kochelle salts may be given to keep the bowels open. 
 
 RHEUMATISM. 
 
 There are different forms of rheumatism and some of the forms 
 have several different names. Acute rheumatism, acute articular 
 rheumatism, inflammatory rheumatism, and rheumatic fever are 
 terms applied to one and the same disease. A milder form of the 
 affection is called subacute rheumatism. In this form the symptoms 
 are less severe, but the disease is more prolonged. It may continue 
 for a long time and become chronic. Chronic rheumatism, however, 
 or the different affections and deformities of joints to which this 
 
42 
 
 term is frequently applied may develop independently of any acute 
 or subacute attack. 
 
 The term muscular rheumatism indicates an affection of the mus- 
 cles as distinguished from joint affections. Lumbago and stiff neck 
 are varieties of muscular rheumatism. The muscles, however, to 
 a greater or less extent may be involved in any form of rheumatism. 
 
 Other conditions simulating rheumatism, occuring in connection 
 with, or directly due to gonorrhea, or to syphilis, are called gonor- 
 rheal rheumatism or syphilitic rheumatism, as the case may be. 
 
 Acute rheumatism (rheumatic fever) is a comparatively common 
 disease in all climates within the temperate zone. It occurs chiefly 
 during the winter and spring. Exposure to a cold, damp atmosphere 
 is the most frequent exciting cause in persons predisposed to the 
 disease. 
 
 It may or may not begin with a chill or with a sore throat. The 
 larger joints are usually affected. Swelling, heat, redness, tenderness ; 
 and pain are the chief symptoms. The inflammation is apt to shift 
 from one joint to another. The pain and fever are usually increased 
 in proportion to the number of joints involved. The majority of 
 cases are attended with profuse perspirations, scanty, highly acid 
 urine, coated tongue, and constipation. The heart is frequently 
 involved. 
 
 Treatment. Wrap the joint in cotton or flannel; keep them very 
 quiet the slightest movement aggravates the pain. Flannel wrung 
 out of hot water and applied to the joint sometimes affords relief. 
 Chloroform liniment may be applied if the pain is severe, or cold 
 applications may be Applied if agreeable to the patient. 
 
 Place the patient in a good bed, between blankets, and let him wear 
 flannel next to his skin. Change the flannel frequently and bathe 
 the body with tepid water. 
 
 For internal medication give salicylate'of sodium in doses of 10 to 
 15 grains (0^6 gm. to 1 gin.) every two hours until about eight doses 
 are taken or the pain is relieved, then give it in smaller doses of 
 from 3 to 5 grains (0.2 gm. to 0.3 gm.) every six hours. Dover's 
 powder may be given at night to control pain and restlessness. 
 Patient may be allowed to drink lemonade or pure water to satisfy 
 his thirst. 
 
 The food should be soft and nourishing and given every three 
 hours. Epsom or llochelle sajts should be given to keep the bowels 
 open. The patient should be kept in bed for a few days after the 
 symptoms have subsided. The duration of the disease is very uncer- 
 tain. The acute symptoms may subside in a few days and the patient 
 may be up and about in a week or ten days, but relapses are common 
 and the acute may pass into the subacute or chronic form. 
 
 In chronic rheumatism there is stiffness and pain. A cracking or 
 
43 
 
 grating sound is frequently produced when the joints are suddenly 
 moved. In severe cases the joints become enlarged and distorted. 
 The deformity is sometimes very great. 
 
 The treatment consists chiefly in local application of liniments, 
 etc., which afford relief because of the rubbing (massage) by which 
 they are applied. Severe pain in the joint may be relieved by cold 
 applications (flannel wrung out of iced water, applied to the joint 
 and covered with oiled silk or oiled muslin). Hot aplications to the 
 joints are sometimes of value. 
 
 Five to eight grains (0.3 gin. to 0.5 gm.) of iodide of potassium 
 in a teaspoonful of sirup of sarsaparilla and a little water, or in 
 water alone, may be given three times a day after meals. 
 
 The general health should be looked after. The skin should be 
 kept in good condition by frequent baths of tepid water. The 
 bowels should be moved at least once a day. Patient should be 
 allowed good food. Fresh air is also important. 
 
 In muscular rheumatism the muscles most frequently affected 
 are those of the back (lumbago), side of neck (stiff neck or wry 
 neck), and side of chest (pleurodynia). Exposure to cold, sudden 
 cooling of the body especially after active exercise, and sitting in 
 a draft of air are the chief causes, or exciting causes. 
 
 As a rule there are no symptoms other than the stiffness and pain 
 on motion. The muscles may be slightly swollen, and very sensi- 
 tive. Sometimes the attacks come on suddenly and apparently with- 
 out cause, or following a slight twist or strain, as a " kink in the 
 back," or patient may wake up in the morning with a stiff neck. 
 
 Treatment. In acute cases salicylate soda may be given in 5 or 
 10-grain doses (0.3 gm. to 0.6 gm.) every three hours until four or 
 six doses are taken. Apply hot applications, dry heat, hot-water 
 bag, or a hot poultice locally, or the heat may be applied by a flat- 
 iron, over folds o'f flannel or a piece of blanket, and the rheumatism 
 u ironed out." Later apply liniment with friction (massage). Keep 
 the affected muscles at rest. If the muscles of the chest are affected, 
 apply strips of adhesive plaster, the same as for fractured rib. Acute 
 attacks are of short duration, but relapses are not uncommon, and 
 chronic forms are frequently met with. Good food, fresh air, arid 
 attention to the general health are especially important in the treat- 
 ment of chronic muscular rheumatism. 
 
 Gonorrheal rheumatism, (gonorrheal inflammation of joints) may 
 occur during an acute attack or gonorrhea, but it is more frequently 
 associated with chronic gonorrhea or gleet. One or several joints 
 may be affected. There may or may not be considerable fever. If 
 only one joint is affected it is apt to be the knee or the ankle. In 
 chronic cases the pain is sometimes centered in the heel. The attack 
 may begin in the wrist, elbow, or shoulder. The disease is not always 
 
44 
 
 limited to the joints. Sometimes the inflammation is in the tissues 
 outside the joint proper, in the sheaths of the tendons of muscles, 
 or in the fascia of the soles of the feet. The swelling is frequently 
 quite marked. In chronic cases there may be effusion (" water on 
 the joint"). In very severe cases suppuration occurs (abscess 
 forms). The eye and the heart may also be seriously involved. 
 
 Treatment is not very satisfactory. Give a teaspoonful of elixir 
 of iron, quinine, and strychnine three times a day before meals, and 
 from 5 to 10 grains (0.3 gm. to 0.6 gm.) iodide of potassium in a 
 little water or in a teaspoonful of sirup sarsaparilla after meals. 
 Keep the joint at rest. Apply a flannel bandage. Change it fre- 
 quently and wash the joint with hot water and soap. In chronic 
 cases liniments and passive motion should be applied. Tincture of 
 iodine may be painted over the joint. 
 
 Syphilitic rheumatism, so called, is associated with secondary or 
 tertiary syphilis. The joints, and the shafts of long bones may be 
 affected thickened and painful. The pain is always worse at night, 
 but this is true to a less degree of pain from any cause. 
 
 The treatment is by iodide of potassium, beginning with 10 grains 
 (0.66 gm.) of iodide of potassium three times a day after meals and 
 gradually increasing the dose. Ten drops of the tincture of the chlo- 
 ride of iron with a grain (0.1 gm.) of quinine in a wineglassful of 
 water may be given before meals. Good food and attention to the 
 bowels are important. 
 
 DELIRIUM TKEMENS. 
 
 Delirium tremens occurs as an incident in the life of persons 
 addicted to the excessive use, or rather to the abuse, of intoxicating 
 liquors. 
 
 Loss of appetite, sleeplessness, or a marked mental depression are 
 the chief symptoms of the first stage of the affection which is known 
 among drunkards as " the horrors." 
 
 As the disease advances the patient talks incoherently, has a wild 
 expression, his mind wanders from one thing to another, he answers 
 questions in a rambling manner, he fancies he is being pursued by 
 wild animals, or that he sees rats, snakes, and other animals crawl- 
 ing on the w T alls or around his bed. Or he may imagine himself .to be 
 engaged in his regular duties, or as master of the ship, giving direc- 
 tions to the men. 
 
 The delirium is always worse at night, but the patient requires 
 careful watching all the time. He may try to jump overboard and 
 commit suicide. 
 
 Delirium tremens may be confounded with acute inflammation of 
 the brain, or with acute mania (insanity), or with certain forms of 
 
45 
 
 pneumonia, and any one of these diseases may also be present. Pneu- 
 monia is a frequent complication of delirium tremens, and in fatal 
 cases may be the direct cause of death. 
 
 In favorable cases the symptoms begin to improve in three or four 
 days from the onset, the patient sleeps and gradually recovers. 
 
 Treatment. The patient requires constant attendance. Physical 
 restraints should be avoided if possible. To support the patient and 
 to procure sleep are the great objects of treatment. Careful feeding 
 is very important. Milk or concentrated broths should be given at 
 regular intervals of two hours. A cold bath is of value in some 
 cases, especially if agreeable to the patient. In other cases a warm 
 bath or a hot footbath may have a better effect. The continuation of 
 alcoholic stimulants in small or moderate quantities may be advisable 
 in some cases. 'A few drops of tincture of capsicum or tincture of 
 ginger may be given in water or in a little whisky and water every 
 two or three hours. 
 
 The serious symptoms are largely, if not entirely, due to the sleep- 
 lessness, and if several hours of sound sleep can be procured improve- 
 ment is almost sure to follow. To this end bromide of potassium in 
 30-grain (2 gm.) doses may be given in water every three hours, 
 morphia or opium are not to be recommended in this disease except 
 under the immediate direction of a physician. 
 
 SYPHILIS. 
 
 Syphilis is a constitutional disease. It is contagious, or commu- 
 nicable, and is usually acquired during sexual contact. It may, how- 
 ever, be contracted in many different ways, direct and indirect. It 
 begins by a primary lesion or sore called a chancre at the seat of inoc- 
 ulation (where the virus enters), and is followed by eruptions of the 
 skin of different forms and different degrees of severity and variable 
 duration. Sores also appear at the angle of the mouth, and mucous 
 patches develop on the lips, tongue, inner sides of the cheeks, and 
 sore throat is very common. 
 
 Mucous patches or syphilitic warts are also frequently seen about 
 the anus or in any region where the skin is moist. The hair fre- 
 quently falls out, the eyes are sometimes seriously involved, and sooner 
 or later every organ in the body may become affected. A man suffer- 
 ing from syphilis in active form should not be allowed to go on 
 board a ship, and if the disease breaks out while on the voyage he 
 should be isolated, or at least be compelled to use separate drinking 
 cups, knives, spoons, forks, towels, etc. He should under no circum- 
 stances smoke the pipe belonging to another man nor allow another 
 man to smoke his pipe. All his belongings should be kept strictly to 
 himself, for unless the greatest care is taken other men of the crew 
 
46 
 
 will suffer. Chancre of the lip may be acquired by smoking the pipe 
 of a syphilitic. 
 
 The primary or initial lesion of syphilis (the hard chancre) usually 
 appears about three weeks after exposure, but may be as early as ten 
 or twelve days or as late as five or six weeks. It begins as a red spot, 
 or papule, which usually breaks and forms a small ulcer with hard 
 edges; sometimes the sore appears as a simple excoriation or super- 
 ficial ulcer without hard edges. The neighboring lymph glands 
 become, in the course of a week or two, enlarged and hard. They 
 seldom suppurate. About a month or six weeks later the skin erup- 
 tion and other secondary symptoms begin. The lymph glands above 
 'the elbow, along the side and back of neck, and all over the body are 
 usually enlarged. Patient frequently complains of headache and 
 pain in the limbs, always worse at night, and may have slight, occa- 
 sionally considerable fever. 
 
 Treatment. For the primary sore bathe the part with soap and 
 water, and dust calomel or bismuth, or oxide of zinc, or a mixture of 
 these remedies over the sore twice a day ; or instead of the powder 
 " black wash " may be applied, or in some cases, if there is much irri- 
 tation or suppuration, iodoform may have a better effect. 
 
 If secondary symptoms, eruptions of skin, etc., appear, give a pill 
 of protiodide (green iodide) of mercury, -J- grain (0.01 gm.), three 
 times a day. The mouth and teeth should be kept clean by means of 
 a soft toothbrush and castile soap and water, or water to which a 
 small quantity of bicarbonate of soda (baking soda) or tincture of 
 myrrh has been added. If mucous patches appear in the mouth 
 smoking must not be allowed. As soon as the ship arrives in port 
 send or take the man to the Marine-Hospital office and receive the 
 advice of a surgeon as to further treatment. 
 
 SOFT CHANCRE ( CHANCROID). 
 
 Soft chancre or chancroid is a virulent ulcer. It usually begins 
 within twenty- four or thirty-six hours after exposure, first as a red 
 spot, but rapidly developing into an ulcer covered with thick yellow- 
 ish pus. The period of development is about three or four days. 
 Sometimes a week elapses from the time of exposure to the develop- 
 ment of the sore, and occasionally a period of incubation is as long 
 as ten days. A sore appearing within a few days, or a week, or even 
 as late as ten days after the exposure is usually regarded as a chan- 
 croid. But in practice this is not a safe rule, for the reason that 
 many venereal sores are of a mixed character. A hard or syphilitic 
 chancre contracted two or three weeks ago, makes its appearance 
 to-day. A soft chancre or chancroid contracted two or three days 
 ago, makes its appearance to-day. The inoculations of both poisons 
 
47 
 
 take place at the one and same spot, the result is a mixed chancre ; or 
 if two sores appear the origin of one may be syphilitic, the other 
 chancroidal. It is therefore difficult, if not impossible, in many 
 cases to determine the character of the disease from the period of 
 incubation or from the appearance or local characteristics of the 
 chancre. A mixed chancre is a syphilitic chancre (a hard chancre), 
 while its appearance may be precisely like that of the soft chancre or 
 chancroid. The only safe plan is to regard all venereal sores as sus- 
 picious. But while this is true, treatment for syphilis should not be 
 commenced before the appearance of secondary symptoms, for unless 
 such symptoms appear it is impossible to determine that syphilis 
 really exists in any case. The mixed chancre, as already stated, is 
 essentially a syphilitic chancre, and the beginning of constitutional 
 disease. Its local effects, however, may be precisely the same as those 
 of soft chancre or chancroid. The ulcer (or ulcers sometimes there 
 are two or more) may remain as small as a pea or grow as large as 
 a quarter, and if it become phagedenic (eating) may spread over a 
 large portion of the surface of the body. It is also proper to state 
 that a secondary syphilitic sore may appear under the foreskin, as 
 well as at any other place on the body, and that cancer (epithelioma) 
 of the organ may begin as a small ulcer. The latter, however, is a 
 rare disease as compared with the different varieties of chancre, the 
 vast majority of which are of venereal origin. 
 
 The most frequent complication of soft chancre or chancroid is 
 inflammation of the lymph glands of the groin (bubo), known to 
 the sailor as " blue balls." Another troublesome and serious com- 
 plication is the elongation and contraction of the orifice of the fore- 
 skin (phimosis), on the inner surface of which the sores may be 
 located, and the swelling and tension may be so great as to pro- 
 duce gangrene (mortification). If the foreskin is very tight and 
 pulled back and can not be brought forward again the condition 
 is know T n as paraphimosis, which produces great swelling, the same 
 as if a string were tied around the organ, frequently resulting in 
 severe ulceration and destruction of tissue. This condition may 
 also be the result if the inflammation and swelling are marked and 
 the foreskin is very tight. 
 
 Treatment. The best treatment for soft chancres or chancroids is 
 cauterization with nitric acid. The parts should be first thoroughly 
 washed with soap and water, and dried. The nitric acid should 
 then be carefully applied to the sore by means of a thin glass rod, 
 taking care to prevent the acid from running over the surrounding 
 tissues, or if it does run over, then to immediately soak it up by 
 means of a piece of blotting paper. If the sore is first touched with 
 carbolic acid the application of the nitric acid will be less painful, 
 
48 
 
 and the carbolic acid alone is probably, next to nitric acid, the best 
 local remedy. 
 
 If a glass rod is not at hand, a wooden toothpick or thin stick 
 may be wrapped with a bit of absorbent cotton and then dipped 
 into the acid and applied to the sore. When the cauterization is 
 complete every part of the sore and a narrow border around it will 
 be white. If one application is not sufficient another should be 
 tried. The sore should then be dried and covered with a small 
 piece of gauze or absorbent cotton, and later a dusting powder of 
 calomel or iodoform or bismuth may be applied. If the sore extend 
 into the opening of the urethra (the meatus) iodoform had better be 
 applied in place of the acid, for if the acid should run into the 
 urethra it might result in great harm. 
 
 If phimosis exist the cavity of the foreskin should be syringed 
 out with hot water, and if there are sores under the foreskin Avhich 
 can not be reached by the acid the cavity should be syringed with 
 a solution of one part of carbolic acid to forty parts of water (1 to 
 40), or with a solution of one part of bichloride of mercury (corro- 
 sive sublimate) to three thousand parts of water (1 to 3,000). Soft 
 chancres or chancroids appearing at the anus or rectum should be 
 treated by frequent washings of warm water and the application of 
 iodoform. The strong acids must not be applied to this region. 
 
 In all cases, wherever the sore is located, cleanliness must be insisted 
 upon, and, as already stated, in nearly all inflammations of whatso- 
 ever character, hot water alone is a valuable remedy; and rest in bed 
 is of equal importance. If a lump (bubo) appear in the groin, rest in 
 bed is of the greatest importance. The diet should be light but nour- 
 ishing. Tincture of iodine, pure or diluted one-half with alcohol, 
 may -be painted over the lump, but it is not of much value. Rest is 
 the important thing. If the bubo go on to suppuration, it should be 
 carefully opened with the point of a knife, and kept open by a strand 
 of aseptic gauze, which must be frequently changed, and enough gauze 
 should be placed on top of the wound to absorb the discharges. The 
 soiled gauze should be burned, and the person handling it must be 
 careful to wash his hands in soap and water and in one of the anti- 
 septic solutions already referred to. The patient's bowels should be 
 moved once a day, and eight drops of the tincture of chloride of iron 
 in water should be given three times a day, and as soon as the vessel 
 arrives in port he should be sent to the Marine-Hospital surgeon. 
 
 GONORRHEA ( CLAP ) . 
 
 Gonorrhea is a specific inflammation of the urethra due to a micro- 
 organism, called gonococcus. It usually begins during the first week 
 after exposure, sometimes as early as three or four days and occasion- 
 ally as late as ten days or two w r eeks. The first symptoms are a 
 
49 
 
 tickling or itching sensation and a slight swelling about the lips of the 
 orifice of the urethra. A purulent creamy colored discharge soon 
 appears, and a burning or stinging pain attends the passage of urine. 
 The inflammation gradually extends to the deeper parts of the 
 urethra, and, unless checked by medication, reaches its height about 
 the end of the second or during the third week. The patient may 
 experience great difficulty in passing water. If the inflammation run 
 very high, abscesses may form in the tissues around the urethra, and 
 swelled testicle and bubo are frequent complications; also painful 
 erections and bending of the organ (chordee). Phimosis, or para- 
 phimosis occurs if the foreskin is tight or becomes involved in the 
 inflammation. 
 
 If phimosis occur and if the cavity of the foreskin is not thor- 
 oughly and frequently washed out, " venereal warts " are apt to form. 
 
 True gonorrhea, if carefully treated, gradually subsides and recov- 
 ery may take place in from three to four weeks. A urethral discharge 
 that recovers in a few days or a week is probably a simple urethritis. 
 
 Gonorrhea is urethritis (inflammation of the urethra), but ure- 
 thritis is not necessarily gonorrhea. 
 
 Treatment. Rest in bed, light diet, plenty of water to drink, pref- 
 erably vichy or apollinaris, regularity in eating and sleeping. Keep 
 the bowels open by taking a moderate dose of Epsom or Bochelle salts 
 in the morning. Avoid strong coffee and tea, all stimulants, and 
 greasy articles of food. Keep the body and mind at rest. Bathe 
 frequently in hot water. Be very careful not to convey any of the 
 pus from the urethra to the eyes. (Gonorrheal inflammation of the 
 eyes is a very serious disease, which not infrequently results in total 
 blindness and loss of the eyes.) 
 
 Give 10 grains (0.6 gm.) of citrate of potash in water three times 
 a day, also 10 or 15 drops of oil of sandalwood three times a day. 
 The sandalwood oil may be given in capsules or dropped on a lump 
 of sugar. If much pain in the back or over the region of the kidneys 
 follow the use of the sandalwood, it must be discontinued for a time 
 or the dose lessened. Later in the disease, about the end of the second 
 week, a mixture of balsam copaiba may be given in one or two tea- 
 spoonful doses three times a day in place of the sandalwood, or the 
 copaiba may be given in doses of 5 or T drops in capsules. 
 
 If the chordee is troublesome, apply cloths wrung out of cold water 
 and give a tablet of codeine, one-sixth grain (0.01 gm.), three times 
 a day. 
 
 When the acute symptoms of the disease -have subsided use an 
 injection of sulphate of zinc, 2 or 3 grains (0.12 gm. to 0.2 gm.) to an 
 ounce (30 c. c.) of water, or 1 grain of argonin (0.06 gm.) to an 
 ounce (30 c. c.) of water, three times a day. 
 1325604 M 4 
 
50 
 
 A snug suspensory bandage worn from the beginning may prevent 
 the complication of swelled testicles. If the patient is lying in bed, 
 the dragging of the testicles should be prevented by placing them on 
 a support. The best local remedy for swelled testicles is heat, which 
 may be applied by pieces of cloth or flannel wrung out of hot water or 
 by means of hot flaxseed poultices, frequently renewed. The flax- 
 seed meal should be thoroughly moistened with hot water and placed 
 between two layers of cheesecloth or other thin material. It should 
 then be put around the scrotum and covered with cotton. Oiled silk 
 or oiled muslin should be placed over the cotton to retain the heat. 
 
 STRICTURE OF THE URETHRA. 
 
 True or organic stricture of the urethra is a narrowing of the 
 tube. It is commonly the result of long-continued or neglected 
 gonorrhea. Stricture of the urethra may be produced by direct 
 injuries, as kicks or falls on the perineum, or by the use of too 
 strong injections, or by the careless passage of instruments. 
 
 Occasionally stricture results from simple urethritis, not gonor- 
 rheal, and symptoms not unlike those of stricture are sometimes 
 caused by a stone in the bladder obstructing the passage, and by an 
 enlarged prostate gland. 
 
 Gonorrheal stricture of the urethra is usually of slow development. 
 It may be several months or years after the attack of gonorrhea 
 before the patient becomes conscious of any change in the size or 
 shape of the stream. First there may be only a twisting or flatten- 
 ing of the stream. In severe cases it gradually becomes smaller and 
 smaller, until it is no larger than a knitting needle and passed with 
 great difficulty, or it comes away drop by drop, and finally results 
 in complete retention. One of the earliest symptoms of stricture is 
 a gleety discharge from the urethra " gleet means a stricture/' 
 
 Occasionally retention of urine is the first symptom of the disease. 
 
 Sudden retention may be due to spasm of the urethra (spasmodic 
 stricture) . 
 
 Spasmodic stricture may occur independently of any specific dis- 
 ease of the urethra, but it is more frequently a complication of organic 
 stricture. Exposure to cold and wet (catching cold), or a debauch, 
 are the usual exciting causes. 
 
 When* retention occurs the bla,dder gradually becomes distended 
 and a fullness or distinct tumor may be felt in the lower part of the 
 abdomen, which in severe cases may extend as high as the navel. 
 Sometimes there is an involuntary flow, or an overflow of urine from 
 a distended bladder patient says he can not hold his water, and in 
 such case it may be difficult to convince him that he is suffering from 
 retention, until a catheter is passed and a quantity of urine is 
 withdrawn. 
 
51 
 
 Treatment. A neglected stricture of the urethra is a serious dis- 
 ease, the treatment of which is very difficult in many cases, even in 
 the hands of the most experienced surgeon. 
 
 The attention of the ship's captain is rarely called to a case until 
 there is an actual stoppage or retention of urine, and unless this 
 
 PIG. 1. How to use catheter. 
 
 condition is relieved the consequences are extremely serious and 
 death may be the result. 
 
 Place the patient on his back with his knees slightly drawn up, and 
 try to pass a catheter. The instrument should first be thoroughly 
 cleansed by placing it in boiling water. It should then be oiled with 
 
 FIG. 2. Shows the curve of the channel through which the catheter must pass. 
 
 olive oil, and carefully passed into the urethra and effort made with 
 
 the greatest gentleness to pass into the bladder. (Figs. 1 and 2.) 
 
 It is a good plan to have several sizes of catheters ready at the same 
 
 time, and to try the largest one (about a No. 9 English) first; if this 
 
52 
 
 fail, try the smaller ones. If a catheter can not be passed at the first 
 trial, place the patient in a hot bath, give him a Dover's powder, and 
 an hour or two later try the catheter again. If it is not practicable to 
 place the patient in a full bath of hot water, then cover his belly 
 and other parts of his body with flannels wrung out of hot water and 
 change them every fifteen minutes. The object of the hot bath and 
 the Dover's powder is to produce relaxation. Sometimes a patient 
 will pass his water in the bath. If, however, the symptoms are very 
 urgent, if the patient can not pass any water, and after the most care- 
 ful and gentle manipulation the catheter can not be passed into the 
 bladder, there is but one thing left to be done, and that is to puncture 
 the bladder immediately above the bone (the pubes) at the lower part 
 of the belly. This is done by means of a curved trocar and cannula. 
 A very small incision through the skin (about half an inch long) is 
 first made by a knife, the trocar and cannula are then thrust down- 
 ward and backward into the bladder. The trocar is then withdrawn 
 and the cannula is secured in place, a soft catheter is passed through 
 it, and in this way the bladder is emptied. The cannula may be kept 
 in place, if necessary, for several days. Before beginning this opera- 
 tion the belly should be carefully washed and scrubbed with soap and 
 water and then with alcohol, the instruments should be boiled, and the 
 operator's hands should be thoroughly cleansed. 
 
 If possible to obtain the services of a surgeon in reasonable time, 
 this operation should not be attempted by the captain. 
 
 ITCH (SCABIES). 
 
 This trouble is produced by an insect which burrows into the skin, 
 particularly between the fingers and between the toes, but also at 
 other situations where the skin is most delicate. 
 
 Careful examination will show small vesicles on the skin, but most 
 of the eruption is due to the scratching. The itching is always worse 
 at night. The disease is spread by personal contact or by clothing. 
 
 Treatment. Sulphur ointment is the remedy. Bathe or scrub the 
 body thoroughly with soap and water, dry the skin, and then apply 
 the ointment. Repeat the process once a day, preferably in the even- 
 ing, just before turning in, bathing with soap and water each time 
 before applying the ointment. 
 
 BOILS. 
 
 A boil is a circumscribed inflammation of the skin and connective 
 tissue. It is often caused by infection following a slight wound or 
 scratch of the skin, but may occur apparently without any cause. It 
 begins as a small red pimple, and gradually increases in size and 
 forms a dusky red swelling, the size of a silver dollar or less. The 
 central portion of the swelling sloughs, or forms a " core," and as 
 
53 
 
 soon as the core is separated or cast off, the inflammation subsides, the 
 pain lessens, arid the ulcer begins to heal. 
 
 Treatment. Hot applications ground flaxseed poultice frequently 
 renewed, until the central portion of the boil is softened, then the 
 separation of the core may be aided by an incision. The incision 
 should be made by a thin blade, thoroughly boiled before it is used. 
 After the core is discharged the ulcer should be dressed with aseptic 
 gauze, held in place by a bandage. 
 
 PILES. 
 
 Piles are varicose dilatations of the veins of the rectum. The 
 symptoms may be slight or severe. Inflamed piles are very painful. 
 There is a constant burning sensation at the anus, which is greatly 
 increased during and immediately after each movement of the bowels. 
 When the veins rupture you have " bleeding piles." Occasionally 
 the inflammation of a nodule results in an abscess. 
 
 Treatment. Piles are frequently due to habitual constipation, and 
 when that condition is improved the piles often disappear, or at least 
 cease to be troublesome. The bowels should be kept in good condi- 
 tion. One easy movement should take place regularly every day. 
 This desirable habit should be brought about by careful attention to 
 diet and by drinking water in the morning before breakfast, rather 
 than by the use of cathartics. 
 
 In acute attacks, if the bowels are constipated give a full dose of 
 salts; put the patient on light, soft diet. Apply ice to the anus or 
 inject cold water into the rectum. A hot application or poultice is 
 sometimes very grateful. If the piles protrude, especially if they 
 become strangulated, they should be pushed back with the finger; 
 oil or vaseline may be applied. If the piles are large and persist- 
 ently painful, see a surgeon and have them removed by operation, 
 which is the only sure cure. 
 
 INJURIES HEMORRHAGE (BLEEDING). 
 
 In all cases of injury careful examination should be made of the 
 part, after carefully washing the hands. 
 
 ^Hemorrhage is of three kinds arterial, venous, capillary. 
 
 Arterial (bright-red blood from arteries in jets or spurts). 
 
 Venous (dark-red or purple blood welling out or flowing from 
 veins in steady stream). 
 
 Capillary (blood oozing from the capillaries over the general sur- 
 face of a wound). 
 
 If the bleeding is by jets or spurts, pressure should immediately 
 be made above the wound by the thumb or finger, or better by tying 
 rubber tubing around the limb, or, in the absence of such a tube, a 
 
54 
 
 bandage, handkerchief, suspender, strap, or soft rope may be used to 
 stop or lessen the flow of blood ; the blood vessel should then be seized 
 and drawn gently forward with a "pair of artery forceps and the 
 ends tied with catgut or silk in a reef knot, when the tubing or strap 
 should be loosened or removed. 
 
 If the blood vessel is torn but not completely divided, tie a ligature 
 around the vessel on each side of the wound. 
 
 Straps or bandages applied to control or lessen the danger of 
 hemorrhage must always be placed above the wound that is to say, 
 between the bleeding point and the heart. In wounds of the foot, 
 for example, if the arteries spurt, pressure should be made in the 
 hollow back of the knee. If the blood is flowing slowly or oozing 
 and does not come by jets or spurts, gauze or lint wrung out of hot 
 water should be applied and firmly bandaged over the wound, or hot 
 water may be poured over the wound before applying the gauze or 
 lint. In any case it is well to cleanse the wound with hot water. 
 The oozing may also be stopped by exposing the wound to fresh air 
 and by allowing a stream of cold water to fall upon it, and then ap- 
 plying pressure. 
 
 Before beginning the treatment of any wound or any bleeding 
 point, the operator must carefully cleanse his hands and arms, also 
 the wound and surrounding parts, and the instruments and silk liga- 
 ture should be boiled as will be described under the head of wounds. 
 
 In the after treatment of severe bleeding the patient should be kept 
 perfectly quiet in mind and body, his head should be lowered by 
 raising the foot end of his bed or bunk. Give him plenty of fresh 
 air, but keep his body warm ;md give him hot drinks. After reaction 
 the temperature of the body may rise a degree or two above normal, 
 but if this should continue longer than two or, at most, three days, 
 the dressing should be removed and the wound thoroughly irrigated, 
 first with hot water then with a solution of bichloride of mercury 
 (1 to 5,000), and dressed with aseptic gauze. 
 
 WOUNDS. 
 
 Incised wounds inflicted by sharp cutting instruments may, after 
 the bleeding has been stopped, be drawn together with the fingers 
 or with a needle and thread, a thin layer of absorbent cotton applied 
 over the wound and then saturated with collodion. Strips of 
 adhesive plaster may be used over the dressing. The parts should be 
 thoroughly cleansed, first by scrubbing with hot water and soap the 
 skin to be shaved if hairy then washed with alcohol, and then again 
 with hot water before the edges are drawn together. The needle and 
 silk thread and all instruments should be boiled before they are used. 
 The operator must roll up his sleeves, scrub his hands and arms with 
 hot water and soap, clean and trim his finger nails, scrub again with 
 
55 
 
 soap and water, then with alcohol, and finally soak his hands in a 
 solution of bichloride of mercury (1 to 1,000) before beginning the 
 operation. The wound, if deep, should not be completely closed, one 
 end should be left open for drainage, unless the patient is under the 
 direct care and treatment of a surgeon. 
 
 Contused and lacerated wounds with torn and ragged edges, espe- 
 cially if the surrounding parts are bruised or crushed, should not be 
 drawn tightly together. The bleeding from lacerated wounds at the 
 time of the accident is not so profuse as in incised wounds, but the 
 shock is greater, and very troublesome and serious hemorrhage may 
 come on within a few hours or later. To guard against this the 
 wound should be carefully examined (the operator's hands and all 
 instruments to be first prepared as above described), and if any blood 
 vessels have been torn they should be tied with silk ligatures, though 
 they may not be bleeding at the time. Sweet oil should then be 
 rubbed over the surface and the edges of the wound and adjacent skin, 
 and this in turn scrubbed off with soap and warm water, and then 
 with alcohol, and finally with a solution of bichloride of mercury (1 
 to 5,000). Thick layers of clean (sterile) gauze dressing should then 
 be applied and held in place by means of a bandage. If the wound is 
 large, the edges of a portion of it may be carefully drawn together. 
 A strand of gauze should then be placed in the bottom of the wound 
 and allowed to project through the opening to the surface, so that it 
 may drain into the layers of gauze placed on top. 
 
 When dressings become soaked with the discharges they do more 
 harm than good; they must, therefore, be changed as soon as the 
 soaking is apparent, and the change must be made with all the 
 aseptic precautions exercised in the operation. Clean hands, clean 
 instruments, clean dressings, clean everything, are the watchwords. 
 Water that has been boiled is perfectly safe, and boiling is the best 
 disinfectant for instruments. 
 
 The stitches may be removed from a wound about the fifth or 
 sixth day, or earlier if they begin to cut or irritate. If the wound 
 is large they need not all be taken out at the same time. 
 
 Gunshot wounds are frequently more or less contused and lacer- 
 ated, and unless one of the main blood vessels is divided, or the lung 
 or other internal organ penetrated, the bleeding is slight. The 
 general treatment for such wounds is about the same as for other 
 lacerated wounds already described, but if the materials for thor- 
 oughly cleansing the wound are not readily at hand, and if there 
 is not much bleeding, the wound had better be let alone, simply cover- 
 ing it with antiseptic gauze until the patient can be placed under the 
 care of a surgeon. No effort should be made by the master to find 
 or feel the bullet or other missle by a probe or other instrument, 
 especially if the wound is in the chest or abdomen, as there is more 
 
56 
 
 danger in searching for it than in leaving it where it may be lodged. 
 The wound made by a Mauser bullet not infrequently looks as if 
 made by a large needle a punctured wound. 
 
 Punctured wounds are made by a narrow sharp-pointed instru- 
 ment, e. g., pin, needle, dagger, or point of a knife or stiletto. They 
 may penetrate to any depth, and if the instruments are clean and 
 no large blood vessels or nerves have been wounded, withdrawal 
 of the instrument may be followed by rapid recovery. But if such 
 wounds are produced by irregularly shaped blunt instruments, or 
 by nails or splinters of wood, and especially if contaminated by any 
 poisonous material, the walls of the wound track are at once dan- 
 gerously contused, lacerated, and infected, and if large blood vessels, 
 nerves, or other organs have been injured the danger is very great, 
 and the patient should be placed under the care of a surgeon as 
 soon as possible, for unless the master is sufficiently familiar with 
 the nature of such wounds and the anatomy of the part to lay it open 
 to the bottom by additional incisions, he can do little more than 
 apply antiseptic dressings to the surface, and keep the patient quiet. 
 
 BURNS OR SCALDS. 
 
 Burns or scalds are serious, and dangerous to life in proportion 
 to the extent and depth of the injury. A burn covering a large 
 area and producing mere reddening and swelling of the skin is as 
 serious as a burn one-half the size in which the skin is destroyed. 
 The danger is from shock ; from fever following reaction ; from hem- 
 orrhage following sloughing, and from congestion and inflammation 
 of internal organs. Burns of slight extent or moderate degree are 
 not so dangerous, and most of the cases commonly met with will 
 recover. But all cases require careful treatment. 
 
 Treatment. For shock give whisky or brandy. In slight or mod- 
 erate burns or sunburn apply clean cloths wet with warm satu- 
 rated solution of bicarbonate of soda (baking soda) . In severe burns, 
 cut away the clothing, avoid exposure to cold, wash the part with 
 warm saturated solution of bicarbonate of soda, or with solutions 
 of borax or boric acid. The parts burned or the entire body, except 
 the head, may be kept immersed in tepid or warm water for days. 
 Prick the blister with a clean (aseptic) needle, but do not remove 
 the cuticle. Sprinkle with dry bicarbonate of soda or with powdered 
 borax and dress the part with thick layers of clean (asceptic) cotton. 
 (Cotton may be rendered aseptic by heating it in an oven to a point 
 just short of burning.) The dressing should be changed only when 
 absolutely necessary. Keep the patient quiet and his bowels active. 
 Pain or restlessness may be relieved by morphine sulphate, \ grain 
 (0.01 gm.), repeated in two hours if necessary. Carron oil (equal 
 parts of linseed oil and lime water) is an old remedy that affords 
 
57 
 
 considerable relief if applied to the surface. Vaseline is also some- 
 times used. The scars resulting from burns and scalds always con- 
 tract, and in severe cases terrible deformities are produced. These 
 may be prevented to some extent by active and passive motion and 
 by splints. 
 
 EFFECTS OF COLD FROSTBITE. 
 
 Severe cold depresses the action of the heart suspends the circu- 
 lation. These effects are first noticed in the ears, nose, fingers, and 
 toes. Numbness and tingling are the first symptoms, then loss of 
 sensation. If not too long exposed, the circulation may be restored 
 by proper treatment. But if the exposure is long continued, or if 
 the cold is very intense, the parts are hopelessly frozen and gangrene 
 will be the result. The parts may look all right for a few days after 
 reaction, arid then become discolored, bluish, and finally black. 
 Another effect of extreme cold is an overpowering sense of drowsi- 
 ness, but to lie down under such circumstances and go to sleep is 
 almost certain death. 
 
 Treatment of frostbites, as recommended l>y the Surgeon-Gen- 
 eral. 1. Do not bring the patient to the fire, nor bathe the parts in 
 warm water. 
 
 2. If snow be on the ground, or accessible, take a woolen cloth in 
 the hand, place a handful of snow upon it, and gently rub the frozen 
 part until the natural color is restored. In case snow is not at hand, 
 bathe the part gently with a woolen cloth in the coldest fresh water 
 obtainable ice water if practicable. 
 
 3. In case the frostbite is old and the skin has turned black or 
 begun to scale oft', do not attempt to restore its vitality by friction, 
 but apply carron oil on a little cotton; after which wrap the part 
 loosely in flannel. 
 
 4. In all cases, as soon as the vitality has been restored, apply the 
 carron oil, prepared according to Service formula. As it contains 
 opium, do not administer morphia or other opiate. 
 
 5. In the case of a person apparently dead from exposure to cold, 
 friction should be applied to the body and the lower extremities, and 
 artificial respiration practiced as in cases of the apparently drowned. 
 As soon as the circulation appears to be restored, administer spirits 
 and water at intervals of fifteen or twenty minutes until the flesh 
 feels natural. Even if no signs of life appear, friction should be 
 kept up for a long period, as instances are on record of recovery after 
 several hours of suspended animation. 
 
 Carron oil (Service formula) : 
 
 Olive oil or linseed oil (raw). 
 Limewater, of each 12 parts. 
 Tincture of opium, 1 part. 
 Mix. 
 
58 
 
 CALP WOUNDS. 
 
 Treatment. Examine the parts carefully ; clip and shave the hair 
 from a wide area about the wound; wash with warm water; draw 
 the edges of wound together with the fingers and apply absorbent 
 cotton and collodion. Stitches of silkworm gut, silver wire, or catgut 
 may be used. The stitches must not be drawn tightly, the edges 
 simply brought together. Bleeding is often severe, but usually stops 
 under pressure or after the stitches have been put in and the dressing 
 applied. But if an artery spurts it must first be tied. A few strands 
 of silkworm gut may be put in at the most dependent part of the 
 wound for drainage, but this is not usually necessary. No part of 
 the scalp should be removed, no matter how slender its attachment. 
 If replaced it will probably retain its vitality. Dress the wound with 
 a pad of clean (aseptic) gauze and apply a bandage, not tightly. 
 
 The stitches, if of silkworm gut or wire, should be removed the 
 fourth or fifth day. Unconsciousness and bleeding from the ears are 
 grave symptoms, indicating fracture of base of skull or rupture of 
 blood vessels within. 
 
 WOUNDS OF THE FACE. 
 
 Treatment. Wounds of the face may be treated in the same man- 
 ner as wounds of the scalp, using fine silkworm gut or catgut for 
 sutures, but greater care must be exercised in introducing the stitches, 
 and the edges should be brought into accurate apposition. The 
 stitches should be removed on the third day, and narrow strips of 
 adhesive plaster applied over a light dressing placed next the wound, 
 as adhesive plaster should never come in direct contact with the edges 
 of a wound; and if the wound is small, adhesive strips or cotton and 
 collodion may answer the purpose from the beginning, without 
 stitches. 
 
 INJURIES TO THE CHEST. 
 
 Contusions of the chest and fracture of the ribs are of frequent 
 occurrence, and it is not always easy to determine in a given case 
 of injury to the chest walls whether fracture actually exists, but if 
 in doubt, give the patient the benefit, and treat the case as one of 
 fracture. 
 
 Fracture involving several ribs, or one or more ribs at two points 
 each, is not difficult to make out, for in addition to the sharp pain 
 in breathing, and the bloody expectoration which is present in cases 
 where the lung is wounded, there is considerable deformity. 
 
 In single fracture of the ribs there is little or no deformity, but 
 the pain in breathing and coughing is apt to be severe. Pressure 
 on the broken bone is also quite painful, and if a hand is placed 
 over the seat of injury, or a finger on either side of the fracture, and 
 
59 
 
 the patient requested to cough, a grating may be felt, unless the rib 
 is covered with heavy muscle or fat, when, as before stated, it may 
 be difficult if not impossible to say whether or not fracture exists. 
 
 Treatment. Strips of adhesive plaster, 3 or 4 inches wide, and 
 long enough to extend from the spine to the middle or a little beyond 
 the middle of the breastbone, should be applied horizontally from 
 the armpits downward over the whole side of the chest. Each piece 
 to be forcibly applied at the end of expiration (when the lungs are 
 empty) and to overlap the preceding piece to one-half its width. 
 Any slight outward deformity at the seat of fracture may be reduced 
 by pressure before the plaster is applied at that point. A broad 
 bandage should then be applied around the chest from below upward. 
 
 INJURIES TO THE BACK. 
 
 Sprains of the spine are of all degrees of severity. In slight 
 sprains the muscles alone are involved, and beyond a temporary 
 stiffness, and pain over a limited area, there may be no trouble. 
 
 In severe sprains it is difficult to determine the degree of injury. 
 Marked pain and stiffness are always present, and not infrequently 
 paralysis of the legs, bowels, and bladder. Death may be produced 
 by shock, or occur later from secondary effects of the injury". 
 
 Treatment. Rest in bed. Epsom salts to move the bowels; rub 
 the back with soap liniment. Apply a binder or bandage around 
 the body from the hips up over the chest. Give Dover's powder for 
 pain and restlessness, and repeat the same if necessary in two or 
 three hours. See that the bladder does not become distended. If 
 necessary introduce a catheter and draw off the urine. 
 
 BROKEN BONES ( FRACTURES). 
 
 There are many varieties of fracture. A fracture is said to be 
 simple where there is no open wound directly over the bone injury; 
 compound when there is an opening in the skin and soft parts extend- 
 ing down to the broken bone; comminuted when the bone is broken 
 in several places; complicated when associated with other injuries, as 
 dislocation of the joint or rupture of the main artery of the limb; 
 impacted when one fragment is driven into another. 
 
 The reliable signs or symptoms of simple fracture are deformity, 
 crepitus (grating) when tlie ends of the broken bone are rubbed 
 together, unnatural or false point of motion, and, if in the shaft of a 
 long bone, shortening, due to the fact that in most cases the break is 
 obliquely across the bone and the fragments override. But in trans- 
 verse fracture, where the break is straight across the bone at a right 
 angle with the long axis of the bone, or in a fracture near a joint, 
 there may be no shortening and no deformity. In fractures of cer- 
 
60 
 
 tain bones, as the skull or the spine, or in an impacted fracture, there 
 may be no motion. In fracture of the kneepan or the elbow the frag- 
 ments are pulled apart by the muscles, so there is lengthening instead 
 of shortening. 
 
 Examination should always be made as soon as possible after the 
 accident. Under the^ most favorable circumstances it is difficult in 
 some cases to determine whether a bone is broken or not, and the 
 difficulty is greatly increased if the examination is delayed until 
 inflammatory swelling has set in. In fractures of the extremities the 
 sound limb should always be placed alongside the injured one for 
 comparison. The shortening in fracture of the thigh may be from 
 1 to 3 inches, but it must not be forgotten that in some persons there 
 is a natural difference of as much as half an inch in length of the 
 pair of legs ; and a limb may be otherwise naturally deformed which 
 should not be mistaken for accidental deformity. In the leg below r 
 the knee there are two parallel bones (tibia and fibula). In simple 
 fracture affecting only one of these bones the shortening and deform- 
 ity and crepitus are less marked ; and the same may be said of the 
 forearm, if fracture exists in only one of the bones (radius or ulna). 
 If both bones of the leg (tibia and fibula) or of the arm (radius and 
 ulna) are affected, there may be considerable deformity, and it is a 
 curious fact that fracture of these bones seldom occurs on the same 
 level. The distance between the fractures may be from 1 to 3 inches, 
 usually greater in the leg than in the forearm. 
 
 Crepitus (the sound heard, or feeling imparted to the hand when 
 the broken ends of the bone are rubbed together) is a valuable symp- 
 tom of fracture, but it can not always be detected, and when other 
 marked signs or symptoms are present, need not and should not be 
 looked for. In fractures of the leg below the knee or of the forearm, 
 involving only one of the bones, it is hard to make out because of the 
 difficulty of rubbing the broken ends together, and Avhen much swell- 
 ing exists the difficulty is increased, or a false crepitus may be pro- 
 duced. In impacted fractures, which occur chiefly in the neck of the 
 thigh bone, no effort should be made to obtain crepitus. The impor- 
 tant thing in such cases is not to disturb the impacted fragments, for 
 if pulled apart recovery is rendered more difficult. 
 
 FRACTURE OF THE LOWER JAW. 
 
 Fracture of the lower jaw may be simple, compound, or com- 
 minuted. The mucous membrane of the mouth is nearly always 
 lacerated, the bleeding is usually not severe (oozing only), but there 
 may be hemorrhage from an artery (the inferior dental), saliva drib- 
 bles from the half -open mouth, the teeth may be out of line, pain is 
 apt to be severe, there may be considerable deformity and a false 
 point of motion. 
 
61 
 
 Treatment. Restore the parts to the natural position and keep 
 them at perfect rest, first washing out the mouth with hot water to 
 cleanse it and check bleeding. If the bleeding is very severe pressure 
 should be made by the thumb or finger for a time on the bleeding 
 point if possible, or on the large artery (carotid) on the side of the 
 neck, which may be easily located by the pulsation. Loose teeth or 
 pieces of bone should not as a rule be removed. Mold them into 
 place, bring the teeth and jaw into natural line, and keep them so by 
 a pasteboard or binder's board splint (figs. 3 and 4), held in place by 
 a four-tailed bandage. 
 
 H-H 
 
 FIG. 3. 
 
 FIG. 4. 
 
 FIG. 5. 
 
 FIG. 6. 
 
 Fig. 3 shows the pasteboard or leather as cut out ; Fig. 4 shows the same molded to fit 
 the chin and jaw ; Fig. 5 is a four-tailed bandage, and Fig. 6 shows how they are 
 applied. 
 
 Take a piece of pasteboard about 8 or 9 inches long by 4 inches 
 wide and cut it up in the middle from each end to within about an 
 inch or inch and a half from the center, according to the size of the 
 chin. Dip it in hot water and moM it to the chin and jaw. (Fig. 4.) 
 
 Remove it carefully, line it with absorbent cotton, reapply it, and 
 retain it in place by the four-tailed bandage. (Fig. 5.) The four- 
 tailed bandage may be made in the following manner: Take a 
 bandage or piece of heavy muslin about 3 inches wide and a yard or 
 a yard and a half long. In the middle of this or a little to one side of 
 
62 
 
 the middle cut a slit large enough for the point of the chin ; place the 
 narrower portion upward, then tear the bandage down the middle 
 from each end to within 2 inches of the slit, so as to make four ends or 
 tails; then carry the two upper ends backward and tie at the nape of 
 the neck ; carry the two lower tails to the top of the head and tie in a 
 knot. ( Fig. 6. ) The ends of the knots at nape of neck and top of head 
 may then be tied together to hold them in place and prevent slipping. 
 If necessary, a bandage may also be carried around the head and 
 secured with pins. A splint of this kind may also be made of gutta- 
 percha. 
 
 If the parts can not be kept in place by the methods described, the 
 teeth may be fastened together with silver wire passed between the 
 teeth on each side of the break and twisting the ends together. Feed 
 the patient on liquid food through a rubber tube introduced behind 
 the last tooth or through any space left by the loss of a tooth, the 
 object being to prevent movement of the jaw. Wash out the mouth 
 frequently with hot water, and, if necessary, change the dressing 
 every two or three days until the end of about the sixth or eighth 
 week, when, if all goes well, union will be complete, and the splint and 
 bandage may be discontinued. 
 
 FRACTURE OF THE THUMB AND FINGERS. 
 
 Treatment. Put the fragments in place by extension and pressure ; 
 then cut a piece of pasteboard, leather, cigar box, or thin board long- 
 enough to extend from above the wrist joint to a little below the ends 
 of the fingers and a little wider than the hand. Cover the board with 
 lint or any soft cloth, place the palm of the hand flat upon it, and 
 apply a bandage around the whole hand and wrist. 
 
 If pasteboard or leather be used, it may first be dipped into hot 
 water and then molded to the shape of the thumb or finger and palm 
 of the hand, then lined or covered with cloth, and bandaged as above, 
 care being taken not to make the bandage too tight. 
 
 FRACTURE OF THE FOREARM. 
 
 The forearm extends from the wrist to the elbow. When both 
 bones are broken there is apt to be marked displacement and crepi- 
 tus (grating felt by rubbing the broken ends of the bone together). 
 When only one bone is broken the signs and symptoms are not so 
 clear, but by careful examination the nature of the injury may be 
 determined. When fracture of one of the bones (the radius) occurs 
 near the wrist joint (Colics' fracture) there is generally marked 
 deformity resembling a silver fork in shape. 
 
 Treatment. Prepare two splints of thin board or heavy binder's 
 board, one for the palmar side of the forearm long enough to extend 
 
63 
 
 from the elbow to the palm of the hand. The other for the back of the 
 forearm may be a little shorter, but should extend from the elbow to 
 below the wrist back of the hand. Both splints must be a little wider 
 than the arm so as to prevent the bones from being drawn together 
 by the bandage. Line the splints with several layers of lint, or with 
 absorbent cotton or soft cloth. If deformity exists, reduce it by ex- 
 tension and counter extension. Pull on the hand while an assistant 
 holds or pulls at the elbow, and gently press the projecting fragment 
 to its normal position. Place the arm between the splints in such a 
 way that when bent at an angle the thumb will point directly upward, 
 and the palm of the hand lie flat against the chest. Apply a roller 
 bandage outside and around the splints from fingers to elbow, being 
 careful not to make it too tight, and hang the forearm in a broad 
 sling. 
 
 Another way to hold the splints in place is to apply strips of adhe- 
 sive plaster around them, one at the upper and the other at the lower 
 end. If swelling occurs, the bandage must be loosened. The splints 
 should be worn six weeks or two months, and passive motion that is, 
 gently bending and straightening of the fingers with the other hand- 
 must be made every few days to prevent stiffening. 
 
 FRACTURE OF THE ARM (BETWEEN THE ELBOW AND SHOULDER). 
 
 Treatment. Splints of binder's board dipped in water and molded 
 to the part, or any thin board will answer the purpose if properly 
 
 FIG. 7. 
 
 FIG. 8. 
 
 lined or padded. Place one splint on the outside of the arm extend- 
 ing from the elbow to the shoulder (fig. 7), an internal angular splint 
 extending from the armpit to the fingers on the inner side (fig. 8), 
 and if need be a narrower splint in front and one behind, and the 
 whole surrounded with a well-fitted bandage. Support the forearm 
 by a sling, but leave the elbow free. (Fig. 9.) 
 
 If much swelling occurs, all bandages must be loosened. 
 
 The splint should be worn about eight weeks. Undr the most 
 
64 
 
 favorable circumstances, after fracture, this bone (the humerus) 
 sometimes fails to unite. 
 
 Fractures of the arm (of the humerus) at or near the elbow joint 
 or shoulder joint are frequently very difficult to make out, even by 
 the most skillful surgeon, especially if some time has elapsed since 
 the injury was received; and the treatment of necessity is equally 
 difficult. 
 
 If near or at the elbow joint, and if there is much pain, heat, and 
 swelling, as is apt to be the case, cold applications should be applied, 
 and the arm laid upon a pillow until the swelling has gone down. A 
 
 FIG. 9. 
 
 Fig. 7 is the outside splint to extend from shoulder to elbow ; Fig. 8 is the internal 
 angular splint to be placed between the arm and the body ; and Fig. 9 shows the two 
 splints applied with a bandage around them and the arm from the fingers to the 
 shoulder, with a sling properly arranged to support the forearm but not to raise the 
 elbow. 
 
 rectangular splint of binder's board or leather should then be dipped 
 in hot water and applied to the inner side of the arm and forearm. 
 The splint should be wide enough to extend nearly halfway around 
 the arm. It must be Avell padded and held in place by a roller ban- 
 dange, and the forearm supported by a sling. 
 
 Fracture of the humerus near the shoulder joint may be treated by 
 means of a shoulder cap of thick pasteboard molded to fit the shoul- 
 der and extending nearly to the elbow, or a splint on the outer side 
 of the arm*, and a pad of folded lint or of absorbent cotton under the 
 arm (in the armpit). The shoulder cap or splint should be padded 
 
65 
 
 the same as in any other fracture and the whole surrounded by a 
 roller bandage which encircles the chest, binding the arm to the chest. 
 If the deformity is marked, a second and shorter splint may be placed 
 on the inner side of the arm, taking care that the upper end does 
 not press too hard into the armpit. The arm should then be bound 
 to the chest by a board bandage. 
 
 After the application of any apparatus for fracture of the arm or 
 forearm, the circulation should be carefully watched by feeling the 
 pulse at the wrist. If it can not be felt, or if the fingers swell, the 
 bandages should be removed and reapplied less tightly. 
 
 FRACTURE OF THE THIGH. 
 
 The thigh bone (femur) extends from the hip to the knee. Frac- 
 ture of this bone may occur in any portion of the shaft, but the most 
 common seat of fracture is about the -middle or the middle third. 
 Fractures high up near the hip joint are frequently very difficult to 
 make out, and the results of treatment in such cases, even under the 
 care of skillful surgeons, are not always satisfactory. 
 
 In fracture of the middle or middle third of the bone, the deform- 
 ity is usually produced by the lower fragment (the broken end of 
 the lower portion of the bone) being drawn up behind and to the 
 inner side of the upper fragment ; the weight of the limb then causes 
 rotation and the foot and toes are turned outward. 
 
 If the fracture is a little higher up, displacement is shown by the 
 upper fragment, which, by the action of the muscles, is thrown 
 strongly forward and outward. In either case there are complete 
 loss of power, shortening to the extent of 1 to 2 or 3 inches/ pain on 
 the slightest movement, crepitns (grating) if the broken ends of the 
 bone are rubbed together, and abnormal motion. 
 
 In impacted fractures, which are met chiefly at or near the hip 
 joint, the shortening may be, and usually is, less marked. Loss of 
 power is usually complete, but not always. Patients have been 
 known to stand and even walk a few steps. Injuries of this kind 
 require the greatest care ; the limbs should be handled very caref ully. 
 If on slight traction or manipulation crepitus is not felt, no further 
 attempt should be made to obtain this symptom, for in doing so the 
 impacted bones may be pulled apart, which is to be avoided unless 
 especially directed by a skillful surgeon. 
 
 Treatment. About all the master of the vessel may reasonably be 
 expected to do in impacted fracture is to apply a broad bandage 
 around the hips and place the patient in a good bed on a firm mat- 
 tress and* make lateral support by means of sand bags, one on the 
 outside long enough to reach from the upper end of the hip bone to 
 the foot, the other along the inner side of the leg from the crotch to 
 1325604 M 5 
 
66 
 
 the foot. Fill the bags three-quarters full of dry sand. Keep the 
 leg straight, toes upward. 
 
 Treatment of nonimpacted fracture of the thigh bone at or near 
 the hip joint. Apply a broad bandage around the hips and place 
 both legs on the double-inclined plane (fig. 10) , or make extension and 
 fix the limb in the straight position by means of a long splint (a 
 splint extending from the armpit to the foot) , or by the weight and 
 pulley, or by the long splint and the weight and pulley combined, 
 in the manner now about to be explained in connection with the 
 
 Treatment of fractures of the shaft of the thigh bone. In frac- 
 ture of the shaft of this bone the signs and symptoms, as already 
 
 FIG. 10. Shows a double inclined plane A and B are hinges, C indicates four cleats. 
 
 FIG. 11. Shows the same in use with the weight and pulley 1 is the double inclined 
 plane, 2 and 3 are circular pieces of adhesive plaster to prevent 4. the longitudinal 
 strip on each side of the thigh, from slipping; 5 and 6 are the pulley and weight. 
 
 stated, are usually well marked. If the fracture is at the upper end 
 or in the upper third of the bone, especially if the upper fragment is 
 tilted forward, the double-inclined plane (fig. 11) well padded or 
 covered with pillows, with weight and pulle}^ attached by means of 
 adhesive plaster stuck to each side of the thigh as far as the knee, 
 affords the easiest and probably the best means of treatment. But 
 in the majority of cases when the fracture is farther down, about the 
 middle or in the middle third of the bone, the weight and pulley with 
 
67 
 
 the leg and thigh in a straight line (fig. 12), or the weight and pul- 
 ley and long splint combined (fig. 13), are better adapted if properly 
 applied. Sand bags may also be used in connection with any of the 
 straight splints placed alongside. In all cases the fracture should be 
 
 FIG. 12. 
 
 Fig. 12 shows the weight and pulley applied with the leg and thigh in the straight 
 position the adhesive strips being attached to the leg as well as the thigh. 
 
 FIG. 13. 
 
 Fig. 13 shows the long lateral splint extending from the armpit to a point a little 
 helow the foot. It is bandaged to the body and the lower extremity, and may be 
 used with the weight and pulley. 
 
 Fro. 14. 
 
 Fig. 14 shows a fractured thigh on a double-inclined plane with three short splints ap- 
 plied and held in place by three strips of adhesive plaster. A shows two of the three 
 splints the third one being on the inner side. B indicates three strips of adhesive 
 plaster. 
 
 reduced by gradually pulling and carefully pressing the broken bones 
 into their natural position. In addition to the splints already men- 
 tioned, short splints of narrow strips of thin board or binder's board 
 should be applied directly over the seat of fracture. (Fig. 14.) 
 
68 
 
 If a double-inclined plane (fig. 10) is not at hand, two broad pieces 
 of board may be nailed together at a suitable angle and used instead, 
 always properly padded or covered with pillows. 
 
 The weight and pulley (figs. 12 and 15). The weight and pulley 
 are applied as follows: Measure the distance from 1 inch below the 
 crotch to a point 4 inches below the foot. Cut a strip of adhesive 
 plaster exactly twice as long as the distance just measured and 3 
 inches wide, and stretch it on a table or on the floor, with the 
 sticky side up. Get a block of wood 4 inches long, about 3 inches 
 wide, and about \ inch thick, with a hole bored through the center 
 large enough to admit a large cord. Place the block exactly in 
 the center of the long strip of adhesive plaster. Cut another strip 
 of plaster the width of the first and 18 inches long, and place it 
 on the first strip, sticky surfaces together, so as to include the block 
 between the center of each. Thus a stirrup is made and the plaster 
 kept from sticking to the ankle bones, because it would make them 
 
 o 
 
 FIG. 15. 
 
 A shows the long strip of adhesive plaster ; B shows the short strip. C is the hlock of 
 wood 4 x 3 x | inches with a hole in the center. D shows the block placed between the 
 two strips of plaster, all ready for application to the leg or thigh. 
 
 sore. The long strip of plaster on each side of the stirrup is then 
 applied to the leg and thigh after shaving on each side the surface 
 to which it is to be applied, extending from a point just above the 
 ankle bone to a point about 1 inch below the crotch on the inner 
 side and to the same level on the outer side, being careful to keep the 
 block square when the two ends of the plaster are stuck to the limb. 
 A roller bandage is then applied over the plaster from the ankle 
 up. A strong cord is then passed through the hole in the block 
 and knotted so that it can not slip through, the other end being 
 passed over a pulley attached to the foot of the bed or elsewhere, as 
 may be convenient, on a line with the extended limb, and a weight 
 of from 5 to 30 pounds, as may be necessary or comfortable to the 
 patient, gradually increased, attached. The same kind of appa- 
 ratus may be used with the double-inclined plane, except that the 
 plaster is applied only to the thigh, the stirrup coming just below 
 the bent knee. 
 
69 
 
 Counter extension may be obtained by raising the foot end of the 
 bed on blocks 4 to G inches high. The short splints should be well 
 padded and extend well above and below the fracture, and be held 
 in place by strips of plaster or bandage. 
 
 The long splint gives additional support and prevents outward 
 rotation of the leg. It should be well padded, and have a- cross- 
 piece at the lower end to keep it in position. Treatment will be 
 required for a period of eight to ten weeks, but the extension may 
 be lessened about the end of the sixth week and passive motion made 
 at the knee joint. 
 
 FRACTURE OF THE KNEECAP. 
 
 Fracture of the kneecap may be transverse, vertical, or oblique. 
 The bone may be broken into two or more irregularly shaped pieces. 
 
 Symptoms and signs. Loss of poiuer, inability to extend the 
 joint or raise the limb from the bed. In the transverse variety the 
 
 FIG. 16. 
 
 Fig. 16 shows a splint and bandage applied for fracture of the knee cap. A is a notch 
 in the board to prevent slipping of the bandage. B is the end of a bandage which is 
 to be carried above the knee over the bandage shown at A. 
 
 fragments are widely separated. If seen soon after the accident, 
 the line of fracture the gap between the fragments may be seen 
 and felt. Swelling rapidly appears and the signs are obscured. 
 
 Treatment. Various forms of apparatus are employed, and in hos- 
 pital practice the injury is frequently treated by surgical operation, 
 with good result. The simplest form of treatment is to place the 
 limb on a long posterior splint (fig. 16) with the foot raised so as 
 to relax the thigh muscles, or if the patient is propped up in bed by 
 pillows or a back rest, the limb may be allowed to lie on a level. 
 
 Apply iced water or the ice bag for a few days, until the swelling 
 and heat have subsided; then remove the splint and apply a roller 
 bandage from the foot to upper end of thigh. The turns of the 
 bandage below and above the knee should be made in an oblique 
 
70 
 
 direction, figure-of-eight fashion, so as to press and hold the frag- 
 ments of bone together; the indications being, as in other fractures, 
 to restore the broken ends of the bone to their natural position and 
 keep them there. A pad of cotton should be placed in the hollow 
 back of the knee and another smaller pad on the front of the thigh 
 above the upper fragment before the bandage is applied. The splint 
 should then be relined with layers of dry cotton or folds of lint and 
 the limb placed upon it as before, secured by another roller bandage. 
 If swelling or numbness of the foot is complained of, the bandage is 
 too tight, and must be removed. 
 
 If the bandages become loose, as they are apt to do every few 
 days, they should be reapplied. 
 
 The long splint should be worn about six weeks or two months, 
 when it may be replaced by a shorter molded splint of leather, felt, 
 or pasteboard to prevent motion at the joint when the patient may 
 be allowed to w r alk with canes or crutches. The short splint should 
 be worn for at least a month, and then a suitably constructed knee 
 cap should be worn for one year to support the joint. More or less 
 stiffness of the joint is to be expected. 
 
 FRACTURE OF THE LEG (BETWEEN THE KNEE AND ANKLE). 
 
 The leg extends from the knee to the ankle and has two bones, 
 tibia and fibula. 
 
 Fracture of the leg may be simple or compound. Both bones may 
 be broken or only one; the line of fracture may be oblique or trans- 
 verse. When both bones are broken at the middle or lower third 
 the deformity is usually quite marked. The break is apt to be in an 
 oblique direction and at a lower level in the tibia (the shin) than in 
 the fibula. In simple fracture of the upper part of the leg the de- 
 formity may be less marked, but if the knee is involved there may be 
 great swelling because of acute and serious inflammation of the 
 joint. 
 
 When the shaft of only one bone (the tibia or fibula) is broken 
 there is not much displacement because in such case the sound bone 
 acts as a side splint. Fracture at the lower end of the tibia at the 
 projection on inner side of ankle is sometimes mistaken for sprained 
 ankle, and if the small fragment of bone is not accurately adjusted 
 and kept in proper position the result may be a weak and stiff joint. 
 
 The fibula may be fractured at any point, but the important frac- 
 ture of this bone is known as " Pott's " fracture. (Figs. 17 and 18.) 
 This fracture occurs about 3 inches above the ankle, on outer side of 
 the leg, and is accompanied or complicated by outward dislocation of 
 the" foot, and not infrequently by the breaking or tearing off of the 
 tip of the lower end of the tibia. 
 
71 
 
 Treatment. If the line of fracture is oblique, the limb must be 
 handled very carefully so as to prevent injury to the soft parts by the 
 sharp ends of the bone and thus avoid the conversion of a simple 
 fracture into a compound one. 
 
 A Pott's fracture should be treated as follows : Take a board splint 
 
 FIG. 17. Shows the appearance of the right foot after a " Pott's fracture." 
 
 long enough to extend from the knee to a few inches beyond the sole 
 of the foot. Pad the splint well, having the lower end of the pad- 
 ding at least 2 inches thick, and do not let it extend quite to the ankle 
 joint below. Apply the splint to the inner side of the leg so that the 
 foot and ankle project below the padding. The foot and leg are 
 
 FIG. 18. Shows on the skeleton the point of fracture in the small bone of the leg and 
 the outward displacement of the bones of the foot. 
 
 then bandaged to the splint in such a way as to turn the foot inward 
 and thus correct the outward displacement. (Fig. 19.) 
 
 In all ordinary cases of simple fracture of the leg the master of the 
 vessel can probably do no better than to place the leg in a fracture 
 
 FIG. 19. Shows the splint applied for a " Pott's fracture." A shows the thick padding 
 (3 inches) ending just above the ankle. The bandage B keeps the foot turned in and 
 prevents the tendency to outward displacement. 
 
 box (fig. 20) containing a soft pillow, and if necessary an extra pad 
 of cotton or oakum for the heel. The side pieces of the fracture 
 box are fastened each by two hinges to the backboard so as to be easily 
 opened or closed. A pillow is placed on the backboard and after 
 
72 
 
 the fracture is reduced, by extension and counter extension, the leg is 
 carefully placed upon the pillow and the sides of the box are closed 
 or drawn together closely enough to make easy and equable support 
 to the broken bones. Two or three holes should be bored in the upper 
 edge of the sideboards so that they may be tied together, or strips of 
 bandage may be tied around the box. Two mortise holds should be 
 made in the footboard for the reception of strips of adhesive plaster, 
 so that in addition to the fracture box the weight and pulley may be 
 applied to overcome any shortening or deformity. Another good 
 plan is to line the backboard (the bottom of the box) with a layer of 
 cotton or folds of lint and then fill in and surround the leg with bran. 
 In the absence of any of the apparatus mentioned, three well- 
 padded splints may be applied one on each side and one on the back 
 of the leg. But if there is any displacement or overriding the frac- 
 ture must be reduced and held in proper position while the splints 
 are being applied. 
 
 PIG. 20. 
 
 Whatever form of appliance is adopted care must be taken that the 
 foot is at a right angle with the leg, the toes pointing directly upward. 
 The inner side of the kneecap, the projection on the inner side of the 
 ankle, and the inner side of the big toe should be on the same line. 
 
 In the hospital, or where the patient is under the care of a surgeon, 
 a fixed dressing of plaster of Paris, or silicate of soda, may be used 
 to the greatest advantage after the first week, or, in some cases, from 
 the very beginning of treatment. 
 
 COMPOUND FRACTURES. 
 
 Compound fractures are serious accidents and require prompt 
 attention. The general principles of treatment so far as the bone 
 is concerned (place it in normal position and keep it there) are the 
 same as for simple fracture. But to do this and at the same time 
 give proper attention to the wound in the soft parts (the open wound 
 extending down to the bone) frequently demands the highest surgical 
 skill. 
 
 Shock from loss of blood is the immediate danger. Inflammation, 
 erysipelas, blood poisoning, or lockjaw may set in later, and still 
 later the patient may become exhausted from long-continued suppu- 
 ration. 
 
73 
 
 Treatment. If the wound is very small it should be well cleaned 
 with hot water (water that has been raised to the boiling point and 
 allowed to cool down to about 120) or by antiseptic solution (sol. 
 bichloride mercury 1 to 5,000), then covered with antiseptic gauze, 
 and the case treated as a simple fracture. 
 
 In nearly all cases, however, the safest and best plan is to leave 
 the wound uncovered by splint or bandage, so that light dressings 
 may be easily applied and frequently changed. The wound should 
 be thoroughly cleansed with hot water and antiseptic solution, and, 
 after reducing the fracture, the splints, or extending apparatus, 
 should be so arranged that the wound is freely accessible and easily 
 drained. Strips of antiseptic gauze should be placed in the wound 
 and gently carried down to the bottom by means of a probe, and a 
 larger piece of gauze in loose folds should be laid over the wound. 
 
 The gauze dressing should be renewed every day or every second 
 day, or as often as necessary to keep the wound well drained until 
 it heals from the bottom. 
 
 In severe cases amputation may be necessary to save life, and in 
 all cases the patient should be placed under the care of a surgeon as 
 soon as possible. 
 
 DISLOCATIONS. 
 
 A bone is dislocated or " out of joint " when it is displaced or 
 forcibly separated from another bone entering into the composition 
 of a joint. 
 
 Dislocations may be complete or incomplete. A dislocation is 
 complete when the articular surfaces are entirely separated and the 
 ligaments torn, as in dislocation of the hip joint; incomplete when 
 the articular surfaces are not entirely displaced. Dislocations may 
 be simple, compound, or complicated. 
 
 A dislocation is simple when there is no wound of the skin and soft 
 parts when the articular surfaces are not exposed to the outer air; 
 compound when there is an open wound and the outer air is brought 
 into contact with the articular surfaces of the joint; complicated 
 when besides the dislocation there is a fracture and serious damage 
 to the soft parts, or to blood vessels or nerves. 
 
 Dislocations are said to be most common in adult or middle life, 
 when the bones are strong and the muscles powerful. In the young 
 and old the boires are more apt to break. There are, however, strik- 
 ing exceptions to this rule when applied to the elbow joint and the 
 shoulder joint. The elbow joint in young subjects is frequently dis- 
 located; and dislocation of the shoulder joint in old men is not 
 uncommon. 
 
 Symptoms and signs of dislocations. Deformity is always present 
 and may be determined by comparing the injured side with the 
 
74 
 
 sound side. The head or end of the bone is in an abnormal position;" 
 the attitude of the limb is changed; the patient can not move the 
 limb; and when the surgeon or the master tries to move the joint he 
 finds it very stiff. There may be shortening or lengthening. For 
 example, in dislocation of the hip the head of the thigh bone may be 
 thrown outward and upward, when there will be shortening of the 
 leg ; or it may be forced downward and inward, when the length of the 
 limb will be increased. 
 
 Treatment. The indications are to replace the bones in their 
 natural position and to keep the parts at rest until the ligaments and 
 damaged tissues about the joint are healed. A dislocation should be 
 reduced immediately after the accident, whilst the patient is faint and 
 the muscles are in a relaxed condition. 
 
 Having thus briefly described a dislocation and the treatment indi- 
 cated, the question now arises, How shall the treatment be applied, 
 how shall the dislocation be reduced ? And when it is taken into con- 
 sideration that the reduction of dislocations not infrequently taxes 
 the skill of the most experienced surgeon (even with the aid of gen- 
 eral anesthetics), it is hardly to be expected that a nonprofessional 
 man will be able to accomplish the desired results in many cases. It 
 must also be borne in mind that there are certain dangers attending 
 efforts at reduction, especially at the larger joints, if improperly or 
 too forcibly applied such as fracture of bone or rupture of blood 
 vessel. 
 
 DISLOCATION OF THE FINGERS. 
 
 Dislocation of the bones of the fingers may be backward or 
 forward. 
 
 Treatment. Extension and counter extension and manipulation. 
 Pull the finger directly in line with the hand, and when fully extended 
 make pressure on the head of the bone. Reduction is usually effected 
 without much difficulty. Place the finger on a well-padded splint 
 for one week, then make passive motion, and, if necessary, the splint 
 may be worn for another week. 
 
 DISLOCATION OF THE THUMB. 
 
 Dislocation of the thumb may be backward or forward. 
 
 Treatment. The treatment is not the same as for dislocation of 
 the fingers, and reduction, especially of the backward dislocation, is 
 usually very difficult. Try by pushing the end of the thumb upward 
 and backward until it stands perpendicularly on the bone from which 
 it is dislocated (fig. 21), then make strong pressure against the base 
 of the dislocated bone from behind forward, sliding it on the bone 
 beneath till it gets to the end, then flex or bend the thumb into place. 
 (Fig. 22.) 
 
75 
 
 DISLOCATION OF THE WRIST. 
 
 Dislocation of the wrist joint may be backward or forward. It is 
 a rare injury. Fracture about the wrist is more common, and is 
 sometimes mistaken for dislocation. A stiff joint is apt to be the 
 result. 
 
 Treatment. Extension, counter extension, and direct pressure. 
 Grasp the hand of the patient, pull in a straight line, and have an 
 assistant pull on the forearm in the opposite direction, and when the 
 parts are fully extended make direct pressure upon the wrist bones. 
 Apply a bandage, and place the hand and forearm on a well-padded 
 splint for a week ; then remove the splint and make passive motion at 
 
 FIG. 21. 
 
 FIG. 22. 
 
 Pig. 21 shows a backward dislocation of the right thumb. A. is the head of the bone 
 in the hand and B is the bone in the thumb which has slipped backward and rests on 
 the first bone below or behind its head. Fig. 22 shows how to replace it. The thumb 
 should be brought out perpendicular to the hand (see arrow A) and its base pushed 
 forward (see arrow B) till it reaches the end of the first bone, then it should be bent 
 into the palm of the hand. Fig. 22 shows the bone in the proper position for bending. 
 
 the joint ; reapply the splint and remove it after an interval of another 
 week. If there is much pain or swelling after reduction of the dislo- 
 cation, apply cold water or lead-opium wash. 
 
 DISLOCATION OF THE ELBOW. 
 
 Dislocations of the elbow are serious accidents. They present a 
 variety of forms, backward, forward, outward, and inward, and these 
 are divided into a number of subvarieties. One or both bones may be 
 
76 
 
 involved, and the dislocation may be associated with fracture. Re- 
 duction in some cases is comparatively easy, in others it is very diffi- 
 cult, even in the hands of experienced surgeons. 
 
 Without a thorough knowledge of the anatomy of the normal joint 
 it is very difficult to understand the different forms of dislocation, and 
 of necessity equally difficult to apply the proper treatment. 
 
 Immediately after the accident and before swelling sets in the 
 injured elbow should be carefully compared with the sound one. 
 When the normal arm is extended (straight) the tip of the elbow and 
 the bony points on either side should be in a transverse line across the 
 joint. If these prominences are found out of line, dislocation or frac- 
 ture is probably present. 
 
 FIG. 23. 
 Dislocation of the shoulder. 
 
 Treatment. Fixation of the arm above the elbow, extension or 
 flexion of the forearm, and direct pressure by means of the thumbs or 
 fingers on the head of the dislocated bone, so as to push it back into the 
 socket. After reduction an angular splint should be applied to inner 
 side of arm (fig. 8), lightly bandaged, and the forearm carried in a 
 sling. Cold water or lead-opium wash may be applied to reduce 
 inflammatory action. Passive motion should be employed at the end 
 of a week. 
 
77 
 
 DISLOCATION OF THE SHOULDER. 
 
 [After Helfrich.] 
 
 Dislocation of the shoulder joint is a very common accident. It 
 occurs as frequently as all other dislocations put together. The fre- 
 quency is explained by the great latitude of motion of the joint, the 
 shallowness of the socket, and the size and rounded shape of the head 
 of the bone, the laxity of the capsular ligament, and the leverage 
 exerted on the joint by the long bone. 
 
 There are three chief forms of dislocation of the shoulder, (1) for- 
 ward and downward below the collar bone, (2) directly downward 
 into the armpit, and (3) backward on the shoulder blade. 
 
 The symptoms and signs are pain, swelling, rigidity (stiffness), 
 loss of power, flattening and angular appearance of the shoulder as 
 compared with the other shoulder, abnormal situation of the head of 
 the bones, and change in the axis of the long bone. (Fig. 23.) In 
 the first variety, the most common of all, the head of the bone may 
 be felt in front of the armpit and below the collar bone, and the elbow 
 points outward and backward. In the second the head of the bone 
 may be felt in the armpit, and the elbow points outward. In the 
 third, the head of the bone may be felt on the back of the shoulder 
 blade, the elbow points forward, and the forearm is thrown across 
 the chest. Another valuable sign is that when the elbow is placed on 
 the chest the patient can not place the hand of the injured side upon 
 the opposite shoulder, or if the hand is placed on the shoulder the 
 elbow can not be brought into contact with the chest. 
 
 Treatment. The treatment for the first variety (forward and 
 downward) is as follows: Lay the patient down or let him sit on a 
 chair; bend the forearm on the arm; press the elbow against the 
 side of the chest and hold it there ; rotate the arm outward by carry- 
 ing the forearm outward ; pull steadily on the arm and rotate inward 
 by carrying the elbow upward and forward with forearm across the 
 chest. While this is going on have an assistant place his hand in 
 the armpit and press the head of the bone into place. 
 
 For the second variety (directly downward into the armpit), place 
 the patient on his back; remove your boot; place your heel in the 
 armpit ; grasp the wrist and pull steadily on the arm. If the dislo- 
 cation is in the right shoulder, seat yourself on the right side of the 
 patient and use your right foot; and if the injury is in the left 
 shoulder, seat yourself on the left side and use your left foot. The 
 same principles may be carried out by seating the patient on a low 
 chair and placing your knee in the armpit. 
 
 Another method is to have an assistant stand upon a table and 
 make counter extension with a towel, or a strong piece of soft cloth 
 of any kind, passed under the armpit of the patient, while the oper- 
 
78 
 
 ator pulls the arm downward. The same method may be employed 
 by causing the patient to lie on his back, and an additional advantage 
 may be obtained by placing a rolled bandage or a pad of any kind in 
 the folds of a towel in the armpit. 
 
 In dislocation backward on the shoulder blade, pull the arm for- 
 ward and make direct pressure forward on the head of the bone, or 
 stand behind the patient, draw the elbow backward, and with the 
 thumb press upon the head of the bone and guide it into place. 
 
 After reduction, a soft pad should be placed in the armpit, the 
 upper arm bandaged to the body, and the forearm placed in a sling 
 across the chest. Passive motion at the joint should begin at the 
 end of a week and be repeated daily, but the arm should be carried 
 in the sling about three weeks. 
 
 DISLOCATION OF THE COLLAR BONE. 
 
 The collar bone extends from the upper border of the breast bone 
 to the highest point of the shoulder blade. Dislocation may occur 
 at either end. Reduction is comparatively easy, but it is difficult to 
 retain the bone in position. 
 
 Treatment. Make extension by drawing back the shoulders, the 
 knee, if necessary, being placed between the shoulder blades; push 
 the end of the bone in place, and try to keep it there by a firm pad, 
 fastened by adhesive plaster and bandage. The best result may be 
 obtained by placing the patient at rest on his back for three weeks. 
 
 DISLOCATION OF THE TOES. 
 
 Dislocations of the toes are very rare accidents. The treatment is 
 the same as for dislocation of the fingers. Dislocation of the big 
 toe may be treated the same as dislocation of the thumb. 
 
 DISLOCATION OF THE ANKLE. 
 
 The foot may be dislocated forward, backward, outward, inward, 
 or upward. The dislocation may be complete or incomplete. 
 
 The lower ends of the bones of the leg enter into the formation of 
 the ankle joint, the end of the tibia on the inner side and the end 
 of the fibula on the outer side of the joint. Dislocations of the ankle 
 are usually complicated by fracture of the tip of one or both of these 
 bones; when, in addition, the fibula is broken above the ankle, the 
 injury is known as Pott's fracture, already referred to. 
 
 Treatment. Extension, counter extension and pressure. Flex 
 the leg on the thigh, and the thigh at right angle to body; pull 
 steadily on the foot, while an assistant makes counter extension at 
 the thigh, and press the bones in place. Apply cold water, or lead- 
 opium wash, and place the foot and leg in a fracture box, or apply 
 
well-padded molded splints. Binder's board dipped in warm water 
 and molded to the part and lined with thick layers of cotton will 
 answer the purpose. If a Pott's fracture use the splint shown in 
 fig. 16. Make passive motion at the joint at the end of two weeks. 
 
 DISLOCATION OF THE KNEE. 
 
 Dislocation of the knee may be complete, incomplete, compound, 
 or complicated. The direction of the dislocation may be forward, 
 backward, outward, or inward. The deformity is quite marked. 
 Keduction is not very difficult, but the injury is a serious one and 
 care must be taken in making reduction not to produce additional 
 damage by too forcible extension. Fortunately the injury is exceed- 
 ingly rare. 
 
 Treatment. Extension, counter extension, and pressure. Have one 
 assistant pull steadily, not too hard, on the leg or ankle, while another 
 assistant fixes or pulls on the thigh and presses the bone into place. 
 After reduction apply cold water, or lead-opium wash, and place 
 the leg in a posterior straight splint, well padded, especially below the 
 hollow of the knee, and make passive motion at the end of two weeks. 
 When the patient begins to walk, a kneecap or flannel bandage should 
 be applied. 
 
 DISLOCATION OF THE HIP. 
 
 Dislocation of the hip joint is a serious injury. It occurs much less 
 frequently than dislocation of the shoulder joint. The socket of the 
 hip joint is very deep, and the ligaments and muscles surrounding the 
 joint are very strong and powerful. Dislocation occurs only when 
 the limb is in a certain position, when its axis is changed from that 
 of the body, and when in consequence of any sudden or great force 
 received on -the lower end of the leg or knee the head of the bone is 
 forced through the ligament (the capsule) which surrounds the joints. 
 The head of the bone may then be thrown (1) backiuard and upward, 
 (^backward, (3) forward and downward, (4) forward. The dif- 
 ferent directions indicate the different forms of dislocation. The 
 first is the most common. 
 
 In the first form examination from below up shows the ~big toe 
 turned toward or resting on the instep of the opposite foot ; the knee 
 flexed and resting against thigh at upper margin of opposite knee- 
 cap ; the thigh rotated inward and drawn toward its fellow ; bulging 
 of the hip ; and about 2 inches shortening of the entire limb. 
 
 In the second form the signs are the same as in the first, but less 
 marked. (Fig. 24.) Fracture of the neck of the thigh bone is 
 sometimes mistaken for this injury. But in fracture there is abnor- 
 mal motion, and the foot is turned outward. 
 
 In the third form (fig. 25) the signs are almost exactly the reverse 
 
80 
 
 of the first form. The foot and knee are turned outward, the hip is 
 flattened, and the entire limb is lengthened. 
 
 The signs of the fourth form are nearly the same as those of the 
 third, except that the entire limb is shortened. 
 
 Treatment. The treatment is by manipulation, or by extension 
 and counter extension. 
 
 For the first and second forms of dislocation, above-described treat- 
 ment may be applied as follows : Place the patient on his back on a 
 mattress on the floor. Seize the foot or ankle with one hand and 
 place the other hand under the knee. Flex the leg upon the back of 
 the thigh, and the thigh upon the body to about a right angle ; then 
 carry the knee inward and rotate it inward on its own axis, then sud- 
 denly raise it (lift it toward the ceiling) so that the head of the bone 
 may be thrown over the rim of the socket, and immediately extend 
 
 FIG. 24. 
 
 FIG. 25. 
 
 Fig. 24 shows a backward dislocation of the hip with the knee and toe turned in and 
 the heel raised and the limb shortened. Fig. 25 shows a forward and downward dis- 
 location of the right hip with the knee and toe turned out and the limb lengthened. 
 
 the limb with outward rotation to its normal position so that the head 
 of the bone may return to the socket through the hole in the capsule 
 by which it escaped.. 
 
 The treatment of the third and fourth forms of injury corresponds 
 to that for the first and second, except that the limb should be carried 
 outward first, then inward, across the median line, and rotated 
 inward on its own axis, and then suddenly lifted and brought down 
 to its normal position by the side of its fellow. 
 
 No great force should be used in making these movements. If any 
 considerable resistance is met with in rotating or lifting the bone the 
 movement should be modified in such a way that the head of the bone 
 may follow the path of least resistance. 
 
81 
 
 If extension and counter extension be applied they should follow 
 the line of the axis of the dislocated thigh. It must not be forgotten 
 in the consideration of these methods that the application of too 
 much force or of force improperly applied may produce fracture of 
 
 the bone. 
 
 SPRAINS. 
 
 A sprain is a stretching or wrenching of a joint. The joints most 
 frequently affected are the ankle, wrist, knee, and shoulder. 
 
 The symptoms and signs are pain, swelling, impairment or loss of 
 motion, and discoloration from effusion of blood. When there is 
 much swelling it may be difficult to determine whether sprain or frac- 
 ture, or both, are present. 
 
 Treatment. If seen at once, before there is much swelling, a 
 bandage should be applied from the toes to 2 or 3 inches above the 
 ankle, and the joint should be kept at perfect rest in an elevated 
 position. If much swelling has already taken place apply cold 
 applications continuously for several hours. If the symptoms do not 
 rapidly subside apply hot applications cloths or towels wrung out 
 of hot water and frequently changed. After the swelling has gone 
 down a bandage properly applied will afford considerable benefit. 
 (Fig. 26.) 
 
 FIG. 26. 
 
 Fig. 26 shows the application of adhesive plaster to an ulcer of the leg at A and of an 
 ordinary bandage from the foot up the leg, B. 
 
 The joint must not be kept too long at rest. Passive motion should 
 be performed as soon as the inflammatory symptoms have subsided. 
 
 NOSEBLEED. 
 
 If bleeding of the nose occur in a full-blooded person, especially 
 
 if such person is subject to dizziness, we should not be in too much of 
 
 a hurry to stop it. But if the bleeding is the result of injury or if it 
 
 occur in a person suffering from disease of the heart or lungs or from 
 
 1335604 M 6 
 
82 
 
 the effects of malarial fever, scurvy, or any disease of the general sys- 
 tem, effort should be made to stop it. 
 
 Treatment. Remove all pressure of clothing from neck and chest. 
 Caution patient not to blow his nose. If too weak to stand, place 
 him on his back with his arms raised and his head on a high pillow. 
 Bathe the nose in cold water, apply cold water to back of neck or an 
 ice bag to the forehead. Pack the nostrils with pellets of absorbent 
 cotton soaked in a solution of alum or gelatin. The bleeding is some- 
 times brought under control by the application of hot water to the 
 nostrils. 
 
 In very severe cases the posterior as well as the anterior nares 
 should be plugged. In the absence of a surgeon the application of 
 this method may be attended with some difficulties. But if the 
 master of the vessel decides to try it he may proceed as follows: 
 Pass a fine string twine, about 20 inches long, through the eye of a 
 hard rubber catheter, and thus armed pass the catheter along the 
 floor of the nose to the back of the mouth below the soft -palate; 
 introduce a forceps into the mouth back to the end of the catheter, 
 seize the twine, and bring it out of the mouth. Then tie a pledget 
 of absorbent cotton or lint to the twine about 12 inches from the 
 end of it; then pull on the catheter and the other end of the twine 
 and draw the pledget into the mouth, guided by the finger, behind 
 the soft palate into the posterior nares. He will then have the 
 posterior nares plugged, and one end of the twine hanging out at 
 the mouth and the other end at the nose. 
 
 Secure the ends of the twine by tying them together, and allow 
 the plug to remain about two days. 
 
 The pledget of cotton or lint should be about an inch long and 
 half an inch wide. 
 
 DIRECTIONS FOR RESTORING THE APPARENTLY DROWNED. 
 
 As practiced in the United States Life-Saving Service. 
 
 Note. These directions differ from those given in the last re- 
 vision of the Regulations by the addition of means for securing 
 deeper inspiration. The method heretofore published, known as the 
 Howard, or Direct Method, has been productive of excellent results 
 in the practice of the Service, and is retained here. It is, however, 
 here arranged for practice in combination with the Sylvester method, 
 the latter producing deeper inspiration than any other known method, 
 while the former effects the most complete expiration. The com- 
 bination, therefore, tends to produce the most rapid oxygenation of 
 the blood the real object to be gained. The combination is prepared 
 primarily for the use of life-saving crews where assistants are at 
 hand. A modification of Rule III, however, is published as a guide 
 
83 
 
 in cases where no assistants are at hand and one person is compelled 
 to act alone. In preparing these directions the able and exhaustive 
 report of Messrs. J. Collins Warren, M. D., and George B. Shattuck. 
 M. D., committee of the Humane Society of Massachusetts, embraced 
 in the annual report of the society for 1895-96, has been availed of, 
 placing the Department under many obligations to these gentlemen 
 for their valuable suggestions. 
 
 Rule I. Arouse the patient. Do not move the patient unless in 
 danger of freezing; instantly expose the face to the air, toward the 
 wind if there be any ; wipe dry the mouth and nostrils ; rip the cloth- 
 ing so as to expose the chest and waist; give two or three quick, 
 smarting slaps on the chest with the open hand. 
 
 FIG. 27. 
 
 If the patient does not revive, proceed immediately as follows : 
 Rule II. To expel water from the stomach and chest (see fig. 
 27). Separate the jaws and keep them apart by placing between the 
 teeth a cork or small bit of wood ; turn the patient on his face, a large 
 bundle of tightly rolled clothing being placed beneath the stomach; 
 press heavily on the back over it for half a minute, or as long as fluids 
 flow freely from the mouth. 
 
 Rule III. To produce breathing (see figs 28 and 29). Clear the 
 mouth and throat of mucus by introducing into the throat the corner 
 of a handkerchief wrapped closely around the forefinger; turn the 
 patient on the back, the roll of clothing being so placed as to raise the 
 pit of the stomach above the level of the rest of the body. Let an 
 assistant with a handkerchief or piece of dry cloth draw the tip of the 
 tongue out of one corner of the mouth (which prevents the tongue 
 from falling back and choking the entrance to the windpipe), and 
 
. 84 
 
 keep it projecting a little beyond the lips. Let another assistant 
 grasp the arms just below the elbows and draw them steadily upward 
 by the sides of the patient's head to the ground, the hands nearly 
 meeting (which enlarges the capacity of the chest and induces inspi- 
 ration). (Fig. 28.) While this is being done let a third assistant 
 take position astride the patient's hips with his elbows resting upon 
 his own knees, his hands extended ready for action. Next, let the 
 assistant standing at the head turn down the patient's arms to the 
 sides of the body, the assistant holding the tongue changing hands if 
 necessary a to let the arms pass. Just before the patient's hands 
 
 FIG. 28. 
 
 reach the ground the man astride the body will grasp the body with 
 his hands, the balls of the thumb resting on either side of the pit of 
 the stomach, the fingers falling into the grooves between the short 
 ribs. Now, using his knees as a pivot, he will at the moment the 
 patient's hands touch the ground throw (not too suddenly) all his 
 weight forward on his hands, and at the same time squeeze the waist 
 between them, as if he wished to force anything in the chest upward 
 out of the mouth ; he will deepen the pressure while he slowly counts, 
 one, two, three, four (about five seconds), then suddenly let go with a 
 final push, which will spring him back to his first position. 6 This 
 completes expiration. (Fig. 29.) 
 
 At the instant of his letting go, the man at the patient's head will 
 again draw the arms steadily upward to the sides of the patient's 
 head as before (the assistant holding the tongue again changing hands 
 
 a Changing hands will be found unnecessary after some practice ; the tongue, 
 however, must not be released. 
 zA child or very delicate patient must, of course, be more gently handled, 
 
85 
 
 to let the arms pass if necessary), holding them there while he slowly 
 counts one, two, three, four (about five seconds). 
 
 Repeat these movements deliberately and perseveringly twelve to 
 fifteen times in every minute thus imitating the natural motions of 
 breathing. 
 
 If natural breathing be not restored after a trial of the bellows 
 movement for the space of about four minutes, then turn the patient 
 a second time on the stomach, as directed in Rule II, rolling the body 
 in the opposite direction from that in which it was first turned, for 
 the purpose of freeing the air passage from any remaining water. 
 Continue the artificial respiration from one to four hours, or until the 
 patient breathes, according to Rule III; and for a while, after the 
 appearance of returning life, carefully aid the first short gasps until 
 
 FIG. 29. 
 
 deepened into full breaths. Continue the drying and rubbing, which 
 should have been unceasingly practiced from the beginning by assist- 
 ants, taking care not to interfere with the means employed to produce 
 breathing. Thus the limbs of the patient should be rubbed, always 
 in an upward direction toward the body, with firm-grasping pressure 
 and energy, using the bare hands, dry flannels, or handkerchiefs, and 
 continuing the friction under the blankets or over the dry clothing. 
 The warmth of the body can also be promoted by the application of 
 hot flannels to the stomach and armpits, bottles or bladders of hot 
 water, heated bricks, etc., to the limbs and soles of the feet. 
 
 Rule IV. After treatment. Externally: As soon as breathing is 
 established let the patient be stripped of all wet clothing, wrapped 
 in blankets only, put to bed comfortably warm, but with a free 
 circulation of fresh air, and left to perfect rest. Internally: Give 
 
86 . 
 
 whisky or brandy and hot water in doses of a teaspoonful to a 
 tablespoonful, according to the weight of the patient, or other stimu- 
 lant at hand, every ten or fifteen minutes for the first hour, and as 
 often thereafter as may seem expedient. Later manifestations: 
 After reaction is fully established there is great danger of congestion 
 of the lungs, and if perfect rest is not maintained for at least forty- 
 eight hours, it sometimes occurs that the patient is seized with great 
 difficulty of breathing, and death is liable to follow unless immediate 
 relief is afforded. In such cases apply a large mustard plaster over 
 the breast. If the patient gasps for breath before the mustard takes 
 effect, assist the breathing by carefully repeating the artificial respi- 
 ration. 
 
 MODIFICATION OP RULE III. 
 
 [To be used after Rules I and II in case no assistance is at hand.] 
 
 To produce respiration. If no assistance is at hand and one person 
 must work alone, place the patient on his back with the shoulders 
 
 FIG. 30. 
 
 slightly raised on a folded article of clothing; draw forward the 
 tongue and keep it projecting just beyond the lips: if the lower jaw 
 be lifted the teeth may be made to hold the tongue in place ; it may 
 be necessary to retain the tongue by passing a handkerchief under 
 the chin and tying it over the head. 
 
 Grasp the arms just below the elbows and draw them steadily 
 upward by the sides of the patient's head to the ground, the hands 
 nearly meeting. (See fig. 30.) 
 
87 
 
 Xext lower the arms to the side and press firmly downward and 
 inward on the sides and front of the chest over the lower ribs, 
 drawing toward the patient's head. (See fig. 31.) 
 
 Repeat these movements twelve to fifteen times every minute, etc. 
 
 INSTRUCTIONS FOR SAVING DROWNING PERSONS BY SWIMMING TO THEIR 
 
 RELIEF. 
 
 1. When you approach a person drowning in the water, assure him, 
 with a loud and firm voice, that he is safe. 
 
 2. Before jumping in to save him, divest yourself as far and as 
 quickly as possible of all clothes; tear them off, if necessary; but if 
 there is not time, loose at all events the foot of your drawers, if they 
 are tied, as, if you do not do so, they fill with water and drag you. 
 
 3. On swimming to a person in the sea, if he be struggling do not 
 seize him then, but keep off for a few seconds till he gets quiet, for it 
 
 FIG. 31. 
 
 is sheer madness to take hold of a man when he is struggling in the 
 water, and if you do you run a great risk. 
 
 4. Then get close to him and take fast hold of the hair of his head, 
 turn him as quickly as possible onto his back, give him a sudden 
 pull, and this will cause him to float, then throw yourself on your 
 back also and swim for the shore, both hands having hold of his 
 hair, you on your back, and he also on his, and of course his back to 
 your stomach. In this way yon will get sooner and safer ashore than 
 by any other means, and you can easily thus swim with two or three 
 persons; the writer has even, as an experiment, done it with four, 
 and gone with them 40 or 50 yards in the sea. One great a'dvantage 
 
88 
 
 of this method is that it enables you to keep your head up and also 
 to hold the person's head up you are trying to save. It is of primary 
 importance that you take fast hold of the hair and throw both the 
 person and yourself on your backs. After many experiments, it is 
 usually found preferable to all other methods. You can in this man- 
 ner float nearly as long as you please, or until a boat or other help 
 can be obtained. 
 
 5. It is believed there is no such thing as a death grasp; at least 
 it is very unusual to witness it. As soon as a drowning man begins 
 to get feeble and to lose his recollection, he gradually slackens his 
 hold until he quits it altogether. No apprehension need, therefore, 
 be felt on that head when attempting to rescue a drowning person. 
 
 6. After a person has sunk to the bottom, if the water be smooth, 
 the exact position where the body lies may be known by the air 
 bubbles, which will occasionally rise to the surface, allowance being 
 of course made for the motion of the w r ater, if in a tide way or 
 stream, w r hich will have carried the bubbles out of a perpendicular 
 course in rising to the surface. Oftentimes a body may be regained 
 from the bottom, before too late for recovery, by diving for it in 
 the direction indicated by these bubbles. 
 
 7. On rescuing a person by diving to the bottom, the hair of the 
 head should be seized by one hand only, and the other used in con- 
 junction with the feet in raising yourself and the drowning person 
 to the surface. 
 
 8. If in the sea, it may sometimes be a great error to try to get 
 to land. If there be a strong " outsetting " tide, and }'Ou are swim- 
 ming either by yourself or having hold of a person who can not 
 swim, then get on your back and float till help comes. Many a 
 man exhausts himself by stemming the billows for the shore on a 
 back-going tide, and sinks in the effort, when, if he had floated, a 
 boat or other aid might have been obtained. 
 
 9. These instructions apply alike to all circumstances, whether as 
 regards the roughest sea or smooth water. 
 
APPENDIX. 
 
 THE UNITED STATES PUBLIC HEALTH AND MARINE-HOSPITAL 
 
 SERVICE. 
 
 The United States Marine-Hospital Service was established by an act of Con- 
 gress approved July 16, 1798. By this act Congress imposed a tax of 20 cents 
 a month on every seaman employed on vessels of the United States engaged in 
 the foreign or coasting trades, and out of the money collected by authority of 
 this act the President of the United States was authorized to furnish tempo- 
 rary relief to sick and disabled seamen. The said act was amended March 2, 
 1799, extending the operations of the law so as to include the officers and sea- 
 men of the Navy ; but in the year 1811 separate hospitals were established for 
 the Navy. 
 
 Under an act of Congress approved June 29, 1870, the hospital tax was in- 
 creased from 20 to 40 cents a month, at which rate it was continued until 
 1884, when, by an act of Congress, the hospital tax was abolished and the ton- 
 nage tax was made available for the ordinary expenses of the Service (for the 
 care and treatment of sick and disabled American seamen). 
 
 By act of Congress approved July 1, 1902, the name of the Service was 
 changed to that of the Public Health and Marine-Hospital Service of the 
 United States. 
 
 The medical corps of the Public Health and Marine-Hospital Service consists 
 of the Surgeon-General, surgeons, passed assistant surgeons, acting assistant 
 surgeons, and sanitary inspectors. 
 
 The Surgeon-General is the head of the Service. He is required by law, 
 under the direction of the Secretary of the Treasury, to supervise all matters 
 connected with the Public Health and Marine-Hospital Service, including the 
 National Quarantine Service and the medical work in connection with the 
 Immigration Service. 
 
 RELIEF STATIONS, BENEFICIARIES, ETC. 
 
 [Extracts from the Regulations, Public Health and Marine-Hospital Service, 1903.] 
 
 BELIEF STATIONS. 
 
 PAR. 404. A relief station of the Public Health and Marine-Hospital Service 
 is a port or place where an officer of the Service is on duty to extend relief to 
 seamen or where an officer of the customs service is specifically authorized 
 to extend said relief. 
 
 PAR. 405. Relief stations shall be divided into the following classes : 
 
 Class I. United States marine hospitals. 
 
 Class II. All other stations under command of a commissioned officer. 
 
 Class III. All stations under charge of an acting assistant surgeon where 
 there is a contract for the care of sick and disabled seamen. 
 
 Class IV. All other relief stations not included in the above classes. 
 
 89 
 
90 
 
 BENEFICIARIES. 
 
 PAR. 411. The persons entitled to the benefits of the Public Health and 
 Marine-Hospital Service are those employed on board in the care, preservation, 
 or navigation of any registered, enrolled, or licensed vessels of the United 
 States, or in the Service on board of those engaged in such care, preservation, 
 or navigation. Officers and crews of the Light-House Establishment, officers 
 and crews of the Revenue-Cutter Service, seamen employed on the vessels of 
 the Mississippi River Commission, seamen employed on the vessels of the Engi- 
 neer Corps of the Army, and keepers and crews of the United States Life- 
 Saving Service are entitled to the facilities of the hospitals and relief stations 
 under special rules hereinafter prescribed. 
 
 PAR. 412. Officers on vessels of the Coast and Geodetic Survey, and seamen 
 thereon, who are not enlisted men from the Navy, are entitled to the benefits of 
 the Service. 
 
 PAR. 413. Seamen employed on yachts are entitled to treatment, provided the 
 said yachts are enrolled, licensed, or registered as vessels of the United States. 
 
 PAR. 414. Seamen employed on United States army transports or other ves- 
 sels belonging to the Quartermaster's Department, United States Army, when 
 not enlisted men of the Army, are entitled to the benefits of the Service. 
 
 PAR. 415. No person employed in or connected with the navigation, manage- 
 ment, or use of canal boats engaged in the coasting trade shall, by reason 
 thereof, be entitled to any benefit or relief from the Service. 
 
 PAB. 417. Seamen taken from wrecked vessels of the United States are entitled 
 to the benefits of the Service if sick or disabled, and will be furnished care and 
 treatment without reference to the length of time they have been employed. 
 
 PAR. 418. Seamen employed on merchant vessels of the United States returned 
 to the United States from foreign ports by United States consular officers, 
 if sick or disabled at the time of their arrival in a port of the United States, 
 shall be entitled to the benefits of the Service without reference to length of 
 service. 
 
 PAB. 419. A sick or disabled seaman, in order to obtain the benefits of the 
 Service, must apply in person, or by proxy if too sick or disabled so to do, at 
 the office of the Public Health and Marine-Hospital Service, to an officer of that 
 Service, or to the proper customs officer acting as the agent of the said Service 
 at stations where no medical officer is on duty, and must furnish satisfactory 
 evidence that he is entitled to relief under the regulations. 
 
 PAR. 420. Masters' certificates and discharges from United States shipping 
 commissioners, made out and signed in proper form, showing that the applicant 
 for relief has been employed for sixty days of continuous service " in a regis- 
 tered, enrolled, or licensed vessel of the United States," a part of which must 
 have been during the sixty days immediately preceding his application for relief, 
 shall entitle him to treatment. The phrase " sixty days' continuous service " 
 shall not be held to exclude seamen whose papers show brief intermission 
 between short services that aggregate the required sixty days. 
 
 PAR. 440. Seamen taken sick or injured while actually employed on a doc- 
 umented vessel shall be entitled to treatment at relief stations without reference 
 to the length of their service. 
 
 PAR. 421. The certificate of the owner or accredited commercial agent of a ves- 
 sel as to the facts of the employment of any seaman on said vessel may be 
 accepted as evidence in lieu of the master's certificate in cases where the 
 latter is not procurable. 
 
 PAR. 422. Masters of documented vessels of the United States shall, on 
 demand, furnish any seaman who has been employed on such vessel a certifi- 
 
91 
 
 cate (Form 1915) of the length of time said seaman has been so employed, 
 giving the dates of such employment. This certificate will be filed in the marine- 
 hospital office or office of the customs officer when application is made for relief, 
 whether the relief is furnished or the claim rejected. 
 
 PAR. 423. Any master of a vessel or other person who shall furnish a false 
 certificate of service, with intent to procure the admission of a seaman into 
 any marine hospital, shall be immediately reported to the nearest United 
 States attorney for prosecution. 
 
 PAB. 424. When an interval has occurred in the applicant's seafaring service 
 by reason of the closure of navigation on account of ice or low water, such inter- 
 val shall not be considered as excluding him from relief unless the sickness or 
 injury for which he applies for relief be the direct result of employment on 
 shore. 
 
 HOSPITAL BELIEF. 
 
 PAB. 480. A sick or disabled seaman entitled to the benefits of the Service 
 shall be admitted to hospital only in cases where the gravity of the disease 
 or injury from which he suffers is such as to require hospital treatment in 
 the opinion of an officer of the Service, or of a reputable physician designated by 
 the Department to act at a place where no officer is stationed. 
 
 PAB. 442. Temporary relief only is contemplated, and admission to hospital 
 is not intended to permit an indefinite residence therein for cause other than 
 actual disease or injury. 
 
 PAB. 482. Officers shall not be required to attend sick or disabled seamen 
 on board vessels or to visit them in harbor, except at the discretion of the 
 officer to whom the application is made. 
 
 OUT-PATIENT BELIEF. 
 
 PAB. 467. Sick and disabled seamen entitled under these regulations to the ben- 
 efits of the Service whose diseases or injuries are of such a nature that they 
 can properly be relieved by medicines, dressings, or advice, without admission 
 to hospital, shall be treated as out-patients, and furnished medicines, dressings, 
 surgical appliances, or advice, as the case may require. 
 
 PAB. 434. When a seaman who has received continuous treatment at the out- 
 patient office for a period of two months applies for further treatment, he must, 
 to entitle him to treatment, furnish a new cerificate of service, showing that 
 he is still following his vocation as seaman, or give satisfactory evidence that 
 such service has been prevented by closure of navigation or by sickness, the 
 latest dates of service, and, in case of lack of recent service, its explanation, to 
 appear in each new relief certificate. 
 
 THE BEVENUE-CUTTEB SEBVICE. 
 
 PAB. 444. The officers and crews of the Revenue-Cutter Service will receive 
 hospital or out-patient treatment, as hereinafter provided, on certificate signed 
 by the commanding officer or executive officer of a revenue cutter without regard 
 to length of service. The certificate shall contain a description of the applicant 
 for relief. Officers on leave or waiting orders may sign their own certificate. 
 
 PAB. 449. At ports where there is a marine hospital station, when an officer 
 or member of a crew of the Revenue-Cutter Service, on account of injury or 
 illness, requires the immediate attention of a physician, and on account of the 
 exigency of the case it is impossible to convey the patient to the marine hos- 
 pital or office, temporary provision for medical attendance or care may be made 
 by the commanding officer, who will immediately report his action to the proper 
 marine-hospital representative at the port, and the treatment thereafter will 
 
92 
 
 be conducted by tfle Public Health and Marine- Hospital Service in the manner 
 provided in the annual circular entitled " Contracts for care of seamen, etc.," 
 if in the judgment of the proper officer of the Public Health and Marine-Hospital 
 Service it can be done without detriment to the patient. * * * 
 
 PAE. 450. Commissioned medical officers and acting assistant surgeons of the 
 Public -Health and Marine-Hospital Service will render professional aid to offi- 
 cers of the Revenue-Cutter Service residing at the port at their residences when 
 said officers of the Revenue-Cutter Service for any reason can not avail them- 
 selves of the accommodations offered by the marine hospital and when they are 
 physically unable to present themselves at the marine-hospital office. The med- 
 icines or appliances prescribed shall be furnished from the dispensary of the 
 Public Health and Marine-Hospital Service when practicable. 
 
 THE MISSISSIPPI RIVER COMMISSION. 
 
 PAR. 452. Masters, officers, and crews, of vessels in the service of the Missis- 
 sippi River Commission shall be entitled to the benefits of the Marine-Hospital 
 Service (except at stations of the fourth class) under the same regulations as 
 govern the admission of seamen on documented vessels. * * * 
 
 THE ENGINEER CORPS, UNITED STATES ARMY. 
 
 PAR. 453. Seamen employed on vessels under the charge of the Engineer Corps 
 of the United States Army shall be admitted to the benefits of the Marine-Hos- 
 pital Service without charge at stations of the first, second, and third class upon 
 the written request of the commanding officers of said vessels. 
 
 THE LIFE-SAVING SERVICE. 
 
 PAR. 454. Keepers and surfmen of the Life-Saving Service will be treated in 
 the marine hospitals, but not at their homes, and will receive out-patient relief 
 only at the dispensaries connected with the Service. Keepers and surfmen will 
 be entitled to the ordinary accommodations of the hospitals, and will comply 
 with all rules and regulations relating to discipline and management. 
 
 PAR. 455. An applicant must present a certificate signed by a keeper, district 
 superintendent, or assistant inspector of the Life-Saving Service, in the form 
 prescribed by the Department, testifying to his services as keeper or surfman of 
 a life-saving station, and giving other satisfactory evidence that he is entitled to 
 treatment. When it is impracticable to obtain the certificate, signed as above 
 required, an affidavit of the applicant as to the facts of his employment may be 
 accepted. The applicant must be required to sign his name to the certificate 
 before it is signed by the officer issuing it. 
 
 PAR. 456. The certificate must show that the applicant is borne upon the rolls 
 of the Life-Saving Service at the time of making the application. Applicants 
 who have been discharged from the Life-Saving Service, being no longer mem- 
 bers thereof, are not entitled to treatment. 
 
 PAR. 457. During the period when the life-saving stations are open sick or 
 injured keepers or surfmen will be admitted to hospital or out-patient treatment 
 according to the necessities of the case. 
 
 PAR. 458. During the months when the stations are closed sick or injured 
 keepers or surfmen will be admitted as above, unless the sickness or injury 
 is the result of employment not connected with the United States Life-Saving 
 Service. If injured or taken sick during said months as a result of employment 
 not connected with the Life-Saving Service, treatment will not be granted. 
 
 PAR. 459. Under the terms of the act of August 4, 1894, a marine hospital will 
 not be considered a home for sick or disabled keepers or surfmen of the Life- 
 
93 
 
 Saving Service. . Temporary treatment alone is permitted, and no keeper or 
 surfman will be retained in hospital longer than ninety days unless special 
 authorization is given by the Bureau. 
 
 THE LIGHT-HOUSE SERVICE. 
 
 PAR. 460. Officers and crews of the several vessels belonging to the Light- 
 House Establishment, including light-ships, may be admitted to the benefits of 
 the Public Health and Marine-Hospital Service upon the application of their 
 respective commanding officers. 
 
 UNITED STATES ARMY AND NAVY. 
 
 PAR. 461. Officers and enlisted men of the United States Army and Navy may 
 be admitted for care and treatment as patients of the Service only upon the 
 written request of their respective commanding officers. Every such admission 
 shall be immediately reported to the Surgeon-General by the officer in charge 
 of the station, on a daily report (Form 1957) or relief certificate (Form 1916), 
 accompanied by a copy of the request upon which such officer or enlisted man 
 was admitted. They shall be furnished treatment at stations of the first, sec- 
 ond, and third class only. The rate of charge to be made for the care and 
 treatment of the said officers and enlisted men will be fixed by the Department 
 at the beginning of each fiscal year. 
 
 FOREIGN SEAMEN. 
 
 ' 
 
 PAR. 462. The accommodations provided for the care and treatment of the 
 patients of the Public Health and Marine-Hospital Service are also available 
 to foreign seamen at relief stations of the first, second, and third class upon 
 the application of the consular officer of the nation under whose flag they are 
 sailing or upon the application of the masters of the vessels upon which said 
 seamen serve, provided satisfactory written security is given for the* payment 
 of the expenses of such care and treatment, at rates fixed annually by the 
 Department. * * * 
 
INDEX. 
 
 Page. 
 
 Acute rheumatism (rheumatic fever) . 42 
 
 Alcoholic liquors 9 
 
 Ankle, dislocation of - 78 
 
 Apparently drowned: 
 
 To expel water from stomach and chest of, illustration (fig. 27) 83 
 
 To produce breathing in, illustration (figs. 28, 29) . . . 84-85 
 
 To produce respiration in, illustration (figs. 30, 31 ) 86-87 
 
 Appendix: 
 
 Beneficiaries 90 
 
 Engineer Corps, United States Army 92 
 
 Foreign seamen . . . 93 
 
 Hospital relief 91 
 
 Life-Saving Service . . 92 
 
 Light-House Service 93 
 
 Mississippi River Commission 92 
 
 Out-patient relief . 91 
 
 Relief stations 89 
 
 Revenue-Cutter Service 91 
 
 United States Army and Navy 93 
 
 Arm, fracture of (between elbow and shoulder) . . 63 
 
 Splints and bandages for treatment of, illustrations (figs. 7, 8,9) 63-64 
 
 Treatment of . .63 
 
 Articles, miscellaneous 7 
 
 Asiatic cholera 24 
 
 Back, injuries of 59 
 
 Treatment of 59 
 
 Bandage for treatment of ulcer, illustration (fig. 26) 81 
 
 Bandages and splints for treatment of fracture of: 
 
 Arm, illustrations (figs. 7,8,9) .... 63-64 
 
 Kneecap, illustration (fig. 14) 69 
 
 Lower jaw, illustrations (figs. 3, 4, 5, 6) 61 
 
 Beriberi . . 29 
 
 Bleeding 53 
 
 Boils . 52 
 
 Treatment of 53 
 
 Box, fracture, for treatment of fracture of leg, illustration (fig. 20) 72 
 
 Broken bones . 59 
 
 Burns or scalds ... 56 
 
 Treatment of 56 
 
 Capsules 8 
 
 95 
 
96 
 
 Page. 
 Catheter: 
 
 Curve of channel through which must pass, illustration (fig. 2) 51 
 
 How to use, illustration (fig. 1) 5 1 
 
 Chancre, soft ; _ . . 46 
 
 Chest and stomach, to expel water from, illustration (fig. 27) _. 83 
 
 Chest, injuries of . 58 
 
 Treatment of 59 
 
 Cholera (epidemic cholera, Asiatic cholera) _ 24 
 
 Treatment of 26 
 
 Cliolera morbus (cholera nostras, sporadic cholera) . . 36 
 
 Treatment of . . 36 
 
 Chronic rheumatism . . 42 
 
 Clap (gonorrhea) 48 
 
 Colic 37 
 
 Treatment of ....... 37 
 
 Collar bone, dislocation of . 78 
 
 Treatment of _ - 78 
 
 Compound fractures - . 72 
 
 Treatment of 73 
 
 Delirium tremens 44 
 
 Treatment of 45 
 
 Diarrhea . 35 
 
 Treatment of 35 
 
 Directions for restoring the apparently drowned . _ 82 
 
 Dislocations . _ 73 
 
 Ankle, treatment of 78 
 
 Collar bone 78 
 
 Treatment of . . 78 
 
 Elbow.. 75 
 
 Treatment of . . 76 
 
 Fingers. ,__. 74 
 
 Treatment of . _ . 75 
 
 Hip 79 
 
 Illustration (figs. 24, 25) .... .... 80 
 
 Treatment of . . 80 
 
 Knee 79 
 
 Treatment of . . 79 
 
 Shoulder 77 
 
 Illustration (fig. 23).. 76 
 
 Treatment of . 77 
 
 Symptoms and signs of . 77 
 
 Thumb.. 74 
 
 Illustration (fig. 21 ) 75 
 
 Treatment of 74 
 
 Toes 78 
 
 Treatment of ... 78 
 
 Wrist - 75 
 
 Treatment of _ 75 
 
 Double inclined plane for treatment of fracture of thigh, illustrations 
 
 (figs. 10, 11) 66 
 
 Drowned, directions for restoring the apparently _ . 
 
 Drowning persons, instructions for saving, by swimming to their relief _. 
 
 Drugs and medicines . . , 
 
97 
 
 Page. 
 
 Dysentery 32 
 
 Symptoms of 32 
 
 Treatment of __ 33 
 
 Tropical.. 32 
 
 Effects of cold, frostbite 57 
 
 Treatment of . . . 57 
 
 Elbow, dislocation of 75 
 
 Treatment of 76 
 
 Elixirs, tinctures, essences, etc 9 
 
 Epidemic cholera 24 
 
 Erysipelas (St. Anthony's Fire) . . - 40 
 
 Treatment of 41 
 
 Essences, elixirs, tinctures, etc 9 
 
 Face, wounds of 58 
 
 Treatment of 58 
 
 Fever, malarial 16 
 
 Treatment of . . 19 
 
 Fever: 
 
 Pernicious malarial 18 
 
 Rheumatic (acute rheumatism) 42 
 
 Treatment of .- 42 
 
 Yellow _ 11 
 
 Fingers, dislocation of 74 
 
 Treatment of- _. 75 
 
 Fingers and thumb: 
 
 Fracture of 62 
 
 Treatment of _ 62 
 
 Forearm, fracture of _ 62 
 
 Treatment of 63 
 
 Fracture: 
 
 Arm (between elbow and shoulder) 63 
 
 Treatment of . . 63 
 
 Arm splints and bandages for treatment of, illustrations (figs. 7, 8, 9) _ _ 63-64 
 
 Forearm _ 62 
 
 Treatment of 63 
 
 Kneecap _ _ _ 69 
 
 Symptoms and signs of : ' 69 
 
 Treatment of _ 69 
 
 Leg (between knee and ankle) _ 70 
 
 Treatment of 71 
 
 Leg, fracture box for treatment of, illustration (fig. 20) 72 
 
 Lower jaw 60 
 
 Splints and bandages for treatment of, illustrations (figs. 3, 4, 5, 6) _ 61 
 
 Treatment of . . . 61 
 
 Fracture, Pott's: 
 
 Appearance of right foot after, illustration (fig. 17) 71 
 
 Application of splint for, illustration (fig. 19) 71 
 
 As shown on the skeleton . illustration (fig. 18) 71 
 
 Fracture of thigh 65 
 
 Double inclined plane for treatment of, illustrations (figs. 10, 11) 66 
 
 Long splint for treatment of, illustration (fig. 13) 67 
 
 1325604 M 7 
 
98 
 
 Fracture of thigh Continued. Page. 
 
 Short splints for treatment of, illustration (fig. 14) _ 67 
 
 Treatment of _ . 65 
 
 Weight and pulley for treatment of, illustration (fig. 12) 67 
 
 Fracture of thumb and fingers 62 
 
 Treatment of 62 
 
 Fracture box, for treatment of fracture of leg. illustration (fig. 20) 72 
 
 Fractures, compound 72 
 
 Treatment of 73 
 
 Frostbite, treatment of 57 
 
 Gonorrhea (clap) 48 
 
 Treatment of 49 
 
 Gonorrheal rheumatism 43 
 
 Hemorrhage 53 
 
 Hip, dislocation of 79 
 
 Illustrations (figs. 24, 25) 80 
 
 Treatment of 80 
 
 Illustrations: 
 
 Appearance of right foot after a Pott's fracture (fig. 17) 71 
 
 Application of splint for Pott's fracture (fig. 19) 71 
 
 Application of weight and pulley in treatment of fracture of thigh 
 
 (fig. 15) - 68 
 
 Bandage for treatment of ulcer (fig. 26) 81 
 
 Catheter, how to use (fig. 1) ._. 51 
 
 Curve of channel through which catheter must pass (fig. 2) 51 
 
 Dislocation of shoulder (fig. 23) .. 76 
 
 Dislocation of the hip (figs. 24, 25) .. 80 
 
 Dislocation of thumb and method of replacing (figs. 21 , 22) _ _ _ 75 
 
 Double inclined plane for treatment of fracture of the thigh ( figs .10,11). 66 
 
 Fracture box for treatment of fracture of leg (fig. 20) _ . 72 
 
 Long splints for treatment of fracture of the thigh (fig. 13) . 67 
 
 Pott's fracture as shown on the skeleton (fig. 18) 71 
 
 Respiration in the apparently drowned (figs. 30, 31) _ _ 86-87 
 
 Short splints for treatment of fracture of the thigh (fig. 14) 67 
 
 Splint and bandage for treatment or fracture of kneecap (fig. 16) 69 
 
 Splints and bandages for treatment of fracture of arms (figs. 7, 8, 9).. 63-64 
 Splints and bandages for treatment of fracture of lower jaw (figs. 3, 4, 
 
 5,6) 61 
 
 To expel water from stomach and chest (fig. 27) 83 
 
 To produce breathing in the apparently drowned (figs. 28, 29) . . 84-85 
 
 Weight and pulley for treatment of fracture of the thigh (fig. 12) 67 
 
 Injuries of: 
 
 Chest 58 
 
 Treatment of . . 59 
 
 Back 59 
 
 Treatment of . . 59 
 
 Instructions for saving drowning persons by swimming to their relief 87 
 
 Instruments, surgical . 7 
 
 Itch (scabies) \ 52 
 
 Treatment of 52 
 
 Jaw, lower, fracture of 60 
 
 Splints and bandages for treatment of, illustrations (figs. 3, 4, 5, 6) 61 
 
 1 Treatment of _ . 61 
 
99 
 
 Page! 
 
 Knee, dislocation of . . . 79 
 
 Treatment of 79 
 
 Kneecap, fracture of . . 69 
 
 Symptoms and signs of 69 
 
 Treatment of 69 
 
 Leg, fracture of (between knee and ankle) 70 
 
 Treatment of . :_ 71 
 
 Liquors, alcoholic 9 
 
 Lower jaw, fracture of 60 
 
 Splints and bandages for treatment of, illustrations (figs. 3, 4, 5, 6) . _ 61 
 
 Treatment of 61 
 
 Lozenges 8 
 
 Malarial fever _ . 16 
 
 Pernicious 18 
 
 Treatment of 19 
 
 Medicines and drugs 8 
 
 Miscellaneous articles 7 
 
 Muscular rheumatism . 42 
 
 Nosebleed 81 
 
 Treatment of ... 82 
 
 Pills .... 8 
 
 Plague 26 
 
 Pott's fracture: 
 
 Appearance of right foot after, illustration (fig. 17) 71 
 
 As shown on the skeleton, illustration (fig. 18) 71 
 
 Application of splint for, illustration (fig. 19) . . 71 
 
 Pernicious malarial fever 18 
 
 Treatment of . . 19 
 
 Piles .. 53 
 
 Treatment of ... 53 
 
 Quinsy (sore throat) 39 
 
 Restoration of the apparently drowned, directions for . . .. 82 
 
 Rheumatic fever (acute rheumatism) 42 
 
 Treatment of 42 
 
 Rheumatism: 
 
 Acute (rheumatic fever) 42 
 
 Treatment of . . 42 
 
 Chronic 42 
 
 Treatment of . _ 43 
 
 Gonorrheal 43 
 
 Treatment of 44 
 
 Muscular _ 42 
 
 Treatment of 43 
 
 Syphilitic-. 44 
 
 Treatment of 44 
 
 St. Anthony's fire (erysipelas) 40 
 
 Scabies (itch) 52 
 
 Scalds or burns 56 
 
 Treatment of 56 
 
 Scalp, wounds of 58 
 
 Treatment of - - - 58 
 
 Scurvey ... 38 
 
 Symptoms of 38 
 
 Treatment of . . 39 
 
100 
 
 Page. 
 
 Shoulder, dislocation of 77 
 
 Illustration (fig. 23) 76 
 
 Treatment of.. 72 
 
 Smallpox 21 
 
 Treatment of 23 
 
 Soft chancre 46 
 
 Treatment of r 47 
 
 Sore throat (tonsilitis, quinsy) 39 
 
 Treatment of 40 
 
 Splints : 
 
 For Pott's fracture, application of, illustration (fig. 19) 71 
 
 Long, for treatment of fracture of thigh, illustration (fig. 13) 67 
 
 Short, for treatment of fracture of thigh, illustration (fig. 14) 67 
 
 Splints and bandages for treatment of fracture of lower jaw, illustrations 
 
 (figs. 3,4.5,6) 61 
 
 Splints and bandages for treatment of fracture of arm, illustrations (figs. 
 
 7,8,9) . 63-64 
 
 Splints and bandages for treatment of fracture of kneecap, illustration 
 
 (fig. 16) : 69 
 
 Sprains 81 
 
 Treatment of . 81 
 
 Stomach and chest, to expel water from, illustration (fig. 27) 83 
 
 Stoner , George W. , surgeon 3 
 
 Stricture of urethra 50 
 
 Directions for passing catheter, illustrations (figs. 1,2) _ 51 
 
 Treatment of ;... 51 
 
 Surgical instruments 7 
 
 Sunstroke 34 
 
 Treatment of _ . 34 
 
 Syphilis . . 45 
 
 Treatment of _ 46 
 
 Syphilitic rheumatism 44 
 
 Tablets 8 
 
 Tablet triturates. 8 
 
 The apparently drowned, directions for restoring _ 82 
 
 The plague 26 
 
 Thigh, fracture of _ 65 
 
 Double inclined plane for treatment of, illustrations (figs. 10, 11) 66 
 
 Long splint for treatment of, illustration (fig. 13) - _ 67 
 
 Short splints for treatment of, illustration (fig. 14) _. 67 
 
 Treatment of 65 
 
 Weight and pulley for treatment of, illustration (fig. 12) 67 
 
 Thumb and fingers, fracture of ___ _. 62 
 
 Treatment of . . . 03 
 
 Thumb, dislocation of 74 
 
 Illustration (fig. 21 ) 75 
 
 Treatment of 75 
 
 Tinctures, elixirs, essences, etc 9 
 
 Toes, dislocation of * 78 
 
 Treatment of : 78 
 
 Tonsilitis (sore throat) '__ 39 
 
 Tropical dysentery 
 
 Ulcer, bandage for treatment of, illustration (fig. 26) 81 
 
101 
 
 Page. 
 
 Urethra, stricture of 50 
 
 Weight and pulley : 
 
 Application of, in treatment of fracture of thigh, illustration (fig. 15). 68 
 
 For treatment of fracture of thigh, illustration ( fig. 12) 67 
 
 Wounds of face 58 
 
 Treatment of . . 58 
 
 Wounds of scalp 58 
 
 Treatment of 58 
 
 Wounds and injuries : 53-54 
 
 Wrist, dislocation of . 75 
 
 Treatment of 75 
 
 Wyman, Walter, Surgeon-General - 57 
 
 Yellow fever 11 
 
 Treatment of . . 14 
 
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